RU2475197C1 - Method of revision plastic hip replacement in unstable endoprosthesis components inserted in wing of ilium in congenital high hip dislocation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely traumatology and orthopaedics, and is applicable for the purpose of revision operations on hip joint. At the first stage, a posterioexternal approach to the hip joint is performed. Two holes are formed crosswise along a posterioexternal surface of femur below an end of an endoprosthesis leg. A cortical layer of the bone is transected between these holes. The holes shaped after the endoprosthesis leg are formed on both ends of the posterior and anterior surfaces of femur to make marks for V-osteotomy. Osteotomy without dissecting a greater trochanter away and with preserving ventral gluteal muscle, gluteus minimus muscle and vastus muscle is performed. A formed muscle-coated skin flap is drawn back to expose a marrowy canal. The endoprosthesis leg and a cement mantle are removed. A femoral head is dislocated from a cotyloid position. After the cotyloid component is removed together with the cement mantle from the wing of ilium; the formed bone bed is packed with surrounding tissues; the upper layers are tightly closed. Then dissected bone fragment is placed back in place and fixed with wire sutures. The wound is closed. A proximal end of femur is reduced to a level of the cotyloid cavity. At the second stage, the bone bed is formed in the true cotyloid cavity; the cotyloid component is implanted therein, and an open part of the cup is reinforced with an allograft. A dissected bone cover is opened on a proximal end of femur. A revision hip component is implanted so that a centre of the femoral head is placed on the same horizontal line with an apex of the preserved greater trochanter. The femoral head is set into the cotyloid component. The wound is closed.

EFFECT: method provides preventing developing unstable components of the endoprosthesis, reducing an extremity length, tissue injuries, blood loss, postoperative complications, and length of operation.

1 ex, 15 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in revision operations on the hip joint.

Among orthopedic diseases, congenital dislocation of the hip takes first place both in frequency and in the number of published works. And until today, this problem is relevant (1; 2; 3; 4).

For adult patients with congenital high dislocations of the thigh due to acetabular dysplasia in order to restore limb supportability, increase the range of motion and improve the quality of life, total arthroplasty with fixation of the acetabular component in the ilium wing is performed (Fig. 1) (5; 6; 7; 8).

However, with the development of instability of the components of the endoprosthesis installed in this zone, the problem arises of how to remove its components, in what sequence and in what way, given the limited mobility of the thigh and its anatomical underdevelopment. Analyzing the literature on the causes of failures during implantation of the acetabular component in the ilium wing, A. Plushenko. (9) summarized the authors' opinion: the ilium wing with high dislocations of the thigh is not suitable for placement of the acetabular component of the endoprosthesis in it, since it is impossible to achieve complete restoration of the function of the muscles surrounding the joint. Craniolization (upper location) of the artificial cavity reduces the safe range of motion in the joint due to the threat of impingement. Moreover, the revision operation is much more difficult than the primary (9; 10; 11).

In the domestic medical literature, we did not find information about methods for removing the unstable components of an endoprosthesis installed in the ilium wing with congenital high dislocation of the hip. As the closest analogue, we adopted the “Method for surgical correction of hip joint deformities” (12). The essence of this method is reduced to a two-stage operation. The first stage of anteroposterior access to the hip joint "... remove the neck and head ..., scar tissue, impose ... an external fixation apparatus, lower the thigh with the formation of a soft tissue regenerate, at the second stage perform bone autoplasty of the acetabulum and establish an endoprosthesis ..." (12).

The disadvantages of this method are:

- a high risk of developing infectious-purulent complications associated with the imposition of an external fixation apparatus and subsequent distraction for lowering the thigh (13). That is, a possible failure when performing the first stage can exclude the second stage - the installation of an endoprosthesis. In this case, the supportability of the operated limb is completely lost and its shortening is preserved. In patients with osteoporosis, the needles and rods of the device can migrate in the distraction mode - holding the threaded rods in a closed way through the nadacetabular and subrovert region of the pelvis is associated with a high risk of penetration of the rod end into the pelvic cavity and damage to large vessels and nerves. In addition, the passage of threaded rods through muscle tissue in this area can lead to increased pain and a slower rate of hip distraction in the apparatus;

- the patient's stay in the external fixation apparatus, which completely immobilizes the hip joint, greatly complicates the possibilities of hygienic procedures for the period of lowering the thigh and requires constant monitoring of the skin around the spokes in order to prevent infectious complications;

- after removing the device, it takes time to heal the spoke wounds, only then the second stage of surgical treatment is performed. The authors did not specify how long it takes for wounds to heal, and did not mention that the stretched thigh muscles during the distraction process contract for 2-3 weeks after removal of the apparatus and the hip moves up;

- transplantation of a free bone autograft from the iliac crest to the bottom of the acetabulum treated with spherical cutters is ineffective, since osseointegration from a bone autograft lacking blood supply into the metal cup of the endoprosthesis is doubtful, and instability (loosening) is possible when loading on the lower limb. resorption of the autograft. Reliable fixation is achieved by direct contact between the vascularized bone and the implant itself (14; 15; 16);

- the authors of the patent believe that in 2-3 weeks of distraction the apparatus forms a soft tissue regenerate. At the same time, its anatomical location and size, physical properties, how a capsule is formed from it without sources of blood supply, and what role it performs are not clear. If from it “they form a capsule of the joint ... which prevents the shortening of the limb ...” (12), then this is a profound error. As for the role of the capsule in the changed joint, it is minimal and therefore it is excised during endoprosthetics (17).

The authors of the application for the invention propose to carry out not correction of the deformation of the hip joint with its subsequent primary endoprosthesis replacement, but a two-stage revision reconstructive surgery of the endoprosthesis of the hip joint with instability of the components of the endoprosthesis installed in the wing of the ilium with congenital high dislocation of the hip.

The technical result of the proposed method is achieved in that the removal of the components of the endoprosthesis is carried out sequentially: first, femoral, then acetabular. This creates a convenience for surgical manipulations in the wound, helps to reduce tissue trauma and reduce blood loss:

- the implementation of a V-shaped osteotomy of the thigh eliminates the risk of fracture, as is observed when the leg of the endoprosthesis is removed with a hammer (18), and the preservation of the wide muscle on the cut off bone prevents its displacement in the process of increasing traction of skeletal traction;

- V-shaped osteotomy performed by posterior-external access to the hip joint, allows you to save a large trochanter and muscles attached to it. At the same time, the top of the greater trochanter is the main reference point in establishing the center of rotation of the endoprosthesis head;

- after removal of the acetabular component from the iliac wing, the resulting bone bed is filled with surrounding tissues, the upper layers of which are tightly sutured, which eliminates the possibility of hematoma formation with subsequent complications;

- restoration of limb length is achieved by skeletal traction for tuberosity of the tibia, which ensures uniform stretching of the muscles of the thigh and pelvis, eliminates the risk of possible complications when using the external fixation apparatus, including traction damage to the sciatic nerve;

- implantation of the acetabular component of the endoprosthesis with a rough coating based on the press-fit effect in the true cavity with fixation with screws increases the stability of its fit into the acetabulum;

- the creation of additional support for the boneless endoprosthesis cup is carried out by a canopy of a simulated allograft with screws fixing it to the ilium body, which increases the load area and its uniform distribution to the acetabulum;

- an increase in the amplitude of movements and an improvement in the function of the muscles surrounding the hip joint is achieved by maintaining a large trochanter by restoring the center of rotation of the endoprosthesis head, that is, the true center of rotation of the prosthetic joint, which prevents the development of instability of the components of the endoprosthesis;

- the exclusion of certain operations of taking an autograft from the iliac crest and applying an external fixation apparatus reduces blood loss and tissue trauma, reduces the time of surgery.

The result is achieved by the fact that the V-shaped osteotomy of the proximal end of the femur without cutting off the apex of the greater trochanter with preservation of the middle and small gluteal and broad femoral muscles on it, with the legs removed from the bone marrow canal, is performed as the first step from the posterior-external access to the hip joint the endoprosthesis and after removal of the acetabular component together with the cement mantle from the iliac wing, the resulting bone bed is tamped with surrounding tissues, the upper layers of which are sutured tightly, then cut The left part of the femur bone is placed in its place, it is fixed with wire sutures and the wound is sutured, then, after lowering the proximal end of the femur to the level of the true acetabulum, the second stage is to form a bone bed in it, the acetabular component is implanted in it with the bare part of the cup reinforced with an allograft and then install the revision leg of the endoprosthesis in the bone marrow channel of the thigh so that the center of rotation of the endoprosthesis head is restored, after which the head of the femoral component they are put into the acetabulum and the wound is sutured.

The figures depict

Figure 1 - dummy. The location of the acetabular component in the ilium wing.

Figure 2 - plotted holes at the proximal end of the femur for a V-shaped osteotomy.

Figure 3 - line of a V-shaped osteotomy on the inner-lateral side of the thigh.

4 is a line of a V-shaped osteotomy on the outer lateral side of the thigh.

Figure 5 - the cut off bone fragment is lifted by hooks.

6 - a cut off fragment of the thigh is retracted anteriorly.

7 - the mantle (from bone cement) and the leg of the endoprosthesis are removed.

Fig - the head of the femoral component dislocates from the acetabulum.

Fig.9 is a diagram of the atlas of anatomy. The horizontal line connecting the center of the femoral head and the apex of the greater trochanter.

Figure 10 - dummy. The horizontal line indicating the center of rotation of the endoprosthesis head.

11 - radiograph of the pelvis of the patient S. upon admission.

Fig - radiograph of the hip joint of patient S. in a direct projection. Stage of hip reduction by skeletal traction.

Fig - x-ray of the thigh in a direct projection of the patient S. Achieved the result of lowering the proximal end of the thigh to the middle of the acetabulum.

Fig - x-ray of the hip joint of patient S. after surgery.

Fig - radiograph of the pelvis of a patient S. 5 years after surgery.

The method is as follows: in the patient’s position on the operating table on the healthy side, rear-external access to the hip joint is made with a longitudinal incision of the skin, subcutaneous tissue of the fascia and partially gluteus maximus muscle 2-3 cm above the palpable posterior-outer edge of the greater trochanter. In the distal direction, the broad thigh muscle is dissected along a rough line (linea aspera) to the length of the leg of the endoprosthesis installed in the femoral canal. In the lower corner of the wound along the posterior-outer surface of the femur, 2 holes are drilled at a distance of 1-1.5 cm from each other in the transverse direction below the end of the leg of the prosthesis. An electric saw cuts the cortical layer of the femur between these openings with an auger hole at an angle to the longitudinal axis on both sides with an interval of 2-3 cm along the posterior and anterior surface of the femur (Fig. 2), which creates guidelines for the V-shaped osteotomy of the proximal end of the thigh ( in the form of the leg of the endoprosthesis). Chisels perform an osteotomy of the proximal end of the thigh along the lines connecting the holes (Fig. 3; 4), without cutting off the greater trochanter and retaining attachment of the middle and small gluteal and broad thigh muscles on it. After dissection of the broad muscle of the thigh along the posterior edge of the formed gap, a bone flap covered with a muscle in the shape of a "triangle", with chisels (or hooks), rises and retracts anteriorly (Fig. 5; 6). In this case, the bone marrow canal is exposed, in which the femoral component with the cement mantle is located. The mantle and leg are removed (Fig.7). Holding the extracted leg with a brush and traction “toward you” with a change in direction, the head of the femoral component dislocates from the acetabulum (Fig. 8). Scar tissue is dissected around it. The cement mantle together with the acetabular component exfoliates from the bone bed in the ilium and is removed. The naked bed is tamped with surrounding scar tissue, the adjacent edges of which are tightly sutured to the upper layers. The cut off bone fragment is placed in its place and fixed with wire sutures. The wound is sutured with active drainage. For tibial tuberosity, skeletal traction is applied with an increasing load to lower the top of the greater trochanter to the level of the true acetabulum for a period of 4 weeks (on average).

The second stage removes skeletal traction, provides surgical access to the true acetabulum, forms a bone bed in it with implantation of a cementless press-fit effect with a rough coating of the acetabular component, which is additionally fixed to the ilium with screws. The uncovered portion of the cup is strengthened with a simulated allograft with its screws fixed to the ilium body. Then wire sutures are removed from the proximal end of the femur, a cut off bone “lid” is opened, a bone bed is formed in the bone marrow canal and a revision leg of the femoral component is hammered into it so that the center of the femoral component head is located on the same horizontal line with the apex of the large trochanter (Fig.9; 10), what is achieved the true center of rotation of the prosthetic joint. The free spaces between the bone walls of the canal and the leg of the endoprosthesis are tightly filled with allocrosh. The bone “lid” is closed and fixed along the length of the cut bone with 3-4 wire sutures. The femoral component head is inserted into the acetabulum and the wound is sutured.

Clinical example: a patient, 47 years old, was admitted to the institute’s orthopedics clinic with a diagnosis of instability of the components of the endoprosthesis installed in the wing of the right iliac bone due to congenital high dislocation of the thigh.

From the anamnesis it is known that in 2001 in Syktyvkar, an operation was performed to install an endoprosthesis in the wing area of the right ilium. In connection with the development of instability of the acetabular component in 2002, she performed the operation of replacing the acetabular component with fixing it with cement. In 2004, after a fall, the patient revealed instability of both components of the endoprosthesis (Fig. 11), and therefore the patient was sent to the institute to resolve the issue of tactics for further surgical treatment. After examination and preparation on February 7, 2005, the first stage of the reconstructive operation was performed: removal of the femoral component by means of a V-shaped osteotomy of the proximal end of the femur, then the acetabular component, together with the surrounding cement mantle, from the bone bed in the ilium, which is plugged with surrounding tissues. After suturing the surgical wound, skeletal traction was applied for the tibial tuberosity to lower the tip of the greater trochanter to the level of the true acetabulum (Fig. 12; 13). The second stage, after 4 weeks, the skeletal traction was removed, access to the hip joint was made, the bone bed was formed in the true acetabulum with the installation of a cementless press-fit effect with a rough coating of the acetabular component, additionally fixed with screws to the ilium. The boneless portion of the endoprosthesis cup is strengthened with a simulated allograft with its fixation to the ilium as well as screws. Wire sutures were removed from the proximal end of the femur, the bone marrow canal was opened and a cementless revised femoral component selected according to the template was implanted with the restoration of the center of rotation of the endoprosthesis head. The cut off cover is put into place and fixed by three wire seams (Fig. 14). The wound is sutured. After the operation, a course of treatment was carried out aimed at restoring the function of the operated joint. Discharged in satisfactory condition with an amplitude of movements necessary for self-care, and recommendations for further treatment under the supervision of doctors at the clinic in the community.

After 5 years, the patient sent a letter of appreciation, in which she reported on the full restoration of support ability and painless movements in the hip joint. He works as a lifter in a hospital. On the x-ray of the operated joint, the correct relationships between the components of the endoprosthesis are preserved (Fig. 15).

BIBLIOGRAPHY

1. Stomatin S.I., Moraru N.T. Diagnosis and treatment of congenital hip dislocation. “Stinz”, 1986, p. 3.

2. Korzh A.A., Tikhonenkov E.S. et al. Dysplastic coxarthrosis. M .: Medicine. 1986, pp. 7-8.

3. Abeltsev V.G. Surgical treatment of dysplastic coxarthrosis. M .: Medicine. 2008, pp. 191-197.

4. Akhtyamov I., Sokolovsky O. Surgical treatment of hip dysplasia. Kazan, 2008, pp. 16-17.

5. Turenkov S.V. Improving the methods of surgical treatment of dysplastic coxarthrosis. Abstract. dis. for a job. student step. Cand. honey. sciences. Mound. 2003.23 p.

6. Turenkov S.V., Akhtyamov I.F. Analysis of the results of surgical treatment of dysplastic coxarthrosis with various options for total hip arthroplasty. J. Genius Orthopedics. 2003, No. 2, pp. 19-23.

7. Jasty M., Harris W.N. Total hip reconstruction using frozen femoral read allografts in pazients acetabular loss. Orthop. Clin. North America 1987. V. 18, p. 291-299.

8. Anderson M.J., Harris W. Total hip artroplasty with insertion of the acetabular compontnt without cement in hips with total congenital dislocation or marced congenital dysplasia. J. Bone Joint Surg. Amer. 1999, V.81, p. 347-354.

9. Plyushchev A.L. Dysplastic arthrosis. M. 2007. Summer-print, p. 363.

10. Jerosch J., Stembeck J., Stechmann J., Guth V. Influence of a high hip center on abductor muscle function. Arch. Ortop. Trauma Surg. 1997. p. 385-389.

11. Nikolenko V.K., Buryachenko B.P. and others. Hip replacement. M .: Medicine. 2009, p. 92.

12. Nikolenko V.K., Buryachenko B.P., Drakin A.I., Aksenov Yu.V. A method for surgical correction of hip deformities. Patent for invention No. 2173108.

13. Novikova E, Paltseva I, Oganesyan O. et al. System for the treatment of damage to bones and joints, taking into account the role of biological zones of the skin. M .: Binom. 2004, pp. 8-9.

14. Nikolenko V.K., Buryachenko B.P. and others. Hip replacement. M .: Medicine. 2009, p. 22; 142 (plastic bottom of the cavity).

15. Tikhilov P.M., Shapovalov V.M. Manual for arthroplasty. St. Petersburg, 2008, pp. 60-61.

16. Abeltsev V.P. Surgical treatment of dysplastic arthrosis. M .: Medicine. 2008, p. 108.

17. Plyushchev A.L. Dysplastic coxarthrosis. M. 2007. Summer print, p. 366.

18. Plyushchev A.L. Dysplastic arthrosis. Summer print. 2007, pp. 403-404, pp. 431-432.

Claims (1)

The revision method of reconstructive hip replacement in case of instability of the components of the endoprosthesis installed in the wing of the ilium with congenital high dislocation of the thigh, characterized in that the first stage provides posterior-external access to the hip joint, along the posterior-outer surface of the femur below the end of the leg of the endoprosthesis two holes in the transverse direction, they intersect the cortical bone layer between these holes, form on both sides along the back and the open surface of the femur, the holes in the form of the legs of the endoprosthesis, creating guidelines for the V-shaped osteotomy, along the lines connecting the holes, perform an osteotomy without cutting off the major trochanter, preserving the middle, minor gluteal muscles and broad muscle of the thigh on it, and the resulting bone flap covered exposing the bone marrow canal, remove the endoprosthesis leg with a cement mantle, dislocate the head of the femoral component from the acetabulum, and after removing the acetabular component together with the cement mantle from The resulting bone bed is tamped with the surrounding iliac bone, the upper layers of which are sutured tightly, then the cut bone fragment is placed in its place and fixed with wire sutures, the wound is sutured and then the proximal end of the thigh is brought down to the level of the acetabulum, the second stage is used to form the bone bed in true acetabulum with implantation of the acetabular component and strengthening the uncovered part of the cup with an allograft, open the cut off bone cover on the proximal at the end of the femur and the revision femoral component is implanted into the bone marrow canal so that the center of the femoral component head is in the same horizontal line with the apex of the preserved greater trochanter, after which the femoral component head is inserted into the acetabulum and the wound is sutured.

Images