RU2637105C1 - Method for plasty of defects of acetabulum antero- and posterosuperior edge with structural autobone in hip joint endoprosthesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: bone bed is formed in the true acetabulum by milling cutters. The area of "undersupplication" of the endoprosthesis pelvic component in the area of acetabulum defect is estimated. Osteoperforation with spokes is performed on the acetabulum defect surface with its treatment with bone spoons. An autotransplant is made, for this, the femur head is separated, cutting across the femur neck with an electric saw, the femur head is cut across from the neck saw line into two parts, the most proper part is selected, processed with a bone clipper, bringing geometry of this part up to congruence with the acetabulum surface defect, while maintaining the cortical layer. The autotransplant is oriented with its cortical layer outwards, so that a part of the autotransplant hangs into the acetabulum area, and is preliminarily fixed with spokes in the area of the defect. The position of the autotransplant is checked and, if necessary, corrected. The autotransplant is fixed with compression screws. The overhanging part of the autotransplant is treated with spherical mills. The shape of the bone bed is controlled by placing a test cup into it. A cement-free pelvic component is installed. The pelvic component is jammed due to a tight fit with respect to the angles of inclination and antetorsion. Spokes are removed. The femoral component of the endoprosthesis is installed. The head of the femoral component is inserted into the pelvic component.

EFFECT: stability of the endoprosthesis pelvic component.

2 dwg

Description

Technical field

The invention relates to medicine, namely to orthopedics and traumatology, can be used in the surgical treatment of dysplastic and post-traumatic coxarthrosis, the treatment of patients with injuries and consequences of damage to the acetabulum.

State of the art

Injuries, as well as post-traumatic and congenital defects of the hip joint are often causes of disability. Various methods are known for treating injuries and defects of the acetabulum. Publicly available sources provide methods for transosseous, osseous, combined osteosynthesis, reconstructive endoprosthetics.

The prior art method for plastic surgery of the acetabulum with dysplasia ([1], patent RU 2207076), including cutting off the head of the femur and introducing it into the acetabulum. The severed femoral head and acetabulum are freed from the cartilage layer. The posterior-lateral section reveals the trochanteric region of the femur and the posterior wall of the capsule of the hip joint. The last U-shaped dissect. The cut flap of the capsule is taken on the holder. Dislocate from the joint and resect the head and neck of the femur. The femoral head and acetabulum are freed from cartilage. The femoral head with a pendulum saw is cut along the axis of the neck into two, and then into four equal fragments. Successively adapt each of the segments of the femoral head along the perimeter of the acetabulum. The articular side is pressed against the underlying part of the edge of the acetabulum and fixed with a screw, with the spongy side of each graft slightly extending into the cavity of the acetabulum. The acetabulum is treated with club-shaped milling cutters. A part of each graft protruding into the cavity is also cut off with a cutter, which forms a rounded bed for the installation of an implant cup. An endoprosthesis cup is installed, which presses the graft to the defect in the edge of the acetabulum. Install the leg of the endoprosthesis in the diaphysis of the thigh. Restore the integrity of the joint capsule. The wound is sutured in layers with the installation of a drainage system.

The disadvantage of this method [1] is the complete removal of cartilage from the femoral head, from which the graft is formed, the lack of treatment of the bone bed in the region of the acetabular defect, aimed at stimulating regenerative processes. As a result, sufficient conditions are not created for adequate blood supply to the defect area, conditions for increment, and organotypic reconstruction of the graft, which leads to unsatisfactory quality of the formed bone tissue regenerate and increases the risk of instability of the acetabular component of the endoprosthesis in the postoperative period.

A known method of hip arthroplasty for a bone defect in the acetabulum ([2], patent RU 2475202). Access to the hip joint. After capsulotomy, a dislocation of the femoral head is performed. The head of the femur is treated with a concave cutter with maximum preservation of the autoplastic material of the head in the form of a hemisphere, with the removal of cartilage and subchondral plate. Cross the neck of the femur. The head is removed along with the neck from the joint. The formed autograft is cut off. In the region of the acetabulum defect, a spherical bed is formed by a curved cutter, corresponding to the diameter of the autograft. An autograft is placed in the area of the defect and temporarily fixed with needles. Form the acetabulum. Remove the knitting needles. The autograft is fixed with spongy screws. The acetabular component of the endoprosthesis is installed. The femoral component of the endoprosthesis is implanted. Reduce the endoprosthesis head. The wound is sutured.

In this method [2] also complete removal of the cartilage and subchondral plate from the femoral head, from which the graft is formed, does not perforate in the area of the acetabulum defect. Sufficient conditions are not created for adequate blood supply to the defect area, conditions for increment and organotypic reconstruction of the graft, which leads to unsatisfactory quality of the formed bone tissue regenerate and increases the risk of instability of the acetabular component of the endoprosthesis in the postoperative period.

A known method of two-stage hip arthroplasty ([3], patent RU 2171643), which involves the use of external fixation of bone fragments and subsequent implantation of the components of the endoprosthesis. The first stage is the reduction of the femoral head to the level of the acetabulum with subsequent fixation. The second stage is hip replacement.

However, the method [3] is adapted for the treatment of patients with a displacement of the femoral head in the proximal direction relative to the acetabulum. Method [3] involves a long two-stage treatment. It is difficult to achieve strong fusion of the pelvic bones, which is necessary to maintain the stability of the implanted hip prosthesis. A stable position of the pelvic bones and acetabular fragments is a prerequisite for the subsequent stable implantation of the hip prosthesis.

A known method of plastic surgery of the bottom of the acetabulum ([4], patent RU 2157669). Cutting off the head of the femur, releasing it and the acetabulum from the cartilaginous layer, cutting off the proximal part of the head. A transplant is formed from a part of the head. The diameter of the sectional plane of the fragment should exceed the diameter of the acetabular bottom defect. The graft is inserted into the acetabulum, flattened against the defect from the side of the articular cavity with a plane of section. In the cavity and the part of the head protruding into it, a rounded cutter with a diameter smaller than the diameter of the acetabulum forms a bed for the endoprosthesis cup.

A known method for the replacement of the acetabulum with a defect in its bottom ([5], patent RU 2474394), including removing the femoral head, processing the acetabulum, cutting off part of the head with the subsequent formation of a graft from it, and the diameter of the sectional plane of the fragment must exceed the diameter of the defect of the acetabular bottom cavities, the placement of the formed graft in the defect of the bottom of the acetabulum. A polyhedron with the maximum possible number of faces is formed from a defect in the acetabulum bottom, then a polyhedron is formed from half of the graft on the side of its convex surface so that the shape and dimensions of the formed polyhedron correspond to the shape and dimensions of the polyhedron at the bottom of the acetabulum, and when the formed graft is placed in the defect the bottom of the acetabulum combines both polyhedra.

The disadvantage of these methods [4; 5] consists in the fact that a sufficiently strong fixation of the graft to the acetabular defect is not provided. Tunneling of the bone bed in the area of the acetabulum defect is not performed. As a result, sufficient conditions are not created for adequate blood supply to the defect area, conditions for increment, and organotypic reconstruction of the graft, which leads to unsatisfactory quality of the formed bone tissue regenerate and increases the risk of instability of the acetabular component of the endoprosthesis in the postoperative period. During installation, the pelvic component tends to loosen, the implant becomes unstable and there is a need for reconstructive implant replacement.

A known method of hip replacement for fractures and post-traumatic defects of the acetabulum ([6], patent RU 2360627). The essence of the method consists in expanded access to the joint, removal of the head, implantation of the pelvic and femoral components of the prosthesis, conducting tests for the direction and stability of the prosthesis, replacing the rasp with the femoral component of the prosthesis, setting the prosthesis head into the cavity and layer-by-layer wound closure. In this case, an osteotomy of the femoral neck and removal of the head without the use of a screw extractor are performed. Then process the cavity to the cancellous bone and determine the size of the localization of the acetabulum. In addition, the resected femoral head is treated to remove cartilage and the subchondral plate. Then it is placed in the treated cavity with the overlapping zone of its defect. Then, the implantation bed of the pelvic component is modeled from the head, which is fixed with spongy screws to the acetabulum. Try and install a standard pelvic component. The use of this invention allows for reliable primary fixation of the components of a standard endoprosthesis for fractures and post-traumatic defects of the acetabulum.

The disadvantage of this method [6] is the complete removal of the cartilage and the subchondral plate from the femoral head from which the graft is formed, the lack of processing of the bone bed in the area of the acetabular defect, aimed at stimulating regenerative processes, such as osteperforation (tunneling). As a result, sufficient conditions are not created for adequate blood supply to the defect area, conditions for increment, and organotypic reconstruction of the graft, which leads to unsatisfactory quality of the formed bone tissue regenerate and increases the risk of instability of the acetabular component of the endoprosthesis in the postoperative period.

From the prior art it is clear that the development and implementation of new, combined, organ-saving methods of treating congenital and acquired pathology of the hip joint is an urgent task of modern traumatology, since there are no methods that fully satisfy all needs.

SUMMARY OF THE INVENTION

The objective of the invention is the need to expand the existing operational set of methods for plastic surgery of the defect of the anterior and posterior superior edges of the acetabulum with structural autologous bone during hip joint endoprosthetics in order to improve the quality and effectiveness of treatment. Ensuring the replacement of the acetabulum defect with structural autologous bone, providing conditions for the transplantation of the graft with the pelvic bone, the formation of regenerate, organotypic reconstruction of the graft and adjacent bone tissue with the formation of a full bone mass. Ensuring the possibility of implantation and jamming of the pelvic component of the endoprosthesis (cup) due to tight fit (press-fit) in the true acetabular region, with the restoration of the rotation point of the hip joint.

The technical result consists in ensuring the increment and restructuring of the autograft filling the acetabulum defect, ensuring complete osseointegration and stability of the pelvic component of the endoprosthesis, restoring normal biomechanical conditions for the functioning of the hip joint. In general, the technical solution allows us to solve the problem. The risk of instability of the pelvic component of the endoprosthesis after its implantation is reduced. The survival of the hip joint prosthesis is ensured.

The technical result is achieved by the fact that in the method of plasticity of the defect of the anterior- and posterior-upper edge of the acetabulum with structural autobone during hip joint replacement, access to the hip joint is made, the bone bed is formed in the true acetabulum with milling cutters, the area of "under-covering" of the pelvic component of the endoprosthesis is evaluated areas of the acetabulum defect, perform osteoperforation with the needles of the surface of the acetabulum defect and treat it with bone spoons, make an autotransl antat. To do this, the femoral head is separated by cutting an electric saw across the neck of the femur; from the sawdust side, the neck is cut across the femoral head into two parts. The most preserved part is selected, it is treated with bone nippers, bringing the geometric shape of this part to congruency with the surface of the acetabular defect, while maintaining the cortical layer of the head. The autograft is oriented outwardly with the cortical layer, so that part of the autograft hangs in the acetabulum and is pre-fixed with needles in the area of the defect. Check the position of the autograft, if necessary, correct. The autograft is fixed with compression (spongy) screws. The hanging part of the autograft is treated with spherical cutters. The shape of the bone bed is controlled by placing a test cup in it. Provide a complete bone bed for the pelvic component of the endoprosthesis. The cementless pelvic component is installed. Pelvic component is jammed due to tight fit with observance of tilt angles and antetorsia. The spokes are removed. The femoral component of the endoprosthesis is installed, the head of the femoral component is inserted into the pelvic component, the wounds are drained and sutured.

The method provides an autograft with minimal loss of bone mass, creating a full contact across the entire surface between the autograft and the bone bed in the area of the acetabulum defect. Osteoperforation activates blood flow, accelerates metabolic processes, contact with the spongy surface of the autograft contributes to organotypic bone remodeling, formation of bone regenerate, full graft ingrowth and the formation of a bone mass around the hip joint prosthesis cup. Which, combined with centering in the true acetabular region, ensures a stable installation of the pelvic component of the endoprosthesis, its micromotion is reduced, the survival rate of the endoprosthesis is increased, the likelihood of the need for revision endoprosthetics is reduced, and the time of bone grafting is reduced.

The invention is illustrated by graphic materials, which show:

FIG. 1 - A copy of the x-ray of the patient's left hip joint before treatment;

FIG. 2 - A copy of the x-ray of the patient's left hip joint after treatment.

The method is as follows.

The method is used for hip arthroplasty. Access to the hip joint. In the patient's “lying on their side” position, extended access to the joint is performed to visualize the hip joint and the marginal defect of the acetabulum. The trochanteric region is exposed in layers. With the help of an electric knife, the middle and small gluteal muscles are dissected in the projection of the greater trochanter. The joint capsule is dissected. The shape and dimensions of the acetabulum defect are determined. In the true acetabulum, a bone bed is formed by milling cutters, alternately using special milling cutters to process the acetabulum to the cancellous bone and good immersion of the milling cutter. The area of "under-covering" of the pelvic component of the endoprosthesis is estimated, for this a test cup is installed in the bed, its stability, planting density, and the required volume of bone grafting of the defect area are determined. The necessary shape and dimensions of the autograft are determined to replace the acetabulum defect and the formation of the bone mass necessary to cover the area of "under-coverage" of the test cup. The test cup is removed. Osteoperforation is made with the needles of the surface of the acetabulum defect, to a depth of subchondral cancellous bone and its processing with bone spoons for cleansing bone cysts, the remnants of cartilage and scar tissue are removed. An autograft is made. To do this, the femoral head is separated by cutting an electric saw across the neck of the femur. A bone autograft is formed from the head, corresponding in geometry and size to an acetabulum defect. On the sawdust side of the neck, the femoral head is cut across into two parts. The most preserved part is selected, it is processed with bone nippers, bringing the geometric shape of this part to congruence with the surface of the defect. At the same time, the cortical layer of the head is retained. The autograft is oriented outwardly with a cortical layer so that part of it hangs in the acetabulum and is pre-fixed with needles in the area of the defect. Check the position of the autograft, if necessary, correct. The autograft is fixed with two or three compression (spongy) screws. Preservation of the cortical layer and orientation of the autograft with the cortical layer to the outside ensures the creation of compression efforts by means of compression screws, due to the stop of their heads in the cortical layer of the autograft. The cortical layer prevents the screw heads from sinking into the autograft. Re-process the acetabulum with a fixed autograft in it. The hanging part of the autograft is treated with spherical cutters. The shape of the bone bed is controlled by placing a test cup in it, and a full bone bed is provided for the pelvic component of the endoprosthesis. With a specially designed tool, the cementless pelvic component of the endoprosthesis is installed, it is jammed due to tight fit, observing the angles of inclination and antetorsia. The angle to the frontal plane is from 40 to 50 ° and the angle to the sagittal plane is from 10 to 20 °. The spokes are removed. Establish the femoral component of the endoprosthesis. For implantation of the femoral component, the canal of the femur is treated with rasps. The rasp is removed and the cementless femoral component of the endoprosthesis corresponding to the size of the rasp is inserted into the proximal fragment. A functional test is carried out on the stability of the prosthesis in a cavity with modular heads, the size of the head necessary for implantation is determined, and the head is installed. The femoral component head is inserted into the pelvic component. The wound is washed with saline, layered sutures are applied to the wound, the sutures on the skin are closed with aseptic dressings.

Clinical example

Patient K., 57 years old.

Diagnosis: left-sided coxarthrosis of stage III, subtotal defect of the roof and anterior edge of the acetabulum, subluxation of the thigh of Crowe stage III (Fig. 1). Upon examination of the patient, the presence of pain and restriction of movements in the area of the left hip joint were determined.

Conducted computed tomography of the pelvis. From the images from a computer tomograph, the shape and dimensions of the defect in the acetabulum were previously determined. According to the state of the hip joint, the need for endoprosthetics was determined. They planned the course of surgical intervention. The patient was taken to the operating room. Under anesthesia, after processing the surgical field, access to the hip joint was made. In the “lying on the side” position of the patient, extended access to the joint was performed to visualize the hip joint and the marginal defect of the acetabulum. Layered the trochanteric layer in layers. With the help of an electric knife, the middle and small gluteal muscles were cut in the projection of the greater trochanter. The capsule of the joint was dissected. The geometric shape was visually determined and the dimensions of the acetabulum defect were determined using a measuring tool. In the true acetabulum, a bone bed was formed by cutters, and the acetabulum was alternately processed with special cutters to the cancellous bone and the cutter was well immersed. We estimated the area of "under-covering" of the pelvic component of the endoprosthesis; for this, we installed a test cup in the bed, determined its stability, planting density, and the required volume of bone grafting of the defect area. The necessary geometric shape and dimensions of the autograft were determined, which are necessary to replace the acetabulum defect, the formation of the bone mass and cover the area of "under-coverage" of the test cup. The test cup was removed. They performed osteoperforation with the needles of the surface of the acetabulum defect, to a depth to the subchondral cancellous bone and processed it with bone spoons to clean the bone cysts, removing the remnants of cartilage and scar tissue. An autograft was made. For this, an electric saw was cut across the neck of the femur, and the femoral head was separated. A bone autograft was formed from the head, corresponding in geometric shape and size to an acetabulum defect. On the sawdust side of the neck, the femoral head was cut transversely into two unequal parts. We chose the most preserved most part, processed it with bone nippers, brought the geometric shape of this part to congruence with the surface of the defect. At the same time, the cortical layer of the head was preserved. The autograft was oriented outwardly with a cortical layer, so that part of it hung in the acetabulum, and previously fixed with knitting needles in the area of the defect. Checked the position of the autograft. The autograft was fixed with two compression (spongy) screws to the pelvic bone. Re-treated with a mill an acetabulum and an overhanging part of the autograft. The shape of the bone bed was monitored by periodically placing a test cup in it, providing a complete bone bed for the pelvic component of the endoprosthesis. Using a specially designed tool, the cementless pelvic component of the endoprosthesis was installed, jammed due to tight fit. The angle of inclination to the frontal plane of 45 ° and the angle of inclination to the sagittal plane of 15 ° were established. The pelvic component of the endoprosthesis (cup) was fixed with two spongy screws. Knitting needles removed. The femoral component of the endoprosthesis was installed. The femoral component head was inserted into the pelvic component. The wound was washed with saline, layered stitches on the wound, and covered with aseptic dressings. In the postoperative period, they underwent a course of rehabilitation treatment. Conducted physical therapy classes. They removed postoperative edema and pain by exposure to optical radiation with a wavelength of 540 nm, contact labile in the area of the operated hip joint for 10 minutes, 10 procedures. At the control examination, after 2 years, signs of bone increment and autograft restructuring are observed radiographically, a single bone mass is formed around the pelvic component of the endoprosthesis, the center of rotation of the hip joint is restored, the endoprosthesis is stable (Fig. 2).

The method is used by the authors in the FSBI "RSC WTO named. G.A. Ilizarova »Ministry of Health of Russia.

Claims (1)

A method for repairing anterior and posterior superior defects of the acetabulum with structural autobone during hip replacement, characterized by the fact that they access the hip joint, form a bone bed in the true acetabulum with milling cutters, evaluate the area of "undercoating" of the pelvic component of the endoprosthesis in the region of the pelvic endoprosthesis hollows, perform osteoperforation with the needles of the surface of the acetabulum defect and treat it with bone spoons, make an autograft, for this eating the femoral head by cutting an electric saw across the femoral neck; from the sawdust side, cutting the femoral head across the femoral head into two parts, choosing the most preserved part, processing it with bone cutters, bringing the geometric shape of this part to congruency with the surface of the acetabulum defect, while retain the cortical layer of the head, the autograft is oriented outwardly with the cortical layer, so that part of the autograft hangs in the acetabulum, and pre-fixed pizza into the defect area, check the position of the autograft, correct it if necessary, fix the autograft with compression screws, process the overhanging part of the autograft with spherical cutters, control the shape of the bone bed, place a test cup in it, provide a full bone bed for the pelvic component of the endoprosthesis, install the cementless component the pelvic component is jammed due to a tight fit, observing the angles of inclination and antetorsia, the needles are removed, the beams are installed renny component endoprosthesis femoral component head to reduce a pelvic component, the wound is drained and sutured.

Images