RU2644935C1 - Method for hip arthroplasty in a high-energy double column acetabular fracture with dislocation of central type - Google Patents

Abstract

FIELD: medical equipment.

SUBSTANCE: invention relates to traumatology and orthopedics and can be used for hip arthroplasty in a high-energy double column acetabular fracture with dislocation of central type. Method comprises resecting a femoral head and femoral neck, removing them from the acetabulum. Transplant from the femoral head is being formed by sawing off the neck from the head and a osteochondral fragment from the opposite side of the head. On the side of sawing off the neck from the head, the bone fragment is being resected at an angle of 30° to the sawing plane and occupying 1/3 of the sawing area. Cartilagineus layer is being removed from the head. Cartilagineus layer of the acetabulum is being removed without injuring the protruding fragment of one of its walls. Treated transplant of the femoral head is being immersed in the acetabulum with turning the transplant in the frontal plane by 180° and then turning in the sagittal plane so that canted surface of the transplant formed as a result of neck sawing is being placed on the protruding bone fragment of the acetabulum. Treated transplant is being impacted into the cavity, treated with a hemispherical cutter until the moment of forming a round shape with a 3–5 mm transplant thickness. Wall defects are being eliminated by impaction of bone chips obtained after cutting an acetabulum with the placed transplant. Support ring is being mounted with screws. Polyethylene monoblock of the endoprosthesis is being placed on the bone cement in the outer hemisphere of the support ring. Endoprosthesis leg is being mounted in the femoral bone canal, the endoprosthesis head is being inserted on the leg cone and inserted into the acetabulum.

EFFECT: method allows to reduce traumatism, create conditions for full consolidation of the acetabular fracture, provide early rehabilitation of the patient.

1 cl, 11 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of patients with a high-energy two-column acetabular fracture caused by a central dislocation of the hip.

There are many ways to reconstruct the acetabulum when it is destroyed due to prolapse of the femoral head into the pelvic cavity after a high-energy injury: a fall from a height, road traffic and work-related injuries. As a rule, traumatologists choose osteosynthesis of the pelvic bones with restoration of the integrity of the pelvic ring: external fixation devices, bone osteosynthesis with plates and screws, a combination of different methods. These are long (3-6 hours) and very traumatic operations.

According to some authors, surgical interventions in the area of the acetabulum are often quite large-scale, long and traumatic, so you need to weigh the pros and cons in order to decide on them. On the other hand, both acetabular injuries, and especially operations in many victims, contribute to the development of aseptic necrosis of the femoral head, which subsequently requires hip replacement. Therefore, good results of surgical treatment can be expected in no more than half of the operated patients, and with an increase in the period from the time of the operation, the results will be worse, as deforming arthrosis of the hip joint progresses. If after 2 years, aseptic necrosis and deforming arthrosis are observed in every 2 victims, then after 10 years - in 70% of the examined patients, and after 20 years - with rare exception, in all.

Various surgical approaches to the acetabular fracture are described in order to perform osteosynthesis of the pelvic bones with plates and screws, often resorting to traumatic osteotomies of the greater trochanter of the thigh or / and iliac wing (A.A. Grin, A.V. Runkov, I.L. Shlykov, Choice of surgical access in the treatment of two-column acetabular fractures, Traumatology and Orthopedics of Russia, 2014; (1): 92-97).

Such types of surgical interventions can entail a number of negative consequences for the patient:

- fatal outcome - 3.2-7.5% due to pulmonary embolism, acute cardiovascular and cerebrovascular insufficiency due to post-traumatic (1.0-1.5 liters of blood loss) and postoperative (1.0-2, 0 liter of blood loss) anemia;

- post-traumatic deforming arthrosis, aseptic necrosis of the femoral head - 16.6-38.5%;

- heterotopic ossification of soft tissues surrounding the hip joint - 26-42.5%;

- damage to the pelvic vessels and nerves - 7-12%;

- disability of the patient - 50% or more;

- repeated surgical intervention due to the development of avascular necrosis of the femoral head and acetabulum after osteosynthesis (hip arthroplasty) - 26-38%.

Considering the options for reconstructive restoration of the acetabulum with two-column pelvic fractures, a method is known in which access to the anterior column is performed according to Zhude-Leturnel. A revision, anatomically correct reposition, and metal osteosynthesis of a fracture of the anterior column of the acetabulum are performed. The patient is turned on his stomach. From the Kocher-Langenbek section, revision, reposition and metal osteosynthesis of a fracture of the posterior column of the acetabulum are performed. On the second day after metal osteosynthesis of both columns of the acetabulum of the patient activate - put on crutches. The method allows to ensure anatomically correct reposition, improve outcomes of fracture treatment (US Pat. RF No. 2581270).

This method is characterized by all the disadvantages described above: greater trauma and blood loss, the duration of the operation is more than 3 hours, skeletonization of bone fragments leads to aseptic necrosis of the hollow and head of the thigh, the risk of damage to the neurovascular bundle, inflammation of the postoperative wound.

There is another method for the treatment of polyfocal pelvic fractures with acetabular fractures using an external fixation device, including reposition of bone fragments and their fixation. According to the invention, separate reposition of the fragments of the pelvic bones through the threaded rods is carried out, while at least one threaded rod is inserted into each bone fragment and secured separately to the external elements of the device, the threaded rods being inserted into the sacrum body through the base of the lateral ridges, and from the displaced bone fragment of the acetabulum the hollows and heads of the femur form a single block with the help of knitting needles, which are displaced in the right direction behind the femur, after which the fracture is fixed through a puncture in the skin they are pressed with a compression screw or a rod that introduces perpendicular to the fracture line (US Pat. RF No. 2157669).

The presented method for stabilization of the pelvic ring is very cumbersome and difficult to tolerate by patients - for a long time (about 3-6 months of immobilization in the device), there are obvious limitations in the supine and sitting position. The risks of soft tissue inflammation in the area of installation of screws and spokes are not excluded, and, as a result, the presence of a long infection process leads to bone resorption and loosening of the screws, loss of reposition of bone fragments.

There is also a method of stabilizing an acetabular fracture with screws (RF patent No. 2547803). The method includes a 1 cm skin incision in the region of the apex of the ischial tubercle. Perform a closed reposition. After achieving satisfactory contact of the fragments under the control of the electron-optical transducer (EOP), a 3 mm screw of the required length is drawn through the fracture line outside the cavity of the hip joint through the fracture line outside the cavity of the hip joint to the ileal body until inter-fragment compression is achieved. The guide vanes open and the collet guide is removed from the wound. Through the same incision in the region of the apex of the sciatic tubercle, a second 3 mm screw is drawn. The next step, through a skin incision of 1 cm, from a point 2 cm above the level of the acetabulum, through the body of the ilium and the fracture line, one 3 mm screw is inserted into the upper branch of the pubic bone. The method allows to increase the stability of osteosynthesis.

Despite the fact that the method is less traumatic and the intervention is short-lived, the method has drawbacks. Namely, it is impossible to achieve full stability of the acetabular fracture with screws, which explains the postoperative management of the patient - eliminating the load on the leg for up to 8 months. The method does not include bone grafting of acetabular defects. In this case, the blood circulation of the femoral head is not investigated, which may entail the development of aseptic necrosis of the hollow and femoral head in the period from 6 to 12 months after surgery, and this will lead to hip joint arthroplasty.

Of the available sources of information, the authors were unable to find the closest analogue.

The objective of the proposed technical solution is to perform total hip arthroplasty without reduction and bone osteosynthesis of bone fragments with plates and screws for a two-column acetabular fracture and central hip dislocation.

The technical result is to reduce the morbidity of surgical access, the creation of conditions for the full consolidation of an acetabular fracture in the early stages, early rehabilitation of the patient.

The technical result is achieved through the use of the method of hip replacement with a high-energy two-column fracture of the acetabulum with a central dislocation of the hip, characterized by performing front access to the hip joint, arthrotomy, then the head and neck of the thigh are resected, they are removed from the acetabulum, the head is removed, the sawing off her neck and on the opposite side of the head sawdust - a bone-cartilaginous fragment, on the side of the neck sawdust from the head a bone fragment is resected at an angle of 30 ° to the plane of the sawdust and occupying 1/3 of the area of the sawdust, the head is freed from the cartilaginous layer, the cartilaginous layer of the acetabulum is removed without injuring the fragment of one of its walls protruding in it, the processed femoral head transplant is immersed in the acetabulum with its rotation in the frontal plane by 180 ° and then turning in the sagittal plane so that the beveled surface of the graft resulting from cervical sawdust is mounted on the protruding bone fracture ok acetabulum, the treated graft is imposed into the cavity, treated with a hemispherical cutter until a round shape is formed with a graft thickness of 3-5 mm, the wall defects are eliminated by impaction of bone chips obtained after milling of the acetabulum with the graft installed, then the support ring is screwed onto bone cement is installed in the outer hemisphere of the support ring a polyethylene endoprosthesis monoblock is installed, an endoprosthesis leg is installed in the femoral canal, on the cone Roy pushed onto the implant and reduce a head it into the acetabulum, drained and sutured the wound in layers.

Various designs of acetabular bowls of hip arthroplasty are known, developed both by domestic (US Pat. RF No. 2108071) and foreign firms (firms DePuy, Zimmer, Biomet, Implantcast, Linc).

To implement the proposed method, the acetabular component of the hip joint endoprosthesis was chosen, which is used in conjunction with the femoral component and is intended to restore the supporting and motor functions of the lower limbs of a person during surgical treatment of diseases and injuries of the hip joint. The acetabular component consists of a polyethylene acetabular monoblock (bowl + insert), which is mounted on the cement in the bone bed of the acetabulum with the inner surface, and the head of the femoral component of the endoprosthesis is moved in the outer surface of the monoblock.

The method is illustrated by drawings.

FIG. 1 - two-column fracture of the acetabulum; FIG. 2 - preparatory filing of the femoral head and the installation of the graft in the acetabulum; FIG. 3 - development of the cavity with the graft; FIG. 4 - installation of the support ring and components of the endoprosthesis; FIG. 5 is a view of the support ring in the sagittal plane; FIG. 6 - x-ray two-column fracture of the acetabulum with a central dislocation of the thigh; FIG. 7 is a radiograph of the hip joint arthroplasty after such a fracture; FIG. 8 and 9 - computed tomography and 3D reconstruction of a two-column acetabular fracture; FIG. 10 and 11 - selective angiography; the arrows indicate the zones of arterial thrombosis, where 1 is a two-column fracture, 2 is an acetabulum, 3 is a sawdust of the neck, 4 is a bone fragment of the head, 5 is a recess of the cervical sawdust, 6 is a prepared graft, 7 is a fragment protruding into the cavity, 8 is a sagittal plane , 9 - frontal plane, 10 - spherical cutter, 11 - hemispherical transplant, 12 - support ring, 13 - screws, 14 - polyethylene monoblock of the endoprosthesis, 15 - head of the endoprosthesis.

The method is as follows.

In preoperative planning, computed tomography and selective angiography are performed to determine the nature of damage to the structures of the acetabulum and the degree of circulatory disturbance of the hip joint. Under spinal anesthesia in the patient’s position on the healthy side, front access to the hip joint is provided. The head and neck of the thigh are resected, removed from the acetabulum. A neck is cut off from the head and on the opposite side the head sawdust is a bone-cartilage fragment 10 mm thick. On the side of the neck sawdust (3), a bone fragment (4) is resected from the head at an angle of 30 ° to the sawdust plane and occupying 1/3 of the sawdust (neck sawdust (5)). prepared graft (6). The acetabulum is treated with a bone spoon or a curved raspator so that the entire cartilaginous layer of the cavity is removed and the fragment (7) protruding into the cavity is not injured. The cavity is not milled at this stage Fracture fragments of both columns of the acetabulum are not repaired and are not fastened with plates and screws. A prepared graft (6) of the femoral head is placed in the acetabulum with 180 ° rotation in the frontal plane (9) and then rotation in the sagittal plane (8) in this way so that the notch of the cervical sawdust (5) of the transplant is mounted on the bone fragment (7) of one of the walls of the acetabulum, which will allow the graft to cling to the fragment and not be displaced along the direction of the spherical cutter (10). A transplant turn of 180 ° is used so that the denser bone tissue of the cervical sawdust of the head forms the basis of the formed hemispherical graft (11) of the acetabulum after its processing with cutters. Then, after the hemispherical graft (11) of the femoral head is implanted (impacted) into the cavity, the acetabulum is processed with spherical cutters (10) until the round shape of the cavity is formed and the thickness of the formed hemispherical graft is 3-5 mm (11). The remaining wall defects are eliminated by the impact of bone chips obtained after milling of the acetabulum with a hemispherical graft installed (11). Then, a support ring (12) is mounted sequentially in the formed acetabulum, which is fastened to the walls of the cavity by screws (13), which makes the head transplant immobilized, which contributes to its better engraftment and reconstruction into bone marrow. On bone cement, a polyethylene monoblock (14) of the endoprosthesis is immersed in the outer hemisphere of the support ring (12); an endoprosthesis leg is installed in the femoral canal, on the cone of which a head (15) of the appropriate size is selected and inserted; reduction of the endoprosthesis head into the acetabulum is performed. The operation ends with drainage and layered suturing of the wound.

The method provides the full consolidation of the acetabulum, reduces the invasiveness of the operation, reduces postoperative complications and provides the possibility of early loading of the patient's leg. Six similar operations were performed over a period of 2016-2017, all patients underwent computed tomography and selective angiography before the operation, in which all patients confirmed a two-column acetabular fracture and a gross violation of the blood supply to the femoral head. The term of postoperative observation is from 3 months to 1.5 years. All patients returned to daily activities, three patients began to carry out their work duties.

Clinical example.

Patient, 59 years old. He was admitted to the clinic on November 28, 2016, operated on 12.12.2016. Diagnosis: closed comminuted fracture of both columns of the pelvis with a central dislocation of the head of the left femur, impression fracture of the femoral head (Fig. 6). The mechanism of injury is a fall from a height of 3 meters to the left foot 10 days before admission to the hospital. On preoperative planning after computed tomography, it was found that both columns of the pelvis were damaged and there was an impression fracture of the femoral head (Figs. 8 and 9). Selective angiography showed the absence of blood flow along the lateral, envelope of the femoral artery and arteries of the femoral head, as well as the absence of capillary phase of blood supply along the medial, envelope of the femoral artery (Figs. 10 and 11), the arrows indicate thrombosis zones). The operation is performed according to the described method. In FIG. 7 presents a radiograph of total hip arthroplasty according to the method proposed by the authors. The duration of the operation is 1 hour 20 minutes. Blood loss during surgery - 250 ml, drainage per day after surgery - 200 ml. The postoperative course is smooth, the patient is activated on the 4th day, it is allowed to proceed to the left leg on the 12th day after the operation, primary wound healing, sutures were removed on the 13th day.

In the proposed technical solution, bone fragments of the acetabular fracture are not repaired and are not fastened with plates and screws, as in bone osteosynthesis, but are isolated from pressure during loading and secondary displacement by the endoprosthesis head by installing a hemispherical graft prepared from the joint head and pressed by the support ring . All these techniques allowed performing total hip arthroplasty with a high-energy two-column acetabular fracture with a central hip dislocation.

Claims (1)

The method of hip joint replacement with a high-energy two-column acetabular fracture with a central hip dislocation, characterized by performing front access to the hip joint, arthrotomy, then the head and neck of the thigh are resected, they are removed from the acetabulum, and a graft is formed from it from the head on the opposite side of the head sawdust - a bone-cartilaginous fragment; on the side of the neck sawdust, a bone fragment is resected from the head at an angle of 30 ° to the plane la and occupying 1/3 of the sawdust area, the head is freed from the cartilaginous layer, the cartilaginous layer of the acetabulum is removed without injuring the fragment of one of its walls protruding in it, the processed graft of the femoral head is immersed in the acetabulum with a 180 ° turn in the frontal plane and then turning in the sagittal plane so that the beveled surface of the graft formed as a result of the cervical sawdust is mounted on the protruding bone fragment of the acetabulum, the processed trans lanthate into the cavity, treat it with a hemispherical mill until a round shape is formed with a graft thickness of 3-5 mm, eliminate wall defects by impaction of bone chips obtained after milling of the acetabulum with the graft installed, then fix the support ring with screws on the bone cement into the outer hemisphere of the support ring a polyethylene endoprosthesis monoblock is installed, an endoprosthesis leg is installed in the femoral canal, on the cone of which an endoprosthesis head is inserted and put into the acetabulum th cavity, drained and sutured the wound in layers.

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