RU2397720C2 - Method of single-step bilateral hip arthroplasty at bilateral dysplastic coxarthrosis with fully dislocation and high displacement of whirlbones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly for traumatology and orthopedics. Intersecting spokes with tipping are passed over the upper front iliac spine, upper back iliac spine and intersecting spokes through the lower third of the femoral bones. Spokes passed through iliac bones are fixed in the arcs of the Ilizarov fixator. Spokes passed through the lower third of the femoral bones are fixed in the rings of the Ilizarov fixator. Rings and arcs of the Ilizarov fixator are connected with each other by threaded rods. On the second day after the operation began bringing down of the femoral bones is started by distraction until the reach of normal level of the location of round ligaments of femur towards the acetabulum. Then without taking off the apparatus of external fixation, skeletal traction system is mounted on each limb to one of the spokes passed in the bottom third of the femur. Dismantling of the apparatus of external fixation is carried out, leaving only the spoke on which the skeletal traction system is mounted. The achieved position is maintained by skeletal traction up to healing of spokes wounds. A one-stage bilateral hip replacement is carried out. The operation is performed in the patient's condition on his back on the operating table. The anterior-lateral approach to the hip joint is carried out. The proximal part of the femur is exposed. The head of the femur is resected. The acetabulum is handled with cutters. The fixing ring is installed. The endoprosthesis cup is installed on the bone cement. Sawdust femur is administered to the wound. The endoprosthesis femoral component is punched into the medullar canal. The hip reduction by traction on the extremity axis and rotation is carried out. After the control of amount of movements in the joint a joint capsule is formed of the soft tissue regenerate formed during the distraction of the femur. The wound is tamponed with napkins. 2-3 provisory sutures are put on the skin, then the same operation is made on the second hip joint. Then the provisory sutures and tampons are removed from the side of the first reconstructed joint. Control of hemostasis is carried out and the wound is sutured with leaving 2-3 drainages for 48-72 hours. Then on the second joint and provisory sutures and tampons are remove, too. Control of hemostasis is carried out and the wound is sutured with leaving 2-3 drainages for 48-72 hours. When installing the apparatus of external fixation each three intersecting spokes with tipping are passed through the upper front iliac spine, through the rear upper iliac spine and three intersecting spokes through the lower third of the femur. Bringing down the hips is carried out of 1 mm per day, in four installments of 0.25 mm each, while the movement of both hips at 0.25 mm is made synchronously. Moving both hips is carried out synchronously and with the same speed, until the moment when the head of the femur of one of the hip reaches the normal level position relative to the acetabulum. Then bringing down the first hip is stopped, and bringing down the second hip is continued until the normal level of the femoral head position relative to the acetabulum. Movement of both hips is conducted with a different speed, so as achievent the normal level of the femoral head position relative to the acetabulum occurres simultaneously. The bringing down of the hips is carried out within 6-8 weeks. When dismantling the apparatus of external fixation the apparatus symmetrically arranged elements on the iliac and femoral bones are dismantled simultaneously. The operation of single-step bilateral endoprosthesis replacement is carried out in 3 days after healing of wounds from spokes.

EFFECT: method provides surgical correction of severe congenital dislocations of both hips with formation of joint capsule made of soft tissue regenerate bone formed during distraction, complete recovery of the limb support ability, pain control and restriction of joint movement, elimination of possibility of traction injury of the sciatic nerve and vessels during the operation 4 dwg, 1 ex, 8 cl

Description

The invention relates to medicine, namely to traumatology and orthopedics in the treatment of congenital bilateral dysplasia of the hip joints.

Treatment of bilateral congenital dysplasia of the hip joints is one of the most difficult problems of modern orthopedics [1]. As a rule, the disease develops in young women, often leading patients to disabilities between the ages of 35-50. In cases of far-reaching changes in the hip joints, the only effective treatment is total arthroplasty. However, with a significant displacement of the femoral heads in the cranial direction, which is observed with congenital dislocations of the femur with the formation of neoarthrosis with the wings of the ilium, simultaneous lowering of the hips and performing endoprosthetics is not possible due to a significant shortening of the limb, pronounced cicatricial changes in paraarticular tissues, and a high risk of traction damage to the saddle nerve and major vessels and bleeding occurring during surgery [2].

A known method of surgical correction of hip deformities according to the patent of the Russian Federation No. 2173108, published in bull. from 09.2001, in which, with significant displacement of one thigh up after injuries, gunshot wounds, congenital dislocations, the thigh in the spoke-rod apparatus is reduced to the optimal position of the trochanteric region relative to the acetabulum, and after removal of the apparatus, total hip arthroplasty is performed [3] .

However, this method is applicable only for unilateral damage to the hip joint and cannot be effectively used for bilateral dislocation of the hips due to the duration of treatment, as well as maintaining a significant difference in the length of the limbs during treatment.

The objective of the invention is to increase the correction efficiency of deformations of the hip joints in cases of severe congenital dysplasia of both hip joints with a complete dislocation of the hips and a significant displacement of them upwards by their simultaneous endoprosthetics after lowering the hips in the Ilizarov apparatus, eliminate traction damage to the sciatic nerve and blood vessels, reduce the morbidity of the operation capsule of the hip joint and restore joint function with a corresponding change in the length of the limbs, as well as reduce rehabilitation time.

Our proposed method includes the following steps.

Three crossed knitting needles are soldered through the upper anterior iliac spine, through the upper posterior iliac spine and three crossed knitting needles through the lower third of the thigh bones, the needles drawn through the front and rear iliac spines are fixed in the arches of the Ilizarov apparatus, the knitting needles drawn through the lower a third of the femur is fixed in the rings of the Ilizarov apparatus, the rings and arches of the Ilizarov apparatus are connected by threaded rods, from the second day after the operation, the lowering of the femoral Then, by distraction, until the normal level of the location of the femoral heads relative to the acetabulum, then, without removing the superimposed external fixation apparatus, the skeletal traction system on each limb is mounted on one of the spokes, held in the lower third of the femur, then the external fixation apparatus is dismantled ( it is advisable to dismantle the symmetrically located elements of the apparatus on the ilium and thigh bones synchronously), leaving only the spoke on which the sk cervical traction, then maintain the achieved position by skeletal traction until the spoke wounds heal, and 3 days after the healing of the wound needles, a one-stage bilateral endoprosthesis replacement of the hip joints is performed as follows: the operation is performed in the patient’s position on the back on the operating table, the anterolateral joint is accessed, and the joint is accessed to the hip the proximal part of the femur, the femoral head is resected, the acetabulum is cut with cutters, Mueller’s reinforcing ring is poured, an endoprosthesis cup is placed on bone cement, a sawdust of the femur is removed into the wound, the femoral component of the endoprosthesis is driven into the bone marrow canal, the thigh is repaired by traction along the axis of the limb and rotation, after controlling the range of movements in the joint, a joint capsule is formed from soft tissue regenerate formed during distraction of the femur, the wound is swabbed with napkins, 2-3 provisional sutures are applied to the skin, after which the same operation is performed on the second hip joint, then the provisional sutures and tampons are removed from the side of the first restored joint, hemostasis is monitored and the wound is sutured with 2-3 drainages left for 48-72 hours, after which the provisional sutures and tampons are also removed on the second joint, hemostasis is controlled and the wound is sutured, leaving for 48-72 hours 2-3 drainages.

It should be noted that the external fixation apparatus with supports mounted on the ilium and thigh bones allows lower limbs to be reduced depending on the situation under various conditions:

- it is possible to lower the hips by 1 mm per day, in four doses of 0.25 mm each, while moving both hips by 0.25 mm synchronously,

- it is possible to move both thighs simultaneously and at the same pace, until the femoral head of one of the thighs has reached a normal level of location relative to the acetabulum, after which the lowering of the first thigh is stopped, and the lowering of the second thigh continues until the normal level is reached the location of the femoral head relative to the acetabulum,

- it is possible to move both thighs at a different pace, so that the normal level of the femoral head relative to the acetabulum is achieved at the same time.

We give a more detailed description of the actions of our method.

First, the operation is performed under epidural anesthesia on the orthopedic table in the position of the patient on the back with the fixation of both limbs on the stop holders with an anti-stop in the perineum. An external fixation device is applied, for example, Ilizarov (Fig. 1), for which 3 cross knitting needles (1) are soldered through the front and rear awnings of the iliac wings and 3 crossed knitting needles through the lower third of the femurs. The spokes are fixed in the arcs and rings (2) of the Ilizarov apparatus with the help of special fixators (3) and extension strips (4), the rings and arcs are connected to each other by threaded rods (5). From the second day after the operation, the lowering of the femurs begins by distraction in an external fixation apparatus, for example, Ilizarov, 1-2 mm per day for 6-8 weeks, sufficient to achieve the optimal position of the femurs relative to the acetabulum. After that, the Ilizarov apparatus is removed, leaving 1 needle in the lower third of the femur to support the achieved distraction by skeletal traction, and after healing of the wound needles, one-stage bilateral endoprosthesis replacement of the hip joints is performed, for which the operation is performed under general anesthesia in the position of the patient on the back on the operating table. The proximal part of the femur is exposed in layers by anterolateral access, the femoral head is resected with an oscillating saw, the underdeveloped acetabulum is cut with spherical cutters, a reinforcing ring, for example Mueller, is installed and fixed with spongy screws. Then set the cup of the implant on bone cement in a tilt position of 45 degrees and an anversion of 10 degrees. In the wound with the help of reduction and external rotation of the thigh, sawdust of the femur is removed. The bone marrow canal is processed with rasps, into which the cementless femoral component of the endoprosthesis, for example, Wagner’s conical leg, is tightly driven in, placing its neck in accordance with the angle of anversion of the installed acetabular component. A metal head of the required length is put on the neck of the endoprosthesis. Reduce the thigh by traction along the axis of the limb and internal rotation. After controlling the range of movements in the joint and thorough hemostasis, a joint capsule is formed from the soft-tissue regenerate formed during distraction of the femur. The wound is swabbed with napkins to reduce bleeding, 2–3 provisional sutures are applied to the skin and a similar operation is performed on the second hip joint. After that, tampons are removed from the side of the first restored joint, hemostasis is monitored, and the wound is sutured, leaving 2-3 silicone drains for 48-72 hours. Similarly, the wound is sutured from the other side.

On the 7-8th day after the operation, the patient is allowed to get out of bed and walk on crutches with a gradually increasing dosage load on the legs for 6-8 weeks, followed by a phased transition to walking with a cane, and then without it.

Operated by the claimed method 2 people. The follow-up period after surgery ranged from 6 months to 3 years. A good result was obtained - the growth of patients increased by 12 cm, movements in the hip joints in full, there was no pain and lameness, they walk without the aid of crutches and canes.

A clinical example confirming the implementation of the claimed method of hip joint replacement in case of bilateral dysplastic coxarthrosis with complete high dislocation of the hips and displacement (by 12 cm) of the femoral heads

Patient I., 45 years old, with a history of bilateral congenital dislocation of the hip, no treatment was carried out in childhood. In the last few years, she noted a change in gait, the appearance of pain in the hip joints at night, pain in the hip joints, and lameness intensified. In the last 2 months there has been a deterioration due to a sharp increase in pain, the patient stopped walking. Radiography diagnosed bilateral congenital dislocation of the hips with a significant displacement of the heads of the femurs up, dysplasia of the acetabulum and femurs. Within a month, conservative treatment was carried out in the hospital - without effect. Received in the GVKG them. Acad. NN Burdenko for surgical treatment. Upon admission, he walks without additional means of support, with difficulty rearranging his legs. A positive symptom of Trendelenburg on both sides. Hypermobility of the hip joints, sharp pain during movements was noted. On radiographs: the heads of the femurs are oval in shape, displaced upward, forming neoarthrosis with the wings of the ilium, the medullary canals of the femurs are narrow, up to 12 mm, the underdevelopment of the true acetabulum, their diameter is not more than 36 mm, the distance from the heads of the femur to the true acetabulum 12 cm (figure 2).

On preoperative planning, it was decided to conduct a two-stage surgical treatment - first lower the femoral heads in the Ilizarov apparatus to the level of true acetabulums, then perform one-stage bilateral hip joint arthroplasty.

July 12, 2004, an operation was performed - fixing the pelvis and hips in the Ilizarov apparatus. From the second day after the operation, synchronized reduction of both thighs was performed at 2 mm per day under radiological control (figure 3). 08/30/2004, the Ilizarov apparatus was removed. 09/01/2004, one-stage bilateral hip joint arthroplasty was performed using hybrid endoprostheses (Mueller reinforcing rings No. 36 on 5 screws, CDH No. 36 cement cups, Wagner cementless conical legs No. 13) with the formation of a capsule of joints from soft tissue regenerates formed during distraction. In the postoperative period, the patient is activated on crutches with a metered load on the legs from the 7th day after the operation.

Discharged October 2, 2004. After 3 years, the position of the endoprosthesis on the roentgenograms is correct, stable (Fig. 4). It goes without auxiliary means, there is no lameness, movements in the hip joints are painless, blood supply and innervation of the feet are not disturbed.

Our proposed method allows surgical correction of severe congenital dislocations of both thighs with the formation of a joint capsule after installing an endoprosthesis from a soft tissue regenerate formed during distraction of the femur, completely restores limb supportability, eliminates pain and limitation of movements in the joint, eliminates the possibility of traction damage to the sciatic nerve and blood vessels during joint replacement surgery.

Information sources

1. Abeltsev V.P. Hip replacement for dysplastic coxarthrosis (optimal treatment methods). Abstract of diss. doctors honey. sciences. - Moscow, 2004, 49 p.

2. Kornilov N.V. Indications for hip joint replacement for dysplastic coxarthrosis / N.V. Kornilov, E.Ya. Grinshtein, G.G. Epstein and others // Materials of the VI Congress of Orthopedic Traumatologists of the CIS. - Yaroslavl, 1993 .-- S.183-184.

3. Pikolenko V.K., Buryachenko B.P., Aksenov Yu.V., Drakin A.I. RF patent No. 2173108, dated 10.09.2001, “Method for surgical correction of hip joint deformities”.

Claims (8)

1. The method of one-stage bilateral joint replacement of the hip joints with bilateral dysplastic coxarthrosis with congenital dislocation of both thighs, including the imposition of an external fixation device, lowering the thigh and installing components of the endoprosthesis, characterized in that cross-spoke needles are brazed through the upper anterior iliac spine, the upper posterior and crossed knitting needles through the lower third of the thigh bones, knitting needles drawn through the ilium, are fixed in the arches of the apparatus And isarov, the knitting needles through the lower third of the femurs are fixed in the rings of the Ilizarov apparatus, the rings and arches of the Ilizarov apparatus are connected to each other by threaded rods, from the second day after the operation, the femurs are reduced by distraction until a normal position of the femoral heads relative to the acetabulum is reached , then, without removing the superimposed external fixation apparatus, mount a skeletal traction system on each limb on one of the spokes, held in the lower third of the femoral spins, then the external fixation apparatus is dismantled, leaving only the spoke on which the skeletal traction system is mounted, then the position is maintained by skeletal traction until the wounds heal and then one-stage bilateral hip arthroplasty is performed as follows: the operation is performed in the patient’s position on the back on operating table, provide anterolateral access to the hip joint, expose the proximal part of the femur, resection coziness of the femoral head, the acetabulum is cut with the milling cutters, the strengthening ring is installed, the endoprosthesis cup is placed on the bone cement, the femur sawdust is inserted into the wound, the femoral component of the endoprosthesis is driven into the bone marrow canal, the thigh is straightened by traction along the limb axis and rotation, after volume control movements in the joint form a capsule of the joint from the soft tissue regenerate formed during distraction of the femur, the wound is swabbed with napkins, 2-3 provisional sutures are applied to the skin, then the same operation is performed on the second hip joint, then the provisional sutures and tampons are removed from the side of the first restored joint, hemostasis is monitored and the wound is sutured, leaving 2-3 drains for 48-72 hours, after which the provisional sutures are also removed and tampons, hemostasis is monitored and the wound is sutured with 2-3 drains left for 48-72 hours. 2. The method according to claim 1, characterized in that when installing the external fixation device, three crossed knitting needles are brazed through the upper front iliac spine, through the upper posterior iliac spine and three crossed knitting needles through the lower third of the thighs. 3. The method according to claim 1, characterized in that the lowering of the hips is 1 mm per day, in four doses of 0.25 mm each, while moving both thighs by 0.25 mm synchronously. 4. The method according to claim 1, characterized in that the movement of both thighs is carried out synchronously and at the same pace, until the moment when the head of the femur of one of the thighs has reached a normal level of location relative to the acetabulum, after which the lowering of the first thigh is stopped , and the lowering of the second thigh continues until a normal level of location of the femoral head relative to the acetabulum is reached. 5. The method according to claim 1, characterized in that the movement of both thighs is performed at a different pace, so that the normal level of location of the femoral head relative to the acetabulum occurs simultaneously. 6. The method according to claim 1, characterized in that the lowering of the hips is carried out for 6-8 weeks. 7. The method according to claim 1, characterized in that when dismantling the external fixation apparatus, symmetrically located elements of the apparatus on the iliac and femoral bones are dismantled synchronously. 8. The method according to claim 1, characterized in that the operation of simultaneous bilateral arthroplasty is performed 3 days after the healing of spoke wounds.

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