RU2502487C1 - Method for osteotomy of proximal end of hip for placement and fixation of hip component of hip implant in congenital high hip dislocation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely traumatology and orthopaedics, and can find application in performing restorative hip operations using common hip components of a prosthetic implant. The method consists in distension of an intramedullary canal of the hip with three length cuts along a lateral external wall of the hip by the length of the existing hip component of the prosthetic implant. A hole is drilled in a lower end of the cuts, and after a prosthetic implant stem has been implanted, the cavity formed between the sawn walls is filled with an autograft. Grooves are sawn around a proximal end of the hip. A wire line is laid therein which is used to tighten the sawn hip walls. Further, the internal wall of the dissected external trochanteric fragment is modelled after a curvature of the proximal end of the hip with the pre-implanted prosthetic implant stem. After that, the hip cuts are closed with the modelled fragment and adapted with the fixation structures. That is followed by hip component repositioning.

EFFECT: using the given invention enables eliminating the distention of the operative wound, separating soft tissues along the perimeter of the bone, avoiding risk of fractures and fissures along the length of the femoral bone, providing the reliable fixation of the hip component in the bone bed, preventing cerclage suture dislocation, ensuring favourable conditions for early rehabilitation of the patients.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used when performing hip joint arthroplasty operations with congenital high hip dislocations.

One of the difficult problems when performing such operations is the difficulty of implantation and reliable fixation of the leg of the endoprosthesis due to the narrow marrow canal due to dysplasia (1). At the same time, there is a high risk of a longitudinal split of the thigh or the impossibility of implanting into the narrow bone marrow canal even the smallest sizes of standard endoprosthesis legs (2; 3).

There is a method of longitudinal osteotomy of the proximal end of the femur for installing the femoral component of the hip joint, which is performed “on one surface” (4), that is, the bone is cut only by one of the walls of the femoral canal.

T. Paavilainen (5) proposed, after transverse cutting of the trochanteric part of the thigh, to perform longitudinal osteotomy of the proximal end of the thigh in the sagittal plane, which helps to push apart both walls of the medullary canal (external and internal) and facilitates the implantation of the endoprosthesis leg, after which the formed cracks in the bone are filled with an autograft. Moreover, the space of the posterior bone cut is filled with an autograft within the range of visibility prior to implantation of the femoral component. The fixation of the outer part of the trochanteric fragment to the outer-lateral wall of the proximal end of the thigh is carried out in the frontal plane by screws passing through the dissected walls of the thigh (Fig. 1). At the same time, T. Paavilainen used legs specially shaped by Biomet specially manufactured by Biomet (Fig. 2), which facilitated the passage of screws through the dissected walls of the thigh. This method is accepted by us as a prototype.

With the described method of implantation and tight fitting of the femoral component into the narrow medullary canal, not only the risk of longitudinal splitting of the femur remains, but it also becomes difficult to hold the screws simultaneously through the trochanteric fragment and the split walls of the femur around the leg of the endoprosthesis and create compression between them. At the same time, it is difficult to achieve full contact of the trochanteric fragment to the outer-lateral wall of the proximal end of the thigh and a reliable tight fit of the femoral component of the endoprosthesis after fixing only with screws, as a result of which a delayed fusion between them and loosening of the endoprosthesis leg with an early load on the operated limb is possible. In addition, it is impossible to carry out full-fledged autoplasty in the cleft of the posterior femoral cut after implantation of the leg of the endoprosthesis and to verify its effectiveness without detaching the soft tissues from the bone. Therefore Plyushchev A.L. and Golev S.N. (3) consider that such a method cannot be recommended for widespread use due to its uncontrolled surgical aggression and invasiveness.

The authors of the application for the invention propose to modify the method of osteotomy of the proximal end of the femur during the operation according to T. Paavilainen, while eliminating the risk of a longitudinal split of the thigh, optimizing the conditions for a tight fit of standard endoprosthesis legs into a narrow bone marrow canal, performing full-fledged autoplasty in the cuts of the thigh, the fit and fixation of the trochanteric fragment to the proximal end of the thigh, covering the sawn sections of the femur, which contributes to the fusion.

The technical result of the proposed method are:

- osteotomy of the proximal end of the thigh is carried out in the frontal plane of the external lateral access to the hip joint, which does not require the expansion of the surgical wound and the separation of soft tissues along the perimeter of the bone;

- performing an osteotomy in the frontal plane to expand the medullary canal allows the implantation to use standard femoral components of any company, the conical shape of which in the distal end has a narrowing of the leg, in the proximal - expansion;

- drilling round holes at the distal end of cuts eliminates the risk of cracks and fractures along the length of the femur with a tight fit of the endoprosthesis leg;

- after implantation of the femoral component of the endoprosthesis in the medullary canal, the free spaces between the sawn fragments of the proximal end of the thigh are densely filled with an autograft and pulled together with wire or other fixing material in the sawn grooves around the circumference of the thigh, which prevents displacement of cerclage sutures and thereby ensures reliable fixation of the femoral component in the bone ;

- modeling of the inner spongy wall of the external trochanteric from a fragment of the thigh provides a snug fit to the extended osteotomized proximal end of the femur (after implantation of the legs of the endoprosthesis), which contributes to the fusion between them and creates conditions for early rehabilitation of patients;

The achievement of the technical result when installing and fixing the femoral component in the medullary canal with a congenital high dislocation of the thigh is achieved by making three longitudinal cuts along the outer-lateral wall of the femur to expand the medullary canal along the length of the existing femoral com-component of the endoprosthesis, drill at the lower end of the cuts holes and after implantation of the endoprosthesis leg, the formed spaces between the sawn walls are filled with an autograft, then around the circumference grooves are sawn at the imperial end of the thigh (in sufficient quantities, depending on the length of cuts and the thickness of the cortical walls of the thigh), into which the wire is laid and the sawn thigh walls are pulled together with it, then the inner wall of the cut external trochanteric fragment is modeled for the curvature of the proximal end of the thigh with an already implanted leg endoprosthesis, close the cuts of the thigh with a simulated fragment and carry out their adaptation with fixing structures, after which the femoral component is directed into the rotisserie supper and the wound is sutured.

The figures depicted

Figure 1. Scheme of hip joint replacement surgery for congenital high hip dislocation according to T. Paavilainen.

Figure 2. Flat legs of the company "Biomet" for performing the endoprosthetics operation according to T. Paavilainen.

Figure 3. Longitudinal osteotomy of the outer lateral wall of the proximal end of the femur, where 1 - cuts of the thigh; 2 - drilled holes in the bases of the cuts of the thigh; 3 - sawn transverse furrows.

Figure 4. Fixation of the endoprosthesis leg in the medullary canal with wire sutures in transverse grooves on the femur, where 4 is a simulated trochanteric fragment; 5 - cerclage seams installed in the grooves for tightening bone cuts.

Figure 5. Fixation of the trochanteric fragment to the osteotomized end of the thigh with wire sutures, where 4 is a simulated trochanteric fragment; 6 - cerclage seams fixing the trochanteric fragment.

Figure 6. Radiograph of the pelvis of patient A., on which the signs of congenital high dislocation of the hips are determined.

Figure 7. Radiograph of the right hip joint of patient A. after endoprosthetics surgery by the proposed method.

Figure 8. Radiograph of the right hip joint of patient A. 6 months after surgery by the proposed method.

The method is as follows. In the position of the patient on the operating table on the healthy side, access to the hip joint is performed by an external-lateral incision. Palpation determine the large trochanter of the femur (as a guideline for access to the femoral head). From the scar tissue, the femoral head is isolated, dislocated into the wound and resected. After transverse femoral osteotomy, the level of which is determined in preoperative planning, the trochanteric fragment is cut into two parts in the sagittal plane. The medial part is removed, the external part is taken backwards together with the muscles surrounding it. The true acetabulum is isolated from the scars in the lower corner of the wound, and after its preparation, the acetabular component is implanted. Given the presence of osteoporosis in the underdeveloped cavity (due to the lack of full joint function), additional fixation of the acetabular component is carried out with screws, or bone grafting of the acetabulum is performed. At the proximal end of the osteotomy part of the thigh, three longitudinal cuts 1 per length of the leg of the endoprosthesis planned for implantation are performed along its outer lateral wall in the frontal plane. In the distal ends of the cuts, holes 2 are drilled (Fig. 3). After implantation of the femoral component of the endoprosthesis into the enlarged medullary canal, the free spaces between the bone cuts are filled with an autograft from the femoral head, or from the removed medial part of the trochanteric fragment. Then, grooves 3 are sawed around the circumference of the cuts, the depth and width of which depends on the diameter of the wire used and the thickness of the cortical wall of the thigh, lay the wire in these grooves 5 and tighten the dissected walls of the thigh. The inner wall of the external trochanteric fragment 4 is modeled according to the curvature of the outer lateral wall of the thigh (Fig. 4) and, after reaching their tight contact, closing the longitudinal cuts of the femur, is fixed with several wire seams 6, screws or other fixing devices (Fig. 5).

Clinical example. Patient A. 37 l. was admitted to the orthopedics clinic 03.23.11 with a diagnosis of dysplasia of both hip joints; congenital high dislocations of both thighs (Fig.6). After examination and preparation, the patient underwent surgery: in a position on the operating table on a healthy side, access to the right hip joint was made externally with a lateral incision. The proximal end of the thigh is highlighted, scars around the head are dissected. The head is dislocated into the wound and removed. Performed a transverse osteotomy of the femur below the level of the small trochanter of the femur. The trochanteric fragment is cut lengthwise in the sagittal plane. The inner part is removed, the outer one, with the muscles surrounding it, is pushed back. In the lower corner of the wound, an underdeveloped true acetabulum is selected from the scars. A bed is formed in it, into which the acetabular component is implanted with its fixing to the pelvic bone with three screws. Three cuts are made on the outer-lateral wall of the proximal end of the thigh in the frontal plane. A femoral component is implanted in the medullary canal. The spaces between the split fragments of the thigh are blocked by autobone. The walls of the thigh are pulled together by four wire seams in transverse grooves made around the circumference of the cuts of the thigh. The inner wall of the outer-lateral part of the trochanter is modeled under the curvature of the outer part of the proximal end of the thigh and is tightly fixed to it by three cerclage wire seams and one screw. The head of the femoral component is set into the acetabular. Amplitude of passive movements in an artificial hip joint with no tendency to subluxations. The wound is sutured. On the control x-ray (Fig.7), the ratios of the components of the endoprosthesis are correct. After 5 days, the patient began walking with crutches and physical therapy exercises. After 2.5 weeks from the day of surgery, the amplitude of the active movements in the joint necessary for self-care was reached and the patient was discharged for outpatient monitoring with recommendations for the continuation of outpatient treatment.

6 months after the operation, the patient reported that movements in the hip joint and support ability of the operated limb had recovered. On the sent radiograph of the hip joint, the correct ratios of the components of the endoprosthesis are preserved (Fig. 8).

Literature

1. Gavryushenko N.S., Movshovich I.A. Joint arthroplasty - which way to go? // Abstracts of the international conference "Achievements of Biomechanics in Medicine". Riga. 1986. pp. 218-223.

2. Plyushchev A.L. Dysplastic coxarthrosis. Theory and practice. M .: Summer print. 2007. Page 271.

3. Plyushchev A.L., Golev S.N. Features of implantation of an endoprosthesis leg during hip dysplasia. Endoprosthetics in Russia. Kazan - St. Petersburg. 2008. Issue 4. Page 54-66.

4. Tikhilov P.M., Shubnyakov II, Bliznyukov V.V. et al. Patent for the invention RU No. 2411013 of 02/10/2011.

5. Paavilainen T. Cementess total Hip arthroplasty for congenialle dislocated or dysplastic Hips: technique for replacement with a straiqht femoral compo nent. Clin. Orthop. 1993.297: 71-81.

Claims (1)

A method of osteotomy of the proximal end of the femur for installation and fixation of the femoral component of the hip joint with congenital high dislocation of the thigh, characterized in that for the expansion of the medullary canal of the thigh, three longitudinal cuts are made along the outer lateral wall of the thigh to the length of the existing femoral component of the endoprosthesis, at the lower end of the cuts holes are drilled and after implantation the endoprosthesis legs, the formed spaces between the sawn walls are filled with an autograft, then circumferentially The proximal end of the thigh cuts the grooves into which the wire is laid and the sawn thigh walls are pulled together with it, then the inner wall of the excised external trochanteric fragment is curved to the curvature of the proximal end of the thigh with the implant leg already implanted, the thigh cuts are closed with a modeled fragment, and they are adapted after fixing structures What is the reduction of the femoral component into the acetabulum and the wound is sutured.

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