RU2474393C1 - Method of cotyloid cavity transposition during double pelvic osteotomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely traumatology and orthopaedics, and may be used for treating hip joint diseases in cotyloid transposition during double pelvic osteotomy. There are performed paraacetabular osteotomy of pubic and iliac bones. An acetabular fragment of hip bone is rotated, fixed with a cylindrical autograft taken from a base of a greater trochanter after having been dissected from a thigh bone, and K-wires. A greater trochanter is reduced and fixed by a screw and a K-wire.

EFFECT: method provides simultaneous elimination of incomplete dislocation of a femoral head and high position of the greater trochanter, reduced length of treatment.

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Description

The invention relates to medicine, namely to orthopedics, and can be used in the surgical treatment of children with diseases of the hip joint.

There is a method of performing transposition of the acetabulum during a double pelvic osteotomy (Barsukov DB Orthopedic and surgical treatment of children with Legg-Calve-Perthes disease: Dis ... Ph.D. medical sciences. - St. Petersburg., 2003. - 269 S.), in which paracetabular osteotomy of the pubic and iliac bones is performed, as well as intertrochanteric osteotomy of the femur to borrow from the distal fragment of the last cylindrical autograft. After this, the acetabular fragment of the pelvic bone is retracted anteriorly, outward and downward, and then fixed in the position of the achieved correction using an existing autograft placed in the iliac diastasis and several Kirchner spokes. Fragments of the femur are fixed with an angular plate with screws without correction of the spatial position of the femoral neck (p. 115-121, Fig. 44, 45 and p. 128-132, Fig. 51).

The disadvantage of the considered method is the inability to use it in a frequently encountered anatomical situation when a subluxation of the femoral head is combined with a shortening of the femoral neck in the normal spatial position of the latter and high standing of the greater trochanter due to shortening of the neck (coxa vara trochanterica).

A similar combination of a subluxation of the femoral head and mucosa vara trochanterica can occur after post-repositional ischemic necrosis of the femoral head (as a result of inadequate conservative treatment for congenital dislocation or subluxation of the thigh), acute hematogenous osteomyelitis, Perthes disease, or idiopathic aseptic necrosis also with various types of epiphyseal dysplasias.

Performing the considered surgical intervention in the described anatomical situation does not solve the problem of the existing high standing of the greater trochanter and associated gluteal muscle dysfunction leading to lameness. In addition, such an intervention can lead to the absence or significant limitation of abduction in the hip joint due to mechanical contact of the apex of the greater trochanter with the outer edge of the displaced acetabular fragment when attempting to abduct the hip. As a result, the second stage of surgical treatment is required in the form of reduction of the greater trochanter, which involves repeated general anesthesia and significantly increases the patient's rehabilitation time in bed.

The objective of the invention is to increase the effectiveness of surgical treatment of children with diseases of the hip joint using a double osteotomy of the pelvis by changing the place of borrowing a cylindrical autograft from the femur, which allows simultaneously with the elimination of the dislocation of the femoral head to eliminate the high standing of the greater trochanter, thereby eliminating the need for repeated surgical intervention and reduce treatment time.

This object is achieved in that in a method for performing transposition of the acetabulum during a double pelvic osteotomy, consisting in the production of paracetabular osteotomies of the pubic and iliac bones with subsequent rotation of the acetabular fragment of the pelvic bone and fixing it with a cylindrical autograft and Kirschner knitting needles, it is proposed after it is cut off from the femur, then lower the trochanter is reduced, followed by fixation to the screws .

Figure 1 presents a diagram of the reconstructed hip joint after cutting off the trochanter from the femur with the indicated levels of osteotomy of the pubic and iliac bones and the place of autograft borrowing.

Figure 2 presents a diagram of a reconstructed hip joint after displacement and fixation using an autograft of the acetabular fragment of the pelvic bone and the greater trochanter.

Figure 3 presents the x-ray of the left hip joint in the anteroposterior projection of the patient with the consequences of acute hematogenous osteomyelitis in the form of pathological subluxation of the thigh and mumps vara trochanterica before surgery.

Figure 4 presents the x-ray of the left hip joint in the anteroposterior projection of the same patient after surgery according to the proposed method.

Pos. 1 - cutoff level of the greater trochanter from the femur

Pos.2 - cut off large trochanter with the designation of the fragment used as an autograft

Pos. 3 - level of osteotomy of the pubic bone

Pos.4 - level of osteotomy of the ilium

Pos. 5 - displaced acetabular fragment of the pelvic bone

Pos.6 - a cylindrical autograft from the base of the greater trochanter, placed in the diastasis of the fragments of the ilium

Pos.7 - moved a large skewer

Pos.8 - a bunch of Kirchner knitting needles, fixing the acetabular fragment of the pelvic bone

Pos. 9 - a screw with a support platform and a Kirschner spoke fixing a large skewer

The method is as follows:

The patient's position on the operating table on a healthy side. Under aseptic conditions, an angular incision is made in the skin and subcutaneous tissue along the outer thigh in the upper third - from the anteroposterior iliac spine to the apex of the greater trochanter and further down the thigh. After a cruciate dissection of the wide fascia of the thigh, the middle gluteal muscle and the muscle straining the wide fascia of the thigh are separated from the bottom-up and through the resulting intermuscular gap, the anterior-lower iliac spine is exposed. Layered exposed and intersected at the level of entry into the acetabulum of the lumbar-iliac muscle tendon. The front and rear edges of the middle and small gluteal muscles are mobilized, after which Gigli's saw is held under the base of the greater trochanter under the upper-outer surface of the joint capsule. The cartilaginous apophysis of the iliac crest is longitudinally dissected to the anteroposterior spine, the incision extends down to the anteroposterior spine and further to the pubic bone. The body of the ilium is exposed subperiosteally to the large sciatic notch, into which Gigli saw is brought. The upper branch of the pubic bone is exposed subperiosteally to the obturator foramen into which Gigli saw is brought. Held a saw Gigli large trochanter 2 is cut off from the femur and leans up after the complete separation of the middle and small gluteal muscles from the capsule of the joint. An oscillating saw forms the upper surface of the femoral neck, which is treated with surgical wax, and a cylindrical fragment 1.0-1.5 cm high is cut off from the base of the greater trochanter, which is later used as an autograft. Carried out by Gigli's saws (or an oscillatory saw), oblique osteotomy of the 3 upper branches of the pubic bone is performed somewhat more medially than the Y-shaped cartilage and the transverse (horizontal) supraclavicular osteotomy of the 4 ilium bodies. Using one of the transposing devices, the acetabular fragment of the pelvis is rotated 5 anteriorly, outward and downward. As a result, diastasis of the ilium fragments appears, into which the existing cylindrical autograft 6 is implanted. The achieved position of the acetabulum is additionally fixed by a bundle of three to four Kirchner spokes 8, drawn from the proximal fragment of the pelvic bone into the acetabular fragment. The cartilaginous apophysis of the iliac crest is sutured with separate nodal sutures, after which the large trochanter 7 with mobilized gluteal muscles is reduced to tension of the latter and fixed to the lateral surface of the femur with a screw with a support pad and Kirschner spoke 9 or two screws with support pads. The wound is sutured in layers leaving the drainage of Redon. An aseptic dressing is applied. A control x-ray and immobilization of the lower extremities with one and a half coxite gypsum dressing are performed.

The positive effect of the invention is as follows: the simultaneous elimination of subluxation of the femoral head and the high standing of the greater trochanter creates the conditions for eliminating the two main causes of lameness in the contingent of patients without repeated surgical intervention and reduces treatment time.

Claims (1)

A method for performing transposition of the acetabulum during a double pelvic osteotomy, which consists in the production of paracetabular osteotomies of the pubic and iliac bones with subsequent rotation of the acetabular fragment of the pelvic bone and fixing it with a cylindrical autograft and Kirschner spokes, characterized in that the autograft is removed from the base after it is transplanted from the base the femur, then a large trochanter is reduced, followed by fixation with a Kirschner screw and spoke.

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