RU2621538C1 - Method for proximal femur defect treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method includes application of an external fixation device to the femoral 1 and pelvic 2 bones, closed metered lowering of the apex of large trochanter 7 to the lower edge of acetabulum 8 is performed using the external fixation device, soft tissues along the outer surface of the upper third of the thigh are exfoliated by the open method, middle and small gluteus muscles 17 are separated subperiosteally from the top of the large trochanter, arthrotomy and revision of the acetabulum are performed, shape of the large trochanter apex is modeled in accordance with the acetabulum size, the femur is crossed over small trochanter 10, proximal femoral fragment 11 is unfolded in the frontal and horizontal planes, forming a cervico-diaphysial angle and anteversion angle, femoral fragments are fixed with implant 13 at the obtained position, the larger trochanter top is directed to the acetabulum, transverse osteotomy 14 over acetabulum is performed, the acetabulum is transposed, inclined outwards and to the front, pelvic bone fragment is fixed to support 4, gluteus muscles are moved to the distal end of the proximal femur fragment together with the periosteum, stabilizeed and fix theobtained position and unload the hip joint EFD, hip joint passive movements are trained, after consolidation of the osteotoming fragments and achievement of stability in the hip joint, EFD is dismantled, the hip is fixed with a splint.

EFFECT: favorable geometric relationships in the joint.

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Description

Technical field

The invention relates to medicine, namely to methods for treating diseases of the musculoskeletal system, in particular to methods for treating pathological dislocation of the thigh in children of preschool and primary school age, using means of external and internal bone fixation.

State of the art

A pathological dislocation of the hip is a condition caused by the destruction of the head and neck of the femur, a violation of the normal ratios (spatial, geometric, mechanical) between the components of the hip joint, due to the pathological process, usually septic coxitis. These violations lead to instability of the hip joint and its dislocation.

A known method of treating hip dislocation in children and adolescents with paralysis (source [1]: patent RU 2392894). From the linear incision in the upper third of the thigh, the proximal femur is distinguished on the outer surface above the trochanteric region. An osteotomy is performed with the dissection of the greater trochanter along with the area of attachment of the gluteal muscles from the femur. Dissection of the overstretched capsule of the hip joint is performed. After separation of the periosteum and soft tissues with a wire saw, an osteotomy of the femur is performed directly above the small trochanter. The proximal femur, including the head and neck of the thigh, is removed. Small skewer skeletonizes. The acetabulum is revised to remove the round and transverse ligaments from it. The small skewer is set into the acetabulum, and the large skewer is fixed to the diaphysis of the femur with transosseous nodal sutures when the middle gluteal muscle is pulled

The method [1] does not provide the necessary stability of the patient during verticalization, the limb is not sufficiently supportive due to the small support area of the proximal end of the femur in the pelvic bone. In addition, this predisposes to relapse of the pain syndrome and to proximal femoral migration, especially in cases when the proximal end of the femur abuts against a dysplastic inclined acetabulum.

Known reconstructive surgery on the hip joint with pathological dislocation of the hip, according to De Palma (source [2]: De Palma AF An Improved Type of Arthroplasty of the Hip Joint // J. Bone Joint Surgery. Vol. 33A, N 4. P. 437 -446, 1951. PMID: 14824192), in which open access is made, the proximal femur is mobilized by crossing the iliopsoas, abducent, adductor muscles, short rotators, dissect the joint capsule, remove the remains of the head and neck of the thigh, process (round off) the top of the spit, set the cap on it, perform the spit osteotomy, bone fragments are developed in the frontal plane with the formation of a cervical-diaphyseal angle of 135 ° and fixed with a plate, the vertex of the trochanter is inserted into the cavity, the gluteal muscles are sutured to the outer edge of the proximal fragment.

The disadvantages of this analogue [2] are the danger of necrosis of the proximal femur due to complete intersection of the periarticular muscles, incomplete restoration of the geometry of the proximal femur without taking into account the peculiarities of the acetabulum, which does not provide stability of the joint and functioning conditions of the gluteal muscles due to a change in the location of their attachment to the femur.

A known method of treating pathological hip dislocation according to A. Axer (source [3]: Axer A, Aner A. A new technique for greater trochanteric hip arthroplasty. J Bone Joint Surgery 66B: 331-333, 1984, PMID: 6725339), in which complete intersection of the muscles surrounding the proximal femur, its reduction for 3 weeks by skeletal traction, post-operative osteotomy with a 180 ° turn of the proximal part, arthrotomy, immersion of the greater trochanter into the cavity, osteosynthesis of bone fragments by the shaft, fixation of the cut gluteal muscles to the trochanter .

However, this method [3] is significantly traumatic, involves the creation of articular ratios and orientations of the proximal femur that are unusual for a normal hip joint, which increases the risk of proximal femoral necrosis and joint instability.

A known method of treating pathological dislocation of the thigh with osteolysis of the neck and head (source [4]: patent RU 2238688). In the method, one-stage trochanteric arthroplasty is performed through two accesses, the acetabulum is freed from the first access, the muscles are peeled from the second access and the muscles are longitudinally dissected from the top of the trochanteric bone, the thigh is crossed in the underrochanteric region, maintaining the connection of the proximal fragment with the muscles, and the trochantericum is repositioned into the acetabulum the cavity, the proximal fragment is rotated in three planes until the center of the greater trochanter apex is reached in the acetabular fossa, the osteosynthesis of fragments is L-shaped the th plate end to side at an age angle, the muscles mobilized along with the periosteum are moved to the end part of the bone sawdust, and, if necessary, the supraperitoneal bone-plastic osteotomy of the pelvis is performed.

However, the known method [4] involves performing two approaches, which increases the technical complexity and aggressiveness of the intervention. Its disadvantage is the danger of developing postrepositional compression in the joint, which can lead to the development of joint stiffness.

A known method for the treatment of pathological hip dislocation (source [5]: Saeid Abrishami, Mohsen Karami, Amin Karimi, Amir Payman Soufali, Hamid Reza Aslani, Kamran Badizadeh. Greater trochanteric preserving hip arthroplasty in the treatment of infantile septic arthritis: long-term results / / J. Journal of Children's Orthopedics 2010; 4: 137-141, PMCID: PMC2839858), in which the arthrotomy, revision of the acetabulum, excision of the lateral part of the trochanter with the gluteal muscles, and mobilization of the proximal femur by intersection of the iliopsoas are performed from the two accesses. adductors, short rotators, perform ancillary osteotomy, deploy bones e fragments for immersion of the trochanteric vertex into the cavity, fix them with a plate, fix the osteotomized part of the trochanter to the outer edge of the proximal fragment, if necessary, an osteotomy of the ilium is performed as a separate step.

The disadvantages of this analogue [5] are the danger of the development of necrosis of the proximal femur due to complete intersection of the periarticular muscles, incomplete restoration of the geometry of the proximal femur, the biomechanics of the abducting muscles is not taken into account, which does not ensure the stability of the joint.

SUMMARY OF THE INVENTION

The objective of the present invention is to provide surgical treatment of pathological dislocation of the hip in children of preschool and primary school age, allowing by combining external and bone fixation, violation of the integrity of the pelvic and femur to compensate for a defect in the head and neck of the femur, to form and stabilize acceptable spatial relationships in the hip joint, to ensure the adaptation of periarticular muscles, joint components to new conditions for the functioning of the joint the possibility of developing a joint in the postoperative period.

The technical result consists in providing favorable geometric relationships in the hip joint by minimizing the integrity of the femur and pelvic bone with a reduction in the patient’s stay in the external fixation apparatus.

The technical result is achieved by the fact that in the method of treating a defect in the proximal femur, an external fixation apparatus is placed on the femur and pelvic bones, an external fixation apparatus is used to produce a closed dosed reduction of the top of the greater trochanter to the lower edge of the acetabulum, and open soft layers of soft tissue on the outer surface of the upper third of the thigh , subperiosteally separate the middle and small gluteal muscles from the apex of the greater trochanter, produce arthrotomy and revision of the acetabulum, model the shape of the apex of the greater trochanter in accordance with the size of the acetabulum, cross the femur over the small trochanter (undertrochanteric detorsion-variating osteotomy), deploy the proximal fragment of the femur in the frontal and horizontal planes, forming a neck-diaphyseal angle and the anteversion angle, fix the fragments of the bone fragment in the achieved position, set the top of the greater trochanter into the acetabulum, perform transverse supraclavicular osteotomy, and produce the transposition of the acetabulum of the hollow, tilt the acetabulum outward and anteriorly, fix the fragment of the pelvic bone to the support, move the gluteal muscles along with the periosteum to the distal end of the proximal fragment of the femur and fix, stabilize the achieved position and relieve the hip joint with an external fixation device, develop passive movements in the hip joint, after consolidation of osteotomized fragments and stability in the hip joint, the external fixation apparatus is removed, the hip enny joint fixed splints.

The above essence ensures the achievement of the claimed technical result.

The invention allows, by performing an osteotomy of an undertooth detorsion-variating optimal transposition of the gluteal muscles, to form the supporting surface of the femur, to create favorable conditions for the functioning of the abducting muscles. The used method of supraclavicular osteotomy provides a dosed transposition of the acetabular fragment, taking into account the shape of the proximal end of the thigh and the condition of the acetabulum, which ensures adaptation of the joint components and the formation of congruent articular surfaces. The prerepositional gradual lowering of the thigh with the help of the apparatus contributes to the dosed stretching and adaptation of the periarticular muscles, which makes it possible to refrain from significant mobilization of the proximal fragment, allows to maintain its connection with the muscles, thereby reducing the risk of necrosis of the proximal femur fragment and eliminating the risk of postrepositional compression of the joint. In general, the above techniques can improve the spatial-geometric relationships in the hip joint. In this case, the use of an external fixation device provides the possibility of unloading and early development of the hip joint, allows you to activate the patient from the first days after the operation, and the osseous plate allows you to limit the patient’s stay in the external fixation device, preventing the recurrence of deformation and dislocation after removing the external fixation device

The invention is illustrated by graphic materials, which show:

FIG. 1 - Scheme of osteosynthesis of the hip joint with closed lowering of the thigh;

FIG. 2 - Scheme of pervertrocheal osteotomy, subperiosteal mobilization of the gluteal muscles;

FIG. 3 - Scheme of fixation of fragments of the femur with a bone plate and an external fixation apparatus after reposition of a dislocation;

FIG. 4 - Scheme of fixation of fragments of the pelvic and femur with a bone plate and an external fixation apparatus after transposition of the cavity;

FIG. 5 - X-ray of the patient's hip joint before treatment;

FIG. 6 - X-ray of the patient's hip joint in the process of lowering the thigh;

FIG. 7 - X-ray of the patient's hip joint after reposition of the dislocation;

FIG. 8 - Radiograph of the patient's hip joint after transposition of the cavity;

FIG. 9 - Radiograph of the patient's hip joint after treatment.

In FIG. one; 2; 3; four; 5; 6; 7; 8; 9 numbers indicate:

1 - femur;

2 - the pelvic bone;

3 - support of the external fixation apparatus (femoral);

4 - support of the external fixation apparatus (pelvic);

5 - ilium;

6 - distal metaphysis of the femur;

7 - a large skewer;

8 - acetabulum;

9 - a hip joint;

10 - small skewer;

11 - proximal femur fragment;

12 - distal fragment of the femur;

13 - implant (osseous plate with screws);

14 - line of osteotomy of the femur;

15 - a fragment of the pelvic bone;

16 - the core of the external fixation apparatus;

17 - gluteal muscles;

18 - hinge assembly.

The method is as follows.

The invention is mainly used in the treatment of a proximal femoral defect in children of preschool and primary school age. In the operating room, an external fixation apparatus is placed on the femur 1 and pelvic 2 bones. To do this, install the supports 3 and 4 of the external fixation apparatus on the iliac wing 5 and the distal metaphysis 6 of the femur 1. After the operation of the external fixation apparatus, a closed dosage reduction of the top of the greater trochanter 7 to the lower edge of the acetabulum is made 8. For this, the support 3 is gradually moved relative to the support 4 with a pace of 1 mm per day, moving the proximal femur until the top of the greater trochanter 7 reaches the level of the lower edge of the acetabulum 8. After this, the patient is re-taken in opera Discount. A longitudinal incision is made along the outer surface of the hip joint 9. Soft tissues are delaminated openly along the outer surface of the upper third of the thigh. Dissect subcutaneous fatty tissue, a wide fascia of the thigh. Allocate a gap between the muscle straining the wide fascia of the thigh and the middle gluteus maximus muscle, displacing posterior the gluteus maximus muscle. Subperiosteally separate the middle and small gluteal muscles from the apex of the greater trochanter 7. For this purpose, the middle and small gluteal muscles are peeled off from the apex of the greater trochanter 7 together with the periosteum. An arthrotomy and revision of the acetabulum are performed 8. For this, the capsule of the hip joint is opened 9. The cavity of the acetabulum 8 is freed from scar tissue. The top of the greater trochanter 7 is modeled according to the size of the acetabulum 8, for this, bone tissue is cut off to form a spherical surface so that its surface is congruent with the surface of the acetabulum 8. An undertrovert detorsion-varying osteotomy is performed. The trochanteric region is isolated below the periosteum, a transverse osteotomy is performed over the small trochanter 10 - the femur is crossed over the small trochanter 10. (Fig. 2 shows the osteotomy line 14). Form the proximal 11 and distal 12 fragments of the femur 1. Fix the proximal fragment 11 of the femur with an implant - a osseous plate 13 with a wedge-shaped area. To do this, at the osteotomy site, from the distal end of the proximal fragment 11 of the femur 1, along the longitudinal axis, a blade of the plate plate 13 is introduced. The proximal fragment 11 of the femur 1 is deployed in the frontal and horizontal planes, forming a cervical-diaphyseal angle and an anversion angle. For this, the proximal fragment 11 is retracted and deflected anteriorly. Connecting with the proximal end of the distal fragment 12. Fix the proximal fragment 11 to the distal fragment 12 with a bone plate 13 to form an angle between the fragments in the frontal plane of 120 °, in the horizontal plane - 15 °. The top of the trochanteric 7 is directed into the acetabulum 8 - by abduction and bending of the thigh, the tops of the trochanteric 7 are immersed in the acetabulum 8, thus forming a movable joint of the femur and pelvic bones. By changing the position of the limb and the simultaneous axial load, the minimum abduction and minimal hip flexion are determined, at which the stability of the formed joint is maintained. In the achieved position, the proximal femur 1 and the supraverticular area of the pelvic bone 2 are connected using cantilever and arcuate curved spokes. Sutured capsule joint. The integrity of the ilium 5 of the pelvic bone 2 is violated - transverse supraclavicular osteotomy is performed. The limb is set in a functionally correct position (90 ° abduction, 180 ° extension), while simultaneously tilting the trough outward and anteriorly to the planned value. The osteotomy of the ilium 5 is fixed - a fragment of the pelvic bone 2 is fixed in the reached position by the rods 16 to the support 4. At the distal end of the proximal fragment 11 of the femur 1, the gluteal muscles mobilized together with the periosteum are moved and fixed with non-absorbable sutures. The wound is sutured in layers. They stabilize the achieved position and unload the hip joint with an external fixation device. Cantilever and arcuate curved needles are removed. The support 4 of the external fixation apparatus, mounted on the wing of the ilium 5, is connected to the support 3, mounted on the distal metaphysis of the femur 1, using rods with hinged nodes 18. Suture is applied to the capsule of the hip joint. The wound is sutured in layers. In the postoperative period, between the support 4 of the external fixation apparatus fixed on the ilium wing 5 and the support 3 fixed on the femur 1, a support distraction of 1.0 mm per week is created to relieve the hip joint 9. After two weeks, the development of passive movements in the hip joint 9 in the sagittal plane by relaxing the hinge nodes 18 of the external fixation apparatus. The external fixation device is removed after the consolidation of fragments of the ilium 5 and stabilization in the hip joint 9, after about 1.5 months. Then the hip joint is fixed with a longet and the development of movements continues.

An example of the method

The patient is 10 years old. Diagnosis: Pathological dislocation, defect of the head of the neck of the left thigh. Clinical signs of pathology: lameness, leading contracture of the left hip joint, shortening of the left lower limb. On radiographs (Fig. 5), a nacetabular dislocation of the left thigh, a defect in the head, neck of the femur, and valgus deformity at the level of the lesser trochanter are noted. Acetabular dysplasia: Acetabular index 35 °. The patient underwent surgery. In the operating room under endotracheal anesthesia, the Ilizarov apparatus supports were installed on the iliac wing and the distal metaphysis of the femur. Within 26 days, the proximal femur was gradually reduced to the lower edge of the acetabulum (Fig. 6). Then the patient is re-taken to the operating room. Under endotracheal anesthesia, a longitudinal incision was made along the outer surface of the hip joint. After dissection of the wide fascia of the thigh, a gap is distinguished between the muscle straining the wide fascia of the thigh and the middle gluteus maximus muscle, the gluteus maximus is posteriorly displaced. From the top of the greater trochanter, along with the periosteum, the middle and small gluteal muscles are detached, which are displaced upwards. Joint capsule reached. Capsulotomy performed. The cavity of the acetabulum is freed from scar tissue. The top of the greater trochanter is given a spherical shape corresponding to the size of the acetabulum. The trochanteric region is marked out subnostally, m. vastus lat, delaminated and displaced distally. A transverse osteotomy is performed above the small trochanter. From the side of the osteotomy along the axis of the proximal fragment, a blade of the DEOST plate is inserted. The proximal fragment is retracted relative to the distal by 60 ° and deflected anteriorly with the formation of an angle between the axis of the fragment and the frontal plane of 15 °. The distal fragment is connected to the end of the proximal fragment and is fixed by the plate with the formation of an angle between the fragments in the frontal plane of 120 °, in the horizontal plane of 15 °. By abduction and flexion of the thigh, the top of the spit was immersed in the acetabulum. Through the load along the axis of the thigh, the stability of the joint is controlled. Joint ratios are maintained in the abduction position of 115 ° and flexion of 160 °. The specified installation is fixed by cantilever knitting needles. Performed transverse osteotomy of the ilium. Two spokes are introduced into the distal fragment, which are curved arcuate and fixed to the support on the femur. The limb is reduced to 90 ° and bent to 180 °. This made it possible to tilt the acetabulum to the planned value (25 ° outward, 20 ° anterior). The achieved position is stabilized by the Ilizarov apparatus. For this, the arch of the apparatus, mounted on the wing of the ilium, was connected to a support mounted on the femur using rods with hinged nodes. The area of the osteotomy of the ilium is fixed by three rods. Gluteal muscles mobilized together with the periosteum are moved to the end part of the distal end of the proximal fragment and fixed with non-absorbable sutures. The wound is sutured in layers. In the postoperative period, between the support of the Ilizarov apparatus fixed on the iliac wing and the support fixed on the femur, support distraction of 1.0 mm per week was performed to relieve the hip joint. Three weeks later, the development of passive movements in the joint in the sagittal plane by relaxing the hinge nodes of the external fixation apparatus began. The external fixation device was removed 52 days after the consolidation of fragments of the ilium. Then continued fixation with a removable plaster cast, development of movements in the hip joint.

2 years after removal of the Ilizarov apparatus, the patient walks with full load on his left leg. The range of motion in the right hip joint in the sagittal plane is 60 °, in the frontal - 25 °. On the roentgenogram (Fig. 9): the proximal end of the thigh has a rounded shape, the acetabulum is oval, the angle WBS is 0 °, the articular surfaces are congruent, the neck-diaphyseal angle is 122 °, the center of the femur in the cavity is sufficient, the Vieberg angle is 30 °, SPGV 100 %

The proposed method is used by the authors to restore the function of the hip joint with pathological dislocation of the thigh in the traumatology and orthopedic department No. 11 of the Federal State Budgetary Scientific Center "VTO" named after Acad. G.A. Ilizarova of the Ministry of Health of Russia.

Claims (1)

A method of treating a proximal femoral defect, characterized in that the external fixation apparatus is placed on the femur and pelvic bones, the external fixation apparatus is used to produce a closed dosed lowering of the top of the greater trochanter to the lower edge of the acetabulum, openly layering soft tissues on the outer surface of the upper third of the thigh, subperiosteal separate the middle and small gluteal muscles from the apex of the greater trochanter, produce arthrotomy and revision of the acetabulum, simulate the shape of the apex of the pain spit in accordance with the size of the acetabulum, cross the femur over the small skewer, unfold the proximal fragment of the femur in the frontal and horizontal planes, forming a cervical-diaphyseal angle and the angle of antversion, fix the fragments of the femur with an implant in the reached position, and adjust the apex of the greater trochanter acetabulum, perform transverse acetabular osteotomy, transpose the acetabulum, tilt the acetabulum outward and anteriorly, fix a segment of the pelvic bone to the support, the gluteal muscles are moved together with the periosteum to the distal end of the proximal fragment of the femur and fix, stabilize the achieved position and unload the hip joint with an external fixation device, develop passive movements in the hip joint, after consolidation of the osteotomized fragments and achieving stability in the pelvis the external fixation apparatus is dismantled, the hip joint is fixed with a longet.

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