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Section 1. Clinical Medicine
Alpisbayev H. Sh., Republican center of pediatric orthopedics
Jurayev A. M.,
Republican specialized scientific and practical medical center of traumatology and orthopedics E-mail: [email protected]
DIFFERENTIATED OPERATIONAL TACTICS IN THE TREATMENT OF DESTRUCTIVE PATHOLOGICAL HIP DISLOCATION AFTER HEMATOGENOUS OSTEOMYELITIS
Abstract. The differentiated operational tactics depending on the severity of destruction of the proximal femur and acetabulum is substantiated. The result of the operation was better in children who open reposition of dislocation was complemented by the plastic acetabulum. Reconstructive -restorative operations in most patients provide stability of the hip joint and thus improve the gait and statics of the patient, reduce pelvic distortion and eliminate the symptom of Trendelenburg.
Keywords: osteomyelitis, hip joint, pathological dislocation, osteomyelitis, hip, septic arthritis, treatment.
Introduction
The consequences of osteomyelitis are characterized by extensive scarring of the skin, subcutaneous fat, muscles, impaired blood supply to the affected segment and destructive changes in bone tissue over a significant length. Acute hematogenous osteomyelitis is 6-12.2% of purulent diseases and in 79.1-88.7% of cases affects the long tubular bones [5]. The most common in patients with this pathology is the proximal femoral metaepiphysis. In this case, the course of the disease in 35-56% of children is complicated by pathological dislocation of the hip. According to A. A. Akhunzyanova with co-authors (2006); M. A. Norbekova with co-authors (2006), from 75% to 100% of children with hematogenous osteomyelitis enter the hospital in late terms, which contributes to the development of orthopedic com-
plications that develop in 22-71.2% of children and in 16.2-53.7% of patients lead to early disability [2; 6; 7]. Despite the development ofvarious surgical interventions, the results remain disappointing. Treatment ofpatients with pathological dislocation of the hip and is currently a difficult and not fully resolved task for orthopedists. It is generally recognized that surgery is the only radical way to treat children with this pathology. It should provide stability of a hip joint for the purpose of improvement of statics and gait of the patient, whenever possible to restore anatomical relations, to reduce shortening of a limb and to keep sufficient mobility. In the surgical treatment of pathological hip dislocation, the primary task is to restore the supporting function of the limb with the preservation of mobility in the joint, followed by the solution of problems to eliminate secondary
deformities and equalize the length of the lower limbs [1; 8; 9].
All methods of operations used in the treatment of pathological hip dislocations can be grouped as follows:
- the use of preserved anatomical formations -reduction in the acetabulum of the residual epiphyseal stump, or a large trochanter of the femur;
- restoration of the femoral neck;
- complete restoration of the epiphysis with bone auto or homotransplant;
- allo- and metal plastics.
Despite the wide variety of treatments, the prognosis for pathological hip dislocation in most cases remains unfavorable. This is evidenced by a large number of residual deformities and discongruence of the femoral head and acetabulum, j oint instability leading to the development of shortening and coxarthrosis [3; 4; 5].
Purpose of the study: this work is devoted to the analysis of outcomes of surgical treatment of children with pathological hip dislocation.
Materials and methods of research. The work is based on the results of observation and treatment of 174 patients with pathological hip dislocation treated in the Department of hip pathology of the Republican Center of pediatric orthopedics of the Ministry of Health of Uzbekistan from 2010 to 2018 yy. Among these patients were 81 boys and 57 girls aged from 3 to 14 years. Clinical, x-ray and magnetic resonance imaging studies were applied in the work.
The optimal age for operative treatment of pathological dislocation of the hip, according to our data, is 4-5 years of age of the child, since by this time most patients end the process of ossification of the structures of the hip j oint, when secondary deformities have not yet formed and the regeneration processes are well expressed. Planning of operation in patients was based on the assessment of violations of anatomical relations in the hip joint, its function, violations of spatial orientation of the bones forming the joint, as well as violations of the size, shape and
integrity of the bones and was carried out taking into account the selected symptomocomplexes and age of the patient. It should ensure the stability of the hip joint in order to improve the statics and gait of the patient, restore the anatomical relationship in the joint, reduce the shortening of the limb and maintain sufficient mobility. Contraindications to operation treatment: the danger of latent infection in patients who had infectious coxitis 1.5-2 years ago and do not have repeated manifestations of the inflammatory process.
Pathological dislocations of the hip are divided by us into distension ones, i.e. without destruction of the articular surfaces and destructive ones - with destruction of the head, neck of the femur sometimes of the acetabulum. When planning the operation, the nature of the deformation of the proximal end of the femur and the state of the articular cavity and Ilium, which allows forming the necessary size of the cavity, were taken into account. All surgical interventions were accompanied by a revision of the hip joint. The choice of the method of operation depended on the patient's age, the extent of the destruction of the head, the neck of the hip of the acetabulum, the degree of hip displacement. In case of destructive hip dislocation, differentiated operational tactics were used depending on the severity of destruction of the proximal femur and acetabulum. We carried out the following complex reconstructive operations:
- open reposition of the stump of the head or neck of the femur with the intertrochanteric - detorsion, shortening, varus osteotomy in 64 children;
- open reposition of the stump of the head or neck of the femur with the intertrochanteric - detorsion, shortening, varus osteotomy with the plastic acetabulum by Pemberton, Lance, rotational pelvic osteotomy by Salter in 34 children;
- open reposition of the head and neck stump with elongation of the last one and transposition of the hypertrophied big trochanter with the gluteal musculature in the caudal direction with fixing using screw and additionally catgut seams in 29 children.
The purpose of such operations is to create stability in the hip joint, eliminate the vicious position of the limb and the most severe of the symptoms of dislocation - a symptom of Trendelenburg, to reduce the shortening of the limb and, if possible, increase the volume of movements in the joint.
Results and discussion. The results of treatment were evaluated in accordance with the achievement of anatomical and functional results. The result of the operations was better in 34 children, to whom the open reposition of dislocation was supplemented by the acetabulum roofplastic. Operations of open reposition ofthe head and stump of the femoral neck were reduced to the opening of the hip joint, revision of the proximal end of the femur and the cavity and the mandatory excision of scar tissue. After the joint was mediated, the movement of the iliac bone fragments, the preserved part of the neck and femoral head were submerged under the newly formed roof of the acetabulum. With the growth of children, gradually increased lateralization ofthe femur, this contributed to the restoration of the function of the middle and small gluteal muscles. It was achieved movement in the joint within the normal range 80 abduction remained significantly limited, however, adduction contractures is not marked by us in the long term. In this group of patients, a good result in the long term was achieved in 14 children, satisfactory - in 19. Only in one case after open hip reposition there was suppuration of the postoperative wound, which did not affect the outcome of treatment. Thus, the experience of surgical treatment of patients with pathological hip dislocation showed that the most favourable outcomes are achieved with the use of open reposition of the stump of the head
or neck of the femur with the intertrochanteric - detorsion, shortening, varus osteotomy with the plastic acetabulum by Pemberton, Lance, rotational pelvic osteotomy by Salter. The widespread use of these surgical interventions can significantly improve the support and dynamic function of the affected limb.
Summary. After hematogenous osteomyelitis of the proximal end of the femur, destruction of the femoral head and neck is often observed, up to their complete destruction. The optimal age for surgical treatment of pathological hip dislocation, according to our data is 4-5 years of age of the child, because by this time most patients end the process of ossification of the structures of the hip joint, and early surgery often causes severe secondary deformities, up to their complete destruction. Indications for a particular type of intraarticular surgery according to our data, should be strictly individual for each patient, depending on the age of the patient, the type and degree of deformation of the elements of the hip joint and the size of the shortening of the lower limb.
Our observations show that reconstructive and restorative operations in most patients eliminate flexion-adductive and external-rotational contracture, provide stability of the hip joint and thereby improve the gait and statics of the patient, reduce pelvic distortion and eliminate the symptom of Trendelenburg. Surgical treatment of children with destructive pathological dislocations of the hip provides for the first stage of stabilization of the hip joint and the second - the restoration of the length of the lower limb. Restoration of the volume of movements in the hip joint depends on the degree of damage to the head and neck of the femur.
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