The method of treatment of chronic damage to the symphysis and sacroiliac joint

 

(57) Abstract:

The invention relates to medicine, namely to orthopedics and traumatology, and may be applicable for the treatment of chronic damage to the symphysis and sacroiliac joint. Share surgical treatment in three stages. Eliminate the first stage of the vertical displacement of the pelvic ring and bring the pubic bone in the apparatus of external fixation with a rate of 5 mm/day for 72 days. In the second step, without removing device, perform the stabilization of the sacroiliac joint by bone plastic surgery. Perform a through 14 d third stage - bone-plastic stabilization of the symphysis. Allow patients the load - walk immediately after the first stage. Recommend wearing leather pelvic girdle within 1 year after the removal of the device. The method allows to restore the anatomical structures of the pelvic ring, to reduce the trauma. 4 Il.

The invention relates to medicine, namely to traumatology.

The frequency of unsatisfactory results of treatment of injuries of the pelvis is 20-30% and has no tendency to decrease (Cherkes-Zadeh D. I. Disability after fractures of the pelvis according to the specialized VTEC CIT is Arutyunova treatment of injuries of the musculoskeletal system in patients with concomitant and multiple trauma. // Orthopaedics, traumatology and prosthetics, - 1988. - 8. - C. 15-18), noting the absolute increase in the number of patients with unstable injuries of the pelvic ring.

The main method of treatment of injuries of the pelvic ring is conservative, but if this method during the acute period is quite effective, with long-standing injuries using its hopeless.

Severe cases of damage to the pelvic ring, accompanied by violation of its integrity, i.e., the combination of a rupture of the sacroiliac joints and the symphysis, lead to its instability. In such cases the entire lateral side of the pelvis is shifted upwards due to the reduction in m. Ileo-psoas, m. Quadratus lumborum and obliques; action adduction thigh is pulled to the middle line; simultaneously into force of gravity and the action of the gluteus all limb rotated outwards.

While (acute period) is not resolved displacement of the pelvis will cause deformation of the pelvic ring disruption of the integrity of the supporting arches standing or sitting, make it difficult to walk due to pain under load, break statics with the development of the "duck walk", lead to the misalignment of the pelvis and scoliotic installation of the spine, patients Ter is the train's own archival material suggests, unlike fresh injuries chronic injuries of the pelvis with a violation of the pelvic ring is quite difficult to restore the proper anatomic relationship. With an increase of the period of limitation for personal injury these difficulties increase due to the severity of degenerative cicatricial changes in synchondrosis joints of the pelvic ring and the muscles surrounding it.

Only surgical treatment of injuries allows patients to avoid validnode. One-stage restoration of the anatomical structures of the pelvic ring with long-standing lesions accompanied by an extensive, fairly traumatic surgery, and, daring him, surgeons rarely manage to eliminate all forms of bias due to severe muscle contractures and fixed offsets (Kaplan L. C. Damage to bones and joints. M, "Medicine", 1979, pp. 331-352), and the failure of this pathology leads to instability, the development of arthritis pain and disability.

In this regard, and to achieve full cure in these patients, with the exception of the disadvantages of the prototype, we have developed a three-step method of surgical treatment of patients.

The indication for surgical treatment with regard to damage to the sacroiliac joint with dislocation or subluxation half of the pelvis.

The first step is the elimination of the vertical displacement of the pelvic ring and the convergence of the pubic bones, as much as possible the gradual mode of not more than 5 mm per day, which takes an average of 72 days and is dosed compression apparatus of external fixation on the basis of the spokes or rods held in the wings of the Ilium. After completion of the first stage of the patient allow physical activity - walking.

The second stage - not removing apparatus, is the stabilization of the posterior pelvic ring by performing bone plastic surgery.

The third and final stage surgical correction involves bone-plastic restoring anterior pelvic ring that was made after the healing of postoperative wounds and the removal of the stitches in region of sacrum, i.e., on the 14th day after the second stage.

The method is performed as follows.

The method of application of the device to the pelvis. Under General anesthesia the patient on the orthopaedic table on the back with pelvic lining and measured thrust for the foot from damage to the sacroiliac joint and a fixed stop with a healthy side who is Aracinovo fields produce a linear incision of skin and subcutaneous tissue in length, 0.5 cm in the projection of the lower front spine, predavanja spine and between the iliac crest. Thereafter, the trocar through the skin incision fix stiletto in a compact substance, through the guide bore through the channels, which enter threaded rods on the depth of the thread. Similarly hold the rods on the opposite side. Rods with brackets fixed on the threaded rod and connect to each other from opposite sides through the ball joint. In the postoperative period in a sparing mode gradually eliminate the vertical offset and the divergence of the symphysis with ball joint and threaded rod (Fig.1 and 2). After the removal of vertical displacement and divergence of the symphysis of the patient is transferred to a more active mode - allow them to go.

The technique of bone-plastic surgery to restore the back half of the pelvis was next. Without removing apparatus, under General anesthesia the patient was laid on the operating table in the prone or side lying position. The incision is started at 2 transverse finger anteriorly from sagawara spine of the Ilium and then continued along the crest of the Ilium backwards, parallel to the midline, conducted over the spinous processes. After separation of the sacral-podpis in the sacrum and the iliac bones are firmly entered autotransplanted. For the fixation of bones that make up the sacroiliac joint and talocrural used a plate of his own design and compremise screws (Fig.3).

The technique of bone and plastic surgery to repair the anterior half of the pelvis is the following. The skin incision was made parallel to the lower transverse crease of the abdomen 1 cm below it. After exposure of the anterior surface of the pubic joint was cut straight abdominal muscles in places attached to your pubic bone to pubic tubercles. Then, using raspatory skeletonema areas of the upper edge of the pubic joint. From the region of the symphysis was removed cartilage and chisel did the wedge-shaped groove on the upper surface of the pubic bone. Cortical autotransplanted taken from the tibia, were laid in the groove and then fixed with screws. Cliff height should match the height of autotransplanted, which can vary from 2 to 4 cm, which is necessary for stable fit it to the bones of the pelvis (Fig.4).

Starting with the first stage and prior to full recovery, actively tactics of conducting patients and rehabilitation. If the first stage of surgical treatment in order COI is served the function of immobilization to create more favourable conditions of reparative regeneration after the first and second stages of surgical intervention in the lesion. Removing the unit was made after 3 months from start of treatment, followed by wearing a pelvic belt in 1 year. Leather pelvic girdle is not within the scope of this application by the object of the invention: this brace has long been known in Orthopaedics and traumatology. Despite the removal of heavy post-traumatic deformity of the pelvic ring, well tolerated by patients used methods of treatment, any complications and recurrence, we did not observe.

Just treated 54 patients, the timing of post-traumatic deformities of the pelvis in all patients were from 3 months or more. Simultaneously reposition and fixation of pelvic ring using a plate or transosseous osteosynthesis was impossible due to the formed fixed deformities rough scars and muscle contracture.

Thus, the three-step method of surgical treatment of chronic damage to the sacroiliac joint and symphysis, not previously described in the available literature, allows to eliminate the rough deformation with the restoration of the anatomical structures of the pelvic ring. Being less traumatic and easily tolerated by patients, it eliminates pain and restores the ability to work, which is confirmed-iliac articulation, consisting in operative stabilization of the symphysis and sacroiliac joint, characterized in that the surgical treatment is divided into three stages, when the first resolve the vertical displacement of the pelvic ring and bring the pubic bone in the apparatus of external fixation with a rate of 5 mm/day. within 72 days; in the second stage, without removing device, perform the stabilization of the sacroiliac joint by bone plastic surgery, and after 14 days. carry out the third stage - bone-plastic stabilization of the symphysis, and the load - walking patients are allowed to immediately after the first stage and subsequently recommend wearing leather pelvic girdle within 1 year after the removal of the device.

 

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