RU2637290C1 - Method for femoral head defect treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: osteotomy of the large trochanter apex is performed. Surgical dislocation of the femoral head is performed from the acetabulum. The cartilaginous cover of the head is dissected along the anterior surface. The periosteum is dissected along the neck axis. The periosteal-chondral flap is peeled off. Longitudinal osteotomy of the lateral part of the head and neck and transverse osteotomy of the lateral part of the neck base are performed. The resulting bone fragment is removed. Spherical shape is provided for the lateral edge of the head. The wound surface of the head and neck is covered with a periosteal-chondral flap. The periosteal-chondral flap is fixed by sutures and screws to the head. The head is inserted into the acetabulum. The large trochanter is transposed. The obtained position of the large trochanter is fixed by screws. An external fixation device is mounted on the pelvic and femoral bones. The obtained position is stabilized and the hip joint is unloaded. Postoperatively, development of passive movements in the hip joint is performed.

EFFECT: method allows to improve spatial relationships in the hip joint, provide the possibility of joint unloading and development in the postoperative period.

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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 a femoral head defect in schoolchildren, using means of external and internal bone fixation.

State of the art

A femoral head defect is a violation of the shape, structure, and size of the femoral head due to aseptic necrosis of various etiologies. This condition contributes to the disruption of the normal relations between the components of the hip joint, limits the mobility of the joint, contributes to the development of femoroacetabular impigement (a condition in which there is a collision of the bones that form the joint), the progression of arthrosis.

Known operation is a modeling resection of the femoral head (hailectomy) (source [1]: McKay DW, Cheilectomy of the hip // Orthop Clin North Am. 1980 Jan; 1 1 (1): 141-160. PMID: 7360498), in which The iliac-femoral approach produces arthrotomy, and the protruding parts of the head and neck are resected using a chisel.

The disadvantage of this analogue [1] is the danger of the progression of arthrosis due to damage to the articular cartilage. With a pronounced flattening of the head, the presented technology does not significantly affect its shape.

A known method of treating deformity of the femoral head (source [2]: EP Kuznechikhin, EV Ulrich. Surgical treatment of children with diseases and deformations of the musculoskeletal system, Moscow, "Medicine", 2004; 356-359), with where the apex of the greater trochanter is isolated and cut off, displaced upward, an arthrotomy is performed, the cartilage cover is dissected and peeled off at the level of the protrusion of the head, the protruding sections are removed with the help of a chisel and Volkman spoon, the defect formed is replaced with an autograft, the cartilaginous flap is fixed with sutures.

However, the known method [2] does not allow to improve the shape of the head with its pronounced deformation, does not make it possible to change the state of the femoral neck, which creates the conditions for maintaining the impidement between the cavity and the neck.

There is a method of treating deformity of the head (source [3]: copyright certificate SU 1388015). In this method [3], trepanation is performed in the area of the lesions of the hip joint, then the cartilage base with part of the bone tissue is exfoliated around the circumference of the head, and then a bone-cartilaginous demineralized allograft is introduced subchondrally into it, which exceeds the diameter of the removed segment of the femoral head.

There is a method of subchondral autoplasty of the femoral head (source [4], patent RU 2257865), in which a trepanation channel is formed in the anterior part of the femoral neck in the direction of the defect, through which necrotic portions of the femoral head are subchondrally removed, a crushed autograft is used as a graft, taken from the ilium wing.

However, the known methods [3, 4] are effective in the presence of a limited subchondral defect of the head and are designed to prevent deformation of the head. Under the conditions of the formed pronounced deformation, they do not affect the restoration of the spherical articular surface of the femoral head.

A known method of modeling osteotomy of the femoral head (source [5]: Leunig M, Ganz R., Relative neck lengthening and intracapital osteotomy for severe perthes and perthes-like deformities // Bulletin of the NYU Hospital for Joint Diseases 2011; 69 (Suppl. 1 ): S62-7, PMID: 22035488). Method [5] includes performing surgical dislocation of the thigh, performing two osteotomies of the head and neck in the sagittal plane with the formation of 3 fragments, removing the middle fragment and osteosynthesis of the medial and lateral fragments, which improves the shape of the femoral head.

The disadvantage of this method [5] is the impossibility of its use in cases of structural disruption and severe deformation of the lateral parts of the head and neck of the thigh.

SUMMARY OF THE INVENTION

The objective of the present invention is to provide surgical treatment of a head defect in school-age children, which makes it possible to compensate for a head defect, eliminate deformation of the head and neck of the femur, form congruent articular surfaces, which will improve spatial relationships in the hip joint and joint function, provide the possibility of unloading and joint development in the postoperative period.

The technical result is to ensure the functioning of the hip joint with a defect of the femoral head.

The technical result is achieved by the fact that in the method of treating a defect of the femoral head, preoperative planning is carried out, the location and size of the osteotomy of the head and neck of the femur are determined by x-ray, access to the proximal femur, osteotomy of the apex of the greater trochanter is performed, and surgical dislocation of the femoral head from acetabulum, the cartilaginous cover of the head is dissected along the anteroposterior surface, the periosteum is cut along the axis of the neck, the periosteal cartilage is exfoliated th flap, in the sagittal plane, an L-shaped osteotomy of the anterolateral part of the head and neck is performed, the obtained bone fragment is removed, spherical shape is given to the lateral edge of the head, the wound surface of the head and neck is covered with a periosteal cartilaginous flap, fixed with the periosteal cartilaginous cartilage and , set the head into the acetabulum, transpose the greater trochanter, fix the achieved position of the greater trochanter with screws, and install the external fixation device on the pelvic and the dermal bones, stabilize the achieved position and unload the hip joint, in the postoperative period, develop passive movements in the hip joint.

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

The invention allows for the normal functioning of the hip joint by creating favorable geometric relationships in the hip joint by changing the shape of the head, improving the congruence of the articular surfaces of the head and acetabulum, changing the point of application of the strength of the gluteal muscles, which, while maintaining articular cartilage, helps to slow the progression of arthrosis. The movement of the greater trochanter creates a redirection of the vector of forces acting on the side of the gluteal muscles, and creates favorable conditions for the functioning of the hip joint. In general, the above techniques can improve the spatial-geometric relationships in the hip joint and ensure its function. At the same time, the use of an external fixation apparatus provides the possibility of unloading and early development of the hip joint, and makes it possible to activate the patient from the first days after the operation. The invention is illustrated by graphic materials, which show:

FIG. 1 - Schematic representation of a defect in the head and deformation of the proximal femur;

FIG. 2 - Scheme of osteotomy of the apex of the greater trochanter and the formation of periosteal-cartilaginous flap;

FIG. 3 - Scheme of osteotomy of the lateral part of the head and neck;

FIG. 4 - Scheme of fixation of the periosteal-cartilaginous flap and the apex of the greater trochanter;

FIG. 5 - X-ray of the femoral head, before treatment;

FIG. 6 - X-ray of the femoral head, after osteotomy;

FIG. 7 - X-ray of the hip during treatment;

FIG. 8 - X-ray of the femoral head, frontal plane, after treatment;

FIG. 9 - X-ray of the femoral head, sagittal plane, after treatment.

The method is as follows.

The invention is used in the treatment of school-aged children with a defect of the femoral head, expressed by its flattening (Fig. 1), accompanied by structural disorders that developed as a result of aseptic necrosis of various etiologies.

In the course of preoperative design, radiographs determine the estimated location of the osteotomy of the head and neck of the femur, the size of the osteotomy line, the size and shape of the femoral head necessary for the normal functioning of the hip joint, compare the horizontal size of the head and the length of the acetabulum arch, size of the head, after removing it parts should correspond to the size of the acetabulum. Access the proximal femur. A longitudinal incision is made along the outer surface of the hip joint. Dissect the wide fascia of the thigh, isolate the posterior outer edge of the trochanteric region, produce an osteotomy of the apex of the greater trochanter 1 (Fig. 2). In the interval between the piriformis and gluteus medius, a capsule of the hip joint is reached. A capsulotomy is performed and the femoral head is dislocated from the acetabulum. On the front surface perform dissection of the cartilage of the head. Along the axis of the neck, the periosteum is dissected. Peel and form the periosteal-cartilaginous flap 2 (Fig. 2). Subperiosteally, the anterior external section of the neck and femoral head is isolated. A longitudinal osteotomy of the lateral part of the head and neck is performed in the sagittal plane and a transverse osteotomy of the lateral part of the base of the neck, as a result of which the osteotomy line 3 acquires an L-shape in direct projection (Fig. 3). The resulting lateral bone fragment is removed. Using a chisel, they give a spherical shape to the lateral edge of the head. If necessary, bone protrusions are removed on the front of the head and neck. The periosteal-cartilaginous flap is placed on the osteotomy surface of the head and neck. The cartilaginous part is fixed with screws 4 (Fig. 4), the periosteum is sutured. Drive the head into the acetabulum. Sutured capsule. Carry out the transposition of the greater trochanter. The top of the greater trochanter is displaced laterally and distally until the correct relations between the head and trochanter are restored (the location of the greater trochanter relative to the head should repeat the location of the greater trochanter for a healthy femur, for example, femur, symmetrical limb), fix it with two screws 5 (Fig. 4). The wound is sutured in layers. The external fixation apparatus is fixed on the iliac wing, support 6 (Fig. 4) and the distal femur fragment, support 7 (Fig. 4), in the metaphysis. In this case, the thigh is set in the position of bringing 95 degrees, extension 180 degrees and internal rotation from 10 to 15 degrees. They stabilize the achieved position and unload the hip joint with an external fixation device. The support 6 (arc) of the external fixation apparatus, mounted on the iliac wing, is connected to the support 7, mounted on the distal metaphysis of the femur with the help of rods with hinged nodes 8 (Fig. 4). In the postoperative period, between the support 6 of the external fixation apparatus fixed on the iliac wing and the support 7 fixed on the femur, support distraction of 1.0 mm per week is performed to relieve the hip joint. After about two weeks, the development of passive movements in the hip joint in the sagittal plane begins by relaxing the hinge nodes of the external fixation apparatus. The external fixation device is removed after 30-40 days. Then the hip joint is fixed with a longet and the development of movements continues.

An example of the method

The patient is 11 years old. Diagnosis: Perthes disease, stage V, head defect, subluxation of the left thigh. Clinical signs of pathology: lameness, pronounced restriction of flexion and abduction of the left thigh. In the radiograph (Fig. 5), the head of the left thigh is sharply flattened, the outer edge is pointed, the neck is shortened, ATD 5.7 mm, subluxation of the left thigh, discontinuity of the Chanton line 0.5 cm, lateral displacement 25%, Viberg angle 5 °. The length of the arch from the outer edge of the U-shaped cartilage to the outer edge of the cavity is 26.9 mm; the horizontal size of the head is 37.8 mm. The approximate width of the resected fragment is 12 mm. The patient underwent surgery.

A longitudinal incision was made along the outer surface of the hip joint. After dissection of the wide fascia of the thigh, the posterior outer edge of the trochanteric region is distinguished, an osteotomy of the apex of the greater trochanter is performed. In the interval between the piriform and middle gluteus muscle, a capsule is reached. Capsulotomy performed. Through casting and external rotation, the head is dislocated from the acetabulum. A cartilaginous cover is longitudinally dissected along the anteroposterior surface of the head. The periosteum is dissected along the axis of the neck. The periosteal cartilaginous flap is peeled and formed. Subperiosteally, the anterior outer section of the neck and head is highlighted. In accordance with preoperative calculations, the boundaries of the resected external fragment of the head were determined. In the sagittal plane, a longitudinal osteotomy of the lateral part of the head and neck and a transverse osteotomy of the lateral part of the base of the neck were performed (Fig. 6). The resulting lateral fragment 12 mm wide was removed. The lateral edge of the head is rounded. The revision of the anterior sections of the head and neck. The periosteal-cartilaginous flap is laid on the osteotomy surface of the head and neck. The cartilaginous part is fixed with three screws 10 × 1.2 mm, the periosteum is sutured with non-absorbable sutures. The head is set into the acetabulum. The capsule is sutured. The top of the greater trochanter is offset laterally and distally, fixed with two screws. The wound is sutured in layers. An external fixation apparatus (Ilizarov apparatus) was installed on the iliac wing and the distal femur fragment in the metaphysis. The thigh is set in the position of casting 95 degrees, extension 180 degrees and internal rotation of 15 degrees. The support of the external fixation apparatus, mounted on the iliac wing, was connected to the support mounted on the distal metaphysis of the femur using rods with hinged nodes (Fig. 7 - the support on the iliac wing is visible). In the postoperative period, between the support of the external fixation apparatus fixed on the ilium wing and the support fixed on the femur, support distraction of 1.0 mm per week was performed to relieve the hip joint. After 18 days, the development of movements in the joint in the sagittal plane by relaxing the hinge nodes of the external fixation apparatus began. The external fixation device was dismantled after 40 days. Then the hip joint was fixed with a longet and continued to develop movements.

2 years after removal of the Ilizarov apparatus, the patient walks with full load on her right leg. The range of motion in the right hip joint in the sagittal plane is 110 degrees, in the frontal - 35 degrees. On the radiograph (Fig. 8; 9): the head of the left thigh has an oval shape, the neck length is restored, ATD 18 mm, SDU 128 °. The length of the arch from the outer edge of the U-shaped cartilage to the outer edge of the cavity is 29.8 mm; the horizontal size of the head is 30 mm. The centering is sufficient: the Chanton line is continuous, the lateral displacement is 0%, the Vieberg angle is 25 °.

The proposed method is used by the authors in the traumatology and orthopedic department No. 11 of FSBI "RRC" WTO "named after Acad. G.A. Ilizarova of the Ministry of Health of Russia.

Claims (1)

A method for treating a femoral head defect, characterized in that preoperative planning is carried out, radiographs determine the location and size of the osteotomy of the head and neck of the femur, access the proximal femur, perform osteotomy of the apex of the greater trochanter, perform surgical dislocation of the femoral head from the acetabulum , the cartilaginous cover of the head is dissected along the anteroposterior surface, the periosteum is cut along the axis of the neck, the periosteal-cartilaginous flap is exfoliated, t longitudinal osteotomy of the lateral part of the head and neck and transverse osteotomy of the lateral part of the base of the neck, remove the obtained bone fragment, give a spherical shape to the lateral edge of the head, wound the surface of the head and neck with a periosteal cartilaginous flap, fix it with the periosteal cartilaginous and cartilaginous graft, set the head into the acetabulum, transpose the greater trochanter, fix the achieved position of the greater trochanter with screws, and install the external fixation device on the pelvis and-hand femur to stabilize the position reached and unload the hip joint, in the postoperative period covers the development of passive movements in the hip joint.

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