The method of surgical treatment of pathological dislocation of the hip with osteolysis of the head and neck

 

(57) Abstract:

The invention relates to medicine, namely to traumatology and orthopedics in the treatment of hip dislocation. The inventive carry out one-step vertelney arthroplasty through two access at the front of the free access acetabulum, rear access behind the broad fascia of the thigh prepare the chin and longitudinally cut through the muscles from the top of the greater trochanter, spherical model of the cartilaginous part of his Apophis, cross the hip in podarennoi the field, keeping the connection proximal fragment with muscles, perforined them in a box under the middle gluteal muscle exercise through this hole reposition twirling in the acetabulum, rootroot the proximal fragment in three dimensions to achieve centration of the top of the greater trochanter in the acetabular fossa, spend decortication area of the small trochanter with the lower part of the proximal fragment hips, carry out the osteosynthesis of bone fragments of the G-shaped plate end in the side under age angle, move on to the mechanical part of the bone sawdust mobilized together with the periosteum of the muscles and the tensor fasciae latae hips. When reduced acetabulum make advertise the top of the greater trochanter in the acetabulum and its concentrations sufficient for joint mobility. 1 C.p. f-crystals.

The invention relates to medicine, in particular for orthopedics and traumatology, and can be used to recover child support ability and function of the hip joint pathological dislocation of the hip with osteolysis of his head and neck.

Such degradation of the neck and the femoral head arise moved in early childhood epiphyseal osteomyelitis or aseptic necrosis of the head when undiagnosed and improperly treated congenital hip dislocation, degenerative processes in the field of head and neck of femur other origin.

Restore good function of the hip joint in such cases is achieved with great difficulty. A regular output in such cases is hip arthroplasty, the greater trochanter (Colonna P. // J. Bone Jt. Surg., 1935. - Vol. 17., p. 110). However, muscle biomechanics when this was not taken into account and often developed by ankylosauria joint. To the same effect led and attempt arthroplasty small spit, which does not match the shape of the acetabulum, is inferior to the big spit in the possibilities of support, allows to reach lower mobility of the joint.

The closest analogue in this area is the way (prototype) operations De Palma (1951), in which after podarennoi osteotomy of the proximal fragments with the greater trochanter of vpravlyaetsya in the acetabulum and fixed two-bladed nail. This requires cutting off the muscles, which then take on the ideological dislocation of the hip. Mon. - Minsk, 1997. - S. 76-77).

The method does not take into account the stabilizing effects of periarticular muscle groups, require clipping of the muscles below the optimal level for consolidation and biomechanics mutual adaptation of fragments and disadvantages of simulation set trochanter often require Vitalievich caps. It also excludes the need for correction of the acetabulum exposed in such cases the reduction.

The invention is directed to solving objectives: increase the efficiency of the method vertelney plastics with osteolysis of the head and neck of the femur and pathological dislocation by substitution restore optimal anatomical-functional correlations in the hip joint.

When performing the proposed method achieve greater stability of the position of the top of the greater trochanter in the acetabulum with sufficient mobility, create a musculoskeletal model closest in biomechanical characteristics and form a healthy joint, provide reliable concentrations apex of the greater trochanter and a good consolidation of fragments after osteotomy.

This is achieved by one-step vertelney arthroplasty after 2 postulate and partial longitudinal cut in the rear access behind the broad fascia of the thigh along with the periosteum of the muscles from the top of the greater trochanter, spherical modeling cartilaginous part of its Apophis, crossing the hip in podarennoi region at a distance equal to the lever arm neck and head healthy side, save link proximal fragment with muscles, punching them in the box under the middle gluteal muscle exercise through this hole reposition twirling in the acetabulum, the rotation for the best adaptation of the proximal fragment in three dimensions to achieve centration of the top of the trochanter in the acetabular fossa, the location of the bottom of the small trochanter and holding decortication lower part of the thigh, the synthesis of fragments of the G-shaped plate end in the side at an angle, equal individual or age norm cervico-diaphyseal angle, the transposition of the end part of the bone sawdust mobilized together with the periosteum of the muscles and tensor fasciae latae hips, implementation in underdeveloped outer edge of the acetabulum in 1 or 2 stages advertures bone-plastic osteotomy of the pelvis.

The method is as follows. Perform figure S-shaped access, reminiscent of access Smith-Petersen. When the access cut through the skin and subcutaneous tissue, then the front of the access exercise on the leading edge strip acetabulum from scarring to the cartilage surface, preparing her to reposition. The posterolateral longitudinal slit partially prepare the chin with the periosteum of the muscles from the top of the greater trochanter, and Apophis give a spherical or ovoid shape. In podarennoi region in the transverse direction across the diaphysis of the femur, thus choose the level section at a distance from the apex of the greater trochanter, is equal to the lever arm of the head and neck of the femur healthy side or approximate age norm such. Perforined scar tissue and shifted muscles, create a box under the middle gluteal muscle and the tensor fasciae latae femur, proximal fragments rootroot in 3 planes, the tip of the greater trochanter set and adapt to the acetabulum to the “suction effect”. Perform decortication area of the small trochanter with part of the adjacent diaphysis to ensure good bone mutual contact of fragments. Fragments synthesize l-shaped plate or similar (plate, Krechmar, plate Blount) end side at an angle equal to the individual or the age norm cervico-diaphyseal angle. Sharp branches plate enter the diaphysis of the femur in the proximal direction, and distal fragments down to a prepared plot m the Cove end side. To the end part of the bone sawdust proximal fragment hem partially mobilized together with the periosteum of the muscles and the tensor fasciae latae hips. When reduced acetabulum perform the same or subsequent stage adverturous osteotomy of the pelvis bone splitting of the Ilium introducing bone graft from the iliac crest, free or muscular leg. Set the spit, and optionally, fragments of the pelvis is fixed spokes, continue unloading on skeletal traction and / or fix the limb in a plaster or polymer hip bandage. In the process of loading the cartilaginous part of the growing experiences of Apophis functional restructuring, adapting to the acetabulum.

Example 1. Patient M., aged 8. Story No. 213. When contacting the hospital revealed significant disturbances in gait, the relative shortening of the right lower limb. Great spit right thigh shifted upward, causing rotation contracture of the right hip, a pronounced limp. History of osteomyelitis of the proximal femur in the 1st year of life. On the x-ray was diagnosed with a dislocated hip with a high offset, a large skewer with a good view of the growth zone is shifted upwards with upons admission: Destructive dislocation of the right hip. The outcome of osteomyelitis of the proximal femur with a complete osteolysis his head and neck. Operated. The operation has been performed on the proposed method. Conducted repositional arthroplasty of the right hip joint by apavisa greater trochanter, corrective centering osteotomy of the right thigh. Nadvertent right pelvic osteotomy. Attention is drawn to the following features of the surgical intervention. On the operations of the joint cavity freed from scars and bone and cartilage remnants of lysed the femoral head. On the distal fragment is made a groove in the form of a recess to adaptation with a small skewer, having the form of a ridge, and at the site of contact on the proximal fragment is executed decorticate. In the bone marrow canal of the proximal fragment entered the field plate Blount, additional fixation screw through a small skewer in the distal fragments with the aim of bias prevention efforts. Reached setting, with a muscular foot on the proximal fragment was preserved, Rotorua when you reposition the tip of the greater trochanter. The operation complements the transposition of the iliopsoas muscle on the anterior surface of the proximal fragment. Made nadvertent pelvic osteotomy with location 2 bone is Alanna fixing spokes temporarily, skeletal traction. On histology remote areas of the head of the basin: pronounced degenerative changes in the cartilage tissue. Metal removed after 10 months after surgery. 1 year after the operation is permitted load. 1.5 years at survey abstraction hips up to 60 degrees, the amplitude of the rotational movements of 50 degrees. On the radiograph large skewer centered in the acetabulum, cervico-diaphyseal angle is maintained at an angle of 130 degrees. Shortening up to 3 cm compensate for the heel, goes without additional funding support.

Example 2. Patient K., 2 years 3 months. Story No. 700. Turned with a diagnosis of pathological dislocation of left hip destructive type. History of osteomyelitis. On artrografii double-contrast signs of true anatomical nepravilnosti. Made repositional vertelney arthroplasty on the proposed method. Achieved after osteotomy resetting the greater trochanter at the hip joint, the surface of which is exposed to the cartilage. The head of the femur and the neck is completely lysed. Found covered with cartilage areas of the small trochanter and the stump of the neck, however, to reposition these sites deemed unsuitable. Allocated behind stereonova/3 diaphysis, the length of the proximal fragment corresponded to the length of the lever of the cervix with the head on the unaffected side. It was retained on the proximal fragment communication with muscular leg middle gluteal muscles, quadriceps muscle, muscle tensor fasciae latae does not intersect maximally preserve the periosteum. Large skewer with a proximal portion of a femur retiremen in 3 planes and turned to the window, back to front between the muscles, set in the acetabulum, and in this position, keeping the orientation parameters of a normal joint, the arm is fixed to l-shaped plate. Achieved reduction with good adaptation and “suction” spread was determined vzaimootnoyoshenijah forms, the situation is further fixed spokes applied transcutaneously. In order not to increase the invasiveness of the intervention, in this repositional stage taking into account the child's age osteotomy of the pelvis was performed. The surgery is completed by imposing the hip dressing. After 6 months when removing metal made nadvertent bone-plastic osteotomy-acetabuloplasty pelvis fragments of the pelvis after the osteotomy is fixed with a bone graft from the iliac crest muscle pedicle.Usov, rotary motion with an amplitude of 35 degrees. Walking with compensation shortening 1.5 cm after 1 year after surgery.

Just made 3 transactions on the proposed method. In all cases achieved bone Union, good centering of the greater trochanter with apavisa in the basin, significant functional profitable range of motion in the hip joint and stability of the limb support.

The positive effect of the application of this method is that it allows one to achieve good recovery of function of the hip joint due to vertelney arthroplasty cartilaginous part of a growing Apophis, consolidation of fragments after osteotomy end side in the simulation of normal physiological parameters cervico-diaphyseal proportions of the proximal femur without breaking its power. Optimum transposition of periarticular muscles in a gentle manner, providing a good trophism. The method can be used during the degradation of the neck and the femoral head-type aseptic process of osteolysis, as well as the consequences of osteomyelitis.

1. The method of surgical treatment of pathological dislocation of the hip with osteolysis of the head and neck by access free from scars to exposure of the cartilage surface of the acetabulum, rear access behind the broad fascia of the thigh longitudinally cut and prepare the chin, together with the periosteum of the muscles from the top of the greater trochanter, spherical model of the cartilaginous part of his Apophis, cross the hip in podarennoi region at a distance equal to the lever arm neck and head healthy side, keeping the connection proximal fragment with muscles, create a box under the middle gluteal muscle and the tensor fasciae latae hips and through this opening exercise reposition the greater trochanter in the acetabulum, rootroot for the best adaptation of the proximal fragment in three dimensions to achieve centration of the top of the greater trochanter in the acetabular fossa, positioning down a small skewer and providing decortication area of the small trochanter with the lower part of the proximal fragment hips, carry out the osteosynthesis of bone fragments of the G-shaped plate end in the side at an angle equal to the individual or the age norm cervico-diaphyseal angle, the mechanical part of the bone sawdust move mobilized together with the periosteum of the muscles and hem the tensor fasciae latae hips.

2. The method according to p. 1, characterized in that when the reduced acetabulum exercise adverturous osteo is

 

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