RU2275875C1 - Method for treating gonarthrosis cases on the background of knee joint varus deformity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves fixing knee joint by applying orthopedic apparatus to injured extremity. The apparatus has hinges with supporting plates preliminarily bent outwards stage-by-stage at an angle exceeding frontal deformity of the knee joint by 3-5°, during the treatment course. Orthopedic insole is additionally used for setting crural axis by redistributing axial load applied to the internal foot part.

EFFECT: enhanced effectiveness of treatment; wide range of functional capability; alleviated pain syndrome manifestations; reduced drug load; prevented knee joint deformity and dystrophic process progress.

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for the conservative treatment of gonarthrosis in patients with varus deformity of the knee joint.

Known methods of treating patients with deforming gonarthrosis, both conservative and operative, have several disadvantages. These include unsatisfactory treatment results associated with the development of contractures, damage to the conjugate joints (hip, ankle) due to a violation of the anatomical axis of the lower leg, suppuration, as well as instability of the endoprosthesis during endoprosthetics, suppuration with intraarticular injections of drugs, especially steroid preparations, progression of varus deformity joint, etc. In the treatment of knee deformities, the concomitant deformity of the feet is almost never taken into account. The consequence of the foregoing is the disability of patients with gonarthrosis.

There is a method of treating gonarthrosis in patients with varus deformity of the knee by osteotomy of the tibia with the removal of deformation and fixation of the lower limb with a plaster cast (M.O. Friedland. Orthopedics. M .: Medghiz. 1954. S. 430-434).

However, this method leads to prolonged patient dynamism, which is especially fraught with somatic complications in adult patients. At the same time, there is no possibility of early rehabilitation, development of movements in the joint, resulting in degenerative-atrophic changes, both in the joint itself and in the tissues surrounding it, which in turn leads to the formation of contractures. Immobilization with a circular gypsum dressing for another two months causes secondary osteoporosis of the segment, especially the cancellous bone. The lack of stable fixation often leads to aseptic necrosis in the area of the condyle of the condyle of the condyle, devoid of blood supply. Often there is a relapse of varus deformity, long-existing joint contractures and purulent wound complications up to osteomyelitis.

There is a method of treating gonarthrosis in patients with varus deformity of the knee by replacing the affected joint with an endoprosthesis (N.V. Kornilov, E.G. Gryaznukhin, V.I. Ostashko, K.G. Redko. Orthopedics. St. Petersburg: Hippocrates. 2001 S. 130-131).

However, this method is often complicated by the instability of the endoprosthesis, which requires repeated surgery, suppuration of the postoperative wound, long-existing bursitis, often contractures. In addition, the operational method can be applied only according to relative indications and, in the case of concomitant somatic pathology, is not always available in a significant number of patients with gonarthrosis.

As the closest analogue, a method for the treatment of gonarthrosis in patients with varus deformity of the knee joint (A.K. Popsuyshapka, Ya. I. Boyko. Express-orthosis for diseases and injuries of the musculoskeletal system. Kiev: Health. 1989. P. 57. -61), including fixation of the knee joint by applying to the affected lower limb an orthopedic apparatus containing bandages on the thigh and lower leg connected by hinges on the supporting plates.

However, the use of the method often causes severe discomfort, increased pain in the joint area, reactive inflammation, accompanied by rapid progression of the pathological process, especially with severe varus deformity. This is due to the fact that the orthopedic apparatus corresponds to the anatomically correct axes of the limb and the sudden removal of the lower leg from the vicious varus position to the anatomically correct one leads to the overstretching of long-toned muscles. In addition, since the position of the deformed feet is also not taken into account and corrected, the load on the ankle joint and the feet themselves increase with standard bandaging of varus-modified knee joints. When correcting deformation of the knee joints, the concomitant pathology of the feet is not taken into account and its correction is not performed. The method does not allow to obtain a stable clinical result, does not provide an increase in the functionality of the limb.

The objective of the invention is to provide a highly effective method of treating gonarthrosis in patients with varus deformity of the knee joint, which provides a stable and pronounced clinical result with an increase in the functionality of the limb and to reduce the number of possible complications.

The essence of the invention lies in the fact that in the method of treating gonarthrosis against varus deformity of the knee joint, including fixing the knee joint by applying an orthopedic brace device containing hinges with support plates to the affected limb, the support plates of the hinges are preliminarily and stepwise bent outward at an angle during treatment 3-5 degrees greater than the angle of frontal deformation of the knee joint, while additionally using an orthopedic insole, with which help is carried out correction B tibia by redistributing the axial load on the inner part of the foot.

Using the invention allows to obtain the following technical result.

The method is highly effective. It provides a stable and pronounced clinical result of treatment, with an increase in the functionality of the limb, reduces pain, reduces the pharmacological burden on the patient, and prevents the progression of deformation of the knee joint and degenerative-dystrophic processes in the knee and adjacent joints.

Using the method reduces the level of disability, improves the "quality of life" of patients and provides them with an "independent life" especially in the case of late stages of the pathological process and with contraindications for surgical treatment.

Using the method has practically no contraindications. A contraindication can only be the initial inability to move, depending on the accompanying pathology.

The technical result is achieved due to the facts established by the authors.

Varus deformity of the knee joints is not so much a cosmetic pathology as a serious illness of the musculoskeletal system, accompanied by a significant deterioration in the statics and dynamics of patients, the formation of secondary changes in adjacent joints, deformation of the feet, skew of the pelvic bones, curvature of the spine, etc. The so-called "light" degrees of deformations are not harmless either, as is commonly believed among a wide range of doctors. By the age of 35-40, a deforming arthrosis occurs in the knee joint, which has been functioning for a long time under abnormal static conditions.

Thus, the removal of the joint in an anatomically correct position with the provision of congruence of the articular surfaces and restoration of the tendon-musculo-ligamentous balance of the knee joint or the maximum possible correction of the existing deformation allows us to achieve our goals. It is known that people have the correct physique with a frontal knee angle of 170 to 179 degrees. the mechanical axis, determined by the vertical position of a person on one leg, is projected within the intercondylar elevation. With dimensions of the frontal knee angle from 165 to 185 degrees. the mechanical axis did not go beyond the base of the joint (the area bounded by the apical condyles). At angles from 165 to 160 and from 185 to 190 degrees. she projected over the outer halves of the condyles. With deformations at an angle of 160 degrees or less. 190 and more degrees. the mechanical axis was determined outside the joint. Thus, with frontal deformation of the knee joint, the axis is shifted inwards or outwards relative to its normal anatomical position. During varus deformity of the knee joint, the axis of the limb passes through the medial region, while the medial condyle is “overloaded”. With hallux valgus - through the lateral region with overload of the lateral condyle.

Frontal deformities of the knee joint can be "unstable" against the background of hypermobility of the lateral ligaments of various etiologies or "rigid" against the background of the formation of osteophytes, exostoses as compensatory stabilization of the unstable knee joint. In the first case, in the supine position, the lower leg can be brought into the correct (or approximately anatomically correct) position. Nevertheless, in the case of an unstable knee joint, the use of therapeutic orthosis, such as a knee pad or brace with hinges, leads to overstretching of long-toned muscles. There is an increase in pain, reactive inflammation in the joint and paraarticular tissues, contracture may form. In addition, with standard bandaging of the frontally deformed knee joints, the load on the ankle joint and foot increases. In the second case, with severe frontal deformity, the use of serial bandages always worsens the function of the limb, greatly enhances the pain syndrome, since the band hinges are oriented to the anatomically correct knee joint. Therefore, the need arises, providing a full load on the entire limb, to unload the pathologically altered condyle as much as possible, followed by the stepwise removal of the knee joint to the position that is as close as possible to the anatomically correct one. Modification-bending of the hinge legs allows you to simulate the existing deformation of the knee joint, with the creation of a minimum correction, to ensure the correct walking algorithm and prevent lateral instability. For additional unloading of the tibial condyle in the process of axial load during walking, individual feet orthosis was used with hypercorrection of the foot position with an orthopedic insole.

As a result of the analysis of the orthosis condition of patients with frontal deformities of the knee joint, the authors developed an algorithm for staged gentle fixation of the knee joint as part of a comprehensive, conservative treatment of gonarthrosis, taking into account the interaction of the conjugate segments: thigh-lower leg, lower leg-foot.

The position of the knee joint is determined by the direction of the axis of the limb. The direction of the latter depends on the condition of the ligamentous muscular apparatus of the joints of the lower limb and the installation of the feet.

Studies of the authors noted that simultaneous correction of the position of the knee joint with a bandage with hinges of more than 5 degrees. worsens the patient's condition: pain intensifies, limb functional capabilities decrease, physical activity level decreases, reactive phenomena occur in the joint - synovitis. In this regard, the correction was carried out in stages and at two levels: the knee joint immediately up to 5 degrees. and valging of the foot.

To eliminate discomfort when using a knee brace and accelerate the rehabilitation process, the entire foot was additionally tilted on the valgus with varus deformation of the knee joint, with it installed on the inner edge, loading the longitudinal arch - since in this case, the foot support area increases. To do this, put the foot on the orthopedic insole and tilt the foot insole on the valgus along the entire length. As a result of our studies on 267 patients, the angle of the foot was set in the range from 15 to 20 degrees.

Empirically revealed the pattern of loading the longitudinal arch of the foot. With a difference between two measurements of the arch in a seated and vertical position up to 3 mm, the possible maximum load was 1 mm. With a difference of 3 to 6 mm, the arch can be loaded 2 mm. Otherwise, in violation of the above sizes, discomfort and pain in the feet, and sometimes in the area of the knee joints, appeared. The loading of the feet with a rigid (fixed) arch and congenital hollow feet led to the “tipping” of the feet, therefore, as we have revealed, such feet needed only a slope on the valgus within 15-20 degrees.

Thus, the combination of valgus correction with a brace made by bending its base plates and an orthopedic insole with transferring the load to the inner surface of the foot made it possible to perform a total correction of the tibial axis with the prevention of a sharp simultaneous change in the position of the knee joint.

The phasing of the orthosis made it possible to accelerate the rehabilitation period with the formation of the correct walking algorithm and axial load on the limb. Adequate axial load on the limb strengthens the bone tissue and allows you to increase the range of motion in the knee joint.

The method is as follows.

After a clinical examination of the patient determine the nature and angle of frontal deformation of the knee joint.

The knee joint is fixed by imposing on the affected limb an orthopedic apparatus-brace of the knee joint containing hinges with support plates.

Before applying the orthopedic device-brace of the knee to the limb, the support plates of the hinges are preliminarily and stage-by-stage during the treatment bent outwardly at an angle exceeding the angle of frontal deformation of the knee joint by 3-5 degrees, while an orthopedic insole is additionally used, with the help of which the axis is corrected lower legs by redistributing the axial load on the inner part of the foot.

For additional unloading of the tibial condyle in the process of axial loading while walking, individual feet orthosis is performed with hypercorrection of the position of the foot with an orthopedic insole. Tilt the entire foot to the valgus, with its installation on the inner edge, loading the longitudinal arch - because in this case, the foot support area increases. To do this, put the foot on the orthopedic insole and tilt the foot with the insole on the valgus along the entire length.

In this case, the longitudinal arch is loaded as follows. Two dimensional characteristics of the heights of the longitudinal arch are removed (sitting on a chair, the knee joint at 45 degrees, and standing under load). The height of the arch h is measured along the scaphoid, palpation determine the protrusion of the scaphoid from the inside of the foot. If the difference between the two measurements in the sitting and vertical position is less than 3 mm, the load is carried out by 1 mm, and the longitudinal arch is lifted by the insole. If the difference is more than 3 mm (from 3 mm to 6 mm), the arch is loaded by 2 mm. A foot with a rigid (fixed) arch and a congenital, hollow foot (over 6 mm) are not loaded, but only tilted onto the valgus within 15–20 degrees, since the additional load “knocks over” the foot.

In the future, as the knee joint adapts to a new position in the brace after a month of walking in the correction position and there is no feeling of discomfort from the lower extremity in the patient, the next knee joint is brought out to the valgus side by bending the support plates of the brace of the knee joint for another 3-5 degrees. After a month, the procedure is repeated if necessary. Thus, the final correction is the removal of the knee joint as close as possible to the anatomical position, in which the patient does not experience discomfort (pain, instability in the joint).

Upon reaching this position, over the next 7-10 days, the valgus insole is replaced with a standard arch support.

As a result of studies conducted by the authors on 267 patients, the angle of the foot to the valgus was set in the range from 15 to 20 degrees.

The method was applied in 36 patients with gonarthrosis on the background of varus deformity at the age from 47 to 79 years (29 women and 7 men). A positive clinical result was obtained, consisting in the fact that the pain syndrome was significantly reduced or completely stopped, after the course of treatment, the range of movements significantly increased, six months later, frontal deformation decreased in 26 patients (an average of 12 ± 2 degrees). The indicators of “quality of life” improved, patients became much more active, which allowed them to become socially independent.

None of the patients had complications as a result of the treatment.

Clinical examples.

Example 1. Patient M., 63 years old, is on outpatient treatment for post-traumatic varus deformity of the right knee joint, gonarthrosis 3 tbsp. The deformation angle is 196 degrees. In the supine position with a fixed hip, passive movements bring the tibia to an angle of 188 degrees. Attempts to wear a serial bandage of the knee joint with hinges lead to increased pain, the occurrence of synovitis, swelling of the limbs, the appearance of pain in the foot and ankle joint. The patient formed a plaster cast in the position of individual hypercorrection in the knee joint. Before applying to the limb of the brace, the legs of the hinges are modified so that their bend corresponds to the individual deformation of the joint plus 4 degrees. outward (towards the normal axis of the limb). For additional unloading of the tibial condyle in the process of axial load during walking, an individual orthosis of the feet was carried out with hypercorrection of the position of the foot with an orthopedic insole. The entire foot was tilted onto the varus with its installation on the outer edge with loading of the longitudinal arch to increase the foot support area. For this, the foot is mounted on an orthopedic insole and is thus inclined to the varus along the entire length. In this case, the longitudinal arch is loaded as follows. Two dimensional characteristics of the heights of the longitudinal arch were taken (sitting on a chair, the knee joint at 45 degrees, and standing under load). The height of the arch h is measured along the scaphoid, for which a protrusion of the scaphoid is palpated from the inside of the foot. Since the difference between the two measurements in a sitting and vertical position was less than 3 mm, the load was carried out by 1 mm, while the longitudinal arch was raised by the insole. Later, after a month, the support plates of the brace-brace hinges are additionally bent by 5 degrees. and the treatment is continued. The patient has no complaints, physical activity increased, night pains stopped, the psycho-emotional state improved. When viewed in dynamics: palpation of the knee joint area is painless, the range of motion in the joint is increased, painless, the patient practically does not use a cane, notes the possibility of a greater load on the joint. Viewed after 6 months. no complaints, active, moves without a cane, fully self-serving.

Example 2. Patient with dysplastic gonarthrosis, varus deformity of the right knee joint. Complains of instability of the knee joint when walking on an uneven surface, pain after exertion and at night. On examination, the angle of varus deformity, equal to 198 degrees, was determined. The knee joint is hypermobile, with passive movements it is withdrawn to an anatomically correct state, however, when using a serial brace with hinges, a persistent pain syndrome occurs. According to the method described above, the legs of the brace are modified by 5 degrees. and corrected the position of the foot with loading the arch by 2 mm. The patient began to walk in brace - no complaints, does not feel discomfort. Rehabilitation treatment was carried out: exercise therapy, FTL, chondroprotectors, drugs that improve microcirculatory circulation, vitamins. Every two months, the support plates (legs) of the brace were bent at 5 degrees. Thus, after three months, the joint is brought to the correct position: the patient uses the brace without experiencing discomfort. The position of the axis of the limb is correct. Two months later, corrective insoles were replaced with individual arch support. Examination after six months and a year: limb function is preserved, pain is absent, the patient moves outside the house with a brace on the knee joint, varus deformity does not progress.

Claims (1)

A method of treating gonarthrosis against a background of varus deformity of the knee joint, including fixing the knee joint by applying to the affected limb an orthopedic brace device containing hinges with support plates, characterized in that the support plates of the hinges are preliminarily and stepwise during the treatment bent outwardly at an angle greater than 3 -5 ° angle of frontal deformation of the knee joint, while additionally using an orthopedic insole, with the help of which the tibia axis is corrected by redistributing Lenia axial load on the inner part of the foot.