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RECONSTRUCTIVE - STABILIZING OPERATIONS AFTER ILIZAROV IN CASE OF DEFECTS OF PROXIMAL END OF FEMORAL BONE.
G.A.Ilizarov, O.A.Kadykalo
(Russian Scientific Ilizarov Center "Restorative Traumatology and Orthopaedies';
General Director - V.I.Shevtsov, M.D.)
Defects of proximal end of femoral bone are referred to the severe pathologies of locomotor system, the treatment of such pathologies is very difficult and actual orthopaedic problem still. The severity of this pathology is complicated by wide scar changes of surrounding soft tissues and as a result of purulent - inflammatory processes and numerous surgeries. Total defects of proximal end of femoral bone on the diaphysis level which occur after tumor resection, unsuccessful endografting or alloplastics of hip joint and infection diseases are considered to be the most difficult. Restoration of supportability and limb length in such patients by traditional treatment methods is difficult and sometimes insolvable task.
Elaborated by one of the authors of the present report (G.A.Ilizarov) reconstructive - stabilizing operations considerably enhance the possibilities of treatment the patients of the pathology. They allow to provide the restoration of supportability and limb length alongwith the widening of perineum space with corresponding reconstruction of proximal end of femoral bone. That improves, especially in female patients, functional treatment results and limb configuration. Relatively low traumatism of surgeries, reliable guided fixation of bone fragments by means of author's apparatus with preservation of movements in knee- and ankle - joints allows the patients to be mobile
beginning from the first days of treatment, creates optimal conditions for the rapid regeneration of bone tissue and functional rehabilitation of the patients.
Depending on defect of proximal end of femoral bone volume and its location in the neighborhood with acetabulum different methods of reconstructive - stabilizing operations are used, they are used simultaneously or consecutively. In large defects of proximal ends of femoral bone with its shifting by the acetabulum level, with large contact area and changes according to the deforming arthrosis type with sharply limited mobility and vivid pain syndrome, reconstructive - stabilizing operation with restoration of limb length is made during one stage. In this case simultaneously with the closed compression arthrodesing in the position of excessive adduction (120 - 130 degrees) of the limb, reconstructive - lengthening compactotomy on the boarder of upper and middle third of the femur. Later on between the fragments of femoral bone the angle, open medially is being created for widening of perineum space and limb lenthening is performed. Surgery methods. Providing the limb with necessary adduction and bending up to 155 - 160 degrees through the crest of supraacetabulum area of iliac bone, which are fixated in tensed position to the arch of Ilizarov apparatus, assembled with the angle of 30 -40 degrees, open medially to the
plate of pelvic cross section. Through proximal and distal ends of femoral bone 2-3 cross wires are inserted, the upper are fixated in the tensed position to the arch and lower to the ring. The arches are connected by the rods, compression is performed by means of nuts screwing in the area of hip - joint.
Later on oblique compactotomy is performed on the boarder of the upper and middle third of
diaphysis of femoral bone in frontal area. Distalend of the femur is abducted to 30 -35 degrees, performing between bone fragments the angle, open medially. Femur is elongated by gradual distraction to the level of functional length of the legs. For illustration we present the following clinical observation.
Fig 1 a,b. Patient and X-ray before treatment
Fig 2 X-ray during the osteosynthesis process
Patient F., 26 years old, medical report No. 1731, diagnosis: defect of the head and neck of the left femur after tuberculosis coxitis, shortening of left lower limb - 13 cm. When she was 22 years old -operation - resection of the left hip - joint with the following arthroplasties (fig lb). On admission the patient complained to the pain in the hip - joint, shortening of the left leg and vivid
limping. Movements amplitude in the area of hip - joint was 30 degrees. The femur is shortened to 10 cm, tibia to 3 cm (fig la). Operation was performed: closed compressional osteosynthesis of left hip - joint in the adduction position 120 degrees with simultaneous reconstruction of proximal end of femoral bone with elongation to 9,5 cm (fig 2). Distraction period was 97 days,
5 fixation period - 100 days. In 6 months after > apparatus removal surgical elongation of the tibia f to 3 cm was performed. Treatment result was observed during 4 years after apparatus removal. In hip - joint bone - ankylosis in flexion position 158 degrees, abduction of proximal femoral third 110 degrees and adduction of proximal part and abduction of lower part - 85 degrees. Functional length of both legs is equal (fig. 3a,b,c)
Fig 3a, b, c. Patient abd the X-ray in 1 year after apparatus removal
In defects of proximal end of femoral bone, accompanied by stable abducting contracture, vivid pain syndrome and rapid limitation of movements for ankylosis gaining in the position of adduction of limb wedge-shaped resection is
used without subluxation of proximal femoral end. for this purpose through small incision external part of acetabulum roof is seen and neighboring part of proximal femoral end. With the help of two chisels along the direction lateral-to-medial vedge-shaped block is cut simultaneously, including acetabulum roof and neighboring part of proximal femoral end (fig.4a). The height of vedge is calculated in such a way that after elongation with abduction of limb up to the necessary angle we should get dense contact of corresponding bones in the area of hip - joint.
This relatively small surgery under conditions of stable compression fixation with the help of author's apparatus allows to get ankylosis in the short period of time. In male patients the limb is adducted to 83-85 degrees and in this position simultaneously with compression arthrodesing limb elongation due to compacto-tomy along the diaphysis is performed. In female patients with the aim of widening of perineum space the reconstruction of proximal femoral end is performed (fig.4b). For this aim arthrodesing in the area of hip - joint is performed with femoral adduction up to 120 - 130 degrees. In the upper third of the femur we perform corrective -elongation compactotomy, distal femoral end is abducted to 30 - 35 degrees, creating between the fragments the angle open medially with simultaneous elongation of femur. Apparatus assembly is the same as above - described. As an example let me show you the clinical observation.
Fig 4a, b, c. Scheme of reconstructive arthrodesis of the hip joint after its vedge-shaped resection
The patient B., 20 years old, medical report No. 1174, was admitted to the hospital on the 18.02.69 with diagnosis: defect of the head and partly the neck of left femur, flexion - abduction contracture of the left femur. At the age of 5 years open reduction of congenital dislocation of femur was performed, it was complicated by aseptic head necrosis. At the age of 12 years -
arthroplasties of left hip - joint. On admission to-the hospital - complaints to he strong pain in the, area of the left hip - joint, vivid limitation of movements in the joint. The femur is located in the* position of flexion 140 degrees and abduction] 75 degrees. Flexion - adduction amplitude is 15( degrees, relative limb shortening is 4 cm. ;
Fig 5a, b, c, d. Scheme of osteosynthesis stages in creation of acetabular-femoral synostosis with reconstractive elongation of the femur.
After the resection of the bone vedge from the acetabulum roof and the upper pole of proximal end of femoral bone compression arthrodesis by means of Ilizarov apparatus in the adduction position is performed. Fixation period is 42 days. After that corrective - elongating compactotomy on the boarder of the upper and middle femoral third with creation between angle fragments for widening of perineum space and elongation. The general period of treatment with apparatus -154 days. After the period of 1 year and 2 months the functional length of both legs is equal, the position of operated limb is functionally profitable. In the area of the hip - joint bone ankylosis is observed. Started working in 5 months after apparatus removal. Difficulties for reconstruction of limb supporta-bility occurs in total defects of proximal end of the bone. This is provided by sharp non -correspondence of the bones /upper third of femoral diaphysis and widened flat acetabulum/, vivid bone atrophy and considerable diastasis between them, consolidation of proximal femoral end with surrounding scar tissues, and with the attempt of insertion into acetabulum leads to considerable crimping of the soft tissues, and sometimes makes obstacles between 11 tissues (fig.5a). For releasing of synostosis conditions and decreasing of limb shortening synosteoses is performed not in the conventional places of acetabulum, but in the lower parts and articular hole with iliac bone.
The reconstruction of the upper third of the femoral bone with the aim of widening of perineum space and elongation is performed simultaneously with synostosis or, in severe cases, the second stage, after gaining of iliac -femoral synostosis.
A.c. 4258263/28-14 The method of treatment of the defect of proximal femoral part. G.A.Ilizarov. Positive decision from 28.06.88.
The operation began with the preparation and coaptation of joint bones. Through the external longitudinal incision proximal end in the upper third of the femur proximal end of femoral bone is seen and decortication along 1,5 - 2 cm is performed. According to the incision in the lower part of acetabulum or along it vedge - shaped hole is formed, corresponding to the form of proximal end. The femur is in the position of adduction 140 - 130 degrees, proximal end of the femur is drown in this hole and temporary fixated by two Kirschner wires with pelvic bones. Through the crest and supraacetabulum area of iliac bone two cross wires are inserted in oblique sagittal direction, which is being fixated under tension to the apparatus arch, assembled under the angle 40 -50 degrees open medially to the cross section area of the pelvis. In the area of distal metaphysis of the femur 2-3 wires are inserted, which are fixated under tension to the ring (fig.5b).
Apparatus supports are connected by 4 threaded rods, compression is created between the synostosis bones. After consolidation and simultaneously with synostosis reconstruction of the upper third of the femur is performed, 2-3 additional wires are inserted under tension to the arch, assembled 5-7 cm.lower the proximal plate of the pelvic cross section. On the border of the upper and middle third of the femoral bone compactotomy is performed. Distal fragment is abducted medially to 40 - 45 degrees after that distal arch and ring is connected by 4 distraction rods (fig.5c). Beginning from the 5 - 6th days of distraction gradual distraction is performed between the fragments by 1 mm per day up to correction of the functional length of the legs (fig.5d)
Clinical observation.
Patient P.30 years old, medical report 12078, was admitted to the hospital with diagnosis: proximal
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end of left femur defect - 21 cm. When she was 19 years old tumor resection of the proximal end of the femur was performed and defect was substituted by bone allograft.
In 1975 allograft was changed by Zatsepin endograft, which was removed in 2 years because of purulent process (fig.6b). On admittance -complaints on unsupportability of the left
Orthopaedic GENIUS December 195
leg,shortening, pains in left hip - joint. Left lir is flailing, in the upper third of the fern pathological movability in every direction observed.
Fig 6a, b. Patient and X-ray on admission
Fig 7a, b, c. Patient and X-ray during osteosynthesis process
03.11.83 open compression arthrodesis is performed in the area of lower part of acetabulum in adduction position of 140 degrees (fig.7a). Fixation by Ilizarov apparatus - 70 days. 17.01.84 - reconstruction of the upper tibial third for widening of perineum space, improvement of femoral configuration and elongation (fig.7b). Result after 1 year: walking without any additional supports, slightly limping, the limb is supportable, functional length of the legs is equal (fig. 8 a,b,c). Patient B., 31 years old, medical report 3612, was admitted to the hospital on 21.02.73 with diagnosis: defect of the proximal end of left femur - 16 cm,chronicle osteomyelitis. Defect appeared after alloplastics, complicated by
osteomyelitis of the proximal end of the left femur in 1964. On admittance the patient complained to unsupportability of the left leg, shortening, pain in the area of the hip - joint (fig-9).
In the upper third of the femur pathological flailing is determined, the leg is unsupportable. On the X-ray the total defect of the proximal end of the femoral bone up to the level of the upper third of diaphysis, acetabulum is damaged and flat (fig.9b). The patient was operated by the same method. Result was observed during 4 years. The limb is supportable, walk without any additional means of support, slightly limping.
She is satisfied with treatment results. Thus, reconstructive - stabilizing operations, elaborated by academician Ilizarov allow to perform full rehabilitation of the patients with defects of the femoral proximal end. Reconstruction of the upper third of the femur is performed with restoration of supportability and limb length.
This operations are advantageous for fema: patients. Perineum space widening provides equ; loading of both extremities,profitable for ga improvement and consider the peculiarities ( genital and other physiological functions of tt woman, improves cosmetic result of treatment.
Fig 9a, b. Patient and X-ray before surgery
Fig 10a, b, c. Patient and X-ray in 4 years after the apparatus removal
