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Operative surgery of aseptic necrosis of caput femori in children
Djurayev Akhrorbek Makhmudovich, Chief of Children's orthopedic department of Scientific research institute of Traumatology and Orthopedics, Ministry of Health Care of the Republic of Uzbekistan, MD, Professor Valiyeva Kamola Nurullayevna, Junior scientific assistant, Radiography department, Scientific research institute of Traumatology and Orthopedics, Ministry of Health Care of the Republic of Uzbekistan
E-mail: [email protected] Rustamova Umida Mukhtarovna, CMS, chief of roentgenologic department of the Scientific research institute of Traumatology and Orthopedics, Ministry of Health Care of the Republic of Uzbekistan
Rakhmatullayev Khayrulla Rakhmatullayevich, CMS, senior scientific assistant, department of pediatric orthopedics, scientific research institute of traumatology and orthopedics, ministry of health care of the republic of Uzbekistan
Operative surgery of aseptic necrosis of caput femori in children
Abstract: We checked 146 patients with aseptic necrosis of caput femori with various geneses in the age from 2 to 14 years old. The choice of surgical method depended on the degree of pathologic changes and the stage of diseases revealed in the check up.
Keywords: aseptic necrosis, caput femori, Pertes disease, diagnostics, children, therapy.
Among all pathologies of skeletal apparatus aseptic necrosis of caput femori takes up to 3%, and among orthopedic diseases of femoral joints up to 25%. Aseptic necrosis of femoral joint is a serious problem of the modern clinical medicine and it is the reason of high invalidization of children [1; 2]. In adult patients 30-40% of arthrosis of femoral joints are complications of incomplete treatment of diseases such as congenital hip displacement and Pertes disease in childhood [3; 5; 7]. Aseptic necrosis of caput femori after bloodless reduction of congenital hip displacement is a dangerous complication of conservative therapy and it often appears due to yatrogenic inadequate orthopedic intervention [4; 6]. The disease proceeds for a long time; 20-25% of the children had expressed deformation of caput femori and later development of deforming cocix arthrosis. Treatment of ANCF in children is a complex and unsolved problem. Various methods of conservative and surgical treatment in the majority of clinical observations prevent getting desirable results.
The objective of our study is the analysis of the results of surgical treatment of aseptic necrosis of caput femori (ANCF) in children.
Materials and methods of the study: We checked 146 patients with aseptic necrosis of caput femori with various geneses in the age from 2 to 14 years old. Among 146 children (173 joints) ANCF after conservative and surgical treatment of congenital hip displacement was registered in 85 children (103 joints), osteochondopathy of caput femori — Pertes disease in 61 children (70 joints).
ANCF after the therapy of congenital hip displacement: injure of the right hip joint were observed in 21 cases (24.7%), leftside in 49 cases (57.6%), bilateral in 15 (17.6%). With PD there were 16 girls (26.3%) and 45 boys (73.7%). Among them 20 right side (32.7%), 35 left side (57.3%), 6 bilateral (9.8%). Children were also divided according to the stages of the disease: first stage of the disease was noted in 15 children (10.2%), the second stage — impression fracture in 47 children (32.2%), fragmentation stage in 58 children (39.7%), recovery stage in 20 children (13.6%), the fifth stage in 4 children (2.7%).
For definition of the general status of patients and study of alterations in hip joint we used clinical, roentgenologic, doplero-metric, MSCT and ultra-sound research methods. Roentgenologic tests were performed on small dose digital roentgen apparatus Flex-avision Shimadzu (Japan), and sonographic tests were performed with the help of sonographic apparatus MyLab 40 Esaote (Italy). Doplerometric tests were performed with the help of Philips IU 22 apparatus manufactured in Holland and Germany, linear sensor with frequency L 9-3 MHz in B - M - 3D - 4D modes. For ultra sound checking we used multi frequency linear sensor with 3.5-7-12 mHz.
Results and discussion. Ultrasonographic signs of ANCF were exudation in the anterior part of joint cavity, cervical area, thickening of caput femori cartilage, thickening of synovial membrane, deformation, fragmentation of ossification nuclear of caput femori. The difference of the thickness of joint cartilage between healthy and injured sides in 80.5% exceeded 3mm. In 69% we detected transitory sinovitis, when duration of the symptoms of pain and limitation of motion was 7-14 days.
For Pertes disease exudation in the cavity of joint was preserved for the whole term of the disease and it was typical both for early and late stages of the disease, including fragmentation stage. In progradient progress of the disease echographically we noted decrease of the distance between acetabular edge and metaphysic of femoral bone, deformation of caput femori with the loss of its height, in comparison with healthy side. In some cases there was absence or significant diminishing of ossification nuclear.
In doplerography of 122 (76.7%) children with ANCF we noted decrease of peak velocity of blood flow in deep femoral artery and circumflex femoral arteries.
Treatment of children with aseptic necrosis of caput femori: conservative orthopedic methods — in 102 children 69.8%; surgical intervention in 44 children 30.1%. Indication for operation was little efficiency of conservative treatment and fast progressing of the pathology.
The aim of surgical interventions was centration of caput femori in acetabulum, normalization of the correlation of joint surfaces
Section 6. Medical science
and improvement of blood circulation and reparation processes in the damaged caput.
44 patients had the following types of surgical interventions dependently on the stage and severity of the disease: — tunneling of the cervix of femoral bone with injection of auto transplant into its lumen in 8 patients; — varizing inter-trochanter osteotomy of femoral bone in 12 patients; — transplantation of the anterior inferior ost of ileac bone on vascular muscular foot; — decompression of hip joint using Ilizarov's apparatus.
The choice of surgical intervention depended on the degree of pathologic alterations revealed in roentegologic and MSCT tests. In the first stage of the disease we performed oper4ations of tunneling of the cervix of femoral bone, tunneling of the cervix of femoral bone with injection of auto transplants in its lumen, decompression of hip joint using Ilizarov's apparatus. In the second and third stages of the disease we performed operation of varizing inter-trochanter osteotomy of femoral bone. The aim of surgical interventions in the initial stages (I, II) of the disease was improvement of blood circulation and reparation processes in the damaged caput; in the II and IV stages — centration of caput femori in acetabulum and normalization of joint surfaces correlation.
After operation plaster cast was applied for 1 month. After removal of the cast physiotherapeutic and medical treatment courses were prescribed additionally.
During postoperative period control x-ray imaging was performed in 6 and 12 months for assessment of the surgical interven-
tion. Application of a complete load on the operated limb of the patients with ANCF was permitted average in a year.
After tunneling of hip joint on doplerography we noticed improvement of blood flow in circumflex arteries of femor. Extra joint reconstructive- restoring interventions promoted preservation of intact bone-cartilage elements and intensification of dynamic reparation of the damaged ones in hip joint, and that had favorable effect on the further development of the joint and promoted fast recovery of its functions in postoperative period. There was decrease of epiphysary deformation, improvement of caput femori centration and congruency of joint surfaces. It was well traced on x-ray pictures, computer tomorgams in postoperative period. Recovery of physiological congruency of the joint reached by means of rotation component of osteotomy and exclusion of the load of the part of aseptic necrosis of caput femori conditions the possibility of early recovery of support function of the limb. In the control roentgenography in postoperative period and stages of the therapy there was no remarkable progression of the disease. The progress of fragmentation period was shortened, reparative processes were more active.
Conclusions:
1. Complex diagnostics will help an individual approach to the therapy of aseptic necrosis of caput femori in children. All the results of instrumental radiologic test complemented each other.
2. The choice of surgical intervention method depended on the stage and severity of the pathologic process. Surgical interventions promote fast recovery of congruency and functions, improvement of blood supply and regeneration processes in hip joint.
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Magrupov Bokhodir Asadullaevich, Professor, Department of Pathology of the Tashkent Medical Academy
E-mail: bokhodir@ mail.ru Vervekina Tatyana Anatolevna, Department of pathologic anatomy of the Republican Research Center of Emergency Medicine, Tashkent, a pathologist E-mail: [email protected] Ubaydullaeva Vladlena Ulugbekovna, PhD, Department of pathologic anatomy of the Republican Research Center of Emergency Medicine, Tashkent,a pathologist E-mail:[email protected]
Characteristics of inflammation mediators changes at calculous cholecystitis
Abstract: Investigation results of anti-inflammatory mediators levels in patients with different types of calculous cholecystitis in compare with blood indexes investigation results in healthy people have been presented in the paper. Comparison of cytokines level ratio in blood and immunocompetent cells in gallbladder tissue has been performed.
