Cysts of the acetabulum and femoral head: treatment and surgery of the hip joint

Coxarthrosis is a gradual destruction of the hip joint: disruption of tissue nutrition, loss of strength of the cartilaginous layer, its division into fibers, abrasion. As a result, the head of the bone is left unprotected. From constant injury to the acetabulum, bone growths (osteophytes) appear as an attempt by the body to compensate for the lack of cartilage tissue. The structure of the bone tissue is disrupted, necrosis of the femoral head and acetabulum occurs (the contours of the head and the edges of the acetabulum become denser). On this basis, cysts form, in this case being a direct consequence of coxarthrosis of the hip joint. As a result, motor function is weakened up to the point of disability, when the only option is endoprosthetics.

Cyst on MRI.

The mechanism of appearance of a bone cyst

A bone cyst is a cavity formed in the bone as a result of metabolic disturbances against the background of increased activity of lysosomal enzymes that break down proteins. A cavity is formed with high-pressure fluid inside, which contributes to the progression of bone tissue destruction. With coxarthrosis, both single and multiple bone cysts can occur.

Cysts that appear against the background of coxarthrosis cannot be filled with bone tissue using conservative methods. Their presence increases bone fragility and complicates endoprosthetic surgery. Doctors usually resort to this type of intervention when joint mobility is almost completely lost and constant pain is present. Although many experts are inclined to believe that it is better to replace a joint at those stages when the destructive process has not yet gone far. In the end, everything depends on the patient’s condition, since some even with stage 2 coxarthrosis have pain that interferes with normal movement.

How is the treatment carried out?

At the initial stages of pathology development, conservative treatment measures are used. Initially, the mobility of the affected joint is limited and physical activity is reduced. Drug therapy is used to treat bone remodeling. Osteotropic drugs are used to relieve pain. To normalize the regeneration of cartilage cells, “Chondroxide” is used, which is a chondroprotector. Vitamin and mineral complexes are used to improve bone structure. Physiotherapeutic procedures have a good therapeutic effect. In case of significant disruption of microcirculation, tissue necrosis and rapid growth of cysts, surgical intervention is indicated. Osteotomy and arthroplasty are used for this purpose. In later stages, endoprosthesis replacement is used.

Installation of the acetabular cup

A series of X-rays are taken, in which it is important to correctly identify and evaluate the signs of arthrosis, since, for example, different methods of fixing endoprostheses are used for dysplastic and hyperplastic coxarthrosis. Sclerosis and cysts directly influence the choice of arthroplasty technique, in particular the method of cup attachment. It is impossible to integrate the coating of a cementless cup into sclerotic bone that has lost its elasticity.

For a more reliable fixation of the cup, the cavity is cleaned down to the level of the spongy substance, since this tissue is able to effectively participate in the process of osseointegration. Cement fixation is also more stable when placed on a spongy substance. It is important to remove as much sclerotic tissue as possible.

After treating the surface of the acetabulum with special cutters, holes for attaching the cup are drilled to the level of the spongy substance, and all cystic formations are cleaned out. The cavities remaining after curettage are filled with a substance obtained either from the head of the femoral bone or from the bone canal. The cavity is washed, tamponed, and a cup is installed. When planting on cement, the required thickness of the mantle layer under the bowl is taken into account.

If a cup of cementless fixation is installed in the presence of cysts, then after all the stages of cleansing the surface of the cavity from osteophytes and scraping out the cystic cavities, the remaining defects are filled with spongy autologous bone - a substance extracted from the head, as well as remaining during the treatment of the medullary canal. The substance is compacted at the bottom of the depression, strengthening it. If the patient’s own autologous bone is not enough, then a special synthetic hypoallergenic material is used. In order to increase reliability, the bowl is additionally secured with screws.

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How is diagnosis carried out?

To make an accurate diagnosis, the doctor collects anamnesis and determines the presence of concomitant diseases. Next, an external examination and palpation of the affected areas is carried out. The most informative diagnostic method is radiography. The stages of cystic reconstruction of the bone structure are characterized by certain signs, which are indicated in the table:

Head installation

If there are cysts, growths and other defects in the bone tissue of the femoral head, it is removed, and a femoral canal is formed in the bone using special devices under the stem of the endoprosthetic component. Next, a bone plug is installed at the bottom of the canal, the material for which is the removed head. A femoral endoprosthesis is installed; the use of cement is determined by indications. The head is immersed in the formed acetabulum. The capsule, muscles, and soft tissues are sutured.

Symptoms of the disease

Often, ankle necrosis is confused with arthrosis due to the similarity of symptoms. The difference lies in the age of the patients (necrosis is typical for people 20–45 years old) and rapid development.

The most characteristic symptoms of necrosis include:

• pain in the ankle that increases over time;
• dysfunction in the form of limited mobility;
• the occurrence of edema;
• appearance of lameness.

Important! Over time, these symptoms increase due to the spread of necrosis and impaired functionality. It becomes difficult to move independently, and the pain interferes with leading a full life, which ultimately forces you to seek medical help.

Rehabilitation

The rehabilitation period is no less important than the proper execution of joint replacement surgery. Not all clinics offer a full program, limiting it to a few days, and patients are often not conscious enough to continue the recovery complex on their own. Therefore, after the operation, it is recommended to go to a specialized sanatorium, or it is better to have a joint replacement performed in a clinic, which guarantees not only high-quality endoprosthetics, but also provides a full rehabilitation course.

All this can be guaranteed by specialized medical institutions in the Czech Republic, where the high professionalism of doctors, the European level of service provision and the availability of natural resources for the restoration of the musculoskeletal system are combined with low prices for Europe. For many years, he has been organizing treatment for patients from the Russian Federation with orthopedic problems in the best clinics in the Czech Republic. The client receives full information support, assistance in paperwork and transportation. All financial issues are discussed in advance, the results are fixed in the contract and no longer change throughout the entire process of treatment and rehabilitation.

Cyst reconstruction of the shoulder joint

Degenerative-dystrophic lesions of the shoulder and subacromial joints with cyst-like restructuring of the articulating bones are observed much less frequently than deforming arthrosis - in less than a third of all patients suffering from degenerative-dystrophic lesions of these joints.

Long-term clinical and radiological observations show that the clinical picture and course of cystic reconstruction of the shoulder joint are closely related to the localization of cystic formations.

In some patients, individual isolated racemose formations arise in the center of the head of the humerus or closer to its anterior surface. Usually one or two cyst-like formations are found in this area.

More often they arise as a result of a single gross injury, are small in size, have a regular round shape, are covered with a clear end plate and are asymptomatic for a long time, or cause moderate constant aching pain in the joint, somewhat intensifying after exercise. The function of the limb is, as a rule, not impaired.

The disease does not tend to progress, does not go into stage II and therefore, as a rule, does not limit the ability to work.

Racemose formations in the greater tubercle, especially those located superficially, have a more pronounced clinical expression. Gradually increasing, they then break into the area of ​​the subacromial joint, causing an acute clinical syndrome of periarthritis with sharp pain, eliminating the possibility of shoulder abduction.

The same severe clinical picture is caused by a racemose restructuring of the outer part of the head of the humerus. With necrosis and pathological fractures of the walls of cystic formations located in this area, the outer portion of the anatomical neck, i.e., the place of attachment of the capsule, is destroyed.

As a result, chronic aseptic arthritis occurs, combined with periatritis, causing significant constant pain and severe impairment of limb function.

During the period of acute phenomena, the end plate of cystic formations often resolves and in the X-ray image they appear not clearly demarcated from the surrounding bone tissue in the condition.

Later, bone marginal growths join, mainly in the distal part of the joint. Particularly significant dysfunction of the musculoskeletal system occurs with the described lesions of both shoulder joints, which, however, is observed very rarely.

The clinical picture of cystic reconstruction of the shoulder joint in its stage II is often very similar to the syndrome of acute calculous bursitis.

In the latter case, there is also an aseptic inflammatory process in one of the mucous bursae of the shoulder joint, but it is not combined with pathological changes in bone tissue and is more successfully treatable, in particular, it gradually subsides under the influence of injections of a 2% novocaine solution.

In contrast, with degenerative-dystrophic lesions of the joint with carpal reconstruction of the articulating bones in stage II, irreversible impairment of limb function and persistent pain are often observed.

The differential diagnosis of cystic reconstruction of the shoulder joint is fully ensured by x-ray examination, which, with calculous bursitis, reveals the normal shape and structure of the bones and at the same time more or less calcification in the area of ​​the inflamed mucous bursa.

In the acute stage of the disease, calcification has the appearance of a very delicate, barely perceptible cloud, which, as the inflammatory process subsides, gradually turns into a uniform, more or less massive calcification.

Subsequently, this inflammatory process is often accompanied by deforming arthrosis of the subacromial joint.

With a degenerative-dystrophic lesion with a cyst-like restructuring of the articulating bones of one shoulder and subacromial joint, the patients’ ability to work is limited; with a bilateral lesion, they lose their ability to work.

We observed this condition, for example, in patient Ch., 47 years old. She has no profession, all her life she has done heavy manual labor, and for the last 8 years she has not worked due to constant pain in her shoulder joints. Intense pain, first in the right and then in the left shoulder joint, appeared 10 years ago for no apparent reason.

The pain made work and even self-care very difficult. After long-term unsuccessful physiotherapy and repeated novocaine blockades, the patient was sent to VTEK and recognized as a group III disabled person. In this regard, she was transferred to work as a cleaner without washing floors. However, the pain continued to increase, especially in the right shoulder joint.

After 2 years, the patient was forced to stop working and was recognized as a group II disabled person.

The examination revealed: atrophy of the muscles of the shoulder girdle and significant limitation due to pain in movements in both shoulder joints, especially abduction. Palpation of the shoulder joints causes sharp pain. All these phenomena are more pronounced on the right.

X-ray revealed a degenerative-dystrophic lesion of the right shoulder joint with cyst-like restructuring of the outer part of the humerus and breakthrough of the cysts into the joint.

Due to the destruction of the end-plate cystic formations, they are not clearly demarcated from the surrounding bone tissue, which is in a state of osteoporosis.

As a result of repeated breakthroughs of cyst-like formations into the joint, significant bone growths developed around the distal areas of the articular surfaces. On the left, a cyst-like restructuring of the structure of the greater tubercle of the humerus without breakthrough into the joint was discovered, i.e. stage I of the same disease.

Aseptic osteonecrosis is not typical for the shoulder joint.

The article was prepared and edited by: surgeon I.B. Pigovich.

Source: //surgeryzone.net/patient/travmatologiya-i-ortopediya/kistovidnaya-perestrojka-plechevogo-sustava.html

Diagnostic methods

If pain in the ankle occurs, you should not delay going to the doctor to avoid massive tissue necrosis. You can contact an orthopedist, podiatrist, surgeon or therapist who will help you navigate the choice of a specialist.

The very first diagnostic method of necrosis is to clarify the triggering mechanisms of its occurrence and the history of development. Next, the doctor conducts a direct examination of the affected area and palpation. Additional examination methods help to establish an accurate diagnosis.

Instrumental diagnosis of aseptic necrosis is quite simple. It consists of conducting the following additional studies:

• radiography;
• MRI;
• CT scan.

Performing a tomographic examination helps to make a diagnosis with great accuracy and begin therapy in a timely manner, at the earliest stages of the development of pathology.

As additional research methods, laboratory tests are prescribed in the form of determining biochemical blood parameters.

Causes

The occurrence of necrosis is provoked by a persistent disruption of the blood supply to the ankle joint. The development of such a condition is possible under the influence of the following factors:

• Fracture.
• Excess weight.
• Sports loads.
• Mountaineering, diving (atmospheric pressure changes).
• Long-term use of glucocorticoids.
• Diabetes.
• Some types of anemia.
• Systemic lupus.
• Chemotherapy.
• Alcohol abuse.

A fracture of the talus can occur as a result of a person falling, a direct blow, sudden extension of the foot, or as a result of a heavy object falling on the foot.

Classification of pathological changes

The gradual process of development of aseptic necrosis is usually divided into several stages:

1. First. At least 10% of the tissues of the talus are affected. There are practically no characteristic symptoms. Sometimes periodic soreness may be bothersome.
2. Second. It is characterized by the occurrence of sclerotic changes and cysts in the area of ​​the talus. It often ends with the formation of cracks in the tissues. Accompanied by a sharp limitation of mobility due to intense pain.
3. Third. At least 30–50% of the bone structure is already subject to pathological changes. Severe, constant pain occurs.
4. Fourth. Characterized by complete destruction of bone tissue. Accompanied by pathological changes in the distal tibia, the formation of osteophytes and cartilage separation. Requires surgical removal of dead bone areas.

Necrosis is usually divided according to the level of damage:

• complete: characterized by almost absolute necrosis of the tissues of the talus;
• localized: characterized by superficial tissue damage, as a result of which only the outer surface of the bone undergoes necrosis;
• deep: the deepest layers are affected.

The main signs of pathological changes are clearly visible on radiographs. This helps to divide necrosis into a number of stages:

1. The beginning of subarachnoid compression of a certain area of ​​the bone body.
2. Partial fragmentation of a specific part of bone and cartilage.
3. Complete fragmentation without displacement.
4. Complete fragmentation with displacement.

The listed classifications help to better navigate the disease and promptly begin competent complex therapy.