RU2267304C1 - Method for reposition of dislocations and instable femoral subdislocations in teenagers - Google Patents

Abstract

FIELD: medicine, traumatology.

SUBSTANCE: one should cross femoral adductors in the site of proximal fixation, resect a skin fragment out of ischial bone for the length of 0.5-1.5 cm being above ischial tuber. One should perform osteotomy of pubic bone at the bottom, dissect ilium either cross-sectionally or semicircularly. Then it is necessary to perform anterior-inferior arthrotomy of a hip joint at dissecting cicatricial tissues that fill cotyloid cavity, rotate mobilized acetabular fragment outwards and backwards by rolling its articular surface onto femoral caput till its complete overlapping. Then one should reset femoral caput into cotyloid cavity and fix both a pelvis and femoral caput in reset position by Kirschner's needles. The innovation suggested enables to restore anatomo-functional proportions in patient's hip joint and decrease traumatism level.

EFFECT: higher efficiency of reposition.

1 cl, 3 ex

Description

The invention relates to medicine, in particular to orthopedics and traumatology, and can be used to restore the adolescence and function of the hip joint during dislocation and unstable subluxation of the hip.

High hip dislocations and unstable subluxations in adolescents are detected with late diagnosis or improper treatment at the previous stages of treatment.

Difficulties of reposition in these cases are associated with a high risk of dystrophic changes, technical difficulties associated with concomitant muscle-ligament-capsule changes, formed by tissue rigidity. A stable reposition is prevented by the formed groove of slipping. As a rule, this bone-cartilaginous trace of dislocation of the femoral head is located in the posterior upper part of the deformed acetabulum.

Reposition of dislocation and unstable subluxation of the thigh in adolescence and youth is achieved with great difficulty. Usually, the operation of choice (analogue 1) in such situations is the operation of the “classical triad” type, including shortening corrective osteotomy of the hip, open reposition of the femoral head, iliac or iliac-pubic osteotomy of the pelvis (Krasnov A.I., Deineko A.N. Surgical treatment of congenital dislocation of the hip in school-age children. // Optimal diagnostic and treatment technologies in pediatric traumatology and orthopedics, errors and complications. / Materials of the symposium of pediatric orthopedic traumatologists of Russia. - S.Pb., - 2003, p.261, 262). The techniques allow for simultaneous decompression of the joint and lowering of the thigh, however, they do not guarantee a stable position of the head in the cavity, the risk of dystrophic changes in this reposition is extremely high in children over 12 years old, after the closure of the Y-shaped cartilage. Another disadvantage is a significant shortening of the limb after such operations. Other methods of closed reposition with the use of transosseous osteosynthesis apparatus in adolescents, proposed by other authors, require long-term external fixation, and even in cases of intervention on the pelvic component, the orientation of the “sliding furrow” is not taken into account. There are no reports on the effective use of these similarly directed techniques for the reduction of hip dislocation in adolescents in children over 14 years of age in the proposed options (Teplenky M.P. Treatment of children with congenital subluxation and dislocation of the hip using the Ilizarov apparatus. Abstract of diss. Cand. Cand. Sciences, 1999; Makushin VD, Teplenky MP Correction of acetabular dysplasia in schoolchildren // Optimal diagnostic and treatment technologies in pediatric traumatology and orthopedics, errors and complications / Symposium materials MA of children's traumatologists and orthopedists of Russia. - S.Pb., - 2003, p. 271-273).

The closest analogue in this area is the method (prototype) of the operation according to Steel H. (Howard H. Steel. Triple Osteotomy of the Innominate Bone // J. Bone Jt. Surg. - 1973. - Vol.55A, No. 2. - P .343-350). However, this method also does not take into account the direction of the formed sliding furrow, therefore, this technique does not allow to achieve a stable reorientation of the depression in such cases. The H. Steel method provides for the rotation of the acetabular fragment after an ilium, pubic and sciatic osteotomy anteriorly and outwardly, but does not create technical capabilities for posterior acetabular rotation in order to prevent relapse in the direction of the sliding groove. The disadvantage is the implementation of the method of 2 accesses, requiring the transfer of the patient during surgery, while access to the sciatic bone damages the gluteus maximus muscle and is very traumatic. The pubic bone, according to the proposal of H. Steel, intersects in the middle of the upper branch, which reduces the mobility of the acetabular fragment after osteotomy, creates conditions for large displacements to disrupt the consolidation process. The method also does not take into account cravings of the adductors and their role in relaxation.

The invention is aimed at solving the problem: improving the efficiency of the method of reposition of dislocation and subluxation of the thigh in patients of adolescence.

When performing the proposed method for the reposition of dislocations and subluxations of the thigh in adolescence, a stable position of the thigh head is achieved by restoring the optimal anatomical and functional ratios in the hip joint that impede the relaxation of the groove of the slip, the morbidity of the method is reduced.

This is achieved by reposition of dislocation or unstable subluxation of the thigh in adolescents using a reorienting triple pelvic osteotomy with arthrolysis of the hip joint, with the intersection of the femoral adductors at the site of proximal attachment, resection of the sciatic bone over the sciatic tubercle of a length of 0.5-1.5 cm performing an osteotomy of the pubic bone at the base, transverse or semicircular dissection of the ilium, performing anterior lower arthrotomy of the hip joint with excision of scar tissue Filling the acetabulum, the acetabular fragment mobilized rotation outward and posteriorly by rolling it on the surface of the articular femoral head until its complete overlap reposition the femoral head in the acetabulum, pelvic fixation and reduction of the femoral head in position Kirschner wires; lowering the thigh in the external fixation apparatus at high dislocations of the thigh to the level of the acetabulum or below its level as a preparatory stage.

The method is as follows. With high dislocations of the thigh, the first step is to lower the thigh relative to the pelvis in the external fixation apparatus to the level of the acetabulum or below its level, with dislocations with a small dislocation and subluxations, the operation is performed in 1 stage. Hip adductors cross at the site of proximal attachment, penetrate deep into the wound up, deep and out to the sciatic bone, around which the lifts are introduced from both sides, and under their protection above the sciatic tuber from the medial side of the sciatic bone, the entire length of the bone is resected. 0.5-1.5 cm for the subsequent possible rotation of the acetabular bone fragment posteriorly. The wound is sutured. Through the second access, the osteotomy of the pubic bone is carried out at the base, in the depth of the wound, the ilium is transversely or semicircularly dissected. In order to reposition and more accurately center the femoral head, anterior lower arthrotomy of the hip joint is performed with excision of the scar tissue filling the acetabulum, creating a contact between the cartilaginous surfaces of the femoral head and the acetabular fossa, and the mobilized acetabular fragment outward and posteriorly rotate in 3 planes, rolling it over the head hips to its full overlap. By means of this directional rotation, the formed posterior upper furrow of sliding is removed from under the support, as a result of which a bone contact is created at the level of the previously created defect of the ischium. They direct the femoral head into the acetabulum, fix the pelvis and femoral head in the adjusted position with Kirchner spokes. In the postoperative period, if necessary, unloading the limb is carried out before consolidation by well-known methods, taking into account the individual characteristics of the patient.

Example 1. Patient K., 12 years old. Medical history No. 256. Was admitted to the hospital with a diagnosis of cerebral palsy, residual subluxation of the left thigh. Gait is difficult, with Mr. Trendelenburg left positive, leading contracture of the left thigh. The radiograph diagnosed a sharp sloping and flattening of the acetabulum, deficiency of the femoral head, neoarthrosis with an undeveloped outer edge of the thigh. The thigh is unstable, with support, its head goes upward in a subluxation along the furrow of sliding into the region of neoarthrosis. The patient was operated on according to the described method of treatment in 1 stage. Myotomy of the adductor muscles of the thigh and osteotomy of the body of the sciatic bone with a resection of its segment length of about 0.5-0.8 cm were performed through the first access on the medial surface of the thigh below the inguinal fold. The second access was performed dissection of the pubic bone at the base, while the pubic-capsular ligament was kept intact. The ilium is dissected in a semicircular manner. The cavity of the hip joint was opened with anterior gentle access, the bottom of the acetabulum was freed from scars, the transverse ligament was released, a bed was created to center the head with the contact of the cartilaginous surfaces. After rotation of the acetabular bone fragment outwards in the horizontal and frontal and posteriorly in the sagittal planes, pelvic fragments are fixed using a bone graft from the iliac wing and Kirchner spokes. The femoral head is set into the lower part of the cavity as a gentle open reduction. The wound is sewn up. In the postoperative period, immobilization and sparing unloading of the operated limb was performed with a derotation boot for 3 weeks, then the immobilization did not continue. As a result of the one-stage operation, good centering and a stable position of the femoral head in the acetabulum were achieved, and hip abduction was increased to 55 degrees. On examination, after 2.5 years after surgical treatment, the patient was diagnosed with a good range of motion in the thigh set - abduction is possible up to 60 degrees, rotation amplitude is 30 degrees, Trendelenburg cm is negative, the x-ray of the femur head is centered in a spherical acetabulum, completely covered with it . Goes a considerable distance, happy with the result.

Example 2. Patient P., 15 years old. Case history No. 1123. Upon admission, the diagnosis was made: “Pathological paralytic dislocation of the left thigh against the background of tick-borne encephalitis. Flexion-causing contracture of the left thigh, vicious position of the limb, unstable unsupported thigh. " On the roentgenogram, the head is at the level of the iliac wing, the thigh is abruptly reduced, abduction is impossible due to the formed rough adducing contracture. A history of 8 years ago was ill with a complicated form of tick-borne encephalitis, left-sided hemiparesis was formed. Relative shortening on the left to 10 cm. The patient was operated on. At stage 1, the Ilizarov apparatus was superimposed with the support of the supports at the level of the iliac wing and the distal third of the thigh. The thigh is reduced to the level of the acetabulum. After 2 months, the apparatus was dismantled, stage 2 surgery was performed according to the described method. The resection of the bone fragment on the sciatic bone was 1.5 cm due to the pronounced sliding grooves. The ilium was crossed transversely, the ilium at the base. An open reposition with the release of cicatricial periarticular and intraarticular tissues was performed sparingly, directly arthrotomy was performed along the femoral neck. According to the type of direction of rotation, the performed triple pelvic osteotomy with the removal of the posterior edge of the acetabulum with the groove sliding off under load can be designated as a rear-stabilizing operation. Fractures of the pelvis are fixed with Kirschner spokes, an additional thigh head is additionally transcutaneously fixed. Reposition achieved. After surgery, skeletal traction was performed for 5 weeks, then only the derotation boot was left for fixation.

3. Example 3. Patient S., 16 years old. History No. 383. Upon admission to the clinic, a congenital high dislocation of the left thigh was diagnosed. Previously not treated. Severe violations of the walking and support functions, relative shortening of the left lower limb 13 cm, vicious position of the limb, gross misalignment of the pelvis. On radiographs before surgery, neoarthrosis in the area of the iliac wing is traced. The patient was operated on in 2 stages. The first stage was a metered reduction of the thigh to the lower edge of the acetabulum for 1.5 months. The second stage performed a triple osteoplastic osteotomy of the pelvis on the left with an open reposition of the femoral head according to the described method. In the postoperative period, after 2 weeks, with the aim of early activation of the patient and unloading, the Ilizarov apparatus was again placed, consisting of supports at the level of the ilium and the lower third of the thigh. The patient is allowed to walk in the apparatus 1 month after the operation, which is dismantled 2 months after 2 stages. Centering of the femoral head has been achieved, consolidation has occurred at the level of the lines of the osteotomy of the pelvis, no relapse of the dislocation has occurred. Kirchner spokes from the pelvis on the left removed 8 months after 2 stages of the operation. Examined 2 years after surgical treatment. In the operated joint, bending to 70 degrees, extension of 180 degrees, abduction of 15 degrees. Goes to medium distances, does not show complaints of pain. On the roentgenogram, the head structure is not broken, the femoral head is centered and completely immersed in the acetabulum, and the femoral neck is shortened. A relative residual shortening of 3 cm is compensated by the heel. I am satisfied with the result.

In total, 4 operations were performed according to the proposed method. In all cases, bone fusion, good centering of the femoral head in the acetabulum, a functionally advantageous range of motion in the hip joint, and stability of the limb during support were achieved.

The positive effect of the application of this method is that it allows to achieve a good and stable centering of the femoral head in the acetabulum, restoration of the function of the hip joint due to the triple corrective osteotomy of the pelvis in a 1 or 2-stage variant. The external posterior rotation of the mobilized acetabular fragment with other elements of intervention, along with sparing accesses, makes it possible to achieve good vertical support, since it does not allow the furrow of slipping formed as a result of a long-existing dislocation to be realized in the future. Achieve sufficient muscle tension and connective tissue formations, restore muscle tone, attached to the greater trochanter. The gentle nature of the intervention provides adequate trophism; aseptic necrosis was not observed in patients operated on in this way. The method can be used in the late reduction of congenital dislocation and subluxation of the thigh in adolescence with concomitant adducting hip contractures and neurological disorders.

Claims (2)

1. The method of reposition of dislocations and unstable subluxations of the thigh in adolescents using a triple pelvic osteotomy with arthrolysis of the hip joint, characterized in that the adductors of the femur cross at the site of proximal attachment, a bone fragment of 0.5-1.5 is resected from the sciatic bone above the sciatic tubercle see, perform an osteotomy of the pubis at the base, transverse or semicircularly dissect the ilium, perform anterior-inferior arthrotomy of the hip joint with excision of scar tissue filling the acetabulum Padin rotating mobilized acetabular fragment outwards and backwards, nakatyvaya its articular surface on the femoral head until it is completely overlap, reduce a femoral head in the acetabulum by fixing the pelvis and the femoral head in the reduction position Kirschner wires. 2. The method according to claim 1, characterized in that with a high dislocation of the thigh, the first step is to lower it to the level of the acetabulum or below its level in the external fixation apparatus, and the second step to carry out the reposition method according to claim 1.