Two iliac osteotomies

Indication Two tibia osteotomy are mainly used for congenital dislocation of the hip from 7 to 9 years old and unilateral congenital dislocation of the hip from 10 to 14 years old. Contraindications 1. Poor general condition and infection of the skin in the surgical area. 2. The femoral head does not reach the position of the acetabulum relative to the plane. 3. The head is large and small, and the joint surface is inconsistent. 4. Hip joint mobility is significantly limited. 5. Being too old. Preoperative preparation 1. Traction: It is necessary to perform limb traction before surgery. Unless the femoral shortening is performed at the same time. Traction can: 1 contracture soft tissue relaxation, surgery easy to reset; 2 after the reduction of the femoral head stability, to prevent re-dislocation due to muscle contracture; 3 reduce the pressure between the femoral head and acetabulum after surgery, to prevent cartilage surface compression Necrosis and aseptic necrosis of the femoral head. In addition to the lower than 3 years of age and the upward displacement of the femoral head can be used for skin traction, generally using Kirschner wire for the treatment of lower bones of the tibia and fibula. For those with high dislocation, the Kirschner wire should be used for traction. Raise the bed 10 to 20 cm when pulling, as a counter traction. The direction of traction should be slightly buckling of the hip, consistent with the longitudinal axis of the trunk or a slight internal traction. If the affected limb is pulled in the outreach position, the femoral head is blocked on the tibia and cannot be pulled down. When the femoral head is brought to the acetabular plane, the affected hip can gradually abduct and straighten to pull the contracted soft tissue. The weight of the traction starts with 2 to 3 kg, and then gradually increases, generally not more than 7 to 8 kg. The traction time is 2 to 4 weeks. If the femoral head is not enough, the time can be extended appropriately. The age and pathology of the sick children are different, and the required traction weight and time are also different. During the traction process, the length of the two lower limbs should be measured. Check whether the groin can touch the femoral head. After 2 weeks of traction, take X-rays once a week to determine the position of the femoral head. Surgery can be performed after the femoral head has descended to the acetabular plane and is maintained for 1 to 2 weeks. If the procedure of simultaneous femoral shortening is used, traction therapy is not required before surgery. 2. Do a good job in the general condition and skin preparation in the operating area. 3. Preparing blood: If it is estimated that the operation is difficult or needs to be done at the same time, it should be matched with blood 300-600ml. 4. The bladder must be emptied or indwelled before surgery. Surgical procedure Incision Starting from the middle of the sacral section, an arc-shaped incision was made, and the anterior superior iliac spine was extended 6 to 8 cm downward in the gap between the sartorius muscle and the tensor fascia. 2. Exposing the joint The deep fascia on the humerus was cut according to the skin incision line. At the distal end of the anterior superior iliac spine 1 to 2 cm, near the lateral edge of the sartorius muscle, the lateral femoral cutaneous nerve is exposed and freely protected, and it is retracted to the inside with a rubber sheet. Bluntly separate and open the fascia lata and sartorius muscles outwardly and medially. The humerus humeral cartilage was cut longitudinally from the middle segment to the anterior superior iliac spine until the bone, and the subperiosteal peel was attached to the lateral part of the epiphyseal cartilage of the iliac wing, the fascia lata, and the anterior aspect of the gluteus medius. Partial and gluteal muscles, showing the upper acetabular rim and the superior lateral part of the hip capsule. Peeling should be performed under the periosteum, and after stripping, gauze should be used to stop bleeding. The medial part of the humerus, humeral cartilage, and the diaphragm are exfoliated from the inner surface of the humeral wing, and exfoliation is also performed under the periosteum to reduce bleeding. The sartorius muscle can be pulled inward with the medial epiphyseal cartilage of the anterior superior iliac spine or the anterior superior iliac spine. After cutting, the suture is sewed with a silk thread and turned and retracted distally. In the anterior iliac spine, the rectus femoris is exposed straight, and it is obliquely cut at 2 cm below the anterior inferior iliac spine, and the rectus femoris reclining head is removed from the upper edge of the acetabulum, and the tendon and the proximal muscle abdomen are bluntly separated. Stitch the free muscle start with a silk thread and flip and pull to the distal end. Do not damage the blood vessels and nerves of the muscle. After the rectus femoris muscle was turned distally, the deep fascia was dissected, and the lateral branches of the circumflex femoral artery and vein were ligated and the adipose tissue under it was exfoliated to reveal the joint capsule. The lateral branches of the circumflex femoral artery should be preserved as much as possible to preserve the blood supply to the femoral head. 3. Treatment of extra-articular disorders The main factors that hinder the extra-articular reduction are the shortening and adhesion of the gluteus medius, the small muscles, and the iliopsoas muscle. The adhesion between the joint capsule and the iliac wing should be completely stripped. In particular, the peeling of the secondary acetabulum should be removed until the upper edge of the true acetabulum is removed. The anatomical relationship is clear. Do not mistake the false acetabulum for true hip. mortar. The joint capsule is fully peeled off from the gluteal muscles and the small muscles, and the upper part of the joint is fully exposed. Push the iliopsoas and pubis muscles inward to reveal the anterior and medial parts of the joint capsule. The hip will be flexed, abducted, and externally rotated to reveal the iliopsoas and the femoral trochanter. Care should be taken to protect the femoral nerve and the femoral artery and vein, and gently retract it together with the pubis and the iliopsoas. The iliopsoas tendon is often shortened, pressed tightly in front of the joint capsule, and also adhered to the joint capsule, and should be peeled off. The iliopsoas tendon can be cut or extended in a Z shape. Continue to peel the inner and lower joint capsules to the acetabular rim. The affected limb was pulled by light hand, the hip was abducted and rotated, and the femoral head was gently pressed in the large trochanter, and the cause of the obstruction was confirmed. After the cause of the extra-articular obstruction of the reduction is excluded, the cause of the displacement in the joint is further removed. 4. Treatment of obstacles in the joint 1 cut switch capsule: 1cm away from the acetabular rim, make a parallel incision with the acetabulum, and then make another mouth along the direction of the femoral neck, the two form a T-shaped, cut switch capsule. If there is a dumbbell-shaped or gourd-like narrowing, the stenosis must be completely removed, and the inner and lower joint capsules should be fully cut until the true acetabular plane, if necessary, the inner and lower joint capsules can be cut off to facilitate the reduction and fullness of the femoral head. Reveal the acetabulum. The edge of the open joint capsule was sutured with a silk thread and retracted. 2 resection of the round ligament and transverse ligament of the acetabulum: usually the round ligament becomes longer and thicker, hindering the anatomical reduction and should be removed. First cut it at the attachment point of the femoral head, then follow the round ligament to find the true acetabulum and cut it at the attachment point of the acetabulum. If the transverse ligament of the acetabulum moves up, the lower third of the acetabular inlet should be removed. 3 Clearing the acetabulum: There is a common fibrous adipose tissue filling in the acetabulum, which also hinders the central reduction and should be completely removed, but the joint cartilage should be avoided. The lips should not be removed generally, which is beneficial to the stability after resetting. However, if the labial valgus is obvious, it can be hooked out from the acetabulum with a blunt object and removed. After removing the obstruction factor, the depth and inclination of the acetabulum, the shape of the femoral head and its surface articular cartilage, and the femoral neck anteversion and neck angle should be examined. Then gently pull the affected limb, suffering from hip flexion, abduction, internal rotation, light pressure on the large femoral trochanter, carefully insert the femoral head into the acetabulum. After the reduction of the femoral head, the hip will undergo flexion and extension, rotation and adduction and abduction, and all aspects of the activity will be unobstructed and the stability of the femoral head. If the acetabulum and femoral head develop well, the femoral neck anteversion angle is <45°, the neck dry angle is between 100° and 140°, and the position of the femoral head is still stable when the hip is straight, mildly adducted, and the external rotation is not stable. Do other surgery. 5. pubic osteotomy After the patella osteotomy was performed according to the Salter procedure, the pubic symphysis and the suprapubic branch were performed along the pubic symphysis and the second median arc incision was made. Cut the skin, subcutaneous tissue and fascia. Separate and pull the male spermatic cord or the female round ligament to the outside. The rectus abdominis and conus muscles are separated and severed at the pubic and pubic symphysis. Free adductor longus muscle tendon from the pubic anterior border. The periosteum was dissected and the medial part of the superior and inferior pubic pubis were dissected under the periosteum to reveal the pubic symphysis and the inside of the obturator. Use the injection needle to gently puncture the fibrous cartilage of the upper edge of the pubic symphysis to find the pubic symphysis and pubic bone junction. Then use a small-nosed single-joint rongeur between the pubic tubercle and the pubic symphysis, close to the pubic symphysis, bite a pubis with a width of 0.7 to 1.3 cm, so that the pubis is completely disconnected. However, it should be noted that the medial segment of the pubis remains a small amount of cancellous bone and the outer segment maintains the integrity of the obturator. Use the towel clamp to lift the lateral end of the pubic osteotomy and peel it 2 to 3 cm below the periosteum along the lower edge of the pubis. 6. Rotation and fixation of the acetabular portion In the distal section of the Salter humerus osteotomy, the forceps were clamped, and the surgeon pulled the forceps forward and downward without pulling outward; and the second towel clamp was used in the lateral section of the pubic osteotomy. Clamping, the surgeon's other hand pulled the towel clamp diagonally backwards and inward. The triangular full-thickness humerus block that is removed is inserted into the gap opened at the humeral osteotomy. The humerus and pubic osteotomy were fixed with two Kirschner wires. 7. Joint capsule formation Thoroughly remove the joint capsule of the secondary acetabulum, remove the excess part of the joint capsule or suture the joint capsule, and trim tightly to eliminate the loose upper pocket-like joint capsule to prevent re-dislocation. When the joint capsule is sutured, an assistant will keep the hip flexed, abducting 30°, and mild internal rotation until the postoperative plaster is fixed. 8. Stitching The rectus femoris muscle is sutured. If there is tension, the rectus femoris muscle can be sutured at the beginning of the straight head. The humerus humerus is sutured in situ, and the deep fascia, subcutaneous and skin are sutured layer by layer.