RU2611898C1 - Method of rear access to acetabulum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: cut is made from the back-upper iliac bone towards the femur greater trochanter with transition to the front outer surface of the hip. Access to the rear roof structures of the acetabulum is provded through the large gluteal muscle. The ligaments of pyrimorm muscle, internal obturator muscle and twin muscles are mobilized and crossed. Muscle ligaments are cut off at the point of attachment to the femur, two bores are pre-formed therein, according to the long coaxial lines of the pyriform and the internal sphincter. The ligaments are sutured. The free ends of sutures from the ligamnts are passed through the formed channels respectively. Ligaments are pulled up to the level of their anatomic attachment to the femur. The free ends of the suture are fixed by means of fasteners.

EFFECT: method allows prevention of circulatory disorders and functional disorders.

2 cl, 10 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for rear access to the acetabulum when performing operations on the hip joint.

One of the most frequent injuries leading to permanent disability is acetabular fractures. Fractures of the posterior wall of the acetabulum account for about one third of all cases and in 70% of cases are accompanied by a posterior, usually, iliac dislocation of the femur (Milyukov A.Yu. et al. Modern approaches to the treatment of patients with injuries of the acetabulum. Politrauma, No. 1, 2006 g., pp. 38-42). Currently, the most common is the surgical treatment of acetabular injuries with the help of posterior operative access, which allows not only to qualitatively repair, but also to fix fragments of the acetabulum. However, many researchers believe that, despite the reposition achieved, the likelihood of developing post-traumatic arthrosis overtakes almost half the cases (Milyukov A.Yu. et al. Modern approaches to treating patients with acetabular injuries. Politrauma, No. 1, 2006, p. 38-42; Runkov A.V. Treatment of acetabular fractures with the use of transosseous osteosynthesis (Abstract, Diss. Kurgan, 1999, p. 24). These data suggest that in this case, an important role in the development of complications, in addition to the severity of the injury and post-traumatic disorders, is played by trophic disorders caused by iatrogenic tissue trauma during traditional surgical interventions.

So, as a result of research on this topic, it was revealed that when performing surgery on the hip joint using posterior access a year after the operation, a number of functional disorders develop from the neuromuscular system and peripheral blood circulation of the lower extremities, causing dystrophic changes in the hip joint 72% of patients (Lobanov G.V. et al. Results of surgical treatment of patients with fractures of the posterior wall of the acetabulum, treated in the traditional way using mations surgical access Kocher-Langenbeck. Trauma. T. 14, №3, 2013, pp. 9-12).

A typical way of posterior access to the acetabulum is the Kocher-Langenbeck surgical access, which we selected as the prototype. The method includes a section from the posterior superior iliac spine towards the greater trochanter of the femur with transition to the anteroposterior femoral surface, access to the posterior structures of the acetabulum through the gluteus maximus, mobilization and intersection of the tendons of the piriform, internal obturator and twin muscles (external rotators of the thigh), surgical intervention in the hip joint, suturing of its capsule and layer-by-layer suturing of the wound (Müller M.E. et al. Guidelines for internal osteosynthesis M.: Ad Marginem, 1996, p. 48). This access provides a good overview of the manipulations, allows for adequate reposition and stable fixation of fractures and is relatively less traumatic, but has significant drawbacks: intersection of tendons of the above muscle group and their subsequent stitching or reinsertion to the femur with displacement from the points of anatomical attachment of the tendons leads to a shortening / displacement of muscle attachment and violation of the isometry of the joint, as a result of which functional disorders of the nervous echnogo apparatus and peripheral circulation, causing degenerative changes in the hip joint.

Thus, there is a need for a method of posterior access to the acetabulum, devoid of the above disadvantages.

In accordance with this, the authors set a task aimed at increasing the effectiveness of treatment in the hip joint area and reducing postoperative complications due to the most accurate fixation of crossed hip rotators to the femur and maintaining joint isometry.

The solution to this problem lies in the proposed method for posterior access to the acetabulum, including an incision from the posterior superior iliac spine towards the greater trochanter of the femur with transition to the front-outer surface of the thigh, access to the posterior structures of the roof of the acetabulum through the gluteus maximus, mobilization and intersection of the tendons of the piriform, internal obturator and twin muscles, surgical intervention in the area of the hip joint, suturing of its capsule and layer-by-layer suturing of the wound, characterized in that the tendons of the muscles are cut off at the place of their attachment to the femur, having previously formed two through channels in it, respectively coaxial to the long axes of the piriformis muscle and internal obturator muscle, the tendons are sutured with suture material, the free ends of suture material from the stitched respectively pass through the formed channels tendons, tighten the tendons to the level of their anatomical attachment to the femur and fix the free ends of the suture material with fasteners.

In FIG. 1-5, the steps of the proposed method for rear access to the acetabulum are presented.

The method is as follows.

Under aseptic conditions under endotracheal anesthesia, an incision is made in the skin and soft tissues from a level below the posterior-superior iliac spine, then the incision is made through the projection of the greater trochanter with a transition to the anteroposterior thigh. On average, the incision length is 10-20 cm. Dissect the muscle straining the wide fascia from the level of the greater trochanter downwards, dissect the gluteus maximus muscle through which access to the posterior structures of the roof of the acetabulum (Fig. 1: (1) - femur, (2) - piriformis muscle, (3) - superior twin muscle, (4) - internal obstructive muscle, (5) - inferior twin muscle). They mobilize pear-shaped (2), internal obturator (4) and twin (3), (5) muscles in the places of their attachment (6), (7) to the femur (Fig. 1). Thus, two independent muscle blocks are mobilized, one block is the piriformis muscle, the second block is the internal obstructive and twin muscles. Two main through channels are formed in the femur, respectively coaxial with the long axes of the piriformis muscle and internal obturator muscle, one through channel (11) from the attachment point of the tendon (6) of the piriformis muscle (2) along its long axis (12) and the second through channel (13) from the point of attachment of a single muscle block (3), (4), (5) along the long axis (14) of the internal obstructive muscle (Fig. 2). The tendons of the mobilized muscles (2), (3), (4), (5) are cut off at the place of their attachment to the femur. Anatomically, the internal obturator and twin muscles (this complex is also called the “triceps muscle of the hip joint”) at the point of attachment to the femur have one common tendon (8), which intersect, keeping this group of external femoral rotators as a single block, thus opening the back access to the acetabulum. The most powerful of this triad is the internal obstructive muscle, so the channel in the femur is formed coaxially with its long axis. The severed tendon of the piriformis muscle is stitched through with suture material, for example, lavsan thread, one of the types of tendon sutures, leaving the free ends of the threads (9). Similarly stitch (10) the tendon of a single muscle block (3), (4), (5) (Fig. 2). Perform surgery in the hip joint and suturing of its capsule. When closing the surgical wound (Fig. 3), the free ends of suture material (9) are passed through the channel (11) from the stitched piriformis tendon (2). Through the channel (13), respectively, the free ends (10) of the suture material are passed from the stitched tendon (8) of a single muscle block (3), (4), (5). Tendons are drawn through the channels (11), (13) strictly to the level of their anatomical attachment (6), (7) to the femur (1) (Fig. 3). Fix the free ends of the suture material (9), (10) in the formed channels (11), (13) with fasteners (15), (16) (Fig. 4, 5). Using the above sequence of actions of the tendon, two independent muscle blocks (one block is the piriformis muscle, the second block is the internal obstructive and twin muscles) are fixed with fasteners in the piriform fossa to the mother places in such a way as to preserve their length and direction. This avoids the subsequent distortion and shortening of the cut off muscles and, consequently, disturbances in the isometry of the hip joint and subsequent degenerative disorders - deforming arthrosis, aseptic necrosis of the femoral head.

The fastening elements can be screws, anchor fasteners, pins made of metal, ceramic or biodegradable material, button fasteners, etc. The free ends of the suture material themselves, tied with a knot (15) (16), previously drawn through the main ( 11), (13) and additional (additional) channels ((11a), (13a) (Fig. 5)). In this case, additional parallel channels are formed next to the previously formed through channels, through which a part of the free ends of the suture material is passed from the corresponding tendon and fixed, in this case, tied to a knot. It is possible to use the above fasteners (screws, etc.) in additional channels. It is impossible to connect the pear-shaped and internal oblique filaments with the twin muscles between the two main channels: each muscle block will pull the filaments in its direction, which will lead to a cut of the femur and a significant displacement of the above muscles.

The choice and use of one or another fastener does not significantly affect the solution of the problem posed by the authors.

After fixation, layered wound closure is performed. Apply aseptic dressings.

Example. Patient E., 36 years old, was admitted to the MONIKI Traumatology Department after a traffic accident with a diagnosis of iliac dislocation of the right femur, comminuted fracture of the posterior wall of the acetabulum on the left. The patient was operated using posterior access to the acetabulum according to the proposed method. The position of the patient during surgery on the right side. An incision was made from a level below the posterior-superior iliac spine through the projection of the greater trochanter with a transition to the anteroposterior thigh. They made a dissection of the muscle, straining the wide fascia, from the level of the greater trochanter downwards, dissected the gluteus maximus upward. They mobilized the piriformis muscle (1). They mobilized the internal obstructive (2) and twin muscles (3), (4) in the places of their attachment to the femur, keeping them as a single block (Fig. 6). Two main through channels were formed in the trochanteric femoral bone, strictly coaxial to the selected muscle blocks: from the place of attachment of the piriformis tendon (1) along its long axis and from the place of attachment of a single muscle block (2), (3), (4) along the long axis of the internal obstructive muscle, nearby, at a distance of 5-6 mm, with the previously formed through channels formed two additional, respectively parallel channels, one additional channel on the main channel, the muscle tendons crossed (1), (2), (3) , (4) (Fig. 7). The truncated piriformis tendon was stitched through with Dacron thread through the tendon suture, leaving the free ends of the threads. Similarly, the tendon of a single muscle block was stitched. Performed a capsulotomy of the hip joint. The fracture was repositioned and fixed with a CHm osseous plate, dislocation reduction, capsule suturing (Fig. 8). At the closure of the surgical wound, the free ends of the suture material from the stitched tendon of the piriformis were passed through the channels: a part in the main and a part in the additional channels. From the stitched common tendon of the internal obturator and twin muscles, suture material was likewise passed through the femur. Tendons (1), (2), (3), (4) were pulled through the canals to the level of their anatomical attachment to the femur. The free ends of the corresponding pairs of mylar threads were fixed by the nodes between the main and additional channels for each muscle block (Fig. 9). They performed layer-by-layer suturing of wounds and applied aseptic dressings.

The patient is allowed to stand upright without axial load on his left leg three days after surgery, was discharged for outpatient treatment after 10 days. Disability recovery - 3 months after surgery. The hip joint is fully anatomically and functionally restored (Fig. 10).

Thus, the proposed method of posterior access to the acetabulum allows to increase the effectiveness of treatment during surgical interventions in the hip joint, to provide a good visual overview of the surgical field, to provide an adequate reposition and stable fixation of fractures, it is rather less traumatic, and at the same time it allows to save the isometry of the hip joint due to the maximum accurate fixation of crossed femoral rotators to the femur and significantly reduce the risk of postoperative complications (def rmiruyuschego osteoarthritis, avascular necrosis of the femoral head).

Claims (2)

1. The method of posterior access to the acetabulum, including an incision from the posterior superior iliac spine towards the greater trochanter of the femur with transition to the anteroposterior thigh, access to the posterior structures of the acetabulum through the gluteus maximus, mobilization and intersection of tendons piriform, internal obturator and twin muscles, surgical intervention in the area of the hip joint, suturing of its capsule and layered suturing of the wound, characterized in that the tendons of the muscles are cut off in at the place of their attachment to the femur, having previously formed two through channels in it, respectively coaxial with the long axes of the piriformis muscle and internal obturator muscle, the tendons of these muscles are sutured with suture material, the free ends of the suture material from the stitched tendons respectively pass through the formed channels, and the tendons are tightened to level of their anatomical attachment to the femur and fix the free ends of the suture material with fasteners. 2. The method according to p. 1, characterized in that next to the previously formed through channels, additional channels are formed through which a part of the free ends of the suture material is passed from the corresponding tendon and fixed with fasteners.

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