The main manifestation of the disease is a decrease in NAS of less than 120°. Two forms of the disease have been identified: congenital varus deformity and developmental varus deformity. Congenital deformity is found in a newborn. The causes of the disease are pressure from the walls of the uterus, aseptic necrosis of the physis and femoral neck, and delayed ossification due to insufficiency of the feeding vessels. Varus is accompanied by signs of dysplasia in the form of flattening of the acetabulum, congenital dislocation or congenital underdevelopment of the hip, as well as different leg lengths. Varus developmental deformity or secondary deformity is diagnosed after the age of 4 years. It is associated with metabolic disorders and occurs in diseases such as rickets, femoral head epiphysiolysis, Morquio's disease, osteogenesis imperfecta, mucopolysaccharidosis, metaphyseal chondrodysplasia, and infection. VDB is both unilateral and bilateral in nature. Unilateral curvature was noted in 60-75% of cases. A bilateral process, which occurs in 25-40% of cases, is largely associated with general metabolic disorders - rickets, osteomalacia, osteogenesis imperfecta.
With VDB, several processes simultaneously occur in the proximal femur that determine the nature of the disease. The action of etiological factors leads to disruption of the ossification of the cartilaginous matrix of the femoral metaphysis, which is called local fatigue dystrophy. The strength of the bone is not enough to resist the force of weight. There is a slow flexion of the femoral neck along with the head and the development of varus deformity of the proximal femur. The flexion moment of the force acting on the proximal femur increases. In the femoral neck, the compression component of the force decreases and its displacement component increases. Pathological flexion of the femoral neck and head develops simultaneously with the physiological growth of the greater trochanter in the cranial direction, as a result of which the apex of the trochanter is set higher than the center of rotation of the hip joint, and the attachment points of the abductor muscles of the hip move closer to each other. The abductor muscles weaken, muscle imbalance occurs, the adductor muscles become dominant, and hip abduction decreases. Varus deformity of the hip is accompanied by a decrease in hip anteversion up to its retroversion, resulting in a decrease in internal rotation of the hip. Varus and version reduce the space for abduction of the hip, which during abduction causes the greater trochanter and femoral neck to push into the edge of the acetabulum and into the ilium. The fixation points of the abductor muscles come closer and weaken. During walking, the strength of the abductor muscles is not enough to lift the pelvis upward on the side of the carried leg. Instead of lifting, the pelvis is lowered on the side of the transferred leg. On the side of the femoral varus, a Trendelenburg symptom occurs with deviation of the trunk towards the supporting leg to reduce the load on the abductor muscles.
A child with VDB has a delay in the onset of independent walking. From the age of 2 years, standing impairment becomes noticeable. The symptoms of the disorder are associated with the symmetry of the hip lesion. With unilateral varus deformity, there is an apparent increase in the size of the greater trochanter and its protrusion in the cranial direction. When the leg is shortened within 1-1.5 cm, there is lameness in the affected leg. If there is significant weakness of the abductor muscles, the child is diagnosed with Trendelenburg's symptom. With a bilateral process, there is a hobbling gait with a large amplitude of trunk deviation in the frontal plane. The difference in leg length increases with age, which leads to worsening symptoms.
VDB is diagnosed using radiography. The radiograph of the femur shows fragmentation of the metaphysis and epiphysis, expansion of the epiphyseal plate, as well as a triangular bone fragment at the junction of the neck with the epiphysis, often along its lower surface. In 3/4 of cases, flattening of the acetabulum was noted. On the radiograph in the anteroposterior projection, Hilgetzreiner's intertrochanteric line is drawn through the Y-shaped cartilage of the acetabulum and a second line along the edge of the femoral epiphysis. An interacetabular-epiphyseal angle is formed, which in a 7-year-old child ranges from 4 to 35°, averaging 20°. In an adult, an angle of less than 20-25° is considered normal. With varus of the proximal femur, the angle reaches 60°. VDB is characterized by a progressive nature of the course. An increase in deformity is accompanied by a deterioration in walking without pain. Spontaneous cessation of the development of hip curvature occurs when the interacetabular-epiphyseal angle is less than 45°.
Treatment
Conservative methods of treating femoral varus deformity in the form of traction or immobilization are considered ineffective. Preventive shoes are used to prevent the development of secondary deformity in the distal parts of the lower limb. Using a shoe insole, the length of the lower limbs is equalized and the progressive shortening of the affected leg is compensated.
Indications for surgical treatment depend on the magnitude of the deformity, the course of the disease and the age of the patient, of which the priority parameter is the angle of curvature of the hip. When the MEU is from 45 to 60°, observation is carried out and an x-ray examination is performed once every six months. Radical treatment methods are resorted to in case of progression of the deformity. Indications for surgery are an increase in MEA of more than 60°, a decrease in NW of less than 100-110°, a positive Trendelenburg sign, as well as a visible deterioration in walking. A contraindication to surgery is the absence of clinical symptoms when the MEU is less than 45°, as well as the absence of curvature progression when the MEU is less than 60°. Compared to the magnitude of the deformity, age is a less important indication for surgery. Each age period has its own advantages for surgical intervention. Early operations before the age of 2 years are rarely performed due to the slight severity of bone deformation. The positive side of intervention at an early age is the possibility of complete remodeling of the deformed bone. The restoration of bone structures after surgery in children aged 18 months is described. In children over 2 years of age, there are more reasons to use surgical treatment methods due to a greater degree of deformity. In a large child, it is relatively easier to fix the bone. The operation is performed for the following purposes:
- correction of varus curvature and anteversion of the femur to reduce the shear force and increase the compression force at the femoral neck;
- equalization of the length of the lower limbs;
- reconstruction of the greater trochanter in order to create conditions for the work of the abductor muscles.
Surgery: subtrochanteric osteotomy
Indications: varus deformity of the proximal femur, MEU more than 60°, NFS less than 100-110°.
A lateral skin incision above the greater trochanter is 10-12 cm long. A pin is inserted into the femoral neck parallel to the upper edge under the control of an image intensifier. Using a drill or oscillating saw, a slot is created in the femoral neck parallel to the wire for the plate. Use a plate bent at an angle of 140°. A horizontal branch of the plate is driven into the bone gap. An osteotomy is made in the subtrochanteric region at a distance across the femur below the angle of the plate. Under the control of the image intensifier, a transverse intersection of the femoral diaphysis is made using an oscillatory saw or osteotome. The proximal fragment of the femur is adducted and the distal fragment is abducted. The proximal fragment is installed on the distal one in such a way that the lateral cortical of the proximal fragment is in contact with the bone sawdust of the distal fragment. The vertical branch of the plate is screwed to the diaphysis of the femur. The triangular bone fragment is repositioned to the femoral neck. The needle is removed. A coxite plaster cast is applied to the affected leg for a period of 8 to 10 weeks.
Treatment results
On average, valgus osteotomy allows you to reduce the MEU5 to 35-40°, and increase the NSA to 130-135°. Subtrochanteric and intertrochanteric osteotomies give approximately similar correction results. In the postoperative period, loss of correction is observed. 9-10 years after the intervention, NRL decreases from 137 to 125°, and MEU increases by almost half. In the postoperative period for 3 years, almost all patients experience closure of the growth zone of the proximal physis of the femur, after which a lag in the growth of the femur is noted. Shortening of the legs is compensated by orthopedic shoes. A significant decrease in thigh length is an indication for surgical intervention. Lengthening of the bones of the short leg is performed more often; shortening of the bones of the contralateral limb is performed less often. Half of the patients after the intervention have weakness of the hip abductors. In 60% of cases, excessive growth of the greater trochanter is observed, which is eliminated by apophysiodesis. In 87% of cases there is a decrease in the size of the femoral head, in 43% of cases there is its flattening, as well as flattening of the acetabulum.
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Valgus and varus deformity
The normal position of the leg corresponds to a conventional line drawn through the first space between the toes, the middle of the knee and the hip joint. Deviation from this line is considered a deformity (violation of the normal position, curvature), which can be varus or valgus.With varus deformity (O-shaped), the middle part of the lower leg visually deviates outward, with hallux valgus deformity The (X-shaped) shin moves inward, the legs resemble the letter X.
Femoral neck
Valgus deformity of the femoral neck is characterized by a change in the neck-diaphyseal angle and its increase. Most often it is combined with valgus deformity of the legs and flat-valgus deformity of the feet. In most cases, this disease is a congenital pathology caused by hip dysplasia, but can also develop as a result of injury or damage to the nervous system. May lead to the development of coxarthrosis (damage to the hip joint).Legs
Deviation of the leg axis, at which the distance between the inner ankles is visually determined to be about 5 cm, the knees are tightly compressed.Valgus deformity of the legs appears in childhood as a result of prematurely allowing the baby to stand, a long stay in a standing position (in the playpen), and impaired crawling. This is due to insufficient strength of muscles and ligaments, and increased load on them. Significant causes of this pathology include rickets, hip dysplasia, and knee injuries. The main changes initially affect the knee joints, some hyperextension occurs, and flat-valgus flatfoot appears. The child complains of tired legs, asks to be held, and notes pain in the legs when walking for a long time. With asymmetrical curvature of the legs, there is a risk of developing scoliosis (curvature of the spine).
Ankle joint
Valgus deformity of the ankle joint is characterized by the heel shifting outward and the foot itself falling inward. Often leads to the development of flat-valgus flatfoot.Foot
Plano-valgus foot deformity (flatfoot) is the most common type of hallux valgus. It is characterized by a change in the direction of the axis of the foot and a decrease in its arches. Most often occurs in childhood. Main reasons:
- congenital disorder;
- traumatic flatfoot due to a bone fracture, damage to the ankle joint, rupture of ligaments;
- static flat feet due to increased load on the joints as a result of excess weight, etc.;
- rachitic flatfoot;
- paralytic flatfoot, as a complication of osteomyelitis.
Valgus deformity of the first toe (Hallux valgus)
With hallux valgus, the metatarsophalangeal joint changes, causing the big toe to move inward. This also disrupts the position of the remaining fingers.Possible causes of big toe deformity
Causes of hallux valgus include:- endocrine changes;
- genetic predisposition;
Symptoms
Manifestations of this disease are the appearance of a “bone” in the area of the affected joint, changes in the position and shape of the remaining fingers. This is accompanied by pain in the joint and foot, and rapid fatigue of the legs. In the area of the “bump” there is redness and slight swelling.Severity of deformation:
1.
Outward deviation of the thumb up to 15 o.
2.
Thumb deflection is from 15 to 20 o.
3.
Thumb deflection is from 20 to 30 o.
4.
Deviation of the thumb is more than 30 o.
With grades 3 and 4 of deformation, complications may develop, such as:
- hammertoe toes;
- painful corns and calluses prone to inflammation;
- pain when walking;
Similar symptoms can occur in some other diseases: deforming osteoarthritis, arthritis, gout. To find out the cause of the “bump” and pain, you need to consult an orthopedist. After the examination, the doctor will prescribe an x-ray examination (a photo of the foot in three projections) and plantography.
As a result of the further development of the pathological process with untreated hallux valgus, many patients develop chronic bursitis (inflammation of the periarticular bursa) and Deuchelder's disease (changes in the structure of the bones of the metatarsus).
Treatment
Flat feet
Treatment of flat feet is a long and labor-intensive process. In this case, it is necessary to constantly wear orthopedic shoes with a hard back, special orthopedic insoles (preferably custom-made), and conduct regular courses of massage and physical therapy. Treatment of hallux valgus
Conservative treatmentNon-surgical methods of treating hallux valgus include wearing orthopedic arch supports and night splints, insoles, interdigital spacers, physiotherapeutic treatment, and therapeutic exercises for the toes and feet. To reduce inflammation, intra-articular administration of diprospan and hydrocortisone (hormonal drugs) is used.
Conservative treatment does not lead to complete recovery; it is used only in the early stages and as preoperative preparation.
Surgery
There are a large number (more than 100) methods of surgical treatment of hallux valgus. The main ones are presented below:
- Exostectomy (excision of some part of the metatarsal head).
- Osteotomy, or removal of part of the phalanx or metatarsal bone.
- Creating a state of immobility of the big toe joint (arthrodesis).
- Restoration of ligaments around the metatarsophalangeal joint of the big toe and their alignment.
- Resection arthroplasty, or resection (removal) of part of the metatarsophalangeal joint from the side of the metatarsal bone.
- Replacement of the affected joint with an implant.
Currently, less traumatic methods of surgical treatment of hallux valgus are used, which significantly reduce the period of postoperative rehabilitation.
Rehabilitation after surgery
On the second day after surgery, you are only allowed to move your fingers. You can walk without stepping on the operated area after 10 days. Weight-bearing on the entire foot can only be done one month after treatment. After six months, if the postoperative period progresses well, you are allowed to play sports with weight-bearing feet and wear high-heeled shoes.Shock wave therapy is considered an effective method for facilitating rehabilitation after surgical treatment of hallux valgus, the effect of which is aimed at improving blood circulation in the tissues, as well as reducing swelling and pain at the surgical site.
Shoes
For hallux valgus, shoes should be soft, with a wide toe and low heels (up to 4 cm).In case of plano-valgus deformity of the foot, it is necessary to wear new shoes with a high and rigid back, 3 cm above the heel, with a dense and high arch support.
Orthopedic insoles
To correct foot deformities, various types of insoles and half-insoles are used. Custom insoles are best for this purpose. With their help, the load on the joints of the legs is reduced, blood circulation in the feet is improved, and the feeling of fatigue in the legs is reduced. Sometimes insoles are difficult to fit into shoes, especially standard ones. Therefore, in order to correct pathological disorders in the foot, you can use half-insoles - a shortened version of a regular insole (without the forefoot).
In some mild cases, your podiatrist may allow you to wear orthopedic heel supports.
Massage for hallux valgus
1. The massage course ranges from 10 to 20 procedures, with an interval of about 1 month. The massage affects not only the legs and feet, but also the back and hips, because... The condition of the entire muscular system involved in movement is of no small importance.2. You should start from the lumbar region. Movements - stroking and rubbing, from the center outwards.
3. Next, you should move to the area of the buttocks, where circular stroking, rubbing and kneading, tapping and stroking are used.
4. On the back of the thigh, intensive rubbing is carried out from the knee joint up the thigh, chopping and stroking.
5. The lower leg should be massaged differently, on the inner and outer surface. All techniques (rubbing, kneading) are carried out intensively inside, and gently outside. This allows you to stimulate the internal muscles and relax the external ones, which leads to correct placement of the foot.
Hallux valgus in children
Hallux valgus deformity in children is mainly represented by flat-valgus flatfoot. In this case, there is an outward deviation of the heel, the appearance of pain during long walking and increased fatigue. With timely initiation and regular treatment, complete recovery of the foot can be achieved. To establish the degree of impairment and determine treatment methods, a consultation with an orthopedist is necessary.Treatment
To treat hallux valgus in a child, attention should be paid to the position of the small patient: in a standing position, the legs should be closed - this reduces the load on the joints and foot. The duration of walks should be limited. Has a good effect on leg alignment: - swimming;
- a ride on the bicycle;
- walking barefoot (especially on sand, grass and pebbles);
- football game;
- exercises on the Swedish wall;
- climbing stairs.
Massage has the best effect on the healing process. It must be carried out in regular courses. Physical therapy is also very important; exercises should be done daily. It’s better to present it in the form of a game so that the child can do them with pleasure. Among the exercises, noteworthy are lifting small objects and crumpling a towel with your toes, rolling a stick with your foot, and getting up from the “Turkish” pose.
If the treatment is ineffective, surgery is resorted to. For this purpose, a varus osteotomy is performed. During the operation, a wedge is cut out of the bone (in case of valgus deformity of the tibia, this is the femur). The bone is connected using screws. After the operation, devices for external bone fixation and osteosynthesis using the Ilizarov method are used.
Before use, you should consult a specialist.Predominantly valgus deformity of the hip joints in children is diagnosed during a routine medical examination by an orthopedist. The pathological condition is quite rare. Both boys and girls are equally susceptible to it. A number of factors can provoke the disease, which are divided into congenital and acquired. If the disease is not treated in a timely manner, serious complications arise.
Why does the pathological condition develop?
A partial lesion in the lateral part of the epiphyseal cartilage located above the head of the bone contributes to the appearance of valgus deformity of the hip joints in small patients. Pathology often develops during life in children due to untreated joint dysplasia. During childbirth, the head of the femur is located in physiological valgus and rotated backward. As you grow older, the ratio changes. In adults, the neck-shaft angle is predominantly 120°. The anteversion angle is approximately 10°. If violations are observed, then in small patients these angles change, which is why valgus deformity of the hip joints develops. In addition, the following factors influence the development of this pathological condition:
- cerebral palsy;
- past polio;
- muscle tissue dystrophy;
- exostosis;
- cancer diseases.
In addition, in exceptional situations, valgus deformity is provoked by a displaced femoral neck fracture and rickets.
What symptoms are observed?
If the pathology develops on one side, then the child develops lameness. Mostly, when a child is diagnosed with bilateral damage to the hip joints, the pathology does not manifest itself in any way. If a unilateral disorder is observed, then most often the limb on this side lengthens, as a result of which the gait changes, and the small patient begins to limp on one leg. The pathological condition is difficult to detect, since the function of the hip joint is preserved.
With the help of X-ray examination, it is possible to detect the disease when the child is one year old. In this case, the femur is bent and creates a right angle. The epiphyseal cartilage is localized almost vertically, and the head of the bone can be enlarged, but it is located in a vertical cavity. If the neck-shaft angle is less than 110°, then the cavity is flat and shallow. If it reaches 130°, the depression develops in the usual way. The trochanter is located above the neck and has a medial slope. As valgus deformity develops, it increases.
Diagnosis of hallux valgus in children
When parents suspect that their child is developing valgus deformity of the femoral neck, it is important to immediately contact a medical facility. First of all, the orthopedist conducts a visual examination. Then the little patient is sent for an X-ray examination, during which an internal rotation of the limb is required. In addition, ultrasound examination of the joints and computed tomography or magnetic resonance imaging are sometimes required.
How is the treatment carried out?
Orthopedic shoes will help to cope with the problem. Conservative therapy, which involves traction or immobility of the hip joint, is ineffective for valgus deformity. They resort to the only method of conservative treatment, which is wearing. With its help, it is possible to prevent the occurrence of deformation of the distal parts of the legs. Thanks to the insole, which is placed in the shoes, it is possible to equalize the length of the lower limbs and compensate for the shortening of the affected leg.
Surgery in the fight against a pathological condition
Therefore, patients suffering from valgus deformity of the hip joint are prescribed surgical intervention. Its type is directly related to the magnitude of the deformation, the severity of the disease and the age category of the patient. If the angle of curvature of the hip is 50°, then surgery is not prescribed. Constant monitoring of the patient and X-ray examinations every 6 months are sufficient. Surgical intervention for such a curvature is resorted to in situations where the deformity is actively progressing.
Direct indications for surgery are:
- increase in angle more than 60° degrees;
- decreased strength of the gluteus medius muscle;
- severe deterioration in walking.
A contraindication is the absence of unwanted symptoms and progression if the angle of curvature is 60 degrees.
Surgery can completely eliminate the defect. As for the age of the patient, the operation is rarely performed on children under 2 years of age. This is due to the fact that during this period the deformation of the femurs and joints is not very noticeable. However, surgical intervention at an earlier age has a significant advantage, which is the ability to completely remodel the affected bone tissue. Thanks to the operation, it is possible to get rid of the valgus curvature of the hip and reduce the displacement of the joint. In addition, after the operation the length of the legs is equalized.
The invention relates to medicine, namely to orthopedics, traumatology in the treatment of varus deformity of the femoral neck. Essence: the spokes are passed through the wing of the ilium, the greater trochanter, the middle and lower thirds of the thigh, the ends of the spokes are secured to the supports of the compression-distraction apparatus, the support on the wing of the ilium is connected and the proximal support on the thigh, and the middle support is connected to the distal one on the thigh, perform intertrochanteric osteotomy of the femur in the direction from bottom to top, from the outside to the inside, the deformity of the proximal femur is corrected, a transverse osteotomy is performed in the lower third of the femur, the intermediate fragment of the femur is shifted medially, fixed in the achieved position, cantilever knitting needles are passed through the greater trochanter and the femoral neck, Knitting needles are passed through the supra-acetabular region, they are bent in an arcuate manner, fixed and pulled to the arc of the apparatus, on days 5-6 after the operation, distraction is carried out between the middle and distal supports at a faster pace along the outer rods of the apparatus, which makes it possible to form the roof of the acetabulum, level the length of the limb, normalize the biomechanical axis. 5 ill.
The invention relates to medicine, in particular to orthopedics and traumatology, namely, it is used in the treatment of varus deformity of the femoral neck using a transosseous fixation device. There is a known method for reconstruction of the hip joint, which involves the immediate restoration of the neck-shaft angle (CHA) and increasing the coverage of the femoral head by supraacetabular osteotomy of the ilium and tilting the distal fragment of the pelvis outward (AS 757155, USSR. Method for correcting the neck-shaft angle and the roof of the acetabulum depressions with varus deformity of the femoral neck. Published 04/28/80, bulletin 31). However, this method involves performing a subtrochanteric wedge-shaped or intertrochanteric angular osteotomy, supraacetabular osteotomy with subsequent fixation with a plaster cast, which does not allow for the gentle formation of the roof of the acetabulum, the elimination of pathological restructuring of the femoral neck, the complete equalization of the length of the limb and the normalization of its biomechanical axis. The objective of the present invention is to develop a method for treating varus deformity of the femoral neck, allowing to increase the coverage of the femoral head without osteotomy of the ilium, eliminate the pathological restructuring of the femoral neck, completely equalize the length of the limb and normalize its biomechanical axis. The problem is solved by the fact that in the method of treating varus deformity of the femoral neck, including performing an intertrochanteric osteotomy and fixing fragments of the femur and ilium in the supports of the transosseous apparatus, at least four cantilever wires are additionally introduced through the region of the greater trochanter, the femoral neck, and through the supra-acetabular region - at least two spokes, the ends of which bend outward, are fixed in the support of the apparatus and tensioned, while a transverse osteotomy of the femur is performed in the lower third, and an intertrochanteric osteotomy is carried out in the direction from bottom to top from outside to inside, after which the intermediate fragment is moved under the area of pathological restructuring of the neck hips. The present invention is explained by a detailed description, a clinical example, a diagram and photographs in which: FIG. 1 shows a diagram of osteotomies of the femur with fixation of its fragments and the hip joint in the supports of the transosseous apparatus; Fig. 2 shows a photo of patient E. before treatment; Fig. 3 shows a copy of the R-gram of patient E. before treatment; Fig. 4 illustrates a photo of patient E. after treatment; Fig. 5 represents a copy of the R-gram of patient E. after treatment. The method is carried out as follows. In the operating room, after anesthesia and treatment of the surgical field with an antiseptic solution, the needles are inserted at four levels (Fig. 1): through the wing of the ilium, the region of the greater trochanter, the middle and lower thirds of the thigh. The ends of the wires passed through the bone are fixed in pairs on the supports of the compression-distraction apparatus. The support on the iliac wing and the proximal support on the thigh are connected to each other using hinges; the middle support and the distal one on the thigh are connected to each other using threaded rods. The connected supports are able to move relative to each other. Then an intertrochanteric osteotomy of the femur is performed in the direction from bottom to top from the outside - inwards. Deformation of the proximal femur is corrected. In the lower third of the femur, a transverse osteotomy is performed and the intermediate fragment of the femur is shifted medially. After which the femur fragments are fixed with supports in the achieved position. Cantilever pins are passed through the greater trochanter and femoral neck, and pins are passed through the supraacetabular region, which are bent in an arcuate manner, fixed and pulled to the arc of the transosseous fixation apparatus, which helps stimulate reparative processes in the femoral neck and roof of the acetabulum. On the 5th-6th day after the operation, distraction is carried out between the middle and distal supports of the thigh at an advanced rate along the external rods of the apparatus, while a trapezoidal regenerate is formed until the length of the limbs is equalized with the restoration of its biomechanical axis. After achieving complete consolidation in the osteotomy areas, the device is dismantled. An example of the method. Patient E. (case history 30556) was admitted for treatment with a diagnosis of: Consequences of hematogenous osteomyelitis, varus deformity of the right femoral neck - 90 o, shortening of the right lower limb 4 cm, combined contracture of the right hip joint (extension - 160 o, abduction - 100 o), valgus deformity of the knee joint - 165 o. The duration of the disease is 5 years (Fig. 2). Upon admission, he complained of fatigue, periodic pain in the right hip joint, lameness, shortening of the right lower limb, limited movement in the right hip joint and deformity of the right lower limb. Trendelenburg's symptom is sharply positive. The X-ray of the pelvis shows deformation of the proximal femur, NDL - 90 o. Destruction of the femoral neck with its fragmentation along its entire length is noted. The acetabulum is dysplastic: the acetabular index (AI) is 32 o, the acetabular floor thickness index (AFTI) is 1.75, the depth index is 0.3. In the operating room, after anesthesia and treatment of the surgical field with an antiseptic solution, needles were inserted at four levels: through the wing of the ilium, the region of the greater trochanter, and the middle and lower thirds of the thigh. The ends of the wires passed through the bone are secured to the supports of the compression-distraction apparatus. The support on the iliac wing and the proximal support on the femur are connected to each other using hinges; the middle support and the distal one on the thigh are connected to each other using threaded rods. Then an intertrochanteric osteotomy of the femur was performed in the direction from the outside to the inside from bottom to top and a transverse osteotomy in the lower third of the femur. The deformity of the proximal femur was corrected and the intermediate fragment of the femur was shifted medially. After which the femur fragments are fixed with supports in the achieved position. Cantilever pins are passed through the greater trochanter and femoral neck, and through the supra-acetabular region - pins that are arched, fixed and stretched to the arc of the transosseous fixation apparatus. On days 5-6 after the operation, distraction was carried out between the middle and distal supports of the thigh with an advanced rate along the external rods of the device until the length of the limbs was equalized and its biomechanical axis was restored, while a trapezoidal regenerate was formed. The distraction was 27 days. The device was removed after 76 days. After treatment there are no complaints, the gait is correct, the length of the legs is the same, the Trendelenburg symptom is negative, the range of motion in the hip and knee joints is full (Fig. 4). On the radiograph of the pelvis, the centering of the femoral head in the acetabulum is satisfactory, NDV - 125 o, AI-21 o, ITDV - 2.3, acetabulum depth index - 0.4 (Fig. 5). The proposed method of treatment is used in the clinic of the Russian Scientific Center "VTO" named after. Academician G.A. Ilizarov in the treatment of patients with varus deformity of the femoral neck. The implementation of this method allows you to achieve good anatomical and functional results by eliminating deformation of the proximal femur, restoring the integrity of the femoral neck, gentle formation of the roof of the acetabulum due to stimulation of reparative processes by additionally inserted knitting needles into the femoral neck and roof of the acetabulum, restoration of the biomechanical axis of the limb when simultaneous unloading of the hip joint with a transosseous fixation device. The proposed method involves the use of well-known instruments produced by the medical industry, does not require additional accessories, devices, or expensive materials and is relatively low-traumatic. Allows for functional loading on the operated limb and exercise therapy in the early postoperative period, which prevents the development of persistent contractures of adjacent joints.
Claim
A method for treating varus deformity of the femoral neck, including performing an intertrochanteric osteotomy and fixing fragments, characterized in that the spokes are passed through the wing of the ilium, the greater trochanter, the middle and lower thirds of the thigh, the ends of the spokes are secured to the supports of the compression-distraction apparatus, and the support is connected to the wing ilium and the proximal support of the femur, the middle support of the femur from the distal one, an intertrochanteric osteotomy of the femur is performed in the direction from bottom to top, from the outside - inwards, the deformity of the proximal femur is corrected, a transverse osteotomy is performed in the lower third of the femur, the intermediate fragment of the femur is shifted medially, fixed in the achieved position, console wires are passed through the greater trochanter and femoral neck, wires are passed through the supra-acetabular region, they are bent in an arc, fixed and pulled to the arc of the apparatus, on the 5-6th day after the operation, distraction is carried out between the middle and distal supports with a faster pace along the outer the rods of the apparatus.
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Difficult cases of primary hip arthroplasty: Proximal femoral deformity
The normal anatomy of the proximal femur is quite variable, and in the vast majority of cases it is possible to manage with standard endoprostheses while following the usual surgical technique. From a practical point of view, a hip may be considered deformed if its shape and size are so unusual that compensation for anatomical abnormalities is required through the use of special surgical techniques or non-standard implants.
Deformities of the proximal femur can be congenital (dysplasia), post-traumatic (improperly healed fractures of the trochanteric region), iatrogenic (therapeutic corrective intertrochanteric or subtrochanteric osteotomies), and also develop as a result of metabolic disorders in bone tissue (Paget's disease).
Hip deformities are classified according to anatomical location, which includes the greater trochanter, femoral neck, metaphysis, and diaphysis. In turn, deformities in each of the listed anatomical zones can be divided according to the nature of the displacement: angular (varus, valgus, flexion, extension), transverse, rotational (with an increase or decrease in anteversion of the femoral neck). In addition, changes in the normal size of the bone and a combination of these signs are possible. The greatest difficulties for treatment are deformations of the femur at two levels and in several planes.
General principles of treatment.
In the presence of femoral deformity, careful preoperative planning is necessary to determine the feasibility of standard approaches and designs. With some deformities, significant difficulties arise in preparing the medullary canal. For example, a displacement of the diaphysis in width in the sagittal plane can lead to perforation of the anterior cortical wall when inserting an endoprosthetic leg. Intraoperative fluoroscopy or radiography allows you to monitor the progress of canal preparation and significantly reduce the risk of perforation of the femoral wall. The surgeon must decide whether he can install the stem by deviating it from the standard position, or whether this is not possible and a femoral osteotomy must be resorted to. The presence of deformation influences the choice of leg geometry and method of its fixation. There are types of deformities that require specially designed femoral components and, in some cases, custom-made femoral components. With severe deformities, there is often a need for an osteotomy of the femur, and in some cases, a two-stage operation.
Thus, unfavorable factors that create difficulties during the operation and influence the choice of prosthetic leg are the following: osteoporosis, deformation of the bone marrow canal in the sagittal and frontal planes, medialization and rotation of the femur, the presence of unremoved metal structures. Before the operation, the surgeon must carefully plan and have at his disposal several designs of endoprosthetic legs of various types of fixation. The surgeon faces the following questions:
- the possibility of immediate or staged elimination of deformity and installation of an endoprosthesis;
- limb length correction;
- restoration of muscle tone;
- choice of endoprosthesis design;
- removal of metal structures installed during previous operations.
We use the following working classification of deformations:
- According to the level of deformation: femoral neck; trochanteric region; subtrochanteric region (upper third of the thigh); two-level.
- By type of displacement: single-plane; two-plane; multiplanar.
Selection of surgical treatment method depending on the level of femoral deformity
Greater trochanter deformity.
There are two main types of deformation of the greater trochanter, which complicate the performance of arthroplasty: overhang of the greater trochanter with blocking of the entrance to the medullary canal and its high location. When the greater trochanter overhangs, the preparation of the canal becomes significantly more difficult, creating a real threat of its breaking off and varus installation of the endoprosthetic leg. The problem of endoprosthetics with a high location of the greater trochanter is the potential for the trochanter to rest on the pelvis (“impingement” syndrome) with the development of posterior instability of the joint during flexion and internal rotation of the hip, and the appearance of lameness due to insufficiency of the abductor muscles of the hip. To prevent these complications, it is advisable to initially perform an osteotomy of the greater trochanter during the approach, which facilitates the preparation of the canal and makes it possible to compensate for the strength of the abductor muscles by lowering the greater trochanter.
Femoral neck deformity.
There are three types of deformity: valgus (excessive neck-shaft angle), varus (reduced neck-shaft angle) and torsion (excessive anteversion or retroversion). Often these types of deformation are combined with each other. The choice of treatment for varus deformity depends on the presence of bilateral or unilateral lesions, as well as the need to change the length of the leg. With a unilateral deformity, as a rule, the affected leg is shorter, and standard structures can be used. If the surgeon wants to maintain the length of the leg with bilateral deformity, it is necessary to consider using a leg with a smaller neck-shaft angle (for example, the Alloclassic leg has an angle of 131°) or with an increased “offset” and a head with an elongated neck. In this case, it will be possible to restore the anatomy of the joint without lengthening the leg.
Valgus deformity of the femoral neck is usually associated with a narrow metaepiphysis and requires the use of stems with a narrow proximal part. In addition, it is advisable to use implants with a neck-shaft angle of 135° or more.
Small torsional deformations of the femoral neck can be compensated by the appropriate position of the endoprosthesis stem. Problems arise when the anteversion angle is greater than 30°.
If the leg is placed in this position, it will lead to limited external rotation and may be accompanied by hip dislocation. You can install the leg in the correct position by installing it on bone cement, or by using conical prostheses (Wagner type). Another way out of this situation may be to use legs of a modular design (such as S-ROM, ZMR). In case of severe rotational deformities, when other surgical methods cannot be used, derotational osteotomy of the femur is performed.
Deformations of the trochanteric region of the femur are extremely variable and have multiple etiologies. In principle, it is possible to use both types of legs. In the preoperative period, careful planning is necessary to determine the optimal position of the stem and the size of the cement mantle. Cemented stems are most often used in elderly patients with signs of osteoporosis. In addition, this option of endoprosthetics is used when there are difficulties with installing a cementless fixation stem.
Radiographs of the pelvic bones of patient V., 53 years old, with left-sided dysplastic coxarthrosis: a — 6 years after therapeutic intertrochanteric osteotomy, progression of coxarthrosis is observed; b - endoprosthetics of the left hip joint with a standard hybrid endoprosthesis (Trilogy cup, Zimmer, Lubinus Classic Plus leg, W.Link with a 126° wide angle). The choice of the stem is determined by its closest correspondence to the geometry of the medullary canal of the femur.
It must be borne in mind that when removing the plate simultaneously (after MWO) with installing a cement fixation stem, difficulties arise with good compression of the cement. To prevent cement from escaping from the holes in which the screws were located, they must be tightly closed using bone grafts made in the form of wedges.
Radiographs of the right hip joint of patient M., 70 years old, with varus deformity of the femoral neck: a - 12 years after therapeutic intertrochanteric osteotomy; b - osteoporosis of the femur, a wide medullary canal predetermined the installation of a wedge-shaped stem with cement fixation (CPT, Zimmer) after removal of the plate.
The use of standard cementless fixation stems is possible after varus and varus intertrochanteric osteotomies, but with a slight change in the neck-diaphyseal angle and medialization of the distal femur. In these cases, it is advisable to use fully covered legs. Sometimes valgus placement of the endoprosthetic stem is justified, but it is advisable to use implants with a 126" neck angle to prevent instability.
Radiographs of patient S., 54 years old, with left-sided dysplastic coxarthrosis: a - deformation of the metaepiphysis of the femur after derotational-valgusizing intertrochanteric osteotomy (8 years after surgery); b - slight medialization allowed the use of a standard AML cementless fixation stem (DePuy); the choice of a stem with a sufficiently extended coating of balls (5/8 of the length) is due to the need for distal fixation of the endoprosthesis due to pronounced compaction of bone tissue at the site of MVO; c, d - 6 years after surgery.
Radiographs of the right hip joint of patient F., 51 years old: a - aseptic necrosis of the femoral head, healed femoral fracture after valgus VIVO, performed 11 years ago; b, c - the VerSys ET cementless fixation stem (Zimmer) is installed with a valgus tilt in accordance with the geometry of the metaepiphysis of the femur, the beak channel of the plate is filled with cancellous autologous bone.
Excessive medialization of the distal part of the femur and rotational flexion-valgus deformity of the intertrochanteric region significantly complicate the choice of implant. In these cases, it is determined by the shape of the channel below the deformation level. With a tapered shape, usually in combination with a small diameter, the implant of choice is the Wagner stem, which provides good primary fixation and does not create problems with the choice of rotational installation.
Single-plane deformity of the trochanteric region with large medialization of the distal fragment and a conical shape of the femoral canal: a - before surgery; b - 2 years after installation of the Wagner (Zimmer) conical leg.
If the bone canal has a round shape, preference is given to revision designs with a round shape of the leg, one of the options of which can be a leg with a “kapkar”. A distinctive feature of this design is the absence of proximal expansion, the presence of special flanges of the proximal part of the stem in the sagittal plane (to create rotational stability of the prosthesis) and a complete porous coating of the stem, providing distal fixation of the prosthesis.
Radiographs of the right hip joint of patient B., 53 years old: a - pseudarthrosis of the neck of the right femur, healed fracture of the femur after mednalizing therapeutic intertrochanteric osteotomy; b,c - taking into account the excessive medialization of the femoral diaphysis, a stem with a “calcar” (Solution, DoPuy) was chosen for endoprosthetics, which has a porous coating along its entire length, which ensures distal fixation of the endoprosthesis.
A distinctive feature of the surgical intervention technique is the need for careful verification of the medullary canal and the entire trochanteric region. Lateralization of the greater trochanter creates a false idea about the localization of the canal, and flexion-extension deformation creates a false idea about its direction. Therefore, one of the common mistakes is perforation of the femoral wall at the osteotomy site. Previous derotation of the proximal part (usually outward) can lead to installation of the prosthesis in a position of excessive anteversion.
Radiographs of the right hip joint of patient G., 52 years old: a - aseptic necrosis of the femoral head, healed fracture after medializing MBO; b - perforation of the outer wall of the femur with the leg of the endoprosthesis at the site of osteotomy (intraoperative radiograph); c - reinstallation of the leg into the correct position with fixation of the greater trochanter with cerclages (1 year after surgery).
Deformation of the subtrochanteric region without pronounced deformation of the medullary canal. With this type of deformation, the greatest preference is given to fixing the implant below the level of deformation; with a round canal, it is advisable to use a round, fully covered stem of cementless fixation; with a wedge-shaped canal, it is advisable to use a conical stem.
Radiographs of patient K., 53 years old, with hip deformity in the subtrochanteric region, congenital hip dislocation (grade C): a - before surgery; b - the Trilogy cup (Zimmer) is installed in an anatomical position, taking into account the deformation of the femur in the middle third, a short conical Wagner stem (Zimmer) is implanted, plastic surgery of the inner thigh at the level of the neck of the prosthesis with an autogenous bone graft.
In case of severe deformation of the subtrochanteric region, the following is required:
- osteotomy at the level of deformity; installation of the acetabular component in an anatomical position;
- correction of leg length by the position of the endoprosthesis leg;
- restoration of muscle “leverage” due to tension and fixation of the greater trochanter or proximal femur;
- ensuring stable fixation of bone fragments after osteotomy.
In case of severe deformities, a fundamentally different surgical technique is required, including osteotomy of the femur.
Radiographs of patient T., 62 years old: a, b - congenital dislocation of the hip (grade D), deformation of the subtrochanteric region after osteotomy with the aim of creating a supporting hip; c - the Trilogy (Zimmer) acetabular component is installed in the anatomical position, wedge-shaped osteotomy of the femur at the height of the deformity with implantation of a conical revision Wagner stem (Zimmer), refixation of the greater trochanter with screws; d - position of the implant and greater trochanter 15 months after surgery.
Deformation at the level of the femoral shaft creates complex problems when selecting an implant. Moderate or minor deformities can be compensated by using a cemented stem placed in the femoral axis correction position. It is important to obtain a sufficient cement mantle around the stem. For large deformities, it is necessary to perform an osteotomy of the femur. Various osteotomy options are possible. Transverse intersection of the bone is a fairly simple manipulation, but it must be borne in mind that this requires strong fixation of the prosthetic leg in both the distal and proximal fragments to prevent rotational instability. Step osteotomy presents great technical challenges, but provides good stability of the bone fragments. After performing an osteotomy, it is possible to use both cemented and cementless fixation stems. However, given that it is difficult to prevent bone cement from getting into the osteotomy area, as a rule, preference is given to round stems of cementless fixation with a full porous coating (for a round canal) or conical Wagner stems for a wedge-shaped canal. As a rule, there is no need for additional fixation of the fragments; however, in doubtful cases, it is advisable to strengthen the osteotomy line with allobone cortical grafts and fixed cerclage sutures.
Taking into account the above, when combining corrective osteotomy with simultaneous endoprosthetics, we have determined the following requirements for surgical tactics:
- sufficient tension of soft tissues at the level of osteotomy with possible free reduction of the head of the endoprosthesis;
- rotational stability of the distal fragment and its correct orientation;
- tight “fit” of the endoprosthesis leg in both distal and proximal fragments;
- sufficient contact of the leg with the distal fragment (at least 6-8 cm);
- creation of stable fixation of fragments due to their fixation according to the “Russian castle” type.
As an illustration, we present an extract from the medical history of a patient with a defect in the bone tissue of the acetabulum and deformation of the femoral diaphysis.
Patient X., 23 years old, was admitted to the clinic in January 2001 with left-sided dysplastic coxarthrosis, supraacetabular acetabuloplasty with a titanium endoprosthesis, a healed fracture after flexion-derotational subtrochanteric osteotomy, a defect of the femoral head, posterior subluxation in the hip joint and shortening of the leg, on 7 cm. In one of the patient's medical institutions, starting in 1999, the following operations were performed successively: supraacetabular acetabuloplasty, subtrochanteric flexion-derotational osteotomy of the femur. As a result of contact of the femoral head with the metal endoprosthesis of the roof of the acetabulum, destruction of the femoral head occurred and its posterior subluxation developed. At the clinic on January 15, 2001, the following operation was performed: the left hip joint was exposed using an external transgluteal approach, the endoprosthesis of the acetabulum roof was removed, and the head of the femur was resected. During the inspection, it was revealed that the acetabulum was flattened, the posterior wall was smoothed, and there was a through defect at the location of the metal plate. The femur is internally rotated (at the osteotomy site) and has an angular deformity (the angle is open posteriorly and is equal to 35°). Bone grafting of the acetabulum defect was performed, a Muller support ring was implanted and fixed with 4 cancellous screws, and a polyethylene liner was installed in the usual anatomical position on bone cement with gentamicin. A wedge-shaped osteotomy of the femur was performed at the height of the deformity, and the femur was repositioned (extension, derotation). After preparation of the medullary canal with drills and rasps, a fully covered, cementless-fixed stem (AML, DePuy) was installed. The osteotomy line is covered with cortical allografts, which are fixed with cervical sutures. In the postoperative period, the patient walked with the help of crutches with a dosed load on the leg for 4 months, followed by a transition to a cane. The leg length deficit was 2 cm and was compensated by wearing shoes.
Radiographs of the left hip joint and computed tomograms of patient X., 28 years old(explanations in the text).
The disadvantages of using round massive legs are atrophy of the bone tissue of the proximal femur, “stress-shielding” syndrome, the clinical manifestation of which is the appearance of pain in the middle third of the thigh, at the level of the “tip” of the endoprosthesis leg, during physical activity. If the bone canal is cone-shaped, it is preferable to use Wagner revision stems, but it must be borne in mind that these implants do not have a bend, so careful selection of the implant length is required.
Radiographs of patient T., 56 years old: a - left-sided disilastic coxarthrosis with dislocation of the femoral head (grade D), deformation of the femur in the upper third and after corrective osteotomy; b - an attempt to enter the canal without osteotomy at the height of the deformity was unsuccessful (intraoperative radiographs); c - an AML stem (DePyu) was installed after a Z-shaped osteotomy of the femur at the height of the deformity, additional fixation of the osteotomy line with a bone autograft from the femoral head; d, e - radiographs after 18 months: consolidation in the osteotomy area, good osseointegration of both components, the tip of the prosthesis rests on the anterior wall of the femur (indicated by the arrow), which causes pain during heavy physical exertion
Radiographs of patient K., 42 years old, with right-sided dysplastic coxarthrosis (grade D), double deformity of the proximal femur: a - before surgery; b - Trilogy cup (Zimmer) installed in an anatomical position, Z-shaped osteotomy of the femur at the height of deformation with fixation of fragments according to the “Russian castle” type, revision Wagner stem (Zimmer); c - stable fixation of both components of the endoprosthesis, consolidation in the osteotomy area after 9 months.
Acetabular fractures are a serious injury, in most cases they are combined and, regardless of the treatment method, have an unfavorable prognosis. Over time, degenerative-dystrophic changes in the hip joint occur in 12 - 57% of victims. 20% of patients develop grade II-III deforming osteoarthritis, and 10% develop aseptic necrosis of the femoral head.
The results of hip replacement after fractures of the acetabulum are inferior to the results of this operation performed for deforming arthrosis of the hip joint. The frequency of aseptic loosening of the acetabular component of cement fixation in the long term (10 years after surgery) in post-traumatic coxarthrosis is 38.5%, whereas in conventional forms of arthrosis of the hip joint it is 4.8%. Mechanical instability of cementless fixation endoprostheses in the patient population under consideration is also high and reaches 19% for the acetabular and up to 29% for the femoral components. Among the reasons for the observed differences are a violation of anatomical relationships, a post-traumatic defect in the bone tissue of the acetabulum, chronic hip dislocation, and the presence of scars and metal structures after previous operations. The earlier appearance of aseptic loosening may be facilitated by the young age of patients and, accordingly, their increased physical activity.
Depending on the anatomical changes after a fracture of the acetabulum and the position of the femoral head, the following working classification was formed:
- I - the anatomy of the acetabulum is not significantly disturbed, the sphericity is preserved, the femoral head is in its normal position;
- II - the presence of a segmental or cavitary defect of the acetabulum with dislocation/subluxation of the femoral head;
- III - consequences of a complex fracture with complete disruption of the anatomy of the acetabulum and a combined defect (segmental and cavitary) of bone tissue with complete dislocation of the femoral head.
R.M. Tikhilov, V.M. Shapovalov
RNIITO im. R.R. Vredena, St. Petersburg