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Orthopaedic GENIUS December 1993
TREATMENT OF PERTES ILLNESS AFTER ILIZAROV
Shevtsov V.l., Kurtov V.M., Karasiova T.Y.
(Russian Scientific Ilizarov Center "Restorative Traumatology and Orthopaedics";
General Director - V.l.Shevtsov, M.D.)
The treatment of Pertes illness in children and teenagers is difficult and sometimes unsolvable problem nowadays.
Suggested different ways of conservative and surgical treatment often fail to get the desired outcome.
Conservative treatment methods are based on the permanent unloading of the hip - joint with the help of tourniquet loaded traction of femur and tibia. But long period of staying in bed in case of tourniquet traction leads to hypodynamic, limb muscles atrophy and in sone cases, especially in children and teenagers, allow to get true unloading of the hip - joint. As a result, after conservative treatment residua, deformations of the head are noted, hypoplasia of acetabulum, that could be the course of coxarthrosis later on. Fixation unloading apparatuses, used for decompression of the hip - joint by the leg weight, do not provide permanent decompression of the hip - joint, decrease the pelvic muscles tension, that leads to the development of residual deformation of the femoral neck, making longer the period of treatment.
Suggested surgical methods, by means of different ways of osteotomies of proximal part of femoral bone and allow to improve the blood -supply of the joint and to prolong the trophic effect of the action due to regenerate in sub- and intratrochanteric area and do not allow to gain
the decompression of the hip - joint and restore
the shape of femoral head.
Surgeries used and aimed at increasing of the^
blood - supply of the hip - joint, and, ii^
particular, nailing, tunnelization of the femoral ■
neck and head also did not meet vast clinical ^
application.
For the above - mentioned conservative andT surgical treatment methods obligatory jointj immobilization without function is indicated. Asl a result, restorative processes in the damaged^ joints is too prolonged and frequently unsuccess-, fill. ( The application of distractional - hinge appara-j tuses for the treatment of patients with pertes, disease allowed some authors (E.S.Tikhonenkov.j Y.I.Pozovsky, 1987) to gain the unloading of hip. - joint with elimination of muscles compression^ In this case, the unloading of the hip - joint in£ longitudinal direction does not include pressure, on the internal and lower parts of acetabulum^ that leads in its turn to the partial restoration oft the head epiphysis and does not provide its right orientation. {
In Russian Kurgan Scientific Center we elabo-j rated the method of treatment of Pertes disease, providing decompression of the hip - joint with< the help of Ilizarov apparatus with active func-, tional loading (A.c. 1561245 G.A.Ilizarov, 1978.,' DCP).
Shevtsov V.I., Kurtov V.M., Karasjova T.Y. "Treatment of Pertess Illness after Ilizarov."
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The method were used in treatment of 10 patients aged from 5 to 15 years: 8 boys and 2 girls. One - sided injury was in 5 patients, two -sided in 5 patients.
The method was performed through the crest, supraacetabulum area of iliac bone 3-4 wires were inserted on different levels in crossed position in the opposite direction. The wires were fixed to the arch support under the pressure. The wires were fixated to the ring apparatus support under pressure. Supports were connected by iistractional rods with hinges nods, on the level Df the level of rotation center of the femoral head considering its following restoration and volume increasing. After the apparatus assembly the iistraction between the arch and ring supports to he direction to the femoral neck axis was Derformed up to reposition of the center of the 'ernoral head (considering the proposed restora-ion) with the acetabulum center. 3n the second day after osteosynthesis the )atients started walking with gradual loading of he limb. They made exercise therapy of knee -jnd ankle - joints and active-passive movements n the hip - joint with preservation of given lecompression force. Supportive distraction for lecompression of the hip - joint was made once n 10-14 days. Control roentgenography was lade once a month. Medical therapy was not sed.
1 all patients in 1 - 1,5 months of the active -assive decompression of the hip - joint with jnctional loading of the limb equal restoration of le epiphysial cartilage was noted, with increas-ig of its height and restoration of the head shape f the femoral bone. Rapid regression of patho-jgically changed parts and restoration of the amoral head shape we connect with stimulating
influence of tension stress on tissues genesis of the hip - joint. In this case we witness the formation of blood - vessels, the trophic is improved and the preserved joint function provides equal loading distribution on the articular ends and the formation of the right head shape, that witnesses the preposition of the articular function with the late loading. In all patients after the end of the treatment the growth plate of epiphyseal cartilage was preserved. In such cases of two - sided injury restoration of epiphysis on the other side was noted.
In cases of two - sided injury the apparatus decompression of the hip - joint was applied from the side of the most vivid pathological changes in the hip - joint. It was noted that the active influence on the zone of the pathological focus of one joint led to the vivid activization of restorative process of the other hip - joint. The average fixation periods was 3-3,5 months. After the apparatus removal the patients were allowed to increase the loading gradually with the help of the crutches. The general period of treatment including the walking with full loading is 1-1,5 years.
Thus, the treatment after Ilizarov of Pertes disease allows to perform the guided correction of restoration of epiphyseal cartilage of femoral neck, providing the right orientation of the growth plate.
CONCLUSIONS:
1. The suggested method appears to be less traumatic and high-effective for treatment of Pertes disease in children and teenagers.
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Orthopaedic GENIUS December 199;
2. Equal distribution of static and dynamic forces on the hip - joint, caused from the one side by the distractional apparatus forces, and from the other - by active muscles contraction of the limb with exclusion of the pressure by injured head of the femur on the internal lower parts of acetabulum, providing the right orientation of the growth plate of epiphyseal cartilage in the process of restoration of the femoral head shape, prevents the development of the secondary deformation of the femoral head,valgus deformation of the neck and the development of instability of the hip -joint.
3. Decompression of the hip - joint in biome-chanical optimal direction with stimulating influence of tension stress on tissues genesis allow to support the full muscles balance, surrounding the hip - joint, with simultaneous equal stretching of the articular capsule and improving the anatomic interrelations in the hip -joint.
4. Functional loading of the limb with preservation of hip - joint decompression provides active muscles contraction, that leads to the increasing of blood - circulation in the hip - joint area, accelerates the dissolving of necrotic tissues and activates the restorative processes not only in the femoral head, but also in the neck and acetabulum.
5. Simplicity, accessibility, hopeful outcomes of treatment method allow to recommend it for the wide application of this method in the clinical practice.
INFORMATION SOURCES:
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1. Tikhonenkov E.S., Posovsky Y.I. The treat ment of congenital femur dislocation and Pertej disease in elderly children and teenagers witl application of distraction - hinge apparatus //Organization of the help and treatment of tht children with the illnesses and traumas o locomotor system: Thesis collection of scientifii practical meeting. Arkhangelsk, 1987, p.p.72-73
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2. A.c. 1561245 (USSR), MKI A 61 B 17/5I1 Treatment method for aseptic necrosis of thf femoral neck of femoral head/ G.A.Ilizarov.-4413971/28-14. Reported 19.04.88 (DCP).
