RU2438609C1 - Method of triple pelvic osteotomy - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely traumatology and orthopaedics. it involves a lateral approach to the upper portion of thigh. It is followed by corrective osteotomy of a proximal portion of thigh with bone wedge resection with its upper section performed directly over a lesser trochanter, and with its other section varying the direction of the required correction. A iliopsoas muscle tendon is cut off from the lesser trochanter. The thigh fragments are moved apart. The muscles are longitudinally separated to a lateral edge of an ischial bone. The ischial bone is transversally or oblique transversally dissected from an interfragmental space directly under a lower edge of a cotyloid cavity with a resection along an osteotomy line of a lateral edge by a ""-shaped or common osteotome 0.5 cm wide, and osteotomy-osteoclasia of its internal edge. Osteosynthesis of the thigh fragments is performed with using a L-shaped metal plate. An anterior pelvic portion is approached. A pubic bone is dissected at its base. An iliac bone is transversally or semicircularly transected above its anterior lower spine. A mobilised acetabular fragment is rotated on a femoral head and medialised. The pelvic fragments are fixed by K-wires. Depending on the relation of the bone fragments, the defects are filled with an autogenous bone resected from thigh. ^ EFFECT: method enables preventing injures of neurovascular formations with simultaneous reconstruction of pelvic and femoral components by the single-step surgical intervention. ^ 3 ex

Description

The invention relates to medicine, in particular to orthopedics and traumatology, and can be used to restore the anatomical relationships and improve biomechanical conditions in the hip joint in patients with impaired centering of the femoral head in the acetabulum, with a deficiency of the bone covering of the femoral head with concomitant deformation of the proximal femur bones.

Such hip deformations result from various pathological processes, including progressive hip dysplasia with residual hip subluxation, congenital hip dislocation, early dysplastic coxarthrosis, the consequences of Perthes disease, osteomyelitis, pathological frontal, torsion, rotational and other deformations of the proximal femur. The choice in favor of simultaneous reconstruction arises when there is a deficiency in the bone cover of the acetabulum of the femoral head with concomitant significant changes in the cervical-diaphyseal angle, when by reconstructing only the pelvic or femoral components it is impossible to achieve optimal concentric immersion of the femoral head in the acetabulum, there is a dislocation of the spherical part of the femoral head due to earlier the changes that have occurred, the difference in the length of the limbs, etc. remains. Ultimately, these are deviations from the anatomical hip ormy when, along with changes in the form and location of the acetabulum, there are attendant deformation of the proximal femur, requiring correction for optimal congruence. Particular difficulties arise in adolescence.

A common solution for such deformities is the simultaneous osteotomy of the hip and pelvis. In this case, a combination of corrective osteotomy of the femur with a pelvic osteotomy of the Salter type, when the ilium in the supraclavicular region intersects. However, in children from school age and older, this can lead to significant lateralization of the joint and an increase in its compressive effects. Maintaining optimal centering of the femoral head in the joint is possible in these cases by triple pelvic osteotomy.

Similar methods are known for triple pelvic osteotomy, in which the ilium, pubic and sciatic bones intersect. These technologies differ from each other in terms of cross-section, the number of accesses and their invasiveness, and the methods of movement of the acetabular component. As a rule, this is a triple pelvic osteotomy without correction of the femoral component, often 2-3 separate accesses are required. In some methods, unremovable fixatives of the acetabular fragment remain. These increase the invasiveness of the intervention. Other analogs are variants of periacetabular triple pelvic osteotomy, when bone dissection levels approach the acetabulum itself, thereby increasing the mobility of the acetabular fragment and there are no unwanted displacements of fragments of the pubic and sciatic bones (Tachdjian M. // Paediatnc Orthopedics. - New York, 1990. - P. 482-502).

The closest analogue for the full restoration of relations in the hip joint is the method of triple pelvic osteotomy - prototype (Sokolovsky AM Features of our technology for triple pelvic osteotomy / AM Sokolovsky, OA Sokolovsky // Actual issues of pediatric traumatology and orthopedics: Materials of a scientific and practical conference for children orthopedists and traumatologists of Russia. - Staraya Russa, 2000. - S.320-322). However, this method is quite complicated in that the dissection of the sciatic bone is performed in the inaccessible depth of the wound, which causes technical difficulties, while there is a great risk of damage to the neurovascular formations.

Effect: increasing the efficiency of the method, simplifying the method, prevention of damage to neurovascular formations while reconstructing the pelvic and femoral components for the 1st stage of surgical intervention.

When performing the proposed method, the most complete reconstruction of the hip joint is achieved with severe violations of the centering of the femoral head with concomitant deformations of its proximal division, subluxation of the thigh.

This is achieved by lateral access to the upper thigh, corrective osteotomy of the proximal femur with a resection of the bone wedge, the upper section of which is carried out directly above the small trochanter, and the second, depending on the direction of the required correction, cutting the tendon of the iliopsoas muscle from the small trochanter, breeding of fragments of the femur, the longitudinal separation of muscles to the lateral edge of the sciatic bone and its transverse or oblique cross-section from the inter-fragment space beneath the lower edge of the acetabulum with a resection along the lateral margin osteotomy with a U-shaped or conventional osteotome up to 0.5 cm wide and osteotomy-osteoclasia of its inner edge, osteosynthesis of femoral fragments with a metal L-shaped plate, access to the anterior part of the pelvis, dissection the pubic bone at the base, transverse or semicircular section of the ilium above the anterior lower spine, rotation of the mobilized acetabular fragment on the femoral head with its medialization, fixation of pelvic fragments with by the power of Kirchner spokes, depending on the ratio of bone fragments of filling defects with a resected bone autograft from the femur.

The method is as follows. In the patient’s position on the healthy side, linear lateral access to the proximal femur is performed. The planned version of the corrective osteotomy of the proximal femur is carried out, in typical cases with a bone wedge resection. When cutting a removable bone wedge, its upper section is carried out directly above the small trochanter, and the second, depending on the direction of the required correction. So, for the correction of varus deformity, a bone wedge is removed that is facing the base medially, and for the correction of hallux valgus deformation is removed with the base laterally. The tendon of the iliopsoas muscle is cut off from the lesser trochanter, the fragments of the thigh are bred, the muscles are longitudinally divided to the lateral edge of the sciatic bone. The sciatic bone is transversely or obliquely transected from the inter-fragmentary space immediately below the lower edge of the acetabulum, while the lateral edge is resected along the osteotomy line with a U-shaped or conventional osteotome up to 0.5 cm wide and osteotomy-osteoclasia of its inner edge is performed. Along with the correction of the varus or valgus deformity achieved by resection of the bone wedge, depending on the location of the most spherical part of the head, the position of flexion or extension is assigned to the proximal fragment, the planned derotation is carried out in the frontal plane to eliminate the vicious position of the limb and osteosynthesis of fragments of the femoral metal G- shaped plate. Access the anterior part of the pelvis, exposing the anterior part of the iliac wing. The pubic bone is dissected at the base, conducting instrumental protection under the periosteum with raspators or hooks-hoists. A transverse or semicircular section of the ilium is performed above the anterior lower spine, a mobilized acetabular fragment is rotated onto the femoral head with its medialization, which is easily carried out by acting on the trochanteric region of the synthesized thigh. The pelvic fragments are fixed using Kirschner spokes, depending on the ratio of bone fragments, defects are filled between the fragments of the pelvis with a bone autograft resected from the hip. The wound is sutured. In the early postoperative period, the allotted position of the thigh is provided, movements in the hip joint are allowed from the first days after the operation.

Case Studies

Example 1. B-Ya E., 11 years old. Case history No. 724. Was admitted to the hospital with a diagnosis of congenital dislocation of the right thigh (after conservative reduction at an early age). Residual subluxation of the right thigh, dysplastic coxarthrosis with pain. The patient was operated on by the developed method. Lateral access in the proximal femur was cut with an oscillating saw and the bone wedge was removed with the base of the inside. When the transplant was isolated, a tenotomy of the iliopsoas muscle was performed. After dilution of the fragments in the depths of the wound by longitudinal stratification of the muscles with lateral access in the transverse direction, the sciatic bone is dissected. In the lateral section, a bone wedge up to 0.5 cm wide was selected as a simple osteotome, with further translational movement using the osteotome lever movement, the inner edge of the sciatic bone is broken according to the type of osteotomy-osteoclasia. Variation of the proximal femur fragment to 125 degrees and elimination of excess antetorsion to +10, fixation by a curved L-shaped plate of the Blount type with medialization of the distal bone fragment were performed. A front access to the anterior wing of the pelvis was performed, an osteotomy of the pubic bone was performed at the base, and a semicircular osteotomy of the ilium was performed using the Jigli saw. Acetabular fragment is rotated on the femoral head, fixation with the help of Kirschner spokes and a bone wedge from a remote femur. A bone wedge for fixing and filling the defect is located outwardly between the fragments of the ilium. The fixation is clinically and radiologically good. On the radiograph, the normal anatomical parameters of the hip were restored, full head coverage, sufficient rotation and medialization of the acetabular fragment of the pelvis were achieved. In the postoperative period, a plaster cast dressing was applied. Movement in the hip joint is permitted from the first days after surgery; no hip dressing was required. 2 months after the operation, walking on crutches is allowed, after 4 months - a full load on the leg. After 2 years, the functional and radiological result was rated as excellent.

Example 2. Patient R., 9 years old. East bol. No. 225. Received with a diagnosis of the effects of epiphyseal osteomyelitis. Coxa vara. The thigh head is “swollen”, ½ acetabulum. Cervical-diaphyseal angle 105 °. The operation according to the proposed method. A typical lateral linear access to the proximal femur was made. Performed an osteotomy of the proximal femur with excision of the bone wedge base outwards. The tendon of the iliopsoas muscle is cut off. After the breeding of fragments, the sciatic bone was isolated during the dilution of the adductor muscles and protected by the lifts. An oblique transverse dissection of the ischium in the lateral part was performed 1 cm below the edge of the acetabulum using a U-shaped osteotome up to 0.5 cm wide, and the medial part was broken using a conventional osteotome. Detorsion and valgization of the proximal fragment were performed - detorsion up to + 10 ° and valgization up to 130 ° degrees. L-plate fixation is typical. The front of the ilium is exposed by front access, the base of the pubic bone is highlighted, which, using the osteotome under the protection of the lifts, is dissected at the base. A transverse section of the ilium was performed using a Jigley saw. The mobilized acetabular fragment is rotated on the femoral head until it completely overlaps, fixation with a wedge-shaped bone graft removed from the femur, and Kirchner spokes. Wound drainage by drainage for reinfusion (Handy-wak system). On the radiograph, correction is achieved, full coverage of the femoral head. The wound is sutured in layers tightly. Aseptic dressing. Plaster cast dressing for 2 weeks. Movement in the hip joint is permitted immediately after surgery. Consolidation occurred after 3 months, at the same time the patient was allowed vertical load on the leg. Metalwork removed 5 months after surgery. 3 years after the operation - full coverage of the femoral head, SCD 127 degrees, walks without limp, no pain. The result is rated as excellent.

Example 3. B. K., 13 years old. Case history No. 1844. He was admitted to the hospital with a diagnosis of cerebral palsy, tetraparesis, paralytic dislocation of the right thigh (previously untreated). Intelligence saved, studying in a regular school at home. The patient was operated on by the proposed method. Through lateral access, a shortening osteotomy of the right thigh was performed with resection of 2 fragments, one of them, the upper, wider at the base, was prepared for fixation during pelvic osteotomy. A sciatic bone is distinguished between the fragments of the thigh and is dissected in an oblique direction with the help of a U-shaped chisel from the outside, and it is broken in the medial section using a conventional osteotome. Completed access to the anterior pelvis. For the purpose of reduction, the capsule of the joint was dissected, the acetabulum was exposed to the cartilaginous surface, and the interponing tissues were removed. The femoral head is exposed, the round ligament of the head is resected, the posterior part of the cavity is spherical, the anterior in the form of a pyramid. In the antetorsion position of 0 °, with an SCD of 125 °, the fragments are fixed with a plate with medialization of the distal bone fragment. The femoral head is set. The anterior bone is exposed at the base, dissected using an osteotome. A transverse ileal osteotomy was performed at the level of the upper edge of neoarthrosis, an acetabular fragment was deployed to the femoral head, and fixation of pelvic fragments after osteotomy using a bone graft taken from the hip and knitting needles. On the radiograph, the dislocation is corrected, complete concentric immersion of the femoral head in the acetabulum. Wound drainage with 2 tubular drains connected to the reinfusion system. Taking into account the concomitant neurological pathology, an additional myotomy of the hip adductors was performed. Plaster hip bandage with a spacer to the opposite thigh in the field of surgery for 2.5 months, followed by rehabilitation. Metalwork removed 7 months after surgery. The patient is verticalized with orthopedic devices 1 year after surgery. The centering of the femoral head in the acetabulum is maintained, loss of correction and aseptic necrosis have not developed.

In total, 12 operations were performed according to the proposed method. In all cases, full bone coverage of the femoral head with the acetabulum was achieved, congruency and stability in the hip joint were achieved, good radiological centering of the femoral head was achieved with restoration of the cervical-diaphyseal angle and a functionally advantageous range of motion in the hip joint, and the supportability of the operated limb was restored. In no case was there damage to the neurovascular formations.

The positive effect of the application of this method is that it allows, with minimal trauma, to facilitate access to the sciatic bone and its safe osteotomy above the sciatic tubercle close to its base, to fully correct all components of the hip joint. Resection of the lateral edge of the sciatic bone allows for sufficient decompression in the joint during acetabular dislocation, and its inner edge is easily broken after osteoclasia or incomplete osteotomy in the process of mobilization of the acetabular fragment. Thus, the risk of osteotomy of the sciatic bone is reduced, additional access to it is not required, the stability of fixation of bone fragments increases, in particular at the level of the ilium section due to filling of the defect with an autograft. In addition to correcting the proximal femur in the frontal plane with correction of varus or valgus deformity, it is possible to improve head contact with the acetabulum due to flexion, extension, and dexion of the proximal fragment, which significantly expands the ability to restore the hip joint in severe deformations and subluxations of the femoral head and violations of congruency articular surfaces. With this method, access to the hip and pelvis are minimized and are less traumatic. So, there is no need to expand the pelvic access down to dissect the sciatic bone. In case of hip dislocation, including paralytic, joint arthrotomy is performed through the same pelvic access, and its expansion is practically not required. The method can be used for combined severe bone deformities of the pelvic and femoral components of the joint, unstable hip joint, subluxation, dislocation of the hip, coxarthrosis.

Claims (1)

The method of triple pelvic osteotomy by periacetabular osteotomy of the sciatic, pubic and iliac bones of the pelvis with acetabular reorientation, characterized in that they provide lateral access to the upper thigh, corrective osteotomy of the proximal femur with a resection of the small wedge, directly above the upper wedge, with upper resection skewer, and the second - depending on the direction of the required correction, cut the tendon of the iliopsoas muscle from the lesser trochanter, make a break and hips, longitudinally separate the muscles to the lateral edge of the sciatic bone and transversely or obliquely cross it from the inter-fragment space directly below the lower edge of the acetabulum with resection along the lateral edge osteotomy with a U-shaped or conventional osteotome up to 0.5 cm wide and its osteotomy-osteoclasia inner edge, perform osteosynthesis of femoral fragments with a metal L-shaped plate, access the anterior part of the pelvis, dissect the pubic bone at the base, cross transversely or semicircularly the ilium above its anterior inferior spine, a mobilized acetabular fragment is rotated onto the femoral head with its medialization, pelvic fragments are fixed using Kirschner spokes, depending on the ratio of bone fragments, defects are filled with a bone autograft resected from the femur.