RU2219861C2 - Method for making arthroplastic repair of talocrural articulation - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves exposing and removing internal malleolus, excising deltoid ligament, making tibia articulation surface resection at the level of subchondral bone, forming a groove in it in frontal plane, selecting mineralized osteochondrous allograft of distal tibial epiphysis having distance between internal malleolus apex and the outmost lateral point of distal tibial metaepiphysis equal to the same distance in recipient case. Protrusion corresponding to excised tibial surface groove is created. The deltoid ligament is transosseously sutured to the internal malleolus after setting the graft. EFFECT: enhanced effectiveness in providing articulation function in walking with no pain syndrome manifestations. 4 dwg

Description

 The invention relates to arthrology and can be used for surgical treatment of post-traumatic deforming arthrosis and post-traumatic deformation of the ankle joint with a primary lesion of the distal metaepiphysis of the tibia by replacing the latter with a mineralized allograft.

 One of the most severe injuries of the ankle joint is a comminuted fracture of the distal metaepiphysis of the tibia, accompanied by significant destruction of the articular surface. All available modern methods of conservative and surgical treatment of this damage are not able to ideally restore the anatomical ratio in the joint, which quickly leads to the development of post-traumatic deforming arthrosis with persistent pain with impaired limb function.

 The main method of treatment of post-traumatic deforming arthrosis of the ankle joint that is not amenable to conservative therapy is its arthrodesis [1, 2].

 But such an operation stabilizes the ankle joint, which does not suit some patients, especially women. In addition, as a result of a violation of the general biomechanics of the foot, the remaining joints of the latter are involved in the pathological process after some time.

 The prototype of the technique proposed by the authors is arthroplasty of the ankle joint, when an interpolating tissue is placed between the joint surfaces - wide fascia of the thigh, dura mater, etc. [1, 2].

 However, these operations do not give the desired result and are currently rarely performed.

 A significant difference between our proposed method for restoring anatomy and, as a result, the function of the ankle joint in post-traumatic deforming arthrosis of it, is the replacement of the distal metaepiphysis of the tibia with an anatomical mineralized bone-cartilage allograft.

 Thus, the claimed method according to the above essential feature is an inextricable causal relationship with the achieved result, i.e. meets the criterion of inventive step.

 At the time of filing the application for the invention, we are not aware of such or identical to the claimed method, which allows us to consider it meeting the criterion of novelty.

 When planning the operation, an X-ray of the ankle joint is performed in two projections with a ruler to determine the size of the distal metaepiphysis of the tibia, which is an important point in the selection of an allograft. The implant should correspond to the size of the removed part of the metaepiphysis of the tibia. To do this, the x-ray in direct projection measures the distance between the apex of the inner ankle and the most lateral point of the distal metaepiphysis of the tibia (figure 1).

 If the distal metaepiphysis is significantly changed and deformed, then measurements are made on a healthy ankle joint.

 Due to this, an exact match of the transplant and the talus of the recipient is achieved. After graft selection, an operation is performed.

 An ankle joint is secreted by the posteromedial access bordering the ankle around 10-12 cm. The subperiosteal is secreted by the inner ankle, the deltoid ligament is cut off, an osteotomy and ankle removal are performed. The articular subperiosteal cavity is used to separate the articular end of the tibia. A wide osteotome resects the articular surface of the distal tibia metaepiphysis perpendicular to the long axis of the tibia at the level of the subchondral bone (2-3 mm from the top of the circumference of the distal tibia metaepiphysis). Then, with a carpal osteotome 6 mm wide, a rectangular groove is formed in the frontal plane with walls equal to the width of the osteotome, the axis of which is the line connecting the middle of the inner-lateral surface of the tibia at the resection level and the middle of the outer ankle at the same level.

 After that, an allograft with a predetermined size is fixed using a preformed rectangular protrusion corresponding to the groove on the resected surface of the tibia, to the latter. The stability of the graft attachment, the range of motion in the joint are checked. The deltoid ligament is sutured transposally to the inner ankle of the graft. Hemostasis is performed during the operation, the wound is drained by active drains and sutured in layers. The limb is immobilized by the posterior plaster cast with the foot, to the upper third of the leg. After removing the sutures, a gypsum boot is applied for up to 2.5-3 months from the day of surgery. After removal of the gypsum, exercise therapy is prescribed. A moderate foot load is allowed after 4.5-5 months from the day of surgery and is brought to full by six months from the moment of surgery.

 Mechanical fixation of the allograft with a groove ensures the stability of the allograft for a month, when it forms a scar adhesion with the tibia, as well as in the future.

 The proposed transplant attachment technique allows to increase the contact area of the bones and to avoid the incongruence of the cavities between it and the bed on the tibia, which are the main cause of failures with other types of plastic.

 The use of a mineralized allograft with a minimum amount of cancellous bone provides sufficient mechanical strength at the time of restoration of joint function and, at the same time, rapid reconstruction of the graft.

 According to the proposed technique, 5 patients were operated on. The observation period is up to 2 years. Two patients have a complete restoration of joint function and the absence of pain during exertion; in three patients, moderate movement restriction remains in the absence of pain.

Clinical example
Patient Smirnov V.N., 38 years old, and / b 4383-99 was admitted to the hospital on 06.15.99 with a diagnosis of a chronic, incorrectly fused fracture of both ankles and the posterior part of the right lower leg, subluxation of the foot outward. Injury 05/05/99 - tucked right foot. In one of the city hospitals, simultaneous closed manual reposition was performed, but restoration of the anatomy was not achieved. Surgical treatment was planned, but due to severe soft tissue swelling and the appearance of conflict, the operation was postponed. The patient was discharged for outpatient treatment to prepare the limb for surgery. In connection with a removable plaster cast (for dressings), the displacement of fragments increased, and a subluxation of the foot appeared posteriorly. 1.5 months after the injury, he was consulted at RosNIIITO named after R.R. Harmful and was hospitalized for surgery.

 On examination: walks on crutches, in the projection of the joint, deformation and moderate swelling of the soft tissues extending to the lower leg. Hyperpigmentation in the area of former conflicts. Skin sensitivity preserved. Palpation in the projection of the fissure of the ankle joint is painful. Soreness increases with movement and axial load. Movement: extension 10, flexion 25 degrees (figure 2).

 06/25/99 an operation was performed according to the methodology presented. Gypsum immobilization lasted 2.5 months (figure 3). After removal of the gypsum - physiotherapy, exercise therapy by gentle methods, massage. Dosed load from 4 months, full six months. At the moment, there are no complaints, the range of motion in the joint is complete, he returned to his previous work (figure 4).

LIST OF REFERENCES
1. Movshovich I. A. Operative orthopedics. M .: Medicine, 1983, 415 p.

 2. Chaklin VD Operational orthopedics. M .: Medgiz, 1951, 499 p.

Claims (1)

The method of arthroplasty of the ankle joint with a predominant lesion of the distal tibial metaepiphysis, characterized in that the mineralized bone-cartilage allograft of the distal tibia is selected, in which the distance between the apex of the ankle and the most lateral point of the distal metaepiphysis is equal to subperiosteally of the inner ankle, clipping of the deltoid ligament, then producing osteotomy miyu and removal of the ankle, subperiosteal allocation of the articular end of the tibia, resection of the articular surface of the tibia perpendicular to the long axis of the tibia at the level of the subchondral bone and the formation of a groove in it in the frontal plane, fixation of the allograft in it corresponding to the groove on the resected surface of the tibial bone , suturing of the deltoid ligament transossally to the inner ankle of the graft.

Images