RU2245683C2 - Method for treating posterior-external rotation instability of knee joint - Google Patents

Abstract

FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: one should form a transplant out of femoral biceps' tendon, form an oblique-cross-sectional transfemoral canal in isometric area upon external femoral condyle, right to the front against insertion fibular collateral ligament, apply proximal end of crossed femoral biceps' tendon through this canal, fix the end of crossed femoral biceps' tendon upon internal femoral condyle. The method enables to prevent tendinous rupture at the site of its new fixation and avoid the loss of articular bending function.

EFFECT: higher efficiency of therapy.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology orthopedics, and can be used to treat chronic posterior-external rotational instability (ZNRN) of the knee joint, characterized by external hyperrotation of the lower leg with posterior subluxation of the external tibial plateau relative to the external condyle of the thigh. ZNRN occurs when the arcuate complex is functionally combining the arcuate ligament, the fibular collateral ligament, the aponeurotic and tendon parts of the popliteal muscle and the lateral head of the calf muscle.

Known methods for treating knee arthritis ZNR include "deepening" in the external condyle conduit of the hamstring tendon (1) or the femoral insertion of the hamstring tendon and peroneal collateral ligament are somewhat dorsal and anterior (2). However, the listed surgical interventions aimed at limiting the external hyperrotation of the lower leg are technically impossible with damage to the tendon of the popliteal muscle in its middle part or in the muscle-tendon junction.

Known methods for plastic reconstruction of the injured tendon of the popliteal muscle, providing static stabilization of the joint, involve the formation in the posterior-outer corner of the knee joint of the replacement ligamentous structure from the distal part of the ileotibial tract or the anterior third of the tendon of the biceps femoris muscle (3).

The disadvantages of these methods include:

- the formation of persistent flexion contractures after the formation of the bone tibial tunnel and surgical manipulations on soft tissues in the posterior-outer corner of the knee joint;

- stretching over time of relatively weak grafts.

Closest in its technical solution to the claimed method, adopted as a prototype, is the method proposed by Clancy (4).

The method consists in the transposition of the tendon of the biceps femoris muscle to the external condyle of the femur with the formation of tenodesis. Thus formed a new collateral ligament allows you to keep the lower leg in a predetermined position, limiting its external rotation and posterior-external subluxation. Due to the close aponeurotic connection between the distal part of the displaced tendon of the biceps femoris and the arcuate complex (5), the distal part of the arcuate complex is tensioned, which additionally helps to stabilize the joint.

The disadvantages of the method adopted for the prototype include the complexity of isometric positioning of the tendon of the biceps femoris on the external condyle of the femur, which leads to a loss of flexion function of the knee joint. The shearing forces arising from movements, in turn, can lead to rupture of the tendon at the site of its new fastening.

The essence of the invention lies in the combination of distinctive features sufficient to achieve the desired technical result, namely, to eliminate the posterior-external rotational instability of the knee joint and improve treatment results by eliminating the disadvantages inherent in the known methods.

The goal is achieved by the fact that in the isometric zone on the external condyle of the femur, immediately anterior to the peroneal collateral ligament, an oblique transfemoral bone canal is formed, the proximal end of the crossed tendon of the biceps femoris is passed through it and it is fixed on the internal condyle of the femur.

Thus:

1. The location of the graft in the isometric zone and its tension in the position of the internal rotation of the lower leg prevents posterior-external subluxation of the lower leg without restricting the flexion-extensor movements in the joint.

2. The functional activity of the biceps femoris as an external rotator of the lower leg is leveled.

The location scheme of the anatomical formations of the knee joint before and after the operation according to the proposed method is shown in FIG. 1 and FIG. 2, where the head of the fibula 1, the lateral head of the calf muscle 2, the fibular collateral ligament 3, the tendon of the biceps femoris 4, or the tibial tract 5 are shown , transplant from the tendon of the biceps femoris 6, transmaxillary bone tunnel 7.

The method is as follows.

A longitudinal incision is made of the skin and fascia 12 cm long along the posterior edge of the contoured iliotibial tract from the lower third of the thigh to the head of the fibula. The tendon of the biceps femoris muscle is released by the stripper from muscle fibers and spurs to the lateral head of the calf muscle. The external condyle of the femur is exposed in the isometric zone, immediately anterior to the insertion of the fibular collateral ligament. In this place, a through oblique transmispersal canal is formed with a drill, equal in diameter to the tendon of the biceps femoris. The biceps tendon is crossed 12-15 cm above the head of the fibula. The proximal end of the tendon is stitched with thread from non-absorbable material. The graft per thread is carried out through the formed bone channel and in a tense state, in the position of flexion and internal rotation of the lower leg, is fixed to the screw inserted into the internal condyle of the femur. After suturing postoperative wounds, the limb is immobilized with a plaster cast in the position of internal rotation of the lower leg and flexion of the knee joint at an angle of 150 °. Two weeks after removal of skin sutures, the tibia from the internal rotation position is transferred to a neutral position with an extension of the immobilization period for another 4 weeks.

Patient Muranov E.A., 27 years old, was admitted to the Scientific and Research Center “WTO” with a diagnosis of chronic post-traumatic posterior-external rotational instability of the severe right knee joint (case history No. 2184). Due to severe lameness due to subluxation of the posterior external condyle of the lower leg, the patient was forced to constantly use a cane and splint. The pronounced instability of the knee joint was the reason for the limitation of the motor activity of the patient and led to the termination of his professional activity. The patient underwent surgery according to the proposed method. Initially, diagnostic arthroscopy was performed. During revision of the knee joint, concomitant damage to the posterior cruciate ligament was diagnosed. From external access, plastic reconstruction of the ligamentous apparatus of the knee joint was performed according to the method described above. The total period of immobilization of the knee in the postoperative period was 6 weeks. After removing the plaster cast, the patient was hospitalized for rehabilitation treatment. A course of physiomechanotherapy with a complete restoration of range of motion in the joint. Re-examined after two months. The patient was satisfied with the result of the operation: active, he doesn’t note instability when walking in the joint.

The considered method can be recommended in clinical practice.

Sources of information

1. Jacob R.P., Hassler H., Staeubli H.U. Observations on rotatory instability of the lateral compartment of the knee. Experimental studies on the functional anatomy and the pathomechanism of the true and the reversed pivot shift sign // Acta Orthop Scand Suppl. - 1981. - p. 191.

2. Hughston J.C., Jacobsen K.E. Chronic posterolateral rotatory instability of the knee // J. Bone Joint Surg.-1985. - 67-A., P. 351.

3. Muller We. The knee: Form, function and ligamentous reconstruction. Springer, Berlin Heidelberg, New York. - 1983.

4. Clancy W.G. Repair and reconstruction of the posterior cruciate ligament // In: Chapman M, ed. Operative orthopedics. Philadelphia: JB Lippincott. 1988. - p. 1651-1665.

5. Marshall J.L., Girgis F.G., Zeiho R. The biceps femoris tendon and its functional significance // J. Bone Joint Surg. - 1972. - 57-A. - p. 1444.

Claims (1)

A method for the treatment of post-traumatic posterior-external rotational instability of the knee joint, including the formation of a graft from the tendon of the biceps femoris muscle and its transposition, characterized in that in the isometric zone on the external condyle of the femur, immediately oblique insertion of the fibular collateral ligament, form an oblique-transverse transverse the proximal end of the crossed tendon of the biceps femoris is passed through it and it is fixed on the internal condyle of the femur.

Images