Method of performing periacetabular triple osteotomy of pelvis in teenagers

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopaedics and can be applied for realisation of periacetabular triple osteotomy of pelvis in teenagers. Access to ischial and pubic bone is realised in projection of adductor muscles - longitudinal adductor access, in position of bending and abduction in hip joint. Tenomyotomy of adductor muscles is performed. In intermuscular space in blunt way performed is access to femur trochantin, where tendon part of iliolumbar muscle is exposed and its tenotomy is carried out. Branch of ischial bone, covered from outside with external obturator muscle, is identified under acetabulum. External obturator muscle is perforated. Ischial bone is bypassed with raspatories from inside and outside and oblique osteotomy is performed in front-to-back direction. Osteotomy of upper branch of pubic bone is performed. Osteotomy of ilium is performed from front access.

EFFECT: method makes it possible to reduce access trauma, provide realisation of surgery under conditions of hip head compression or its high position in case of dislocation.

8 dwg

 

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of hip disease in adolescents with severe forms of violations of relationships in the hip joint caused by breach of the centration of the femoral head, the bone deficit coverage.

The main indications involving the use of a triple osteotomy of the pelvis are: Perthes disease, residual subluxation and dislocation of the hip, dysplastic coxarthrosis, spastic subluxation and dislocation of the hip. Hip dysplasia is a congenital inferiority of the joint, due to its irregular development, which leads to subluxation or dislocation of the femoral head. Spastic subluxation or dislocation of the femoral head - a key element in the development of deformities in the hip joint is an increased tonus of the adductor muscles and the weakness of the gluteal and abductor muscles that inhibit physiological processes decline cervico-diaphyseal angle. As a consequence, the redistribution of the load of the femoral head on the outer edge of the acetabulum and the development of bone deficit coating head through the acetabular component.

There is a wide variety of approaches in the operation triple osteotomy of the pelvis, where the main difference bookmark�greater access to the ischium and the number of accesses. In recent years, the most popular are periacetabular triple pelvic osteotomy, in which the intersection of the pelvis is performed in the vicinity of the acetabulum.

The known method of triple osteotomy of the pelvis by periacetabular ischial osteotomy, pubic and iliac bones of the pelvis with the reorientation of the acetabulum, this exercise lateral access to the upper thigh, perform corrective osteotomy of the proximal femur by resection of the bone wedge, the upper section of which is carried directly above the small trochanter, and the second depending on the direction of the required correction, cut the tendon of the iliopsoas muscle from the small trochanter, plant fragments thighs, longitudinally divided muscle to the lateral border of the ischium and transversely or cooperate her cut from multlanguage space immediately below the bottom edge of the acetabulum with resection of the osteotomy of the lateral edges of the U-shaped or conventional osteotome width of 0.5 cm and osteotomy-osteoclasis its inner edge, perform osteosynthesis of fragments of the femur metal l-shaped plate, provide access to the anterior part of the pelvis, cut through the pubic bone at the base, transverse or semicircular cross podvzdoshnoj� bone above her front bottom spine, rotating mobilized the acetabular fragment to the femoral head with his medialization, which detect fragments of the pelvis with the help of spokes Kirchner, depending on the ratio of bone fragments fill the defects resected from my thigh bone autograft (Patent RF №2438609).

The disadvantages of this method are the high risk of injury to the neurovascular tract, passing through the inner thigh and a significant depth of the wound, passing through all layers of the thigh muscles, which reduces the operational review of the field.

The known method of triple osteotomy proposed by Sokolov A. M. (A. M. Sokolowski Features of our technology triple pelvic osteotomy / A. M. Sokolov, O. A. Sokolov // Actual problems of pediatric traumatology and orthopedics: Materials of scientific-practical conference of the children's orthopedic traumatology of Russia. - Staraya Russa, 2000. Pp. 320-322), according to which the patient on the back with a raised pelvis on the side of the surgery is performed the incision Smith-Petersen. After clipping the iliopsoas muscle from the small trochanter in the lower corner of the wound below the acetabulum 2-3 cm by palpation determine the ischial bone and is isolated subperiosteal. According to the author, the selection of the ischium is the most difficult phase of the operation, since the depth of the wound was significantly increased, and the angle of the surgical dei�the third decreased, but sufficient for safe osteotomy of the ischium. Subsequently, the author refused to carry out a complete osteotomy, replacing it with osteotomy-osteoclasis ischium.

The disadvantages of this method are the large depth of wound and a significant decrease in the angle of operative activity.

The known method of transposition of the acetabulum after triple pelvic osteotomy, whereby as close as possible to the bottom of the trench is performed subperiosteal allocation of the pubic bone. After installing subperiosteal limiters osteotomy is performed. From the same access as close as possible to the bottom of the trench is performed subperiosteal allocation of the ischium upwardly from the ischial tuberosity without affecting the point of attachment of the muscles of the back of the thigh, and after installing subperiosteal limiters is oblique periacetabular osteotomy. After subperiosteal separation of the Ilium is then osteotomy saw Gigli. Produce transposition of the acetabular fragment. The resulting position is fixed spokes of Kirchner. (Patent RF №2414186).

The disadvantage of this method are narrow indications for triple pelvic osteotomy. Application of this method in children with Perthes disease, spastic subluxation and dislocation of the hip, where one of the TC�Cevik pathogenetic mechanisms of development of secondary deformities of the femur and pelvic components is compressed iliopsoas muscle, requires additional access to the small trochanter of the femur.

The method chosen as a prototype.

The object of the invention is the development of an original method of triple pelvic osteotomy of the minimal invasive access.

The technical result of the implementation of the task is a multi-access ischial and pubic bones of the pelvis and the iliopsoas muscle.

The invention consists in the original less traumatic access to the ischium, and through this access can be trometamol the adductor muscles and the lumbar-iliac muscle. The choice in favor of transposition of the acetabulum due to the severity of the deformation of the acetabulum and the age of the patient. The method can be combined with corrective osteotomy of the femur.

The method is carried out as follows. In the patient on the back with a cushion under the hip joint on the side of the operation, the foot in the position of flexion and abduction in the hip joint (Fig.1) make the cut of a length of 7-8 cm in the upper third of the thigh on the inner surface in the projection of the adductor muscles - longitudinal adductors access (Fig.2). After incising the skin and subcutaneous tissue perform trometamol the adductor muscles (as indicated). In the intermuscular interval blunt carry dost�p to the small trochanter of the femur, where allot of the tendinous portion of the iliopsoas muscle (Fig.3) and produce tenotomy m. The Iliopsoas. In place of the cut-off of the adductor muscles, just below the acetabulum of the determine the upper branch of the ischium, which is covered by the outer sphincter muscle. The latter is perforated clamp and seat bone curved bypass aspatore inside and out (Fig.4). There is no need to strictly subperiosteal to highlight the location of the osteotomy. Chisel perform oblique osteotomy in the posterior direction from front. In the upper corner of the wound palpation determine the upper branch of the pubic bone as close as possible to the body of the pubic bone (the leg is necessarily in the position of flexion and abduction in the hip joint to prevent contact with the femoral vessels and nerve), where for small isolated subperiosteal space for osteotomy. Osteotomy performed with a chisel or a saw, Gigli. Surgical wound is sutured leaving rubber graduate.

Osteotomy of the Ilium perform anterior length of 8-10 cm Subperiosteal allocation advertures produced only on the inner surface in a limited area in the venue saw Gigli. On the outer surface of the Ilium do not separate the periosteum. Saw Gigli produce arcuate osteotomy bulge, located n� articular fragment of the pelvis. Clinical example of a method

Patient K. 10 years admitted with a diagnosis of Perthes Disease on the right, 3 Catterall group, the stage of fragmentation. The child was admitted with complaints of pain in the right hip radiating to the right knee. The pains came at movement in the hip joint and by relying on the right lower limb. According to x-ray examinations in the direct projection and the projection Launstein (Fig.5): radiological signs of Perthes disease, saddle deformity of the epiphysis of the right femur, the stage of fragmentation. Shown and underwent surgery. In the patient on the back, after the processing of the entire right lower extremity and groin area up to the navel, in the position of flexion of the lower limb and abduction in the hip joint hold the skin incision in the projection of the adductor muscles - longitudinal adductors access a length of 7-8 cm in the upper third of the thigh on the inner surface. After incising the skin and subcutaneous tissue perform trometamol of the adductor muscles, decompression of the femoral component of the hip joint. In the intermuscular interval blunt access to the small trochanter of the femur, which is isolated tendinous portion of the iliopsoas muscle and produce tenotomy m. The Iliopsoas. In place of the cut-off of the adductor muscles, just below the acetabulum WPA�other determine the upper branch of the ischium, which is covered by the outer sphincter muscle. The latter is perforated clamp and seat bone bypassed curved raspatory inside and out. Chisel perform oblique osteotomy in the posterior direction from front. In the upper corner of the wound palpation determine the upper branch of the pubic bone as close as possible to the body of the pubic bone (the leg is still in the position of flexion and abduction in the hip joint to prevent contact with the femoral vessels and nerve), where for small isolated subperiosteal space for osteotomy. Osteotomy performed with a chisel or a saw, Gigli. Surgical wound is sutured leaving rubber graduate. Osteotomy of the Ilium perform anterior length of 8-10 cm Subperiosteal allocate adverturous only area on the inner surface in a limited area in the venue saw Gigli. On the outer surface of the Ilium do not separate the periosteum to reduce blood loss. Saw Gigli produce arcuate osteotomy bulge located on the articular fragment of the pelvis. Next, using a single-tooth hooks produce the displacement of the acetabular fragment anteriorly and laterally. Under image intensifier control fix the acetabular fragment in the correct position to the body of the Ilium 4-5 spokes. R�well sutured in layers with rubber graduate. X-ray picture of the hip joint after surgery (Fig.6.). Postoperative lower limb is fixed in a circular plaster cast for a period of 3 months. X-ray picture of the hip joint after removal of plaster (Fig.7). Radiographs in frontal projection and the projection Launstein 12 months after surgical treatment (Fig.8).

Triple pelvic osteotomy is an effective high-tech intervention in adolescents.

The advantage of the proposed method is to develop a new access when performing the osteotomy of the bones of the pelvis, osteotomy of the ischium is produced in the safest direction from front to backward.

Such access leads to the reduction of trauma intervention and implements krovoobrazhenie that allowed to avoid red blood cell transfusions.

Decreases the depth of wound when you access the ischium, there is no need to allocate the sciatic nerve. Longitudinal adultery incision minimizes damage to exterior pudendal blood vessels. Does not change the position of the patient during surgery, which reduces the time of surgery.

A method for performing periacetabular triple pelvic osteotomy in adolescents, including osteotomy of the iliac, pubic and ischial bones and�division of the ischium of the same access that pubic bone, characterized in that the access to the ischial and pubic bones is performed in the projection of the adductor muscles - longitudinal adductors access, in the position of flexion and abduction in the hip joint, perform trometamol the adductor muscle, in the intermuscular interval blunt access to the small trochanter of the femur, which is isolated tendinous portion of the iliopsoas muscle and produce its tenotomy, under the acetabulum of the determine the branch of the ischium, which covered the outside of the outer sphincter muscle, the external obturator muscle is perforated, ischium bypass aspatore inside and out and perform oblique osteotomy in the direction from front to back, then do an osteotomy of the upper branch of the pubic bone, and then perform the osteotomy of the Ilium anterior.



 

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