RU2779090C1 - Method for arthrodesis of the sacroiliac joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology, and can be used in the treatment of arthrosis of the sacroiliac joint or instability in this joint by arthrodesis of the half joint. The upper surface of the sacroiliac joint is exposed. The articular surface of the joint gap is excised. An osteotomy of the iliac bone adjacent to the artrezation zone is performed at the level of the excised part of the sacroiliac joint. An autograft is formed in the form of a wedge with the base oriented towards the sacrum. The autograft is displaced to the site of the excised tissues, and upon reaching its contact with the lateral mass of the sacrum, the autograft is fixed with a plate with screws that are inserted into the ilium and the lateral mass of the sacrum.

EFFECT: method ensures efficiency of arthrodesis of the sacroiliac joint and stabilization of the pelvic ring due to full contact of the spliced surfaces of the sacrum and ilium.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of arthrosis of the sacroiliac joint or instability in this joint by arthrodesis of the half joint.

Known methods of arthrodesis of the sacroiliac joints, such as, for example, arthrodesis of the sacroiliac joint according to Smith-Peterson: an arcuate incision is made along the posterior contour of the iliac crest, the posterior iliac bone is cut off, the cartilage of the joint is resected with a chisel. The resected fragment of the ilium is used as a graft. Immobilization in a plaster corset for 3 months (Movshovich I.A. Operative orthopedics. - M.: Medicine. 1983. - 415 p.).

Disadvantages of the method: invasiveness, duration of immobilization, frequent unsatisfactory outcomes. The impossibility of using the method in the presence of inflammation or gross cicatricial changes in the access area - the posterior pelvis.

Another method of arthrodesis of the hip joint is known, which consists in the fact that percutaneously, under the control of an electron-optical converter (EOP), transarticularly, a guide wire is inserted into the body of the S1 vertebra, along which a trocar is inserted to the joint. Through the trocar, curettage of the joint cavity is carried out, after which a biocomposite material is introduced into the joint. The operation is completed by transpedicular fixation of the joint with cannulated screws (Pat. RF 2428136, 2011). operating room.

The purpose of the invention is to improve the results of treatment, due to the full contact of the spliced surfaces of the sacrum and ilium, regardless of the condition of the soft tissues of the posterior surface of the pelvis (common bedsores and rough scars), the method does not require the use of an image intensifier tube and expensive biocomposite materials.

The method is carried out as follows.

Under endotracheal anesthesia, the upper surface of the sacroiliac joint is exposed by iliac access, the articular surface of the joint gap is excised for 2-3 cm. A figured osteotomy of the adjacent iliac bone is performed at the level of the excised part of the sacroiliac joint with the formation of a wedge-shaped graft with a base oriented towards the sacrum, which is shifted to the site of the excised tissues until it contacts the bleeding lateral mass of the sacrum. The achieved contact is fixed with a metal structure, for example, a plate with screws entering the ilium and the lateral mass of the sacrum.

On FIG. 1 shows the scheme of the operation:

A - The sacrum and the left innominate bone, between them is a painful sacroiliac joint 1; B - contours of the osteotomy are indicated: zone 2 of resection of the cortical plate of the lateral mass of the sacrum and wedge-shaped bone autograft 3 formed from the ilium; C - resection of the cortical plate of the lateral mass of the sacrum (the area of the defect is shaded); D - indicates the direction of movement of the autograft 4; E - the lumen of the sacroiliac joint is blocked by a displaced autograft; E - the autograft was fixed with a plate.

Thus, the surfaces of the sacrum and ilium fully contact, which ensures high efficiency of arthrodesis of the sacroiliac joint, and stabilization of the pelvic ring as a whole.

Clinical example. Patient D., 38 years old, fell from a height of the 4th floor, as a result she received a bilateral vertically unstable pelvic injury, a comminuted fracture of the right lateral mass of the sacrum, a fracture of both pubic and ischial bones as part of a severe concomitant injury. She was treated for a long time at the place of residence, the pelvic injury was treated conservatively, as a result of which a post-traumatic vertically unstable deformity of the pelvis was formed: pseudoarthrosis of the right lateral mass of the sacrum, right pubic and ischial bones, improperly fused fracture of the left pubic and ischial bones. On FIG. Figure 2 shows 3d reconstructions of a CT scan of the pelvis of patient D. upon admission to the ICU: A - direct view, B - view corresponding to the inlet projection.

1 year and 3 months after the injury, the patient continued to be disturbed by the inability to support the right lower limb, shortening of the right lower limb by 4 cm, and pain in the pelvic area.

The patient was admitted for treatment at the CITO, where the first stage was the operation of transosseous osteosynthesis of the pelvis with a circular external fixation device. In the postoperative period, the position of the right half of the pelvis in the apparatus was corrected for 1.5 months. After that, the operation was performed at the second stage: completion of the correction of the position of the right half of the pelvis in the apparatus, or sacral blocking on the right, dismantling of the posterior support of the apparatus. On FIG. 3A-D shows radiographs of the pelvis of patient D.:

A - the result of the operation of transosseous osteosynthesis with a circular apparatus, direct projection, B - the same, inlet projection, C - the result of deformity correction and final fixation, direct projection, D - the same, inlet projection.

During the entire postoperative period, the patient moved on crutches without relying on the right leg, the fixation of the pelvis with the apparatus of the anterior frame continued for 5 months after the final operation, after which the apparatus was removed, the patient began to load on the right leg.

After another 6 months, complaints of pain in the posterior pelvis on the right and left persisted. Non-union of pseudoarthrosis of the right lateral mass of the sacrum and the right pubic and ischial bones, bending of the main iliosacral screw and aggravation of the sagittal displacement of the right half of the pelvis were revealed, in addition, degenerative changes in the left sacroiliac joint and signs of its instability were revealed (Fig. 4A, B - radiographs pelvis of patient D.: A - pelvic instability, direct projection, B - pelvic instability, inlet projection). After 1 month, the following operation was performed: closed osteosynthesis of the right pubic and ischial bones with screws, replacement of iliosacral screws on the right, iliosacral blocking on the left (Fig. 4C, D: C - the result of the operation of osteosynthesis of the pelvis with screws, direct projection, D - the same, inlet projection) .

The next step, two weeks later, using the proposed method, was a figured sliding osteotomy of the left iliac bone, open osteoplastic arthrodesis of the left sacroiliac joint, fixation with a plate (Fig. 5A-E and Fig. 6G-K), removal of one of the iliosacral screws on the right, percutaneous arthrodesis of the right sacroiliac joint and bone autoplasty with a graft from the wing of the left iliac bone (Fig. 4D-F - radiographs of patient D. are presented: E - the result of the operation of osteoplastic arthrodesis of the left sacroiliac joint, direct projection, E - ditto, projection inlet.).

The steps of the operation are shown in Fig. 5A-E:

A - borders of the zone of interest on the 3d-reconstruction of the CT scan of the patient's pelvis;

B - exposure of the sacroiliac joint;

B - excision of the articular surface with a chisel;

D - formation of an autograft with a chisel;

E - defined boundaries of the autograft;

E - separation of the autograft from the underlying bone with a curved chisel.

Continuation of the steps of the operation - in Fig. 6G-K:

G - autograft formed and mobilized;

Z - displacement and introduction of the autograft into its bed with the help of a hammer;

And - the final position of the autograft;

K - fixation of the autograft with a plate.

The result after six months: fusion of pseudoarthrosis of the sacrum and the right pubic and ischial bones, ankylosing of the left sacroiliac joint, restoration of the stability of the pelvic ring and supportability of the lower extremities, elimination of the pain syndrome and clinical recovery of the patient were achieved.

Claims (1)

A method for arthrodesis of the sacroiliac joint, characterized in that the upper surface of the sacroiliac joint is exposed, the articular surface of the joint gap is excised, an osteotomy of the iliac bone adjacent to the artrezation zone is performed at the level of the excised part of the sacroiliac joint, an autograft is formed in the form of a wedge with a base, oriented towards the sacrum, the autograft is displaced to the site of the excised tissues, and upon reaching its contact with the lateral mass of the sacrum, the autograft is fixed with a plate with screws that are inserted into the ilium and the lateral mass of the sacrum.

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