RU2703191C1 - Method of treating congenital femoral defects accompanying shortening, underdevelopment of an external condyle in growing children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: inventions refers to medicine, namely to traumatology and orthopedics, and can be used for treating congenital femoral defects accompanying shortening, underdevelopment of an external condyle in growing children. Method involves a haemiepiphysiodesis of a medial portion of a distal femoral growth area with an eight-piece plate, femoral osteotomy, elongation and correction of femoral deformation by transosseous osteosynthesis. Hemiepiphyroidesis and transosseous osteosynthesis are applied successively. At the first stage, hemieiphyphidiosis is performed. After elimination of valgus component of femoral deformation and alignment of condyle of femurs in size, assembly of a compression-distraction apparatus, femoral osteotomy, elongation and correction of a torsion component of femoral deformation and deformation in a sagittal plane by means of compression-distraction apparatus units.

EFFECT: method provides higher clinical effectiveness ensured by sequential haemiepiphysiodesis and transosseous osteosynthesis.

1 cl, 14 dwg

Description

The invention relates to medicine, namely, to traumatology and orthopedics, and is intended for the treatment of congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle, in growing children.

There is a method of treating congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, by performing hemiepiphysiodesis of the medial portion of the distal growth zone with an eight-shaped plate [Burghardt RD, Herzenberg JE. Temporary hemiepiphysiodesis with the eight-Plate for angular deformities: mid-term results. J Orthop Sci 2010; 15: 699-704 DOI: 10.1007 / s00776-010-1514-9]. The essence of the method is that they perform temporary fixation of the medial portion of the distal growth zone, while it temporarily ceases to function. At the same time, the outer portion of the growth zone continues to work, due to which there is a correction of hallux valgus in the frontal plane. The advantages of this method are as follows:

- Minimum trauma, allowing the child to move and step on the operated leg from the first day after the operation;

- Correction of the deformation is carried out at the level of the distal physical plate of the femur, which eliminates the secondary displacement of bone fragments in width as a result of correction;

- As a result of the correction, the external condyle of the femur is aligned in size with the internal, which leads to the formation of a normal intercondylar notch, which, in turn, is an obstacle for dislocation of the patella;

The disadvantages of this method in the treatment of congenital deformities of the femur, accompanied by shortening, are the following:

- Hemiepiphysiodesis of the medial portion of the distal femoral growth zone allows correction of the deformity only in the frontal plane, while it is impossible to eliminate the deformation in the sagittal plane and torsion characteristic of congenital defects of the femur;

- The method of hemiepiphysiodesis is not possible to perform an extension of the femur.

The closest in technical essence and the problem to be solved and chosen as a prototype is a method of treating congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle, in growing children according to Ilizarov [Birch JG, Samchukov ML. Use of the Ilizarov method to correct lower limb deformities in children and adolescents. J Am Acad Orthop Surg. 2004; 12 (3): 144-154.]. This method consists in performing an osteotomy (or corticotomy in combination with osteoclasia) of the femur as close to the apex of the deformity as possible, installing a circular compression-distraction apparatus. Further, in the postoperative period, distraction and correction of deformity are performed using standardized nodes, the so-called "Ilizarovsky hinges" or universal nodes, including those based on computer navigation, the so-called hexapods [Solomin L.N. Correction of femoral deformities according to Ilizarov and the Ortho-SUV apparatus based on computer navigation / Solomin LN, Schepkina EA, Vilensky VA, Skomoroshko PV, Tyulyaev NV // Traumatology and orthopedics of Russia. - 2011.]. The top of the deformation is determined during preoperative planning by radiographs using the anatomical or mechanical axis and joint lines [Paley D., Principles of deformity correction. / D. Paley. - New York: Springer-Verlag, 2005. - 806 p .;].

The disadvantages of this method are:

- in the treatment of congenital defects of the femur, accompanied by shortening, underdevelopment of the external condyle, the apex of deformation determined preoperatively, according to the anteroposterior radiographs, in most cases is located at the level of the knee joint or distal pineal gland (Fig. 1, item 1). Performing an osteotomy at this level is technically impossible, because it is necessary to firmly fix the distal fragment of the femur. At the same time, conducting transosseous elements through a functioning growth zone is prohibited, because they can injure her, cause partial or complete synostosis. Performing an osteotomy outside the apex of the deformity, in this case proximal to it, leads to a secondary displacement of the bone fragments along the width (Fig. 2, pos. 2) during deformation correction, which can negatively affect the strength properties of the distraction regenerate;

- With congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, in most cases there is an external torsion of the femur. When eliminating the torsion component of the deformation, one of the most frequent and serious complications is a dislocation of the patella. It leads to dysfunction of the knee joint. In a healthy child, normally developed femoral condyles form an intercondylar notch, the so-called the patellar surface, in which, with flexion-extensor movements in the knee joint, the patella “held” by the capsule-ligamentous apparatus “glides”. In case of hypoplasia of the external condyle of the femur, the patella does not meet “limitations” from the outside, and the removal of the external torsion leads to its dislocation;

The objective of the invention is to improve the quality of treatment of children with congenital deformities of the femur, accompanied by their shortening.

The technical result of the task is achieved by the fact that in the method of treating congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, including: hemiepiphysiodesis of the medial portion of the distal growth area of the femur with an eight-shaped plate, osteotomy of the femur, lengthening and correction of the femur deformity transosseous osteosynthesis, it is proposed the consistent use of hemiepiphysiodesis and transosseous osteosynthesis, with the first stage performing hemiepiphysiodesis, and after eliminating the hallux valgus deformity and aligning the femoral condyles in size, performing the osteotomy of the femur, installing the compression-distraction apparatus, lengthening and correcting the torsion component of the deformation and deformation of the femur in the sagittal plane using nodes of the compression-distraction apparatus.

A method for the treatment of congenital defects of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, is illustrated by the attached graphic materials, where:

FIG. 1 X-ray diffraction patterns of patient Z., who underwent treatment with transosseous osteosynthesis, before treatment, where:

pos. 1 - the deformation peak is at the level of the distal metaphysis of the femur;

FIG. 2 Photographs of patient Z., who underwent treatment with transosseous osteosynthesis, after treatment, where:

pos. 2 - as a result of accurate correction of deformation, a shift of bone fragments in width occurs;

FIG. 3 Scheme of the proposed method for the treatment of congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, the first stage, where:

pos. 3 - femur;

pos. 4 - growth zone;

pos. 5 - eight-shaped plate;

pos. 6 - screw;

pos. 7 - mechanical axis of the lower limb;

pos. 8 - the outer condyle of the femur;

pos. 9 - the internal condyle of the femur;

pos. 10 - intercondylar notch.

FIG. 4 Scheme of the proposed method for the treatment of congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, the second stage, where:

pos. 11 - compression distraction apparatus;

pos. 12 - osteotomy;

pos. 13 - distraction regenerate;

FIG. 5 Photographs of patient P. before surgical treatment;

FIG. 6 Photographs of patient P. before surgical treatment,

Where:

pos. 14: indicated mechanical axis of the right lower limb;

FIG. 7 Photographs of patient P. before surgical treatment,

Where:

pos. 15 - deformation peak is indicated;

FIG. 8 Photographs of patient P. after the first stage of surgical treatment

FIG. 9 Photographs and X-ray diffraction patterns of patient P. before the second stage of surgical treatment, where:

pos. 16: indicated mechanical axis of the right lower limb;

FIG. 10 Photographs of patient P. in the second stage of surgical treatment in the process of distraction;

FIG. 11 Photographs and X-ray diffraction patterns of patient P. at the second stage of surgical treatment, before correction of the deformity, where:

pos. 17 - universal unit for correction of deformation, the so-called hexapod;

FIG. 12 is a window of a computer program attached to the hexapod at the correction planning step, where:

pos. 18 is a yellow outline indicating the initial position of the distal bone fragment (before correction);

pos. 19 is a red outline indicating the position of the distal bone fragment expected after correction.

FIG. 13 Photographs of patient P. in the second stage of surgical treatment, after correction of deformity;

FIG. 14 Photographs and X-ray diffraction patterns of patient P. at the second stage of surgical treatment, after removal of the CDA, where:

pos. 20 - indicates the mechanical axis of the right lower limb.

A method for the treatment of congenital defects of the femur, accompanied by shortening, underdevelopment of the external condyle in growing children, is implemented as follows. The first stage is hemiepiphysiodesis of the medial portion of the distal femoral growth zone (Fig. 3). For this, from a soft tissue section 3 cm along the inner surface in the lower third of the thigh (Fig. 3, pos. 3), in the projection of the distal growth zone (Fig. 3, pos. 4) of the femur, surgical access is performed. Under the control of fluoroscopy, an eight-shaped plate is installed (Fig. 3, pos. 5) and fixed with screws (Fig. 3, pos. 6), while one screw is placed above the medial portion of the growth zone, and the second under it. The length of the screws is chosen so that it does not exceed 50% of the width of the bone metaphysis. As the child and femur grow, respectively, an x-ray control is carried out every 3 months. As a result of the first stage, due to the functioning of the lateral portion of the growth zone and the “exclusion” of the medial work, the valgus deformation of the femur in the frontal plane is eliminated, the mechanical axis of the lower limb is normalized (Fig. 3, item 7). In addition, there is alignment in the size of the external condyle of the femur (Fig. 3, pos. 8) and the internal (Fig. 3, pos. 9). As a result of this, the previously “smoothed” intercondylar notch (Fig. 3, pos. 10) “deepens”, thereby normalizing the relationship between the femur and the sliding apparatus of the patella, which serves to prevent further dislocation of the patella. After eliminating these deformation components, the eight-shaped plate is removed.

The second ethane (Fig. 4), perform the installation of a compression-distraction apparatus (Fig. 4, item 11), an osteotomy of the femur (Fig. 4, item 12). Then carry out the lengthening of the femur, correction of torsion and deformation of the bone in the sagittal plane. Correction of the deformation is carried out by changing the length of the telescopic racks connecting the modules of the apparatus, according to the calculation performed in the computer navigation program attached to the hexapod. The rate of distraction does not exceed 1 mm / day, the rate of correction of deformation does not exceed 1 deg./day. After the desired elongation is achieved and all components of the deformation are eliminated, the distraction is stopped and the compression-distraction apparatus is left as an external fixative. X-ray control is carried out monthly. After the appearance of radiological signs of bone reconstruction of the distraction regenerate (Fig. 4, item 13), the compression-distraction apparatus is dismantled.

In FIG. 5 presents patient P., 5 years old, with a diagnosis of Congenital malformation of the right lower limb. Shortening of the right lower limb 7.0 cm. Hallux-antecurvation-torsion deformation of the right femur. Hypoplasia of the external condyle of the right femur.

According to the data of preoperative panoramic radiographs, the deviation of the mechanical axis of the right lower limb outwards by 22 mm is noted (Fig. 6, pos. 14), the deformation vertex is located at the metaphysis level, 46 mm proximal to the articular surface of the femoral condyles (Fig. 7, pos. 15) . In addition, according to preoperative computed tomography, it was revealed that the right thigh also has a torsion component of deformation equal to 20 degrees. Severe hypoplasia (underdevelopment) of the external condyle of the right femur is also noted. The first step was a temporary hemiepiphysiodesis of the inner portion of the distal growth zone of the right femur with an 8-shaped plate. The postoperative period was uneventful. A full load on the leg was possible from the first day after the operation. By 5 days after the operation (the moment the child was discharged from the hospital), a full range of movements in the knee joint was noted. At intervals of 3 months, X-rays and clinical observation were performed. Hallux valgus component of the deformity according to panoramic radiographs is eliminated (Fig. 8). According to CT data, alignment of the femoral condyles was also noted in size. Plate removal completed. The period of hemiepiphysiodesis was 380 days.

Before the second stage of surgical treatment, the child noted shortening of the femur, external torsion of the femur and antecurvation, while the deviation of the mechanical axis of the limb (Fig. 9, pos. 16) was within normal limits. The second stage of surgical treatment was started 1 month after plate removal. The spoke-rod circular compression and distraction apparatus was mounted on the right thigh, an osteotomy of the right femur at the border of the middle and lower third. From 5 days after the operation, distraction along the connecting threaded rods was started. The rate of distraction is 0.25 mm × 3 times / day. X-ray control was carried out every 10 days (Fig. 10). After the segment was lengthened by 55 mm, the threaded rods connecting the transosseous modules of the compression-distraction apparatus were replaced by a universal unit based on computer navigation, the so-called hexapods (Fig. 11, pos. 17). In the computer navigation program (Fig. 12), which allows visualizing the axes of the bone fragments, their skygrams before deformity correction (Fig. 12, pos. 18) and their expected position after correction (Fig. 12, pos. 19), the calculation was performed. By changing the lengths of the telescopic racks of the hexapod according to the calculation, the torsion component of the deformation and the residual deformation in the sagittal plane were corrected (Fig. 13). Further, the child was observed on an outpatient basis monthly. The compression-distraction apparatus was dismantled with radiological signs of bone reconstruction of the distraction regenerate. The period of external fixation was 227 days. On panoramic radiographs after removal, an ideal correction of all components of the deformation and the passage of the mechanical axis of the limb were noted (Fig. 14, pos. 20). After removing the device within 3 weeks, a full range of movements in the knee joint was achieved

A positive result of the invention is to improve the quality of treatment of growing children with congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle, namely, lengthening and accurate correction of all components of the deformation of the femur; elimination of hypoplasia (underdevelopment) of the external condyle of the thigh, its alignment in size with the inner and, thereby, prevention of dislocation of the patella when eliminating the external torsion of the femur.

In the treatment of children with congenital malformations of the femur, accompanied by shortening, underdevelopment of the external condyle, the invention will help to reduce the level of childhood disability.

Claims (1)

A method for the treatment of congenital defects of the femur accompanied by shortening, underdevelopment of the external condyle in growing children, including hemiepiphysiodesis of the medial portion of the distal growth area of the femur with an eight-shaped plate, osteotomy of the femur, lengthening and correction of femoral deformity by transosseous osteosynthesis, and different osteosynthesis is used sequentially, with the first step being hemiepiphysiodesis, and after the elimination of the valgus component and deformation of the femur and the alignment of the femur condyles in size, assembling operate compression-distraction apparatus, femur osteotomy, elongation and torsion deformation correction and the femoral component in the sagittal plane deformation using nodes compression-distraction device.

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