RU2161929C1 - Method for stabilizing subchondrous cortical plate of femoral condyles in the cases of degenerative osteoporosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making slot set in congruent relation to the femoral condyle curvature in subcortical projection of cyst positions. A plate from porous titanium nickelide is introduced into the slot. The plate dimensions corresponds in size and in its curvature to those of the mentioned slot. Cartilage separation being the case, the cartilage is additionally fixed with removable screws introduced through the porous plate from the articulation surface side. EFFECT: reduced risk of cartilage degeneration and separation. 2 cl, 4 dwg

Description

 The invention relates to medicine, namely to traumatology and orthopedics.

 Osteoarthrosis is a widespread joint disease that is a common cause of temporary and permanent disability. According to epidemiological studies, 10-12% of the population suffer from osteoarthritis (Astapenko MG, 1977). Over the past decade, disability due to arthrosis has increased 3-5 times.

 Due to the tendency for systemic osteoporosis to increase, the amount of formation of degenerative osteoporotic cysts in the condyles of the thigh increases, they are usually found in the bone marrow below the subchondral plate at an early stage of the disease. Cysts are represented by myxomatous cells surrounded by newly formed bone tissue. Then there is vascularization and fibrosis of loose tissue, and the adjacent bone undergoes remodeling. The formation of cysts is associated with bone resorption by osteoclasts that underwent necrosis and micro-fractures (Niwayama G., 1983). Around the cysts, secondary bone necrosis often occurs. They usually have a diameter of 2-6 mm and are detected by histological examination. Occasionally they are found macroscopically as yellow patches. Necrosis is considered as a result of circulatory disorders and is described as subchondral infarction.

There is a method of treating deforming arthrosis, aimed at removing cysts, stabilizing the subchondral cortical plate (the so-called "scooping osteotomy") by osteoplastic replacement of the defect and normalizing trophic joint by enhancing its vascularization. (Volg A. // Zentrablat. Ortop. - 1952. - V. 77. - P. 887.)
However, this operation was not widely used due primarily to its lack of effectiveness, since in this case the defect is replaced with a bone graft, which in turn undergoes resorption, thereby creating conditions for an impression fracture of the corresponding part of the condyle.

 Closest to the claimed is a method of restoring the articular surface of the cystically altered femoral condyles for osteoarthritis, which consists in partial resection of the femoral condyles, modeling the articular surface and filling the cavity of the cysts with autospongism, characterized in that, in order to ensure movements in the early postoperative period, bone-cut cartilage grafts from the posterior condyles and replace defects in the supporting articular surface (A.S. N 1454423, MKI 4 A 61 B 17/56, published January 30, 89, BI No. 4).

 The disadvantage of the prototype is that it resects the posterior portions of the medial and lateral condyles of the femur, thereby reducing the area of the supporting articular surface and creating conditions for the progression of arthrosis.

 The objective of the invention is to reduce degeneration and detachment of the articular cartilage, improve vascularization of the subchondral plate of the femoral condyle by creating the basis for the cartilage subchondral plate of the condyles of the femur, and reduce the pathological mobility of the cartilage.

The task is achieved in that:
1. In a subcortical projection of the location of the cysts, a groove is performed that is congruent to the curvature of the femoral condyle, into which a plate of porous titanium nickelide is inserted with dimensions corresponding to the dimensions of the said groove and its curvature.

 2. In the presence of cartilage detachment, the latter is additionally fixed with screws carried out from the side of the articular surface through a porous plate, with their subsequent removal.

The novelty of the method:
1. A groove is made in the projection of the location of the subcortical cysts, congruent to the plane of the subchondral plate of the femoral condyle, with dimensions corresponding to the size of the affected condyle, the groove passes through all the cysts, destroying them, forming a single cavity, which is subsequently filled with bone tissue.

 2. In order to stabilize the subchondral cortical plate, a plate made of porous titanium nickelide, which, passing through the cysts, acts as a frame for the subchondral plate of the femoral condyle, was used as a graft.

 3. A support frame has been created that impedes the pathological mobility of the cartilage plate of the femoral condyle, since porous nickel-titanium corresponds to its elasticity in the biological tissues of the body.

 4. Additional fixation with a screw allows you to supplement the fixation of the cartilage in case of detachment, while the screws do not interfere with movement, since they themselves are completely immersed in the cartilage.

 The invention is illustrated by drawings, where in FIG. 1-4 shows a diagram of the operation.

 The essence of the method is as follows.

 In case of degenerative cystic change in the femoral condyles, after arthroscopic debridement of the joint, by internal or external parapatellar access according to Payr (depending on which condyle is damaged), the femoral condyles are exposed, the groove subcortically forms an arched groove (congruent natural curvature of the femoral condyle). In this case, the groove passes through all the cysts, forming a single gap, which serves as the basis for the introduction of the graft in the form of a plate of porous titanium-nickelide. A porous titanium-nickelide plate (brand TN-1P) with dimensions corresponding to the dimensions of the formed groove (in length, width and height) is cooled with chloroethyl, bent in an arcuate manner in the shape of the groove, and introduced subcortially into the formed groove. The arcuate curved plate of porous titanium-nickelide, filling the corresponding slot groove, allows you to evenly distribute external loads on the condyle, thereby preventing excessive mobility of the cortical layer and, as a result, this fracture and detachment of the cartilage, while the porous titanium-nickelide for 3 weeks overgrows with connective tissue, which additionally strengthens the subchondral cortical plate. In the presence of cartilage detachment, the latter is additionally fixed with screws held from the articular surface through the porous plate. The wound is sutured in layers, the joint is drained by a tube, gypsum immobilization. After 4 weeks, the immobilization is removed and a course of physiotherapy (exercise therapy, massage) is carried out without load on the limb. The cartilage fixing screws, if supplied, are removed after 8 weeks using arthroscopic techniques.

Clinical example
Patient L. was admitted to the clinic 02/12/97. with a diagnosis of Right-sided gonarthrosis, osteoporosis, degenerative cystic changes in the medial condyle of the femur 02/13/97 she underwent sanitizing arthroscopy, which revealed excessive cartilage mobility together with the subchondral cortical plate of the medial condyle of the femur. After a course of physiotherapy on March 15, 1997, a second operation was performed: Arthroscopy, stabilization of the subchondral cortical plate of the medial condyle of the right thigh.

 Under mask anesthesia, the surgical field was treated twice with an alcohol solution of chlorhexidine from three approaches (anterolateral, anteromedial and upper patellar), arthroscopy of the right knee joint was performed, on which pathological mobility of the subchondral cortical plate of the medial femoral condyle with incomplete cartilage detachment above the cartilage was revealed . The medial condyle of the thigh is exposed by internal parapatellar access along Payr, the groove is subcortical in the projection of the cysts, arcuate in shape (corresponding to the natural curvature of the femoral condyle). A plate of porous titanium nickelide (grade TN-1P) 3 cm long, 2 cm wide, 0.1 cm high, chilled with chloroethyl, curved in an arcuate manner and inserted subcortically into the formed groove. Cartilage detachment is fixed by three screws held from the side of the articular surface through a porous plate. The wound is sutured in layers, the joint is drained by a tube, gypsum immobilization. After 4 weeks, the immobilization was removed and a course of physiotherapy (exercise therapy, massage) was carried out without load on the limb. The cartilage fixing screws were removed after 8 weeks using arthroscopic techniques, with a complete increase in the cartilage to the underlying cortical plate and the absence of its pathological mobility. Full range of motion restored after 6 weeks. Dosed load is allowed after 10 weeks, full load after 3 months. The patient was examined after 1.5 years, the range of motion was complete, radiological and clinical signs of the progression of osteoarthritis and local osteoporosis were not detected.

 Thus, 5 patients were operated on: in all cases, a good result was obtained (full range of movements, absence of pain), radiologically and clinically, there were no signs of progression of arthrosis. Arthroscopic examination revealed the absence of pathological mobility of the subchondral cortical plate of the femoral condyles and good fixation of cartilage at the site of their former detachment. During the control x-ray examination, there were no signs of subsidence of the articular site of the femoral condyle. Evaluation of the results was carried out one year after the operation.

Using this method gives the following effect:
1. A skeleton of a porous titanium-nickelide plate formed under the articular site prevents the pathological mobility of the subchondral cortical plate of the femoral condyle.

 2. Ensuring the stability of the subchondral cortical plate of the femoral condyle prevents fracture and detachment of the cartilage over the site of cystic condyle reconstruction.

 3. Providing a stable support allows the early development of movements.

 4. The use of a porous implant eliminates the need for an autograft for bone-plastic replacement of cysts, which makes the operation more aesthetic and less traumatic.

 5. The use of arthroscopic techniques makes it possible to remove metal structures almost extra-articularly, which prevents the development of degenerative processes in the articular cartilage and the formation of intraarticular adhesions.

 6. The early development of movements and the presence of stable support for the condyle can improve results and reduce treatment time by 1-1.5 months.

Claims (2)

 1. The method of stabilization of the subchondral cortical plate of the femoral condyles in degenerative osteoporosis, including filling the cysts with a graft, characterized in that in the subcortical portion of the cysts, a groove is performed that is congruent to the curvature of the femoral condyle, into which a plate of porous titanium nickelide-titanium with dimensions corresponding to the dimensions mentioned and its curvature.  2. The method according to claim 1, characterized in that in the presence of cartilage detachment, the latter is additionally fixed with screws carried out from the side of the articular surface through a porous plate, followed by their removal.

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