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Classification and tactics of treatment of congenital varus deformity of the femoral neck. Hip deformities Varus deformity of the femur in children treatment

As well as the occurrence of hip deformities in general, it is based on various reasons. Part of the deformities comes from changes in the hip joint and femoral neck. Deformities in the area of the metaphysis and diaphysis of the thigh can be congenital, rachitic, inflammatory, can be associated with trauma and various tumors.

Symptoms of deformity of the femoral neck.

Deformation of the femoral neck often develops in early childhood, is often the result of rickets, may depend on congenital and dysplastic changes in the skeletal system, and is less often associated with trauma.

The curvature of the femoral neck is characterized by a decrease in the angle between the diaphysis and the femoral neck (to a straight or even sharp one) and is called coxa vara. On the basis of anatomical changes, functional disorders occur, manifested by rocking of the body when walking, limitation of hip abduction, lameness as a result of shortening of the leg.

Swinging of the body when walking at the moment of loading on the sore leg depends on the functional insufficiency of the middle and small gluteal muscles due to the displacement of the thigh upwards. To keep the pelvis in a horizontal position, the patient is forced to tilt the body towards the affected leg. Thus, the so-called duck gait is formed. Often there are complaints of increasing weakness of the lower limb, fatigue, pain when walking and standing.

Deformation related to the previous one are X-shaped legs. The development of this deformity is associated with an uneven load on the femoral condyles and their uneven growth: the growth of the internal condyle gradually leads to the formation of a valgus curvature of the knee joint. Clinically, this deformity is manifested by the fact that the thigh and lower leg form an angle in the knee joint that is open to the outside.

In a child with a similar deformity, the knee joints are in close contact, while the feet are at a great distance from one another. In an effort to bring the feet together, the knee joints come one after the other. Such a deformity of the knee joints is often accompanied by a valgus installation of the feet (deflection of the calcaneal bones outwards). This deformity can lead to pain due to the progressive development of flat feet.

At the heart of another deformity of the legs and knee joints, the O-shaped curvature of the legs, most often lies rickets. An arcuate curvature of the bones of the lower leg with a bulge outward develops in the process of vertical load under the influence of muscle traction during softening of the bones by a rachitic process. The curvature of the lower leg is enhanced under the influence of the traction of the triceps muscle of the lower leg, acting in the direction of the chord forming the arc.

The vicious position of the bones is fixed in the process of their asymmetric growth. The disease is manifested by a duck gait, a positive Trendelenburg symptom, limited abduction and rotation in the hip joint, however, unlike congenital hip dislocation, the head of its valgus deformity is palpable in the Scarpov triangle.

Causes of deformity of the femoral neck.

The causes of valgus deformity of the femoral neck are varied. Allocate congenital, children's or dystrophic, youthful, traumatic and rachitic deformities. In addition, valgus curvature of the femoral neck is observed in systemic diseases: fibrous osteodysplasia, pathological bone fragility, dyschondroplasia. Deformity may be the result of surgical interventions in the femoral neck or any pathological conditions of the bone in this area (consequences of osteomyelitis, tuberculosis, subcapital osteochondropathy).

Congenital valgus deformity of the femoral neck is more often bilateral, and then the disease is detected with the beginning of the child's walking in a characteristic duck gait, which often suggests a congenital dislocation of the hip. In addition, on examination, there is a limitation in the spread of the legs and a high standing of the large skewers. X-ray examination makes it possible to diagnose the disease. Often, the deformity of the femoral neck is combined with other congenital defects: shortening of the limb, a violation of the shape of other joints.

Children's viral deformity of the femoral neck is more often unilateral and is associated with dystrophic processes as a result of trophic disorders and is accompanied by bone tissue restructuring by the type of aseptic necrosis. The disease begins at the age of 3-5 years, under the influence of the load, the deformity of the femoral neck progresses. Clinically, the disease is manifested by lameness, pain, especially after a long walk, run. The affected limb may be shorter and thinner, and hip abduction is limited. The greater trochanter is located above the Roser-Nelaton line, a positive Trendelenburg sign is noted.

In other words, the clinical manifestations are largely identical to congenital hip dislocation. However, there will be no symptoms characteristic of dislocation, such as displacement of the thigh along the longitudinal axis (Dupuytren's symptom), a symptom of a non-disappearing pulse with pressure on the femoral artery in the Scarp triangle.

Diagnosis of deformity of the femoral neck.

Diagnosis in the vast majority of cases does not cause any difficulties for a traumatologist or any other specialist. In order to clarify the position of the end of the femur and exclude probable bone damage, it is necessary to conduct an x-ray examination. Moreover, it must be in two projections.

In the same case, if the diagnosis is in doubt, an MRI of the entire described joint is performed.

Treatment of deformity of the femoral neck.

Correction of such a deformity is effective at the beginning of their formation (on the 1st-2nd year of life). The principle of complex therapy common to most orthopedic deformities is also valid for this group of deformities of the lower extremities. Application and combined with orthopedic treatment (appointment of special splints, wearing special devices).

Treatment is operative.

It is carried out in two directions: therapy of the causes of deformity and surgical (the deformity itself). Based on cases of detection of the disease, it is noted that valgus deformity of the femoral neck appears in a patient from birth. There are rare cases when the deformity occurs with a traumatic or paralytic etiology.

Before starting the operation, it is required to plan the upcoming operation. Find out what methods and constructions can be applied in this case. Thus, the following questions arise before the surgeon:

Simultaneous or staged elimination of hip deformity.
Limb length adjustment.
Removal of old processes in the event that operations of this type were carried out.
Design and installation of the endoprosthesis.

There are more than 100 methods of treating valgus deformity of the femoral neck:

Exostectomy (removal of part of the head of the bone);
Restoration of ligaments;
Replacement with an implant;

In the case when the femoral neck is replaced with an implant, local or general anesthesia is performed before the operation. The surgeon then makes a small incision. Next, the surgeon removes the femoral neck and installs an endoprosthesis that ideally repeats its shape. The prosthesis facilitates movement, helps to correct gait, improve the quality of life, get rid of pain. There are many types of prostheses, which are selected according to the specific case of the disease.

Prevention of hip deformity.

In order to prevent dislocation in the hip area, it is recommended to carefully monitor safety in everyday life and in the process of playing sports.

This raises the need for:

training of various muscle groups, rational physical activity;
the use of exceptionally comfortable clothing and footwear to prevent falls;
the use of professional protective equipment throughout sports activities. We are talking, at a minimum, about knee pads and hip braces;
avoiding any trips on ice, paying attention to slippery and wet surfaces.

In order to fully restore the hip joint after dislocation, it will take, if there are no complications, from 2 to 3 months. This period can only be lengthened if there are concomitant fractures. So, the doctor may insist that a non-long-term skeletal type traction be carried out with further sets of exercises. This is done with the help of a device of continuous inactive movement.

Independent movement using crutches is possible only in the absence of any pain. Until the moment when lameness disappears, it is recommended to resort to additional aids for moving, for example, a cane.

After that, it is recommended to use general strengthening drugs that will affect the structure of bone tissue. It is also important to carry out certain exercises, the list of which should be compiled by a specialist. The regularity of their implementation will be the key to recovery. In addition, it is necessary to treat the damaged area of the thigh as carefully as possible, because now it is one of the weakest points in the body.

Keeping in mind all the rules of prevention and treatment, it is more than possible to quickly and permanently get rid of any consequences of hip dislocation while maintaining the optimal rhythm and tone of life.

In most patients, the deformity of the femur is associated with changes in the structure of its neck. Only 10% of patients have deformity of the femoral head. Basically, this group includes patients after a fracture of the femoral neck with improper fusion of bone tissue.

Primary changes begin with a shortening of the neck and thickening of its area in the region of the diaphyseal joint with the acetabulum of the pelvic bone. the axis of the neck and the central diaphysis are subjected to insignificant deformation, further aggravated by the contraction of certain femoral muscles. With varus deformity, shortening occurs along the inner surface. With valgus deformity, the curvature passes with damage to the external muscles.

In about 70% of cases for such a disease of the musculoskeletal system, the prerequisites are formed at the stage of intrauterine development of the baby. And only in 25% of patients, the deformity of the femur is associated with degenerative lesions of cartilage and bone tissue. Usually, the first signs in this case appear in old age, in the menopause against the background of the development of osteoporosis. The traumatic nature of hip curvature is present in only 5% of patients with clinically diagnosed cases. This is due to the fact that recently, surgical methods for restoring the integrity of tissues have been actively used for fractures of the femoral neck. This allows for complete recovery without the formation of various kinds of degenerative deformities.

In the proposed material, you can learn more about the potential causes of the development of deformity of the femur in children and adults. It also tells about what methods of manual therapy can be effectively and safely treated in order to fully restore the physiological state of the femur.

Why does hip deformity occur?

Primary hip deformity occurs only as a congenital pathology, which may not manifest itself until adulthood. The gradual deformation of the femoral necks is a consequence of the influence of negative factors, such as:

maintaining a sedentary lifestyle;
excess body weight;
smoking and drinking alcoholic beverages;
incorrect positioning of the feet when walking and running;
heavy physical labor with a maximum load on the hip joints;
hip fractures;
wearing high heel shoes.

Secondary deformity of the femoral necks always develops against the background of other diseases of the lower extremities. Among the most likely pathologies are:

deforming osteoarthritis of the hip joints (cosarthrosis);
deforming osteoarthritis of the knee joints (gonarthrosis);
curvature of the spine in the lumbosacral region;
symphysitis and divergence of the pubic bones during pregnancy in women;
incorrect setting of the foot in the form of flat feet or clubfoot;
tendonitis, tendovaginitis, bursitis, cicatricial deformities of the soft tissues of the lower limb.

It is also worth considering risk factors. These include intrauterine pathologies of the development of the bone skeleton, rickets in early childhood, osteoporosis in middle and old age, vitamin D and calcium deficiency, endocrine diseases (hyperthyroidism, diabetes mellitus, adrenal hyperfunction, etc.).

Successful treatment of hip deformity requires elimination of all possible causes and negative risk factors. Only in this case it is possible to get a positive effect.

Varus deformity of the femoral neck (thigh)

Pathology is divided into two types: valgus and varus deformity of the femur, in the first case, the curvature occurs according to the X-shaped type, in the second - according to the O-shaped. Both types are associated with a change in the angle located between the head and the shaft of the femur. Normally, its parameter ranges from 125 to 140 degrees. Increasing this value to 145 - 160 degrees leads to the development of an O-shaped curvature. A decrease in the angle entails a varus deformity of the femoral neck, in which the rotation of the lower limb will be sharply limited.

Abduction of the leg away from the body with varus deformity of the thigh is difficult and causes severe pain in the hip joint. Therefore, the initial diagnosis is often incorrect. The doctor suspects destruction and deformity of the femoral head and acetabulum. To confirm the diagnosis of deforming osteoarthritis, an x-ray image of the hip joint in several projections is prescribed. And during this laboratory examination, a varus deformity of the femoral neck is detected, which is clearly visible on radiographic images in frontal and lateral projections.

In the development of the curvature of the hip, several stages can be identified:

slight deformation with a change in the angle of inclination by 2-5 degrees does not cause discomfort and does not give visible clinical signs;
the average degree is already characterized by a significant curvature and leads to the fact that the patient has problems with the implementation of certain movements in the hip joint;
severe deformity leads to shortening of the limb, complete blocking of rotational and rotational movements in the projection of the hip joint.

In adults, varus deformity often results in aseptic necrosis of the femoral head. Also, this pathology accompanies mucopolysaccharidosis, rickets, bone tuberculosis, chondroplasia and some other serious diseases.

Valgus deformity of the femoral necks (hips)

Juvenile and congenital valgus deformity of the femur is often diagnosed, which is characterized by a rapid progressive course. When looking at a patient with such a deviation, it seems that he brings his legs together at the knees and is afraid to unclench them. X-shaped valgus deformity of the femoral necks can be the result of hip dysplasia. In this case, the first signs of hip curvature appear at about the age of 3-5 years. Subsequently, the angle of deviation will only increase due to ongoing pathogenic processes in the cavity of the hip joint. Shortening of the ligaments and contraction of the muscle fibers will increase the curvature and deformity.

Congenital deformity of the femoral neck in a child may be due to the following teratogenic factors:

pressure on the growing uterus from the internal organs of the abdominal cavity or when wearing tight, squeezing clothing;
insufficient blood supply to the uterus and the growing fetus;
severe anemia in a pregnant woman;
violation of the process of ossification in the fetus;
breech presentation;
transferred viral and bacterial infections in the later stages of pregnancy;
taking antibiotics, antiviral and some other drugs without medical supervision.

Congenital valgus deformity of the femur is characterized by a strong flattening of the articular surface of the acetabulum and a total shortening of the diaphyseal portion of the femur. An x-ray examination shows the displacement of the femoral head anteriorly and upwards with curvature of the neck and shortening of the bone area. Pineal fragmentation may appear later in life.

The first clinical symptoms of valgus deformity of the femoral neck in children appear at the beginning of independent walking. The baby may have a shortened one leg, lameness, a peculiar gait.

The juvenile type of pathology lies in the fact that valgus deformity of the hip begins to actively develop in adolescence. At the age of 13-15 there is a hormonal restructuring of the body. With an excess amount of produced sex hormones, the pathological mechanism of epiphyseolysis (destruction of the femoral head and its neck) can be launched. With the softening of the bone tissue under the influence of the growing body weight of a teenager, valgus deformity begins with a deviation of the distal end of the femur.

At risk are children with obesity and overweight, leading a sedentary, sedentary lifestyle, fond of carbohydrate foods. It is necessary to periodically show such adolescents to an orthopedic doctor for the timely detection of the disease at an early stage of its development.

Symptoms, signs and diagnosis

Clinical symptoms of valgus and varus deformity of the femur are hard to miss. Characteristic deviation of the upper leg, lameness, specific positioning of the legs are objective signs. there are also subjective sensations that can signal such trouble:

pulling, dull pain in the hip joints, occur after any physical exertion;
lameness, dragging of the leg and other changes in gait;
feeling that one leg is shorter than the other;
dystrophy of the thigh muscles on the side of the lesion;
the rapid appearance of a feeling of fatigue in the muscles of the leg when walking.

Diagnosis always begins with an examination by an orthopedic doctor. An experienced doctor will be able to make the correct preliminary diagnosis already during the examination. Then, to confirm or exclude the diagnosis, an x-ray image of the hip joint is prescribed. In the presence of characteristic signs, the diagnosis is confirmed.

How to treat hip deformity?

Valgus deformity of the femur in a child lends itself perfectly to conservative methods of correction. But only in the early stages can the physiological state of the head and neck of the femur be fully restored. Therefore, when the first signs of trouble appear, you should seek medical help.

The following manual therapy methods can be used to treat deformity of the femoral head:

kinesiotherapy and therapeutic exercises are aimed at strengthening the muscles of the lower extremities and, by increasing their tone, to correct the position of the bone head in the acetabulum;
massage and osteopathy allow, due to physical external influence, to carry out the necessary correction;
reflexology starts the recovery process through the use of hidden reserves of the body;
physiotherapy, laser treatment, electromyostimulation are additional methods of therapy.

Any course of correction is developed individually. before treating a deformity of the femur, it is necessary to consult with an experienced orthopedist.

In our clinic of manual therapy, each patient has the opportunity to receive professional advice from an experienced orthopedist absolutely free of charge. To do this, it is enough to sign up for the first appointment.

The main manifestation of the disease is a decrease in NSA less than 120°. Two forms of the disease have been identified: congenital varus deformity and developmental varus deformity. Congenital deformity is found in a newborn. As the cause of the disease, the pressure of the walls of the uterus, aseptic necrosis of the physis and femoral neck, and delayed ossification due to insufficient supply vessels are called. Varus is accompanied by signs of dysplasia in the form of flattening of the acetabulum, congenital dislocation or congenital underdevelopment of the hip, as well as different lengths of the legs. Varus developmental deformity or secondary deformity is diagnosed at the age of over 4 years. It is associated with metabolic disorders and occurs in diseases such as rickets, epiphysiolysis of the femoral head, Morquio disease, osteogenesis imperfecta, mucopolysaccharidosis, metaphyseal chondrodysplasia, and infection. The VDB is both unilateral and bilateral in nature. Unilateral curvature was noted in 60-75% of cases. The bilateral process, which occurs in 25-40% of cases, is more associated with general metabolic disorders - rickets, osteomalacia, osteogenesis imperfecta.

With VDB in the proximal femur, several processes occur simultaneously that determine the nature of the disease. The action of etiological factors leads to a violation of the ossification of the cartilaginous matrix of the metaphysis of the thigh, which is called local fatigue dystrophy. The strength of the bone is not enough to resist the action of the force of weight. There is a slow flexion of the femoral neck together with the head and the development of varus deformity of the proximal femur. The flexion moment of the force acting on the proximal femur increases. In the neck of the femur, there is a decrease in the compression component of the force and an increase in its displacing component. Pathological flexion of the neck and head of the femur develops simultaneously with the physiological growth of the greater trochanter in the cranial direction, as a result of which the apex of the trochanter is set higher than the center of rotation of the hip joint, and the points of attachment of the abductor muscles of the thigh approach each other. There is a weakening of the abductor muscles, muscle imbalance occurs, the dominance of the adductor muscles, a decrease in hip abduction. Varus deformity of the femur is accompanied by a decrease in anteversion of the femur up to its retroversion, resulting in a decrease in the internal rotation of the femur. Varus and version reduce the space for hip abduction, which, during abduction, causes the greater trochanter and femoral neck to rest against the edge of the acetabulum and into the ilium. There is a convergence of fixation points of the abductor muscles and their weakening. During walking, the strength of the abductor muscles is not enough to lift the pelvis up on the side of the carried leg. Instead of lifting, the pelvis lowers on the side of the carried leg. On the side of the varus of the thigh, a Trendelenburg symptom occurs with deviation of the trunk towards the supporting leg to reduce the load on the abductor muscles.

A child with VDB has a delay in the onset of independent walking. From the age of 2, standing disturbance becomes noticeable. The symptomatology of the disorder is associated with the symmetry of the lesion of the hips. With unilateral varus deformity, there is an apparent increase in the size of the greater trochanter and its protrusion in the cranial direction. When the leg is shortened within 1-1.5 cm, there is lameness on the affected leg. With significant weakness of the abductor muscles, the child is diagnosed with Trendelenburg's symptom. With a bilateral process, there is a waddling gait with a large amplitude of deviation of the body in the frontal plane. The difference in leg length increases with age, which leads to worsening of symptoms.

VDB is diagnosed by X-ray. On the radiograph of the thigh, there is a fragmentation of the metaphysis and epiphysis, an expansion of the epiphyseal plate, as well as a triangular bone fragment at the junction of the neck with the epiphysis, more often along its lower surface. In 3/4 cases, flattening of the acetabulum was noted. On the radiograph in the anterior-posterior projection, an intertrochanteric Hilgetsreiner line is drawn through the Y-shaped cartilage of the acetabulum and the second line along the edge of the femoral epiphysis. An interacetabular-epiphyseal angle is formed, which in a 7-year-old child ranges from 4 to 35°, averaging 20°. In an adult, an angle of less than 20-25 ° is considered normal. With varus of the proximal femur, the angle "reaches 60 °. The progressive nature of the course is characteristic of VTP. An increase in deformity is accompanied by a deterioration in walking without pain. Spontaneous arrest of the development of hip curvature occurs when the interacetabular-epiphyseal angle is less than 45 °.

Treatment

Conservative methods of treatment of varus deformity of the hip in the form of traction or immobilization are considered ineffective. Prophylactic shoes are used to prevent the development of secondary deformity in the distal parts of the lower limb. With the help of a removable shoe insole, the length of the lower limbs is aligned and the progressive shortening of the diseased leg is compensated.

Indications for surgical treatment depend on the magnitude of the deformity, the course of the disease, and the age of the patient, of which the angle of femoral curvature is a priority parameter. With MEU from 45 to 60 °, observation is carried out and an X-ray examination is performed once every six months. Radical methods of treatment are resorted to in case of progression of the deformity. Indications for surgery are an increase in MEU greater than 60°, a decrease in NSA less than 100-110°, a positive Trendelenburg symptom, and a visible deterioration in walking. A contraindication to surgery is the absence of clinical symptoms with MEU less than 45°, as well as the absence of progression of the curvature with MEU less than 60°. Compared with the size of the deformity, age is a less important indication for surgery. Each age period has its own advantages for the implementation of surgical intervention. Early operations before the age of 2 years are rarely performed due to the low severity of bone deformity. The positive side of the intervention at an early age is the possibility of complete remodeling of the deformed bone. The restoration of bone structures after surgery in children aged 18 months is described. In children older than 2 years, there are more reasons for the use of surgical methods of treatment due to the greater degree of deformity. In a large child, it is relatively easier to fix the bone. The operation is done for the following purposes:

correction of femoral varus and anteversion to reduce shear force and increase compression force in the femoral neck;
alignment of the length of the lower limbs;
reconstruction of the greater trochanter in order to create conditions for the work of the abductor muscles.

Operation: subtrochanteric osteotomy

Indications: varus deformity of the proximal femur, MEA greater than 60°, NSA less than 100-110°.

Lateral skin incision over the greater trochanter 10-12 cm long. A pin is inserted into the femoral neck parallel to the upper edge under the control of the image intensifier tube. Using a drill or an oscillatory saw, a gap for the plate is formed in the femoral neck parallel to the spoke. A plate bent at an angle of 140° is used. A horizontal branch of the plate is hammered into the bone gap. Osteotomy is done in the subtrochanteric region at a distance of the diameter of the femur below the angle of the plate. Under the control of the image intensifier with the help of an oscillatory saw or an osteotome, a transverse intersection of the femoral shaft is made. The proximal fragment of the thigh is adducted and the distal fragment is retracted. The proximal fragment is placed on the distal one in such a way that the lateral cortical of the proximal fragment is in contact with the sawdust of the bone of the distal fragment. The vertical branch of the plate is screwed to the diaphysis of the femur. The trihedral bone fragment is repositioned to the femoral neck. Remove the needle. A coxite plaster cast is applied to the affected leg for a period of 8-10 weeks.

Treatment results

On average, valgus osteotomy can reduce MEU5 to 35-40°, and increase NSA to 130-135°. Subtrochanteric and intertrochanteric osteotomies give approximately the same correction result. In the postoperative period, there is a loss of correction. 9-10 years after the intervention, the NSA decreases from 137 to 125°, and the MEU increases by almost half. In the postoperative period for 3 years, in almost all patients, the growth zone of the proximal femur physis is closed, after which a lag in the growth of the thigh is noted. The shortening of the leg is compensated by orthopedic shoes. A significant reduction in the length of the femur is an indication for surgical intervention. More often, lengthening of the bones of the short leg is done, less often shortening of the bones of the contralateral limb is performed. Half of the patients after the intervention have weakness of the hip abductors. In 60% of cases, there is an overgrowth of the greater trochanter, which is eliminated by apophyseodesis. In 87% of cases, there is a decrease in the size of the femoral head, in 43% of cases - its flattening, as well as flattening of the acetabulum.

The occurrence of hip deformities is based on various reasons. Part of the deformities comes from changes in the hip joint and femoral neck. Deformities in the area of the metaphysis and diaphysis of the thigh can be congenital, rachitic, inflammatory, can be associated with trauma and various tumors.

Rachitic hip deformities

A characteristic feature of the pathological process in the early period of rickets is the formation of osteoid tissue, which does not undergo timely ossification.

At the end of the disease, when the ossification process has not yet been fully restored, traction of the muscles, especially adductors, and premature load on the legs cause the curvature of the hips characteristic of rickets - the O-shaped thigh (femur varum). Bilateral hip deformity is more common.

Symptoms. Usually the deformity captures the entire thigh and lower leg.

Due to the arcuate deformity of the thigh and changes in the epiphyseal cartilage, the length of the limbs is reduced, there is a disproportion between the length of the trunk and limbs. The physiological axis of the femur is disturbed, and due to improper loading near the ankle joint, secondary deformity of the foot often occurs.

Prevention and treatment. In the period of fresh rickets, with a tendency to deformation of the limbs, it is necessary to fix them with a plaster splint and not allow the load on them until the bone structure is completely restored, which is checked radiologically. Temporarily give unloading orthopedic apparatus. At the same time, vitamin therapy and ultraviolet irradiation of the patient are carried out.

Treatment of the developed deformity of the hip consists of osteotomy, correction of its axis or lengthening.

The osteotomy is done under local anesthesia. The wide fascia, the external broad muscle, the periosteum are dissected with an external incision, the bleeding is carefully stopped. At the height of the greatest deformity of the thigh, an oblique osteotomy is made, skeletal traction is performed or plaster is applied for 2 months, then therapeutic exercises are applied, a careful load in the splint.

With a noticeable shortening of the limb due to hip deformity, it is possible to lengthen the entire limb in two ways: on the thigh or by surgery on the bones of the lower leg. To lengthen the femur, the method of segmental osteotomy according to N. A. Bogoraz is used with the introduction of a font into the medullary canal or Z-shaped osteotomy followed by skeletal traction.

Z-shaped osteotomy is performed as follows. After a Z-shaped dissection of the periosteum, the diaphysis is drilled with a narrow drill in the anteroposterior direction in 3-4 places, and make sure that the drill passes through the back wall.

Then, with a narrow sharp chisel, the femur is split along the length. The channels drilled before this make it possible to produce an osteotomy without any difficulty and of such a size as is required to eliminate the shortening of the femur.

After a Z-shaped osteotomy, some people drive an autograft into the bone marrow canal, which does not interfere with the stretching of the fragments, prevents their displacement and guarantees consolidation.

Then apply skin traction with a sticky patch, cleol, or zinc-gelatin paste with lateral pulls for 2 weeks to prevent lateral curvature.

The following complications are possible with limb lengthening:

temporary muscle weakness from lengthening;
fracture at the site of an earlier osteotomy;
slow consolidation;
vicious union;
limited mobility in the knee after prolonged fixation.

Patients should be kept lying down for a long time, but with active movements in the joints and with emphasis on the legs. With proper postoperative management of the patient, complications can be avoided.

Limb lengthening can also be achieved by osteotomy of the tibia bones.

Recently, various screw devices, in particular the Gudushauri device, have been used to lengthen the femur and lower leg with good results.

Traumatic hip deformities

There are traumatic deformities of the upper third of the thigh, the area of the diaphysis and the distal end.

Symptoms. Hip deformity in the upper third occurs after damage to the epiphysis (epiphyseolysis), fracture of the neck (coxa vara traumatica) or the meta-diaphyseal part of the femur. In the latter case, an angular curvature of the femur develops with its shortening. In diaphyseal deformity of the femur, displacement of fragments along the length and width, violation of the physiological axis of the femur and shortening of the limb are the most important symptoms. Displacement of the distal fragment along the periphery and recurvation of the femur, outwardly hardly noticeable, significantly upset the function of the limb.

Treatment. In the indicated cases, the deformity is surgically eliminated by osteotomy and lengthening of the femur.

Hip deformities of inflammatory origin

Inflammatory processes that occur in the proximal or distal epiphysis of the femur in childhood lead to shortening of the limb and to a change in its shape and function.

The most significant deformations occur after the tuberculous process in the head and neck or in the distal epiphysis. Shortening in such cases sometimes reaches 8-10 cm or more. The shape and axis of the femur also change.

Similar hip deformities and shortening also develop after septic (metastatic) osteomyelitis of the femur that occurred in early childhood after umbilical sepsis.

Symptoms. The main symptoms are hip shortening and lameness. A more careful study can detect abnormal development of the medial or lateral distal epiphysis of the femur, a violation of its growth, sometimes premature synostosis and, as a result, the development of genu varum or genu valgum.

On the radiograph, it is possible to establish a violation of the structure of the meta-epiphyseal section and synostosis.

Treatment. Treatment of a shortened femur can be conservative or surgical. The use of orthopedic appliances or orthopedic shoes is indicated in children. Surgical lengthening of the femur is done with a shortening of more than 4 cm.

The article was prepared and edited by: surgeon

Ticket 36:

1 ) Fractures of the condyles of the femur and tibia: classification, diagnosis, treatment. There are fractures of one of the condyles and both condyles of the femur (intercondylar Y- and T-shaped). Isolated fractures of the condyles usually occur with a sharp deviation of the lower leg inwards (fracture of the internal condyle) or outwards (fracture of the external condyle). Fractures of both condyles often occur as a result of a fall from a great height onto a straight leg. Clinic. With an isolated fracture of the external condyle with displacement of fragments, a valgus deviation of the lower leg (genu valgum) occurs, with a fracture of the internal condyle with displacement, a varus deviation of the lower leg (genu varum). With fractures of both condyles with displacement, anatomical shortening of the limb can be detected. In addition, the joint is sharply enlarged in volume due to hemarthrosis, the limb takes a forced position: the leg is slightly bent at the knee and hip joints. Active and passive movements in the knee joint are sharply painful. On palpation, there is an increase in pain and a symptom of balloting of the patella. The following clinical symptoms are characteristic of fractures of this localization: Pain in the knee joint and the lower part of the thigh, aggravated by palpation and pressure on the condyles. varus or hallux valgus knee joint. Thigh circumference in the region of the condyles increased.contours knee joint smoothed out.Fluctuation at the knee ( hemarthrosis).Ballotion of the patella. Passive movements in the knee joint possible but painful.Sometimes can be defined bone crunch.The diagnosis is clarified by radiographs made in two projections. Treatment. Fractures of the distal femur without displacement of fragments are treated by immobilization with a plaster cast (3-5 weeks) or by I. R. Voronovich: lateral compression osteosynthesis with pins with thrust pads is used. This method allows you to perform all 4 principles of treatment of intra-articular injuries: Ideal reposition fracture (with an accuracy of 2 mm, since only with such a displacement of the articular surfaces is it possible to regenerate hyaline cartilage). Reliable fixation fragments for the entire period of consolidation. Early feature(for the full function of cartilage and its metabolic processes). on the damaged joint. Before fixation, puncture of the knee joint for the purpose of evacuating blood and introducing into the joint 20-30 ml of 1% novocaine solution. During the first 7-10 days after injury, it often becomes necessary to repeat punctures of the joint and evacuate blood, which is one of the ways to prevent post-traumatic arthrosis. traction. The load at a fracture without displacement is 2-4 kg, with displacement - 4-8 kg. The traction period is b weeks, the leg is fixed with the son-in-law Circular plaster cast to the groin for a period of 6 weeks. After removing the bandage, they begin restorative treatment: baths, paraffin, massage, exercise therapy, mechanotherapy. Recovery disability for fractures without displacement of fragments after 3-3.5 months; with displacement of fragments - after 5-6 months. Surgical treatment: shown when bone fragments are not juxtaposed in a closed way. Bone fragments are exposed, repositioned and fixed either with a plate or with 1-2 metal rods. The operated leg is fixed with a plaster cast until a callus is formed. Then proceed to rehabilitation treatment. Surgical intervention allows more accurate repositioning of fragments, their strong fixation and, due to this, earlier start of functional treatment (2-3 weeks from the moment of surgery). Full load on the injured limb is allowed no earlier than after 3.5-4.5 months. Fractures of the condyles of the tibia. Fractures of the condyles of the tibia are intra-articular injuries and occur most often when falling on straight legs or when the lower leg deviates outward or inward. There are fractures of the external condyle, internal condyle, as well as T- and Y-shaped fractures of both condyles. Fractures of the condyles can be impression and chipping type. They may be accompanied by damage to the meniscus, the ligamentous apparatus of the knee joint, fractures of the intercondylar eminence of the tibia, fractures of the head of the fibula, etc. Clinical picture in fractures of the condyles of the tibia, it corresponds to intra-articular damage: the joint is enlarged in volume, the leg is slightly bent, hemarthrosis is detected by the symptom of balloting the patella. The tibia is deflected outwards in case of a fracture of the external condyle or inwardly in case of a fracture of the internal condyle. The transverse size of the tibia in the area of the condyles is increased in comparison with the healthy leg, especially in T- and Y-shaped fractures. On palpation, the area of the fracture is sharply painful. Characterized by lateral mobility in the knee joint with unbent lower leg. There are no active movements in the joint, passive movements cause sharp pain. The patient cannot raise the straightened leg. Sometimes damage to the external condyle is accompanied by a fracture of the head or neck of the fibula. In this case, the peroneal nerve can be damaged, which is recognized by a violation of sensitivity, as well as motor disorders of the foot. X-ray examination allows you to clarify the diagnosis and identify the features of the fracture. Treatment. In case of fractures of the condyles of the lower leg without displacement, a joint is punctured for aspiration of blood and the introduction of 20-40 ml of a 1% solution of novocaine. The injured limb is fixed with a circular plaster cast. From the 2nd day, exercises for the quadriceps femoris are recommended. Walking with crutches without weight on the affected leg is allowed after a week. The plaster bandage is removed after 6 weeks. Loading of the leg is allowed 4-4.5 months after the fracture. With early loading, impression of the damaged condyle may occur. In case of a displaced condyle fracture, both conservative and surgical treatment is used. In some cases, fractures with displacement, especially comminuted, T and V-shaped fractures, can be applied permanent skeletal traction. At the same time, the patient's limb is placed on the Beler splint, the needle is passed through the calcaneus, the load along the axis of the lower leg is 4-5 kg. The duration of treatment with this method is 4-5 weeks, after which the limb is fixed with a gypsum bandage. Further treatment is the same as for a fracture of the condyles without displacement of the fragments. A physiological method with good results of treatment was proposed by I. R. Voronovich. Surgical treatment is indicated for unsuccessful conservative treatment. The operation is performed 4-5 days after the injury: open reposition of the fracture and osteosynthesis with metal structures. The sutures are removed on the 12-14th day, and further management of the patient, as in case of fractures of the condyles without displacement.

2) .Conservative treatment of osteoarthritis of large joints. Methods of the department. Patients with deforming arthrosis it is necessary to observe a certain motor mode aimed at unloading the diseased joint. They should avoid walking for a long time, standing on their feet for a long time or staying in one position, and should not carry weights. In case of severe pain while walking, it is necessary to use a cane or walk with crutches. To unload a diseased joint, even at home, cuff traction with a load along the leg axis of 2-3 kg should be used. With sharp pains that do not go away from the above measures, you can apply fixation of the joint with a plaster cast for 2-4 weeks, but at the same time movements are even more limited, and contractures are aggravated. The goal of conservative treatment of arthrosis– restoration of blood circulation in the tissues of the diseased joint. Therapy should be comprehensive and include not only drug treatment, but also physiotherapy, spa treatment. The conservative treatment described below should be comprehensive and correspond to the stage of development of the disease. Means of microcirculatory influence used to restore the microcirculation system. For this purpose, various agents are used, the pharmacogenesis of which is not the same: angiotrophin, andekalin, depokallikrein, dilminal, inkrepan. They are prescribed in the first stage of the disease in patients without synovitis within 3 weeks. With the development of inflammation in the tissues of the joint, it is better to use agents that inactivate the kinin system - countercal, zalol, trasilol, etc.