RU2802430C1 - Method for surgical correction of pelvic ring for treatment of bladder exstrophy in children - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics; pediatric surgery.

SUBSTANCE: perform osteotomy of iliac bones from both sides, form stylosteophyte from the outer cortical plate using Gigli saw on each side, insert formed stylosteophyte of pelvic acetabular fragment behind the inner cortical plate of iliac wing and perform linear cranial displacement of the acetabular fragment until the stylosteophyte from the outer cortical plate is completely behind the inner cortical plate of the iliac wing. Fix the resulting position of stylosteophyte with Kirschner wires through the iliac wing and pelvic acetabular fragment.

EFFECT: method allows to form a pelvic ring with reliable bar joints and eliminates loss of correction of the initial pubic bones diastasis due to formed stylosteophytes that ensure pelvic ring stable fixation.

1 cl, 4 dwg, 2 ex

Description

The invention relates to the field of medicine, in particular to traumatology, orthopedics and pediatric surgery, and is intended for the treatment of bladder exstrophy in children.

There is a known method of surgical correction of the pelvic ring in patients with bladder exstrophy using posterior vertical osteotomy of the ilium [Lloyd-Roberts GC, Williams DI, Braddock GT: Pelvic osteotomy in the treatment of ectopia vesicae. J Bone Joint Surg Br 1959; 41:754-757], in which the patient, in the prone position, undergoes a complete posterior osteotomy of the outer cortical plate of the ilium, followed by partial osteotomy and osteoclasia of the inner cortical plate of the ilium. Next, the patient is turned on his back and the urological stage is performed in the form of plastic surgery and restoration of the bladder and soft tissues of the anterior abdominal wall. Then the branches of the pubic bones are brought together and fixed with silver wire passed through the obturator foramina. In some modifications, to hold the symphysis in the correct position, they do not use a wire cerclage, but apply an external fixation device.

The disadvantages of this method are that the orthopedic stage is performed while lying on the stomach, and the urological and surgical stage of plastic surgery is performed while lying on the back. Changing the position of the patient's body significantly increases the time of the operation. In addition, according to the literature, loss of correction due to the cutting of the wire cerclage occurs in 50% of cases. When using an external fixation device, an entrance gate for infection is formed and the risk of purulent complications increases.

A known method of pelvic osteotomy for bladder exstrophy [Schmidt AN, Keenen TL, Tank ES, et al. Pelvic osteotomy for bladder exstrophy. J Pediatr Orthop 1993; 13:214-9.], in which an osteotomy of the upper branches of the pubic bones is performed, after which the medial parts of both branches are reduced to the midline.

The known method allows you to completely close the soft tissue defect, however, the disadvantage of this method is, and according to the authors themselves, the development of a complete relapse of the initial diastasis of the pubic bones in almost 85% of cases.

The known “Method of surgical correction of pubic diastasis in bladder exstrophy” [pat. RU No. 2473312, publ. 01/27/2013], in which a transverse osteotomy of the iliac bones is performed on both sides, then two rod compression-distraction devices are installed, and the rods of the devices are oriented crosswise from the right anterior superior spine to the left anterior inferior spine and from the left anterior superior spine to the right of the lower anterior spine, gradual distraction is carried out by rotating the distal nuts on the threaded rods in the proximal direction at a speed of 2-4 mm per day until the pubic diastasis is eliminated, then osteosynthesis of the symphysis pubis is performed with a wire passed through the obturator foramina and after control radiographs confirming the stability of the pelvic ring , the device is dismantled.

The disadvantages of this known method include the complexity of the method itself due to the use of an external fixation device, the use of which creates an entrance gate for infection and increases the risk of purulent complications.

Also known is “Method of surgical treatment of hip joint pathology” [Pat. RU No. 2233134, publ. 07.27.2004], chosen as a prototype for the claimed method. The known method involves performing an osteotomy of the ilium and rotating the acetabular fragment downwards outwards anteriorly. Osteotomy of the ilium is carried out with the formation of a bone spike from the inner cortical plate above the arcuate line, followed by its insertion behind the outer cortical plate and holding it in this position with Kirschner wires.

The known method allows you to lateralize the acetabular fragment, that is, tilt the acetabulum outward and downward, completely cover the femoral head, and the formed bone spike holds the acetabular fragment in the desired position, but at the same time the acetabular fragments move outward to the right and left.

The objective of the present invention is to develop a method for surgical correction of the pelvic ring for the treatment of bladder exstrophy in children, allowing for stable fixation of the pelvic ring.

The technical result of solving the problem is to prevent displacement of the proximal and distal fragments of the pelvis relative to each other due to the bone spikes formed on both sides, forming a locking joint, and allowing to completely eliminate the loss of correction of the initial diastasis of the pubic bones.

The technical result is achieved by the fact that in the claimed method, including dissection of the skin and subcutaneous fatty tissue above the crest of the iliac wing, dissection of the apophysis of the iliac crest with continuation through the anterior superior spine to the anterior inferior spine, isolation of the isthmus of the iliac wing to the sciatic notch with detachment of the periosteum, performing an osteotomy of the ilium with the formation of a bone spike from the cortical plate of the acetabular fragment of the pelvis, according to the invention, an osteotomy of the iliac bones is performed on 2 sides, on each side a bone spike is formed from the outer cortical plate, using a Gigli saw, the formed bone spike of the acetabular the pelvic fragment is inserted behind the inner cortical plate of the iliac wing, and a linear cranial displacement of the acetabular fragment is performed until the formed bone spike from the outer cortical plate is completely inserted behind the inner cortical plate of the iliac wing, the resulting position of the bone spike is fixed with Kirschner wires, through the iliac wing and acetabular pelvic fragment.

The proposed set of essential features, in contrast to the prototype, allows, by forming a bone spike precisely from the outer cortical plate and placing it behind the inner cortical plate of the iliac wing, to bring together the pubic bones, which are initially strongly pushed outward in the pathology of bladder exstrophy, and thereby create a pelvic ring.

Thus, the essential features listed above distinguish this method from known methods and make it possible to restore the correct shape of the pelvic ring and the biomechanical relationship of the pelvis and lower limb.

In fig. 1 - the line of osteotomy of the ilium is presented;

in fig. 2 - shows a diagram of the performed osteotomy and the location of the pelvic bones after transposition of the acetabular fragments;

in fig. 3 - photograph of an osteotomy of the isthmus of the iliac wing, illustrating clinical examples. In the photograph: 2 - anterior superior spine, 5 - osteotomy line of the outer cortical plate; 6 - osteotomy line of the internal cortical plate;

in fig. 4 is a photograph of a formed bone spike, illustrating clinical examples. In the photograph: 2 - anterior superior spine; 5 - osteotomy line of the outer cortical plate.

Designations in Fig. 1: wing of the ilium - 1; anterior superior spine - 2; anterior-inferior spine - 3; pubic bone - 4; osteotomy line of the outer cortical plate - 5; osteotomy line of the internal cortical plate - 6; Diastasis of the pubic bones - 7.

Designations in Fig. 2: Kirschner wires - 8; bone spine of the acetabular fragment - 9.

The method is carried out as follows:

The claimed method of surgical correction of the pelvic ring for the treatment of bladder exstrophy in children is carried out with the patient lying on his back. After dissecting the skin and subcutaneous fatty tissue above the crest of the iliac wing 1 (bikini-type incision), the apophysis of the iliac crest 1 is dissected for 2-3 cm, then the section continues through the anterior superior spine 2 to the anterior inferior spine 3 Subperiosteally, Buyalsky's scapulae distinguishes the isthmus of the iliac wing 1 to the sciatic notch. In the area of the notch, the periosteum is detached using a curved rasp. Using a Gigli saw passed through the sciatic notch, an osteotomy of the isthmus of the iliac wing 1 is performed in such a way that a bone spike 9 is formed from the outer cortical plate with the apex facing cranially. This is achieved by the cranial direction of the outer part of the Gigli saw to the middle of the isthmus of the iliac wing 1, which then changes in the direction of the anterior-inferior spine 3. In this case, the section of the internal cortical plate is performed rectilinearly, in the horizontal plane. Using a single-tooth hook, the acetabular fragment is rotated anteriorly, downward and medially. The formed bone spike 9 of the outer cortical plate of the acetabular fragment is inserted behind the inner cortical plate of the iliac wing 1, and then a linear cranial displacement of the entire acetabular fragment is performed until the formed spike of the outer cortical plate of the acetabular fragment is completely inserted behind the inner cortical plate of the ilium wing 1. The resulting position correction is fixed with two Kirschner wires 8, passed through the wing of the ilium and the acetabular fragment of the pelvis. A similar operation is performed on the contralateral side. The locking articulation formed in this way between the wings of the ilium and the acetabular fragments brings the pubic bones 4 as close as possible and prevents their lateral displacement. If necessary, for more reliable fixation, the pubic bones are fastened together with Mylar sutures.

Thus, the claimed method, in the pathology of bladder exstrophy, in which the pubic bones are initially strongly pushed outward, allows the formation of a pelvic ring by bringing the pubic bones closer to each other, and securing them with a locking joint due to the formed bone spikes of acetabular fragments on both sides. In this case, the roofs of the acetabulum move towards the center, and the wings of the ilium, placed behind the bone spines, create pressure on them from both sides towards each other towards the central line of the body, thereby bringing them together and keeping them from diverging back outwards.

The method is illustrated by the following clinical examples.

1. Patient K., age 5 years, was admitted for planned surgical intervention for bladder exstrophy. An x-ray taken before treatment revealed a diastasis of the pubic bones with a width of 4.5 cm. After dissecting the skin and subcutaneous fat above the crest of the iliac wing (bikini-type incision), the apophysis of the iliac crest was dissected for 3 cm, then the section continued through the anterior superior spine to the anterior inferior spine. Subperiosteally, Buyalsky's scapulae highlight the isthmus of the iliac wing to the sciatic notch. In the area of the notch, the periosteum was detached using a curved rasp. Using a Gigli saw passed through the sciatic notch, an osteotomy of the isthmus of the iliac wing was performed (Fig. 3) in such a way that a “bone spike” with the apex facing cranially was formed from the outer cortical plate (Fig. 4). This was achieved by cranially directing the outer part of the Gigli saw to the middle of the body of the ilium, which then changed in the direction of the anterioinferior spine. In this case, the section of the inner cortical plate was performed rectilinearly, in the horizontal plane. Using a single-tooth hook, the acetabular fragment is rotated anteriorly, downward and medially. The formed bone spike of the outer cortical plate of the acetabular fragment is inserted behind the inner cortical plate of the iliac wing, and then a linear cranial displacement of the entire acetabular fragment is performed until the formed spike of the outer cortical plate of the acetabular fragment is completely inserted behind the inner cortical plate of the ilium wing. The resulting correction position is fixed with two Kirschner wires passed through the wing of the ilium and the acetabular fragment of the pelvis. A similar operation was performed on the contralateral side. The next stage was urological plastic surgery of soft tissues. The wounds are sutured in layers, leaving Redon drainage to the site of osteotomy of the iliac bones. Immobilization with coxite plaster cast. The drains were removed within 24 hours. After 6 weeks, the coxite plaster cast was removed. Plastic surgery of the anterior abdominal wall was successful. A control radiography of the pelvis was performed in a direct projection. Clinically and radiologically, the diastasis is 0 cm. Kirschner wires were removed after 6 months.

2. Patient K., aged 4 years, was admitted for planned surgical intervention for bladder exstrophy. An x-ray taken before treatment revealed a diastasis of the pubic bones with a width of 4 cm. After dissecting the skin and subcutaneous fatty tissue above the crest of the iliac wing (bikini-type incision), the apophysis of the iliac crest was dissected for 2 cm, then the section was continued through anterior superior spine to anterior inferior spine. Subperiosteally, Buyalsky's scapulae highlight the isthmus of the iliac wing to the sciatic notch. In the area of the notch, the periosteum was detached using a curved rasp. Using a Gigli saw passed through the sciatic notch, an osteotomy of the isthmus of the iliac wing was performed in such a way that a “bone spike” with the apex facing cranially was formed from the outer cortical plate. This was achieved by cranially directing the outer part of the Gigli saw to the middle of the isthmus of the ilium, which then changed in the direction of the anterioinferior spine. In this case, the section of the inner cortical plate was performed rectilinearly, in the horizontal plane. Using a single-tooth hook, the acetabular fragment is rotated anteriorly, downward and medially. The formed bone spike of the outer cortical plate of the acetabular fragment is inserted behind the inner cortical plate of the iliac wing, and then a linear cranial displacement of the entire acetabular fragment is performed until the formed spike of the outer cortical plate of the acetabular fragment is completely inserted behind the inner cortical plate of the ilium wing. The resulting correction position is fixed with two Kirschner wires, through the wing of the ilium and the acetabular fragment of the pelvis. A similar operation was performed on the contralateral side. The next stage was urological plastic surgery of soft tissues. The wounds are sutured in layers, leaving Redon drainage to the sites of osteotomies of the iliac bones. Immobilization with coxite plaster cast. The drains were removed within 24 hours. After 6 weeks, the coxite plaster cast was removed. Plastic surgery of the anterior abdominal wall was successful. A control radiography of the pelvis was performed in a direct projection. Clinically and radiologically, the diastasis was 0 cm. Kirschner wires were removed after 6 months.

Thus, the developed method for correcting the pelvic ring for the treatment of bladder exstrophy in children allows the formation of a pelvic ring with a reliable locking joint due to the formed bone spikes that provide stable fixation of the pelvic ring, and eliminates the loss of correction of the initial diastasis of the pubic bones.

Claims (1)

A method of surgical correction of the pelvic ring for the treatment of bladder exstrophy in children, including dissection of the skin and subcutaneous fatty tissue above the crest of the iliac wing, dissection of the apophysis of the iliac crest with continuation through the anterior superior spine to the anterior inferior spine, isolation of the isthmus of the iliac wing to sciatic notch with detachment of the periosteum, performing an osteotomy of the ilium with the formation of a bone spike from the cortical plate, characterized in that an osteotomy of the iliac bones is performed on 2 sides, on each side a bone spike is formed from the outer cortical plate using a Gigli saw, a formed bone spike the acetabular fragment of the pelvis is inserted behind the inner cortical plate of the iliac wing and a linear cranial displacement of the acetabular fragment is performed until the formed bone spike from the outer cortical plate is completely inserted behind the inner cortical plate of the iliac wing, the resulting position of the bone spike is fixed with Kirschner wires, through the iliac wing and acetabular pelvic fragment.