RU2572022C1 - Method of treating congenital abnormal development of pelvic ring accompanying bladder extrophy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: markers - injection needles - are inserted in projection of sacroiliac joints in the longitudinal direction. After an X-ray inspection, an osteoperforation of external cortical plates is performed from one or two punctures at 5 mm in the lateral direction from the sacroiliac joints and in parallel; the perforation openings make a single line. The markers are removed. Flexibility of the pelvic halves is controlled when bringing the anterior pelvic ring together and providing its symmetry; an aseptic bandage is applied; the patient is laid on his/her back with a cushion placed under his/her lower back. Three rods directed towards S2, S3 spines are inserted into an iliac body at a depth of 4-5 cm; the first rod is inserted into the area of an anterior superior iliac spine; the other two - at 1.5-2 cm and 3-4 cm in the proximal direction respectively. The apparatus is assembled on semi-ring supports and connected by threaded rods arranged in front of the pelvis in the horizontal plane, in parallel at 3-5 cm from each other. A dynamic compression follows by approximating the supports along the rods. Once a pubic bone space reaches 2-2.5 cm, and soft tissue tension in this area decreases, after performing a repair of the anterior wall of the bladder and the anterior abdominal wall, the pubic bones are brought together completely under visual control; the apparatus is stabilised; the wound is sutured.

EFFECT: method ensures reducing the length of treatment and the risk of pelvic girdle dysfunction.

1 ex, 10 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of congenital pelvic deformity with developmental abnormalities in the form of bladder exstrophy - one of the serious defects in urology, as well as in the treatment of persistent post-traumatic pelvic ring deformities.

Congenital malformation of the pelvis in the form of bladder exstrophy presents significant difficulties in restoring the continuity of the pelvic ring. With bladder exstrophy, the anterior wall of the bladder and the adjacent section of the anterior abdominal wall are absent, the external genitalia with the urethra are split, and there is also a defect in the anterior parts of the pelvic ring with varying degrees of divergence of the pubic bones. Diastasis between them can reach 12 cm [1]. Moreover, the pubic bones, according to RKT, are shortened by 30% [2, 3], which is associated with “residual divergence of the bosom” [4, 5, 6] after surgical treatment. The pelvis is “flattened” in the frontal plane, which leads to lateralization and retroversion of the acetabulum [4, 6]. The lower limbs are excessively rotated outwards, which leads to duck gait [3, 7].

The reduction of the symphysis and its stabilization ensure the effectiveness of urological operations. High estimates of the reconstruction of the pelvic ring are explained not only by the closure of the front wall of the abdomen and the bladder, but also by “a noticeable improvement in gait” [8].

Known methods of reducing symphysis by dissecting ligaments of the sacroiliac joints [1].

The disadvantages of the method: trauma, possible postoperative complications, the duration of subsequent immobilization, relapse.

A more effective operation is known for the complex solution of problems associated with bladder exstrophy, which consists in the fact that anterior access, with subperiostal ileal excretion, produces a horizontal osteotomy of the ilium body above its anterior lower spine. Using the rods (Fig. 1-a, Fig. 1-b), previously introduced into the body of the ilium, the distal parts of the pelvic halves rotate by 40-45 °. Flattened pubic bones are fixed with a wire suture.

Disadvantage: not always symmetrical rotation of the distal parts of the pelvic halves, the need to fix the pelvic fragments with Kirschner spokes, postoperative complications (up to purulent in the recreated pubic joint), the need for immobilization in the postoperative period with a plaster cast.

The closest, in its technical solution, claimed, is a combined pelvic osteotomy [7]. The method includes supra-osteotomy, from anterior access, between the upper and lower anterior awns, after which rods are inserted into the distal fragments (Fig. 2-a, Fig. 2-b). Then, from the same access, a groove in the bone is “selected” on the inner surface from the sciatic notch - up, parallel and outward from the sacroiliac joint, to the crest of the iliac wing. The wing becomes malleable. To regulate the position of the wings of the pelvis vertically, from top to bottom, rods are inserted.

Overshot osteotomy eliminates the flawed position of the hip joints. The addition to the supraclavicular osteotomy in the form of a “selectable” furrow eliminates the external rotation of the wings of the ilium with muscles attached to them. At the final stage of the operation, all fragments of the pelvis are fixed with the apparatus using the previously inserted rods.

The described surgical intervention is traumatic. Moreover, the pelvis is “flattened” in the frontal plane, which results in lateralization and retroversion of the acetabulum. Separate resolution of problems associated with the "flatness" of the ilium, lateralization and retroversion of the acetabulum, can lead to a disturbance in the normal balance of the muscles attached to the ileal crest (muscles that straighten the spine, square muscles of the lower back, muscles of the abdominal wall), muscles of the pelvis itself ( lifting the anus, coccygeal), as well as the muscles of the pelvic girdle. All three muscle groups are responsible for the dynamic balance of a stable pelvic ring.

Thus, the four axes around which the internal rotations of the wings of the ilium and the distal parts of the pelvic halves are made will not allow symmetrical movement of the four fragments of the pelvic ring. This, in the end, will lead to negative clinical manifestations in the form of violations of the statodynamic functions of the pelvic girdle.

The purpose of the invention is to improve the results of treatment, while reducing the time of inpatient treatment and rehabilitation, reducing the number of complications and relapses.

The essence of the invention is expressed by a combination of essential features sufficient to achieve the desired technical result, and is to ensure high efficiency of the restoration of the pelvic ring and its stabilization, allowing you to activate the patient the day after surgery.

The essence of the invention lies in the fact that a method of treating congenital abnormalities of the development of the pelvic ring during bladder exstrophy involves weakening the pelvic bones to their compliance by sampling the bone mass, and fixing the achieved position of the bones with the apparatus. In the patient’s position on the abdomen, in the projection of the sacroiliac joints, markers - injection needles are installed parallel to them. After x-ray control, from one or two injections, at a distance of 5 mm lateral to the sacroiliac joints and at the same time they perform osteoperforation of the external cortical plates of the ilium. Perforation holes form a single line. Markers are deleted. The compliance of the compliance of the halves of the pelvis while reducing the front of the pelvic ring, and its symmetry. An aseptic dressing is applied, the patient is laid on his back, with a roller under the lower back. Three rods are inserted into the body of the ilium, with orientation to the vertebrae S2, S3, through the ridges, to a depth of 4-5 cm. The first rod is installed in the region of the anterior superior iliac spine, the remaining two are proximal to 1.5-2 cm, and 3-4 cm, respectively. The apparatus is assembled on semicircular supports, interconnected by threaded rods located in front of the pelvis, at a distance of 3-5 cm from each other, in parallel, in a horizontal plane. In the frontal plane, a dynamic renewal compression is created by bringing the supports closer together along the bars until the gap between the pubic bones reaches 2-2.5 cm, and reduces the tension of the soft tissues in this zone. After urologists perform plastic surgery of the anterior wall of the bladder and the anterior abdominal wall, the pubic bones are finally reduced under visual control. The device is stabilized. Stitches on the wound.

The position of the patient on the abdomen provides the ability to select bone mass from the posterior cortical plate of the ilium.

The installation of markers - injection needles in the projection of the sacroiliac joints, parallel to them, provides a symmetrical selection of bone mass from the posterior cortical plate of the ilium.

X-ray control ensures the correctness of the manipulation.

Osteoperforation of the external cortical iliac plates from one or two injections, at a distance of 5 mm lateral to the sacroiliac joints, and parallel to them, so that the holes from the perforation form a single line, provides symmetrical reduction of the pubic bones.

Controlling the compliance of the halves of the pelvis, while reducing the anterior sections of the pelvic ring and its symmetry, provides an anatomically correct recreation of the symphysis.

The application of an aseptic dressing allows you to shift the patient to the back, and the roller under the lower back helps to reduce the pubic bones [9].

The introduction of the rods through the iliac crests, oriented to the vertebrae S2, S3, into the zone where the axis of the small-amplitude movement of the sacroiliac joints is located [9], and the moments of forces acting on the pelvic ring in the cranial and caudal directions are balanced, which ensures the minimum mechanical impact on the ilium during restoration of the pelvic ring. The introduction of rods according to this scheme reduces the likelihood of additional damage to the ilium, allows minimizing efforts to reduce the pubic bones, and also minimizes the load on the external fixation apparatus when the pelvis is balanced after reconstruction [10].

Assembling the apparatus on semi-annular supports on each side of the pelvis, with the rods mounted on the ilium, taking into account the requirements of the general concept of the external fixation apparatus for the pelvis, creates a stable local, and if necessary, adjustable during treatment, compression in the front parts of the pelvis. This ensures high efficiency of reconstruction and stabilization of the reconstructed pelvic ring.

The rapprochement of the supports along the bars until the gap between the pubic bones is 2-2.5 cm and the tension of the soft tissues in this zone is reduced provides freedom of manipulation during plastic surgery of the front wall of the bladder.

The final reduction of the pubic bones under visual control, after the urologists perform plastic surgery of the anterior wall of the bladder and the anterior abdominal wall, ensures the restoration of the continuity of the pelvic ring and its internal relationships.

The method is illustrated in the illustrations, where:

scheme of supraclavicular osteotomy is shown:

in FIG. 1-a - the location of the section and the direction of rotation of the distal pelvic halves;

in FIG. 1-b - type of pelvis after surgery;

The scheme of combined osteotomy is shown:

in FIG. 2-a shows the direction of the sections of the ilium;

in FIG. 2-b is a view of the cortical section of the wings of the pelvis;

in FIG. 3 is a diagram of a corticotomy of the posterior plate of the ilium and the direction of rotation of the halves of the pelvis;

in FIG. 4 - shows a diagram of the pelvis in the frontal projection with the apparatus installed, where: 1 - semicircular supports of the apparatus, 2 - threaded rods, 3, 4 - rods connecting the semicircular supports, 5, 6 - specified directions of application of forces;

in FIG. 5 - overview radiograph of the pelvis of a 5-year-old patient with bladder exstrophy with a divergence of the pubic articulation of 6.5 cm;

in FIG. 6 - overview radiograph of the pelvis in the external fixation apparatus;

in FIG. 7 - CT of the pelvis after dismantling the apparatus, 3D image;

in FIG. 8 - radiographs of the pelvis 1 month after dismantling the apparatus; arrows indicate "traces" of osteoperforations of the ilium;

in FIG. 9 - radiographs of the pelvis 4 months after the dismantling of the apparatus;

in FIG. 10 - function 4 weeks after dismantling the device.

The method is as follows.

In the position of the patient on the operating table on the abdomen, after processing the surgical field, in the projection of the sacroiliac joints longitudinally to them, markers are installed - injection needles. After x-ray control, from one or two injections, at a distance of 5 mm lateral to the sacroiliac joints and at the same time they perform osteoperforation of the external cortical plates of the ilium, while the holes from the perforations form a single line. The compliance of the compliance of the halves of the pelvis with the reduction of the anterior sections of the pelvic ring and its symmetry. Aseptic dressing. The patient is laid on his back, with a roller under the lower back. Three rods 2 are inserted into the body of the ilium, with orientation to the vertebrae S2, S3, through the ridges, 2 to a depth of 4-5 cm. The first rod is installed in the region of the anterior superior iliac spine, the remaining two are proximal to 1.5-2 cm and 3-4 cm, respectively. The apparatus is assembled on semi-cradle bearings 2, in the frontal plane they create a dynamically compressible compression in the front parts of the pelvis. In this case, the semi-ring supports 1 are connected to each other by threaded rods 3 and 4 in front of the pelvis, in a horizontal plane, parallel to each other, at a distance of 3-5 cm. Compression is set in the frontal plane to the front sections of the pelvis, for which the supports 2 are brought together by rods 3 and 4 in directions 5 and 6. Upon reaching the gap between the pubic bones of 2-2.5 cm and reducing the tension of soft tissues in this area, urologists plasticize the front wall of the bladder and the anterior abdominal wall. Then, under visual control, the pubic bones finally reduce, stabilize the external fixation apparatus. Stitches on the wound. Aseptic dressing.

Thus, the proposed method allows to bring together the pubic bones, to recreate the pubic joint in compression mode in the front parts of the pelvis, supported in dynamics. The method allows to activate the patient the day after surgery.

Clinical example.

Patient R., 5 years old, was hospitalized for surgical treatment - the final stage of correction of bladder exstrophy with reduction of the pubic bones.

For the reconstruction of the pelvic ring, the following was done: in order to give hemipelvis flexibility when reducing the symphysis, 5 mm laterally departing from the sacroiliac joints, and parallel to them, from 2 punctures with a 2 mm spoke, almost fused in one line, the outer cortical plates are perforated iliac bones. The patient is laid on his back. An external fixation device is mounted as part of its general concept (4 mm rods). Symphysis reduced to 2/3. After this, the urologists carried out the final correction of bladder exstrophy. AVF.

Under visual control, the pubic articulation was reduced using an external fixation device, which ensured the closure of the diaphragm of the bottom of the pelvis.

Dismantling of the device is made in 14 weeks. The size of the pubic joint after 1 month was 1.2 cm. The function of the pelvic girdle is unremarkable.

When the control radiography of the pelvis after 4 months, the relationship of the pubic bones is the same.

Information sources

1. Perovic S., Brdan R., Scepanovic D. Bladder extrophy and anterior pelvic osteotomy // Brit. J. Urol. - 1992. - V. 70. - P. 678-682.

2. Aadalen R.J., About Phelan E.N., Chisholm T.C. et. al. Correction of the pelvis in bladder exstrophy // Clin. Orthop. - 1980. - N 151. - P. 193-200.

3. Sponseller P. D., Bisson L. S., Gearhart J. P., et. al. The anatomy of the pelvis in the exstrophy complex // J. Bone Joint Surg. - 1995. - V. 77A. - P. 177-189.

4. Gearhart J.P., Forschner D.C., Jeffs R. D. et. al. The anatomy of the pelvis in the exstrophy complex // Brit. J. Urol. - 1996. - V. 155. - P. 689-693.

5. Kantor R., Salai M., Ganel A. Orthopedic long term aspects of bladder exstrophy / Clin. Orthopaed. - 1997. - V. 335. - P 240-245.

6. Thomas W.G., Wilkinson J.A. Bilateral pelvic osteotomies in blader exstrophi // J. Bone Joint Surg. - 1989. - V. 71A. - P. 328-329.

7. Shultz W.G. Plastic repair of exstrophy of bladder combined with bilateral osteotomy of ilia // L Urol. - 1958. - V. 79. - P. 453-458.

8. Sokolovsky O.A., Sokolovsky A.M., Averin V.I., Gassiev N.I. Problematic articles and reviews // Medical News. - 1998. - No. 5. S. 3-7.

9. Khabibyanov R.Ya. External fixation device for the treatment of damage to the pelvic ring. General concept // Practical medicine. - 2012. - No. 8 (64). - S. 62-63.

10. Lesgaft P.F. Selected works on anatomy. - M.: Medicine. - 1968. - 370 s.

Claims (1)

A method for treating congenital abnormalities of the development of the pelvic ring during bladder exstrophy, including the weakening of the pelvic bones to compliance with a selection of bone mass, and the fixation of the achieved position of the bones with the apparatus, characterized in that in the patient’s position on the abdomen, in the projection of the sacroiliac joints, they are installed longitudinally markers - injection needles, after X-ray control, from one or two injections, at a distance of 5 mm lateral to the sacroiliac joints and simultaneously perform osteoperforation the external cortical plates of the ilium, while the holes from the perforation make up a single line, the markers are removed, the compliance of the pelvic halves is performed while the anterior sections of the pelvic ring are reduced and its symmetry is applied, an aseptic dressing is applied, the patient is placed on the back, with a roller under the lower back, into the ileal body bones, oriented to the vertebrae S2, S3, through the ridges, three rods are inserted to a depth of 4-5 cm, the first rod is installed in the region of the anterior superior iliac spine, the other two are proxima 1.5–2 cm and 3-4 cm, respectively, the apparatus is assembled on half-ring supports, connected to each other by threaded rods located in front of the pelvis, in a horizontal plane, in parallel, at a distance of 3-5 cm from each other, in the frontal plane they create a dynamically compressible compression, bringing the supports closer along the bars, after reaching the gap between the pubic bones of 2-2.5 cm and reducing the tension of the soft tissues in this area, after urological plastic surgery of the front wall of the bladder and the anterior abdominal wall, finally DYT pubic bone under visual control, the unit is stabilized, the stitches on the wound.

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