RU2704456C1 - Method for treating ischemic deformation of proximal femur - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, to methods of surgical treatment of locomotor diseases, namely to methods of treating proximal thigh deformities in children. Method comprises mounting an external fixture apparatus on the femoral and iliac bones, hip integrity disorder, formation of proximal and distal bone fragments by C-shaped femoral osteotomy through the base of the neck from the fossa to the lower edge of the neck, movement and fixation of bone fragments using an external fixation apparatus, characterized by that additionally performing oblique osteotomy of greater trochanter, in the direction from the outside to the inside and from the bottom upwards at an angle in range of 30 to 35° to femoral longitudinal axis, bone rods are inserted separately into bone fragments, establishing bone rods in a lateral portion of a proximal bone fragment comprising a neck with a head and an apex of a bone fragment containing a large spit, one-stage corrective turning of proximal and distal bone fragments of femur is performed in two planes, free ends of bone rods are fixed in equipment, performing a gradual hardware transposition of a bone fragment containing a large spit, restored to correct disturbed orientation of greater trochanter relative to head of femur, stabilized position of greater trochanter, fixing bone fragments in a corrected position with intraosseous screws, removing the bone rods through the lateral portion of the proximal bone fragment containing the neck with the head, and an apex of the bone fragment containing the greater trochanter, unloading the hip joint by an external fixation apparatus, after consolidation of bone fragments in zones of osteotomy the apparatus is dismantled and development of motions in hip joint is performed.

EFFECT: provision of favorable geometrical interrelations in hip joint, improvement of conditions of gluteus muscle functioning achieved by means of minimum violation of femoral integrity and adequate unloading of an articulation in postoperative period.

1 cl, 7 dwg

Description

The field of technology.

The invention relates to medicine, to surgical methods of treating diseases of the musculoskeletal system, and in particular to methods of surgical treatment of proximal femoral deformities in children.

The prior art.

Reconstructive operations on the hip joint during deformation of the proximal femur are known, in particular, the technique of varus osteotomy on the upper end of the femur, the so-called Nishio osteotomy (source [1]: Nishio A, Sugioka Y. A new technique of the varus osteotomy at the upper end of the femur. Orthop Traumatol. 1971; 20: 381-381. doi: 10.5035 / nishiseisai.20.381. Access mode: https://www.jstage.jst.go.jp/article/nishiseisai1951/20/3/ 20_3_381 / _pdf / -char / en), the technique of curved intertrochanteric varus osteotomy for osteonecrosis of the femoral head (source [2]: Sakano S, Hasegawa Y, Torii Y, Kawasaki M, Ishiguro N (2004) Curved intertrochanteric varus osteotomy for crosis of the femoral head. J Bone Joint Surg [Br]; 86-B: 359-365), the implementation of which produce an arched osteotomy through the base of the femoral neck from the major to small trochanter. The center of the arc of the osteotomy line should coincide with the center of rotation of the hip joint. The proximal fragment is withdrawn until the desired position is reached. Fragments are fixed with several screws of the appropriate length. These methods make it possible to eliminate the valgus deformity of the neck or femoral head without affecting the position of the apex of the greater trochanter.

The disadvantages of these methods [1; 2] is, the impossibility of correcting the initial high location (proximal displacement) of the apex of the greater trochanter, the limited possibilities of correction of deformation in a horizontal plane with an angle of up to 20 °, the inability to carry out correction of deformation in two planes.

A known method for the treatment of proximal deformity (source [3]: Pollyak MN Surgical treatment of diseases of large joints: Sat. Scientific. Tr. - L., 1986. - P. 20-25), which provides for the implementation of an arched osteotomy from the upper the edges of the small trochanter to the apex of the greater trochanter, a corrective reversal (variation) of fragments in the frontal plane, after which a transverse detorsion osteotomy is performed to eliminate deformation in the horizontal plane.

The specified method [3] makes it possible to carry out correction of deformation in two planes, but does not allow to eliminate a significant initial proximal displacement of the greater trochanter. Significant technical complexity and high invasiveness of the intervention limits its use in children.

A known method of treating proximal femoral deformity (source [4]: Wagner N. Femoral osteotomies for congenital hip dislocation. U. Weil (Ed.), Progress in orthopadic surgery. Vol. 2 Acetabular dysplasia and skeletal dysplasia in childhood, 1978. Springer -Verlag, New York, p. 85-105), including transverse intertrochanteric corrective osteotomy, osteotomy of the greater trochanter with a resection of its base. Elimination of deformation of the neck and femoral head is achieved by changing the position of the distal fragment with the formation of wedge-shaped diastasis. The osteotomy tip of the greater trochanter moves distally and laterally and overlaps the area of the intertrochanteric osteotomy outside.

A known method of treating proximal femoral deformity (source [5]: Jingushi S, Sugioka Y, Noguchi Y, Miura H, Iwamoto Y (2002) Transtrochanteric valgus osteotomy for the treatment of osteoarthritis of the hip secondary to acetabular dysplasia. J Bone Joint Surgery Br 84: 535-539), involving osteotomy and distal transposition of the greater trochanter, wedge-shaped intertrochanteric osteotomy.

The disadvantages of the methods [4; 5] are the technical complexity and high invasiveness of surgery, due to the need for simultaneous isolation and significant movement of several bone fragments, which limits the use of these methods in children. However, there is a difficulty in the subsequent stabilization of osteotomated bone fragments. The methods are also accompanied by compression of the articular surfaces and can lead to the formation of deformation in the intertrochanteric region.

A known method for the treatment of deformity of the proximal femur (source [6]: RF Patent No. 2256423 MPK7 А61В 17/56 “Method for the treatment of deformation of the proximal femur” / V.I. Shevtsov, M.P. Teplenky, V.D. Makushin, T .Yu. Karaseva. Declared. 08.12.03 publ. 06/20/05. Bull No. 20.), Including the implementation of a C-shaped osteotomy in the trochanteric region, the use of transosseous device (compression-distraction apparatus or external fixation apparatus), providing for partial partial correction and subsequent gradual dosage correction ischemic deformation of the proximal femur.

The specified method [6] allows you to eliminate only valgus cervical-epiphyseal and cervical-diaphyseal deformity, has limited capabilities in terms of correction of deformation in the horizontal plane. Correctional reversal of fragments is accompanied by lengthening of the limb by the amount of excess displacement of the apex of the greater trochanter, which does not always correspond to the difference in the relative length of the lower extremities. The method does not allow to restore the broken relationship in the hip joint with high locations of the apex of the greater trochanter combined with valgus neck-epiphyseal and neck-diaphyseal deformity.

SUMMARY OF THE INVENTION

The objective of the present invention is the surgical treatment of ischemic deformity of the proximal femur in children, allowing to eliminate or compensate for pathological deviation of the head and neck, to restore the relationship between the head and the greater trochanter, to improve spatial relationships in the hip joint and joint function, to provide the possibility of unloading and development of the joint in the postoperative period.

The technical result consists in providing favorable geometric relationships in the hip joint, providing improved conditions for the functioning of the gluteal muscles, achieved through minimal disruption of the integrity of the femur and adequate unloading of the joint in the postoperative period.

The technical result is achieved by the fact that in the method of treating ischemic deformity of the proximal femur, including mounting an external fixation apparatus on the femur and ilium, impaired femoral integrity, the formation of proximal and distal bone fragments by means of a C-shaped osteotomy of the femur performed through the base of the neck from trochanteric fossa to the lower edge of the cervix, displacement and fixation of bone fragments using an external fixation apparatus, additionally produce oblique osteotomy omiya of the greater trochanter, in the direction from the outside, inside and from the bottom up, at an angle in the range from 30 to 35 ° to the longitudinal axis of the femur. Separately, the bone rods are drawn into the bone fragments, the bone rods are installed in the lateral section of the proximal bone fragment containing the neck with the head and at the top of the bone fragment containing the greater trochanter. Carry out a simultaneous corrective reversal of the proximal and distal bone fragments of the femur in two planes. The free ends of the bone rods are fixed in the apparatus. A gradual hardware transposition of a bone fragment containing a large trochanter is made, and the disturbed orientation of the large trochanter relative to the femoral head is restored to the correct one. The stabilized position of the greater trochanter is stabilized, bone fragments are fixed in the corrected position by intraosseous screws. The bone rods drawn through the lateral section of the proximal bone fragment containing the neck with the head and the apex of the bone fragment containing the greater trochanter are removed. Unload the hip joint with an external fixation device. After the consolidation of bone fragments in the areas of osteotomy, the apparatus is dismantled and movements in the hip joint are developed.

The invention allows, by changing the position of bone fragments, to eliminate or compensate for elements of ischemic deformation in two planes, to restore articular relations, to improve the congruence of articular surfaces, which helps to slow the progression of arthrosis. The movement of the greater trochanter creates favorable conditions for the functioning of the gluteal muscles. In General, as a result of the method, the spatial-geometric relationships in the hip joint and joint function are improved (approaching normal). In this case, the use of an external fixation apparatus at the initial stage ensures fixation of bone fragments in the required position, then provides transposition of bone fragments to a new position and, after their fusion, provides the possibility of unloading the hip joint, which allows the patient to be activated from the first days after surgery and significantly reduces the risk of dystrophic postoperative complications.

The invention is illustrated by graphic materials, which show:

FIG. 1 is a diagram of a C-shaped osteotomy through the base of the femoral neck, osteotomy of the greater trochanter;

FIG. 2. - diagram of the gradual transposition of a large trochanter by transosseous device;

FIG. 3 is a diagram of the fixation of fragments of the femur with rods and an external fixation apparatus;

FIG. 4 - radiograph of the patient before treatment;

FIG. 5 - radiograph of the patient in the process of releasing the greater trochanter;

FIG. 6 - radiograph of the patient in the process of fixation;

FIG. 7 - radiograph of the patient at the control examination 1.5 years after treatment.

In FIG. one; 2; 3 digits indicate:

1 - femur;

2 - ilium;

3 - a bone rod;

4 - pelvic support of external fixation apparatus;

5 - a spoke;

6 - femoral support of external fixation apparatus;

7 - proximal bone fragment;

8 - distal bone fragments;

9 - a hip joint;

10 - line of the C-shaped osteotomy of the femur;

11 - a half ring;

12 - line oblique osteotomy of the greater trochanter;

13 - a large skewer;

14 - intraosseous screws.

The method is as follows.

The invention is used in the treatment of ischemic deformity of the proximal femur in children when there is a combination of varus or valgus, cervical-pineal deformity of the neck, shortening of the neck, high location (proximal displacement) of the apex of the greater trochanter.

The external fixation apparatus is mounted on the femoral 1 (Fig. 1; 2) and the ilium 2 (Fig. 1; 2). At least three bone rods 3 (Fig. 1; 2) are carried out into the iliac wing 1, fix them with clamps (not indicated on the diagrams) on the pelvic support 4 (Fig. 1;) of the external fixation apparatus made in the form of an arc sector. To fix the pelvic support 4 to the ilium 1, it is permissible to combine holding from 1 to the bone rods and holding from 2 to 4 cantilever knitting needles with thrust pads. Three spokes 5 (Fig. 1; 2) are passed through the distal metaphysis of the femur 1 (Fig. 1; 2), pulled and fixed with the help of spokes (not indicated on the diagrams) on the femoral support 6 (Fig. 1; 2) of the external fixation device made in the form of a ring and half rings connected by threaded rods. At the border of the upper third and middle third of the femur 1 enter two intersecting bone rods 3, fix them on the semicircle of the femoral support 6 using clamps. The thigh is set in the position at which the maximum centering of the head in the acetabulum is achieved, for this the thigh is set in the position of extension 180 °, internal rotation, corresponding to the value of the neck anteversion, adduction (with varus deformity) or abduction (with valgus deformity of the neck or head) . The angle of reduction (abduction) corresponds to the angle between the tangent to the plane of entry into the acetabulum and the line parallel to the epiphyseal plate, which is determined by the radiograph made in the anteroposterior projection. Produce a violation of the integrity of the femur, form proximal 7 (Fig. 1; 2; 3) and distal 8 (Fig. 1; 2; 3) bone fragments. Through two incisions long in the range from 15 to 20 mm along the front surface of the hip joint 9 (Fig. 1; 2), a C-shaped osteotomy 10 (Fig. 1) is made through the base of the femoral neck, from the trochanteric fossa to the upper edge of the small trochanter (up to lower edge of the neck). Set the bone rods 3 proximal bone fragment 7 containing the neck with the head. Through the lateral section of the proximal bone fragment 7 in an oblique sagittal plane, two bone rods 3 intersecting at an angle of 20 to 25 ° are drawn, which are fixed on the half ring 11 (Fig. 1; 2). Bone rods 3 installed in the proximal bone fragment 7 are fixed on the half ring 11 using clamps. Oblique osteotomy 12 (Fig. 1) of the major trochanter is made, through a long incision in the range from 15 to 20 mm in the direction from the outside to the inside and from bottom to top at an angle in the range of 30 to 35 ° to the longitudinal axis of the femur, a bone fragment containing a large trochanter is formed 13 (Fig. 1; 2; 3). Make a corrective reversal of the proximal 7 and distal 8 bone fragments in the frontal and horizontal plane. Hallux valgus deformity is eliminated due to reduction of the distal 8 bone fragment, varus - due to abduction of the distal 8 bone fragment. The half ring 11 is mounted to the femoral support 6 at the level of the hip joint 9 and connected to the pelvic support 4 rods. A bone rod 3 is drawn into a bone fragment containing a large trochanter 13, the free end of which is fixed with a help on the semicircle of the femoral support 6, at the level of the upper and middle third of the thigh using in console consoles (not indicated on the diagrams). Suture the wounds. A bone fragment containing a large trochanter 13 is also moved using an external fixation apparatus. In the postoperative period, by distraction of the bone rod 3, one end of which is installed in a bone fragment containing a large trochanter 13 and the other in a cantilever console, a gradual displacement (transposition) of the apex of the greater trochanter is performed distally and laterally until the relations between the head and apex of the greater trochanter are restored (Fig. 2). The broken orientation of the greater trochanter 13 relative to the femoral head is restored to correct. After the transposition of the greater trochanter, 13 patients are re-taken to the operating room. The achieved position of the greater trochanter 13 is stabilized. Bone fragments 7, 8, 13 are fixed in the corrected position by the intraosseous screws 14 (Fig. 3). For fixation, 3 to 4 intraosseous screws 14 are used, and cantilever spokes can also be used, the ends of the spokes are immersed under the skin. Bone rods 3 removed through the lateral section of the proximal bone fragment 7 containing the neck with the head and the top of the bone fragment containing the greater trochanter 13 are removed. The half ring 11 is removed, the pelvic 4 and femoral 6 supports are connected. Unload the hip joint with an external fixation device. 30-40 days after partial consolidation of bone fragments 7, 8, 13 in the areas of osteotomy 10, 12 of the femur, the apparatus is dismantled and the development of movements in the hip joint 9 begins.

An example of the method.

Patient S., 9 years old, medical record No.XXXX of a hospital patient. Diagnosis: dysplastic coxarthrosis on the left, multiplanar deformation of the proximal left thigh. Complained of lameness, fatigue. Clinical examination data: resulting contracture of the left hip joint (abduction up to 110 °), positive Duchenne-Trendelenburg symptom on the left, relative length of the lower extremities the same. On the radiograph made in the anteroposterior projection (Fig. 4): valgus cervical-epiphyseal deformity, Alsberg angle 100 °, ШДУ 115 °, high position of the top of the greater trochanter, articulo-trochanter distance reduced (ATD = -5 mm), neck shortened (LT = 0.7D). The angle between the tangent to the plane of entry into the depression and the line parallel to the epiphyseal plate 45 °. Anteversion angle 35 °. The femoral head has an irregular, flattened shape. The femoral head is decentered, displaced proximal (discontinuity of the Shenton line 2 cm) and laterally (Reimers 35%). Wiberg's angle is negative.

The patient underwent the first surgical intervention. In the operating room, under intravenous anesthesia, the Ilizarov apparatus was mounted, supporting the femur and ilium, two bony rods and two cantilever spokes, which are fixed in the pelvic support sector, were inserted into the iliac wing. Three spokes were drawn through the distal metaphysis of the thigh, which are stretched and fixed in the ring of the apparatus on the femoral support. Two bone rods were installed on the border of the upper third and middle third of the thigh, which were fixed in the sector, which is connected to the ring mounted on the distal metaphysis of the thigh using threaded rods. The thigh was set to the position of the maximum possible (20 °) abduction, extension 180 °, internal rotation 35 °. The integrity of the femur was broken and proximal and distal bone fragments were formed; for this, C-shaped osteotomy was made through two incisions 15 mm long along the front surface of the hip joint through the base of the femoral neck from the trochanteric fossa to the upper edge of the lesser trochanter. Bone rods were installed in the lateral section of the proximal bone fragment containing the neck with the head. Two bone rods crossing at a 20 ° angle were drawn through the lateral section of the cervix in the oblique sagittal plane, which were fixed in the apparatus sector using clamps. The apparatus sector, installed in the thigh neck region, at the level of the hip joint, was connected by three threaded rods to the sector of the pelvic support of the Ilizarov apparatus. They made oblique osteotomy of the greater trochanter, formed a bone fragment containing the greater trochanter. A large trochanteric osteotomy was made through a 20 mm long incision in the direction from the inside, from the bottom up, at an angle of 30 ° to the longitudinal axis of the femur. A simultaneous corrective reversal of the bone fragments of the femur in the frontal and horizontal planes was performed, by bringing the distal fragment to 45 ° (to an angle of 65 ° with respect to the mediastinum line) and external rotation by 20 °, we performed a corrective reversal of the fragments. A sector installed at the level of the hip joint was connected by three threaded rods to the femoral support, with its sector installed at the level of the border of the upper and middle third of the thigh. The threaded rods between the pelvic support and the sector installed at the level of the hip joint were relaxed. The thigh was taken to an angle of 90 ° with respect to the interosseous line. The achieved position was fixed by threaded rods installed between the sector of the pelvic support and the sector at the level of the hip joint. A bone rod was introduced into the apex of the greater trochanter, the free end of which was fixed to the femoral support sector, which was mounted on the border of the upper and middle third of the thigh, with the help of brackets allowing distraction of the bone rod. Sutured the wound. In the postoperative period, for 16 days by means of distraction along the bone rod installed in cantilever consoles assembled from brackets, a gradual displacement (transposition) of the bone fragment containing the greater trochanter was performed, displacing the top of the trochanter distally and laterally (Fig. 5). The orientation of the greater trochanter relative to the femoral head was restored to anatomically correct. After the transposition of the greater trochanter, the patient underwent a second operation. The stabilized position of the great trochanter was stabilized. Bone fragments were fixed in a corrected position by intraosseous screws and two spokes (Fig. 6). The ends of the spokes are immersed under the skin. The bone rods drawn through the lateral section of the proximal bone fragment containing the neck with the head and the top of the bone fragment containing the greater trochanter were removed. The sector, installed at the level of the hip joint, was dismantled. The pelvic support sector and the femoral support sector, mounted on the border of the upper and middle third of the thigh, were connected by three threaded rods. The hip joint was unloaded with an external fixation device, producing a slight distraction between the pelvic and femoral support. After consolidation of the bone fragments, after 35 days, the Ilizarov apparatus was dismantled and movements were developed in the hip joint. Intraosseous screws and cantilever spokes were removed 6 months after surgery.

After 1.5 years, the patient walks with a full load on the left leg. The relative length of the lower extremities is the same. The range of motion in the left hip joint has fully recovered. On the radiograph (Fig. 7): the head of the left thigh is flattened, has a uniform structure, centered in the cavity. The discontinuity of the Chanton line is 8 mm, the Reimers index is 10%, the Wiberg angle is 15 °. The geometry of the proximal femur improved: cervical-diaphyseal angle 112 °, cervical-epiphyseal deformity eliminated (Alsberg angle 58 °), ATD increased to 10 mm, neck length increased (LT = 1,3D).

For the correction of severe ischemic deformities, as a rule, technically complex, traumatic interventions are used. The application of the proposed method allows to eliminate the pronounced multi-plane deformation of the proximal femur using extra-articular, relatively simple, less traumatic sections of the femur, which can be done through small accesses without trauma to the surrounding soft tissues and muscles. Gradual correction of the position of the greater trochanter reduces the risk of dystrophic complications caused by tension of the paraossal soft tissues and gluteal muscles.

The use of an external fixation device prevents compression of the joint, allows you to activate the patient from the first days after surgery and facilitates care for him during treatment. The use of intraosseous screws and spokes makes it possible to shorten the duration of hardware fixation and begin to develop movements in the joint until the full consolidation of bone fragments.

The proposed method allows to improve the relationship in the hip joint and increase the support of the lower limb.

The proposed method is used by the authors in the FSBI "RRC" WTO "them. Acad. G.A. Ilizarova of the Ministry of Health of Russia.

Claims (1)

A method of treating ischemic deformity of the proximal femur, including mounting an external fixation apparatus on the femur and ilium, impaired femoral integrity, the formation of proximal and distal bone fragments by means of a C-shaped osteotomy of the femur through the base of the neck from the trochanteric fossa to the lower edge of the neck, moving and fixation of bone fragments using an external fixation apparatus, characterized in that they additionally produce oblique osteotomy of the greater trochanter in the direction c outside the inside and from the bottom up at an angle in the range from 30 to 35 ° to the longitudinal axis of the femur, separate the bone rods into the bone fragments, install the bone rods in the lateral section of the proximal bone fragment containing the neck with the head, and at the top of the bone fragment containing large trochanter, carry out simultaneous correction of the proximal and distal bone fragments of the femur in the frontal and horizontal planes, the free ends of the bone rods are fixed in the apparatus , a gradual hardware transposition of the bone fragment containing the greater trochanter is made, the correct orientation of the greater trochanter relative to the femoral head is restored to the correct orientation, the position of the greater trochanter is stabilized, bone fragments are fixed in the corrected position by intraosseous screws, and bone rods drawn through the lateral section of the proximal bone fragment are removed containing a neck with a head, and the top of a bone fragment containing a large trochanter, unload hip joint distraction external fixation device between the femoral and pelvic support, after consolidation of bone fragments in osteotomies zones dismantled machine development and produce movements in the hip joint.

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