RU2395245C1 - Method of revascularisation of femoral bone head - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to traumatology and orthopedics, and can be applied in treatment of vascular affections of femoral bone head of various etiology (osteochondopathy, Perthes diseas, degenerative-dystrophic affection of hip joint, aceptic necrosis of femoral bone head) at the initial sage of disease, without disturbing anatomical interrelationship of joining surfaces of hip joint. Bed for osteosynthesis is formed through two cuts: the first - 2 cm long in region of greater trochanter tip, the second - 4 cm long in subtrochanteric region. Periosteum is detached only in zone of osteotomy. Double osteotomy at intersubtrochanteric level is carried out. In the place of osteotomy diastasis is created; on thickness of cortical layer with the distance between them equal 1.5 cm with further osteosynthesis of hip proximal part. Plate for osteosynthesis is introduced through cut in the region of greater trochanter tip. Fixation of proximal part of plate is carried out by means of screws through preliminarily made cuts, distal part is fixed through two additional cuts each 1.0 cm long under X-ray control.

EFFECT: method allows to eliminate development of false joint in the place of osteotomy.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of vascular lesions of the femoral head of various etiologies (osteochondropathy, Perthes disease, degenerative-dystrophic damage to the hip joint, aseptic necrosis of the femoral head at the initial stage of the disease).

There is a method of treating vascular lesions of the head (Perthes disease), which consists in an extra-articular intertrochanteric derotation-variating osteotomy of the femur (Andrianov V.L., Veselovsky Yu.A., Tikhonenkov BC, Sadofieva V.I. // Traumatology and orthopedics. - 1987 , No. 10. - P.40-44) with the aim of centering the head in the cavity with subsequent prolonged unloading of the operated joint (up to 15 months). Operating (Fig. 1) using this technique, access 1 is from 16 to 22 cm long. Soft tissues are dissected from the apex of the greater trochanter with distal extension along the axis of the thigh to the length of the plate. During the operation, a significant mobilization of the proximal femur is performed to enable detorsion-variating osteotomy of the femur. Then, a wedge-shaped osteotomy with the formation of a 4 wedge-shaped graft is made (Fig. 2) at an intertrochanteric level 3, while the cervical-diaphyseal angle 2 in many patients is approximately 125 to 145 degrees.

Next, removing the graft (figure 2) 4, there is (figure 3) a decrease in the cervical-diaphyseal angle 2 to 110-115 degrees. The osteotomy site after graft removal is as follows 3. By rotating the proximal femur in the direction of arrow 5, we achieve an anversion angle of 5-8 degrees, followed by fixation of the proximal femur 6 with a plate. The onset of consolidation at the osteotomy site is 3 months. Further unloading of the joint up to 15 months.

This method is adopted as a prototype.

The disadvantages of this method are the long recovery period of blood supply to the femoral head from 14 to 16.6 months (average 15 months); high morbidity: significant mobilization of the proximal femur is inevitable, impairing blood supply and disrupting its microcirculation, due to the need to form a bed for the osteotomy and plate; the threat of the development of a false joint at the site of an osteotomy.

The duration of rehabilitation treatment is due to the fact that with a similar osteotomy between fragments, the height of the regenerate and the formation of the vasculature in it are insufficient to ensure complete revascularization of the femoral head. The studies also showed that with prolonged unloading of the joint (Dolnitsky OV, Radomsky AA // Traumatology and orthopedics. - 1987. - No. 10. - P.45-48), the destruction of the cell-free plate, the increase in the size of chondrocytes , matrix excretion, which has a negative effect on the trophic epiphysis of the femoral head.

The objective of the invention is to increase the efficiency of the method, reduce treatment time, reduce the invasiveness of the operation, exclude the development of the pseudoarthrosis at the site of osteotomy.

The technical result consists in the maximum preservation of blood supply to the proximal femur.

This is achieved due to the fact that the bed for the plate and the osteosynthesis of the proximal femur are made through two incisions: one 2 cm long in the region of the apex of the greater trochanter, the second 4 cm long in the undervert region, the bed for the plate is formed over the periosteal, the periosteum is peeled only in osteotomy zone, after which a double osteotomy is performed at the intersubtrochanteric level, the place of each osteotomy is expanded by the thickness of the cortical layer, creating a distance of 1.5 cm between them, followed by osteosynthesis of the proximal hips, while a pre-modeled plate according to an x-ray for osteosynthesis is inserted through an incision in the region of the apex of the greater trochanter, the proximal part of the plate is fixed with screws through previously made incisions, and its distal part through two additional 1.0 cm incisions under x-ray control.

Minimally invasive technology for osteotomy of the proximal femur using cuts 2.0 cm and 4.0 cm long, peeling the periosteum only at the osteotomy site, forming a bed for the plate above the periosteum, carefully preserving the connections of the bone tissue of the proximal femur with the periosteum and adjacent tissues with performing osteotomy can minimize the invasiveness of surgery.

Carrying out the proposed osteotomy of the femur practically makes it possible to achieve 100% cases of fusion of the osteotomy site, to exclude the development of a false joint or non-fusion of the bone at the site of osteotomy in a short time (the period of consolidation at the osteotomy site according to the prototype method is within 3 months, and according to the proposed 2 months).

With double hip osteotomy, due to the regenerate height between the osteotomies of 1.5 cm and, therefore, the formation of a developed vascular network in it, conditions are created to ensure full revascularization of the femoral head in a short time.

Thus, the use of the above methods of surgery allows you to increase the effectiveness of treatment, reduce the time, eliminate the development of complications after surgery.

The proposed method is as follows:

under general anesthesia in the position of the patient on the side, marking of future incisions in the undervert region 8 and in the region of the apex of the greater trochanter 7 with a length of 4.0 and 2.0 cm, respectively (Fig. 4).

After dissection of the fascia and muscles through an incision in the subtrochanteric region (Fig. 4) 8 along the outer surface of the proximal femur above the periosteal parallel to its long axis, the bed for the plate is proximal and distal to form a plate corresponding to its length. The periosteum is exfoliated only in the osteotomy zone.

An oscillatory saw with a blade width of 1.5 to 2.0 cm at the intersubtrochanteric level performs a double incomplete osteotomy under radiological control (under the control of the image intensifier) with the creation of osteotomy (Fig. 5) diastasis 3 for the thickness of the cortical layer with a distance between them equal to 1 5 cm

Next, the osteosynthesis plate (Fig. 6) (for example, with limited contact or with angular stability), previously modeled, is inserted through an incision made in the region of the apex of the greater trochanter, put it on the formed bed, fix its proximal part with screws to the bone through earlier incisions made, and the distal part through (Fig. 4) 9 additional sections of 1.0 cm in under radiological control.

This is what the proximal femur looks like (Fig. 7) after osteotomy 3 and fixation of the plate 6 with screws 10 to the bone tissue. The wound is sutured in layers with drainage by a micro-graduate for a day. Apply an aseptic dressing. The operation can be performed simultaneously from two sides.

Its use allows to reduce the treatment and rehabilitation of patients with vascular lesions of the femoral head, significantly reduce the likelihood of developing postoperative complications, increase the therapeutic effect due to a decrease in trauma and a decrease in the duration of surgical intervention, reduce blood loss during surgical treatment, and stop the development of head destruction for a long period of time , which allows to avoid the operation of total hip replacement at a young age.

Clinical example.

Patient M., 52 years old. And / b No. 10588. As a result of examination on the radiographs of the hip joint there are initial signs of coxarthrosis. On a computer tomogram, signs of progressive coxarthrosis were found. There is a cystic degeneration of the femoral head over a significant area. The patient underwent surgery according to the proposed method. Under general anesthesia in the patient’s position on the side, the markings of future incisions were made in the undertrochanteric region and in the region of the apex of the greater trochanter, 4.0 and 2.0 cm long, respectively. After dissection of the fascia and muscles through an incision in the undertrochanteric region along the outer surface of the proximal femur over the periosteal parallel to its long axis, a bed for the plate was formed proximally and distally with a raspator according to its length. The periosteum was exfoliated only in the osteotomy area.

An oscillating saw with a blade width of 2.0 cm at the intersubtrochanteric level performed double osteotomy under radiological control (under the control of the image intensifier) with the creation of two diastases for the thickness of the cortical layer at the site of osteotomy, with a distance between them of 1.5 cm.

Next, a pre-modeled plate for osteosynthesis with angular stability was introduced through an incision made in the region of the apex of the greater trochanter, its proximal part was fixed with screws to the bone through previously made incisions, and the distal part through additional incisions of 1.0 cm under x-ray control. The wound was sutured in layers with drainage by a micro-graduate for a day. Aseptic dressing. Conducted a course of rehabilitation treatment. Walking with crutches for two months after surgery without loading the operated limb. Exercise therapy. Massage. Electrical stimulation. Within two months, taking medications (osteogenon and structure). One year after the operation, the structure is removed. 5 years after surgery, the patient does not complain of pain in the hip joint. Lameness is absent. The range of motion in the hip joint is complete. On the x-ray of the destruction of the femoral head is not marked, signs of joint deformation, narrowing of the joint space, the appearance of cysts was not detected. Satisfied with the result of the operation.

Claims (1)

The method of revascularization of the femoral head by means of extra-articular osteotomy and bone osteosynthesis, characterized in that the bed under the osteosynthesis plate is formed through two incisions: the first 2 cm long in the region of the apex of the greater trochanter, the second 4 cm long in the undervert region, the periosteum is peeled only in the osteotomy zone and then double osteotomy is performed at the intersubtrochanteric level, two diastases are created at the site of osteotomy by the thickness of the cortical layer at a distance of 1.5 cm between them, followed by osteosynthesis of the proxy of the femoral part of the thigh, while the osteosynthesis plate is inserted through an incision in the region of the apex of the greater trochanter, the proximal part of the plate is fixed with screws through the previously performed incisions, and the distal part through two additional 1.0 cm incisions under x-ray control.

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