RU2424778C1 - Method of treating cervical-epiphiseal deformity of hip - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, in particular to orthopedics. C-shaped osteotomy through neck base is carried out. Lateral part of hip neck is fixed with wires with support sites. Dosed retrodisplacement of lateral part of neck is performed for correct orientation of head with respect to trochanteric area. After that bone fragments are fixed by means of transosteal device until bone regenerate is obtained. ^ EFFECT: method ensures restoration of hip joint biomechanics and prevention of vascular disorders in proximal part of hip, reduction of trauma. ^ 1 ex, 3 cl, 10 dwg

Description

The invention relates to medicine, in particular orthopedics, and is used in the treatment of proximal femoral deformity of various etiologies with the help of transosseous fixation.

A known method for correcting cervical-epiphyseal deformity of the femur, which involves performing an arthrotomy, partial double osteotomy of the base of the femoral neck with a wedge-shaped fragment with an apex directed down and back, is formed on the front surface, removing it, complete violation of bone integrity by osteoclasia, corrective reversal of fragments by internal rotation and limb abduction and fixation of the achieved position using intraosseous rods (Kramer WG et al. Compensating osteotomy at the base of the femoral neck for slipped capital femoral epiphysis. // Bone and Joint Surg. - 1976. - 58-A. - P. 796-800).

A known method for the correction of cervical-epiphyseal deformity of the femur, which involves performing extracapsular osteotomy in the intertrochanteric region, the formation and removal of a wedge-shaped fragment with the base facing up and anteriorly, internal rotation and abduction of the limb to close the resulting diastasis and fixation of the achieved position using intraosseous rods ( Barmada R. et al. Base of the neck extracapsular osteotomy for correction of deformity in slipped capital femoral epiphysis. // Clin. Orthop. - 1978. - No. 132. - P. 98-101).

However, the known method allows to compensate for the shift of the pineal gland posteriorly only by 35-50 °, which limits the possibility of its use in severe (more than 60 °) degrees of pineal gland. At the same time, a corrective turn leads to a shortening of the neck and anterior-medial deviation of the apex of the greater trochanter, which worsens the functioning conditions of the gluteal muscles and in some cases requires transposition of the greater trochanter. A simultaneous correction of the pineal retractors is accompanied by tension of the periosteum and paraossal tissues along the posterior surface of the neck, which adversely affects the blood supply to the femoral head.

The objective of the present invention is to restore the biomechanics of the hip joint and the prevention of vascular disorders in the proximal femur by performing a less traumatic gradual transposition of osteotomized bone fragments.

The problem is solved in that in the method of treating cervical-epiphyseal deformity of the thigh, including violation of the integrity of the femur, moving and fixing bone fragments, a transosseous device is used to fix bone segments, a C-shaped osteotomy is performed through the base of the neck, and the lateral part of the femoral neck is fixed with knitting needles with thrust pads, after which a metered displacement of the lateral cervical posterior is performed to restore the correct orientation of the head relative to the trochanteric region and then the bone fragments are fixed by transosseous device until a bone regenerate is obtained.

To correct the concomitant varus of the cervical-epiphyseal or cervical-diaphyseal deformity, it is advisable to additionally correct the position of the distal bone fragment by means of its abduction or perform additional subtrochanteric corrective osteotomy of the femur.

The present invention is illustrated by a detailed description, a specific example of its implementation and the attached copies of x-rays, on which:

Figure 1 - diagram of the implementation of an osteotomy through the base of the neck and fixation of osteotomy fragments transosseous device;

Figure 2 - diagram of the position of osteotomized fragments of the femur and their fixation after the end of the displacement of the lateral cervical posterior region and the reversal of the proximal fragment in the horizontal plane;

Figure 3 is a diagram of the position of the osteotomized fragments of the femur and their fixation after the completion of the corrective reversal in the frontal plane;

Figure 4 - diagram of the fixation of bone fragments in a corrected position transosseous device after holding the spokes through the trochanteric region, the osteotomy zone, the neck of the femur;

5 is a diagram of the position of the osteotomized fragments of the femur and their fixation after completing an additional subtrochanteric corrective osteotomy of the femur;

6 is a copy of x-rays (anteroposterior and axial projections) of the patient before treatment;

7 is a copy of the x-ray (anteroposterior projection) of the patient after performing an osteotomy through the base of the femoral neck;

Fig. 8 is a copy of the radiograph (axial projection) of the patient during a gradual reversal of the proximal fragment in the horizontal plane (posterior lateral cervical displacement);

Fig. 9 is a copy of radiographs (anteroposterior and axial projections) of the patient after performing an underdental valgizing femur osteotomy;

Figure 10 is a copy of radiographs (anteroposterior and axial projections) of the patient 1 year after treatment.

The method is as follows.

At least four knitting needles are passed through the iliac wing, fix them in an arc support with the help of knitting needles and pull (Figure 1). Three spokes are passed through the distal metaphysis of the femur, fix them in 3/4 rings with the help of spokes and tighten. At the border of the upper third and middle third of the thigh, in the sagittal plane, two knitting needles are crossed at an angle of 30-35 ° with thrust pads towards each other, fix them to the arc and pull. The arc is connected to the support on the distal metaphysis of the thigh using three rods (Figure 1 - 2 rods are shown). The thigh is set in the position of reduction 75-85 °, extension 180 ° and internal rotation corresponding to the value of the aneurysm of the femoral neck. The casting angle corresponds to the angle between the tangent to the plane of entry into the depression and the line parallel to the epiphyseal plate, which is determined by the radiograph made in the anteroposterior projection. Through an incision of 5.0-6.0 cm on the front surface of the hip joint, a C-shaped osteotomy is made through the base of the femoral neck (from the trochanteric fossa to the upper edge of the lesser trochanter). Through the lateral section of the cervix in the sagittal plane, 2 spokes intersecting at an angle of 10-15 ° with thrust pads in front. Then the dorsal ends of these spokes are fixed with threaded rods with a groove and cantilever consoles in an arc support. The ends of the spokes on the front surface of the hip joint are left free. An arc support mounted on the neck of the thigh is connected by three rods (Fig. 1 - 1 rod is shown) with a pelvic support and three rods (Fig. 1 - 1 rod is shown) with a support mounted on the border of the upper and middle third of the thigh. Suture the wound.

In the postoperative period, with the help of knitting needles with thrust pads located in the femoral neck, by means of distraction along the rods installed in cantilever consoles, a gradual displacement of the lateral cervical posterior region is performed, which, accordingly, is accompanied by an anterior advancement of the pineal gland (Figure 2). The degree of reversal of the proximal fragment in the horizontal plane is controlled using x-rays made in axial projection. After the transposition of the proximal fragment in the horizontal plane, fix the front ends of the spokes drawn through the lateral section of the neck, in the arc support with the help of spokes (Fig.3).

In the presence of concomitant varus cervical-epiphyseal or cervical-diaphyseal deformation, when the value of the necessary corrective turn does not exceed 20 °, it is corrected by means of the distal fragment. To do this, perform compression on the outer rod installed between the arc on the neck of the thigh and the arc on the border of the upper and middle third of the thigh (Figure 3). After the corrective reversal is completed, additional intervention is performed. Under anesthesia, at least 4 cantilever spokes are passed through the trochanteric region, the osteotomy zone, the neck and the femoral head (Figure 4). The free ends of the spokes are fixed to the support using a console attachment. The needles previously drawn through the lateral femoral neck are removed. The support mounted on the neck is dismantled. The pelvic arch and the arc installed on the border of the upper and middle third of the thigh are connected by three rods (not shown) (Figure 4).

In the case when the value of the necessary corrective turn exceeds 20 °, an additional subtrochanteric valgus osteotomy is additionally performed (Figure 5). Under anesthesia, 2-3 threaded rods are installed in the trochanteric region. The needles previously drawn through the lateral femoral neck are removed. The support mounted on the neck is dismantled. The rods are fixed in the arc sector. A transverse osteotomy of the femur is made through a 2-3 cm incision along the outer surface of the hip joint under a small trochanter. The distal fragment is diverted to an angle corresponding to the magnitude of the proposed valgization. The arc sector is connected to a support mounted on the border of the upper and middle third of the thigh, three rods (1 rod shown) and to the pelvic support three rods (not shown). Suture the wound.

1.5-2 months after the consolidation of bone fragments in the areas of the osteotomy of the femur, the apparatus is removed, the spokes are removed and the development of movements in the hip joint is started.

An example of the method

Patient N., 9 years old, medical record No. 63478 of a hospital patient. Diagnosis: dysplastic coxarthrosis on the left, multiplanar deformation of the proximal left thigh. Complained of lameness, fatigue. Clinical examination data: adducing, external rotation contracture of the left hip joint, shortening of the left lower limb 2 cm, positive Duchenne-Trendelenburg symptom on the left. On radiographs made in the front-rear and axial projections (Fig.6): varus deformity of the neck of the right femur 95 °, articulo-trochanter distance is reduced (ATD = 0 mm), lateralization of the greater trochanter corresponds to the diameter of the head (LT = 1,1 D) The angle of anterversion of the femoral neck is 15 °. The pineal gland is displaced posteriorly: retroversion of 72 °.

An X-ray diffraction pattern made in the anteroposterior projection forms a 10 ° angle open downward between the tangent to the plane of entry into the depression and the line parallel to the epiphyseal plate.

The patient underwent surgery. In the operating room under intravenous anesthesia, 5 spokes were held through the iliac wing, which were fixed in an arc and stretched. Through the distal metaphysis of the thigh, 3 spokes are held, which are fixed in 3/4 rings and stretched. On the border of the upper third and middle third of the thigh in the sagittal plane two intersecting spokes with thrust pads are held, fixed in an arc, which is connected to the support on the distal metaphysis of the thigh using rods. The thigh is set in the reduction position of 80 °, extension 180 ° and internal rotation of 15 °. Through a 6 cm incision along the front surface of the thigh through the base of the neck (from the trochanteric fossa to the upper edge of the minor trochanter), a C-shaped osteotomy was performed (Fig. 7). Through the lateral section of the cervix in the sagittal plane, two spokes intersecting at an angle of 10 ° with thrust pads in front. The dorsal ends of these spokes are fixed in threaded rods with a groove, which, using console attachments, are fixed to the arc support. The support is connected to the arch on the ilium by rods. Supports mounted on the neck of the thigh and on the border of the upper and middle third of the thigh are connected by rods with hinged devices. Stitched to the wound.

From the sixth day for 16 days, distraction was performed on the threaded rods to displace the lateral part of the neck posteriorly and to correct the position of the pineal gland in the horizontal plane (Fig. 8). After the transposition of the proximal fragment in the horizontal plane, the front ends of the spokes were fixed in an arc support using spokes.

Since the magnitude of the necessary corrective reversal in the frontal plane to eliminate the varus deformity of the neck was 35 °, the correction was carried out using post-operative osteotomy.

In the operating room under anesthesia, 2 threaded rods were inserted through the trochanteric region, osteotomy zone, neck and femoral head. The needles passing through the neck of the femur were removed. Dismantled arc support. The free ends of the rods are fixed in the arc sector, which is installed taking into account the proposed corrective turn and connected with the help of the rods to the pelvic support. A transverse subtrochanteric osteotomy was made through a 3 cm incision; the distal fragment was retracted by 35 °. The support on the trochanteric region is connected by rods to the pelvic support and the arc installed on the border of the upper and middle third of the thigh (Figure 9). Stitched to the wounds.

The duration of fixation of fragments of the femur in the corrected state was 58 days. After dismantling the device and removing the spokes, a course of rehabilitation treatment was carried out.

After a year, the patient walks with full load on her left leg. The relative length of the lower extremities is the same. The range of motion in the left hip joint has fully recovered. On radiographs (Figure 10): the head of the left thigh has a rounded shape and uniform structure, a cervical-diaphyseal angle of 128 °, the ATD index increased to 17 mm, the lateralization of the greater trochanter remained at the same level (LT = 1.1 D), retroversion of the pineal gland completely eliminated.

For the correction of severe (over 60 °) cervical-epiphyseal deformities, as a rule, wedge-shaped and rotational osteotomies are used, which along with high efficiency are characterized by significant complexity, trauma and a significant risk of developing aseptic necrosis of the femoral head.

The application of the proposed method allows to eliminate severe cervical-epiphyseal deformity using an extraarticular, relatively simple, less traumatic femoral section and without causing a violation of the biomechanics of the joint associated with shortening of the neck and ventral deflection of the greater trochanter. In addition, the present invention allows to reduce the risk of developing vascular complications due to tension of paraossal soft tissues.

The proposed method is less traumatic due to the implementation of a small incision with the preservation of the surrounding muscles and soft tissues. The use of an external fixation device allows you to activate the patient from the first days after surgery and facilitates the care of him during treatment.

The proposed method allows to improve the relationship in the hip joint and increase the debatability of the lower limb.

The proposed method is used in the Department of pathology of large joints of the RRC "WTO" them. Acad. G.A. Ilizarova.

Claims (3)

1. A method of treating cervical-epiphyseal deformity of the thigh, including violation of the integrity of the femur, moving and fixing bone fragments, characterized in that a transosseous device is used to fix bone segments, a C-shaped osteotomy is performed through the base of the neck, and the lateral part of the femoral neck is fixed with knitting needles thrust sites, after which a metered displacement of the lateral cervical posterior is performed to restore the correct orientation of the head relative to the trochanteric region, then bone the segments are fixed by transosseous device until bone regenerate is obtained. 2. The method according to claim 1, characterized in that it further corrects the position of the distal bone fragment by abduction. 3. The method according to claim 1, characterized in that they perform additional subtrochanteric corrective osteotomy of the thigh.

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