RU2853047C1 - Method for acetabular plasty of hip joint in coxarthrosis with cystic restructuring using autograft - Google Patents

Abstract

FIELD: medicine; traumatology and orthopaedics.

SUBSTANCE: invention can be used for acetabular plasty of the hip joint with an autograft in coxarthrosis with cystic restructuring. An external Harding approach to the hip joint is performed. Excision of the joint capsule, sawing of the proximal part of the femur along the intertrochanteric line and harvesting of bone tissue from the bone marrow canal of the femur using a fenestrated chisel are performed. The obtained graft is placed in physiological NaCl 0.9% solution. Revision of the acetabulum is performed, its walls are treated with a Volkmann spoon and a set of reamers, the size of the acetabular component is determined and the presence of cystic defects requiring plasty is identified. The prepared bone tissue is preliminarily crushed using Luërs forceps. The autograft is placed in a bone grafting syringe, brought to the bone defect of the acetabulum and the cyst is filled by pressing the syringe plunger, after which the acetabular component of the endoprosthesis is installed and the operation is completed step by step.

EFFECT: reduction of treatment and rehabilitation terms, as well as complete osteointegration of the graft due to the accuracy of autoplasty and complete controlled elimination of the cystic defect of the acetabulum.

2 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, specifically orthopedics, and can be used in the treatment of musculoskeletal deformities and in structures providing strong bone fixation. The invention involves a method for acetabular reconstruction of the hip joint in coxarthrosis with cystic remodeling using an autograft. The method involves harvesting bone tissue from the femoral medullary canal, preparing the graft, and injecting it into the bone defect using a bone grafting syringe.

State of the art

Coxarthrosis, or osteoarthrosis of the hip joint, is a chronic degenerative-dystrophic disease characterized by progressive loss of articular cartilage, subchondral bone remodeling, and secondary changes in the surrounding structures. Coxarthrosis is characterized by degeneration of articular cartilage, development of erosions, and complete loss of the cartilaginous covering; subchondral osteosclerosis and the formation of cystic remodeling in bone tissue caused by impaired microcirculation and load redistribution; development of osteophytes, which form at the edges of the articular surfaces and limit joint mobility; changes in the synovial membrane, including hyperplasia, inflammatory infiltration, and fibrous transformation; fibrosis and thickening of the joint capsule; atrophic and contracture changes in the surrounding muscles. Several generally accepted surgical correction techniques have been proposed for the treatment of this pathology.

A known method for acetabular acetabuloplasty during hip arthroplasty is patented by RU 2340299 C2, issued on December 6, 2006 [1]. This method involves conducting a clinical and radiographic examination of the patient, during which cavernous-cystic changes, anatomical and functional defects of the acetabulum, and the strength regime of the bone bed are assessed. Based on the data obtained, an auto- or allograft with a corresponding microstructure is selected. A bone mixture is prepared intraoperatively in the form of a paste or powder, consisting of crushed auto- or allo-bone in combination with Collapan. The surgical approach is determined by the nature and extent of the lesion and consists of acetabular acetabuloplasty and filling the defects with a bone mixture.

The disadvantages of this technique include slow integration of the allograft into bone tissue, the risk of infectious complications, the need for a significant volume of bone material, unreliable graft attachment with the risk of secondary deformities, the possible development of aseptic instability of the endoprosthesis, gradual graft resorption, and impaired osseointegration. In some cases, if the initial reconstruction fails or degenerative changes progress, repeat procedures are necessary.

A method of hip re- and endoprosthetics is known, which is based on the European practice of strengthening damaged periacetabular areas of the pelvis using metal structures [2]. The approach to plastic surgery depends on the degree of defects, determined on the basis of the seven-link radiographic classification of the German Society of Orthopedics and Traumatology. According to this method, if small cysts, cracks or irregularities of the articular surface (type 1) are detected on CT or MRI, a revision of the affected area is performed, followed by filling the defect with bone chips obtained from the resected femoral head or iliac wing. If protrusion and monosegmental defects of the roof or walls of the acetabulum (types 2-4) are diagnosed, the damaged area is reinforced with an anti-protrusion mesh (Müller, Ochsner or Ganz), onto which the endoprosthesis cup is installed using bone cement. For more complex lesions, such as protrusion with damage to the floor and one of the walls (type 5) or transsegmental defects of the roof, anterior, and posterior walls (type 6), more robust fixation devices are used, such as the Bur-Schneider antiprotrusion mesh or the Piter Brem system. These are secured with screws to the remaining sections of the pelvic bone, and the prosthetic cup is then cemented into place. If the damage affects virtually the entire acetabular structure, causing pelvic instability (type 7), complete restoration of the acetabular region is performed using cemented antiprotrusion systems and additional cemented allografting.

The main disadvantages of this method are: decreased primary stability of the endoprosthesis due to thermochemical damage to the bone when using bone cement; decreased durability of implant fixation and the risk of aseptic loosening due to metallosis; excessive bone loss that is not restored, especially during the installation and subsequent replacement of antiprotrusion systems; the need for regular revision and replacement of structural components due to their limited service life.

A method of acetabular arthroplasty during hip arthroplasty is known [3], which is aimed at improving the fixation of the cementless cup of the endoprosthesis during total hip arthroplasty in patients with osteoporosis. During the surgical intervention, the femoral head is removed from the acetabulum. Four to six cortical autografts of tapering length are formed from the resected femoral neck. The length of each graft is 2.0-2.5 cm. The autografts are made in the form of a cone or wedge, with the base diameter of the cone-shaped grafts being 3-5 mm, and the apex diameter is 1-1.5 mm. Next, channels are formed in the roof and posterior wall of the acetabulum, directed perpendicular to its surface. Autografts are implanted into the resulting channels with the tapered part, achieving their complete immersion in bone tissue. The endoprosthetic cup is then inserted into the acetabulum using a press-fit fixation system. This proposed method improves the stability of the cementless endoprosthetic cup.

The proposed method has several drawbacks. First and foremost, there is a risk of insufficient integration of the autografts, which can lead to their resorption and reduced implant fixation strength. The creation of channels in the roof and posterior wall of the acetabulum, necessary for graft placement, can further weaken the bone structure, increasing the risk of fractures, especially in patients with severe osteoporosis. The presence of autografts can lead to uneven load distribution on the endoprosthesis cup, increasing the risk of micromobility and aseptic loosening. Furthermore, patients with severe bone atrophy or significant resorption may not have sufficient bone material to form grafts, limiting the use of this method.

A method for acetabular protrusion repair during hip arthroplasty [4] is based on a clinical and radiographic classification of protrusion. This approach involves a comprehensive patient examination, radiographic analysis to determine the degree of acetabular protrusion, and the selection of surgical treatment strategies based on the identified changes. If cysts are present in the acetabular wall, they are examined and the defect is filled with bone cement. In cases where the cyst diameter exceeds 20 mm, repair is performed using an autograft or bone chips.

This technique has a number of disadvantages, including a high risk of destabilization of the structure due to insufficient consideration of the trabecular orientation of the grafts; decreased primary stability of the acetabular and/or total endoprosthesis due to inflammatory reactions and resorption of autologous bone materials during the adaptation stage; delayed osseointegration of the grafts, which may prolong the rehabilitation period; and the risk of developing bone cement implantation syndrome when it is used to fix the endoprosthesis components.

Thus, the main disadvantages of current acetabular reconstruction techniques in hip arthroplasty include slow and incomplete osseointegration of grafts, the risk of graft resorption, a high risk of aseptic instability and loosening of the endoprosthesis, and significant bone loss when using metal structures and cement fixation. Furthermore, inflammatory reactions, an increased risk of infectious complications, structural weakening of the bone, poor load distribution, and the need for repeat surgeries as degenerative changes progress are observed.

The essence of the invention

The invention is aimed at creating a new method for surgical treatment of the acetabulum of the hip joint in coxarthrosis with cystic reconstruction using an autograft.

The proposed method of acetabular grafting using an autograft involves harvesting bone tissue from the medullary canal following osteotomy of the proximal femur (femoral neck) and impaction using a bone grafting syringe. Using a fine-grafted chisel, along the femoral neck's sawed-off area along the canal's axis, the future autograft is harvested and dipped in a 0.9% saline solution. Next, the acetabulum is reshaped using burrs. Once the desired dimensions are achieved and deep cysts requiring bone grafting are identified, the bone cysts are grafted using pre-prepared autograft. The syringe is filled with the autograft, brought to the cyst cavity, previously cleared of internal contents, then the plunger of the syringe is pressed and the cyst is filled with the autograft, several light blows are made on the plunger with a hammer, the transplant is inserted and the cyst is filled.

An external Harding approach to the hip joint is performed. After excision of the joint capsule, the proximal femur is filed with a saw along the intertrochanteric line. At the same time, bone tissue is harvested from the femoral medullary canal with a fine-grained chisel. The obtained bone tissue is placed in a 0.9% saline solution. Next, the acetabular walls are prepared with a Volkmann tray and a set of burs, the size of the required acetabular component is determined, and before setting the final cup size, the acetabulum is revised for bone cysts requiring grafting. A bone grafting syringe is filled with pre-prepared autogenous bone, after first kneading the sponge with Luer pliers. The prepared material is then injected into the acetabular bone cyst, and by pressing the syringe plunger, the cyst is filled, eliminating the defect. Next, the acetabular component of the endoprosthesis is installed and the operation is completed in stages.

The depth and width of the defect (cyst) are determined using radiographs. Radiographs are taken at a 1:1 scale, and the contours of the cyst are defined on the radiograph using a ruler.

The method allows for plastic surgery of the acetabulum of the hip joint in coxarthrosis with cystic reconstruction using an autograft, which is due to the following:

When shaping the socket for the acetabular component of the endoprosthesis, an autograft is harvested from the proximal femur. This is used to correct the bone defect. Autograft is harvested from the proximal femur for impaction to correct a bone defect—a cystically reconstructed acetabulum. Harvesting autograft bone eliminates the need for artificial bone or allograft bone. This graft has the properties of bone tissue with physiological ingrowth, such as homogeneity and elasticity.

- the ability to perform earlier and more complete loads using additional support.

Thus, the proposed method allows for plastic surgery of the acetabulum of the hip joint in coxarthrosis with cystic reconstruction using an autograft.

Description of drawings.

The invention is explained by drawings.

Fig. 1. - X-ray image of a cyst of the femoral head.

Fig. 2. - X-ray picture of cystic lesion of the hip joint

Fig. 3. - X-ray image of the final reconstruction after acetabular plastic surgery.

Fig. 4. - diagram of the instrument for collecting bone graft.

Fig. 5. - Intraoperative image of the instrument used to obtain a bone graft.

Fig. 6. - intraoperative image of the moment of bone graft collection.

Fig. 7. - intraoperative image of the bone graft in the developed instrument.

Fig. 8. - image of a set of instruments for obtaining a bone graft.

Clinical examples of application of the invention.

Patient 3, 75, diagnosed with stage 3 right coxarthrosis. Cystic remodeling of the acetabulum on the right. Coxalgia. Stage 2 ROM. Clinical manifestations: complaints of pain in the right hip joint, right groin pain, and aching pain. According to the patient, the pain has worsened over the past 2 years.

Surgical correction performed: Following preoperative preparation, a total hip replacement of the right hip was performed under spinal anesthesia. An external Harding approach to the hip joint was performed. After excision of the joint capsule, the proximal femur was filed with a saw along the intertrochanteric line. At the same time, bone tissue was harvested from the medullary canal of the femur with a fenestrated chisel. The obtained bone tissue was placed in a saline solution, NaCl 0.9%. Next, the acetabular wall was prepared with a Volkmann spoon and a set of burs, the size of the acetabular component was determined, and before setting the final cup size, the acetabulum was inspected for bone cysts requiring grafting. A bone grafting syringe was filled with pre-prepared autogenous bone, and the sponge was pre-compressed with Luer pliers. The prepared material was injected into the acetabular bone cyst, and by pressing the syringe plunger, the acetabular cyst was filled and the defect was repaired. The acetabular component of the endoprosthesis was then installed, and the surgery was completed in stages.

Seventeen patients underwent surgery using the proposed method. Postoperative X-rays performed 3-6 months later demonstrated complete osseointegration and satisfactory defect repair in all patients. No complications, such as infection, persistent pain, loss of correction, or lack of osseointegration of the defect area, were observed.

Sources

1. Malyutin A.P. Method of acetabulum plastic surgery during hip arthroplasty. // RU 2340299 C2. 06.12.2006.

2. Bettin D, Katthagen BD. Die DGOT-Klassifikation von Knochendefekten bei [The German Society of Orthopedics and Traumatology classification of bone defects in total hip endoprostheses revision operations]. Z Orthop Ihre Grenzgeb. 1997 Jul-Aug;135(4):281-4. German, doi: 10.1055/s-2008-1039389. PMID: 9381762.

3. Letov A.S. et al. Method of acetabular arthroplasty during hip arthroplasty. // Patent RU 2396918 C1 dated 06.07.2009.

4. Magomedov H.M. Hip arthroplasty in patients with acetabular protrusion: Candidate of Medical Sciences dissertation / Peoples’ Friendship University of Russia. - Moscow, 2000. 163 p.

Claims (2)

1. A method for plastic surgery of the acetabulum of the hip joint with an autograft in coxarthrosis with cystic reconstruction, including osteotomy of the proximal femur, characterized by the fact that an external Harding approach to the hip joint is performed, the joint capsule is excised, the proximal femur is sawed along the intertrochanteric line and bone tissue is collected from the medullary canal of the femur using a fenestrated chisel, the resulting graft is placed in a physiological solution of NaCl 0.9%, then the acetabulum is revised, its walls are processed with a Volkman spoon and a set of cutters, the size of the acetabular component is determined and the presence of cystic defects requiring plastic surgery is detected, the prepared bone tissue is preliminarily kneaded using Luer nippers, the autograft is placed in a syringe for bone grafting, it is brought to the bone defect of the acetabulum and by pressing on the plunger of the syringe, the cyst is filled, after which the acetabular component of the endoprosthesis is installed and the operation is completed in stages. 2. The method according to paragraph 1, characterized in that the contours of the cyst are determined on an X-ray at a scale of 1:1, using a ruler.