RU2286736C2 - Method for treating deforming arthrosis of knee joint - Google Patents

Abstract

FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: one should form a transplant out of cortical plate taken in area of canal's formation, introduce a thread rod into the transplant followed by compactization of trabecular bone for the depth of 35 mm, not less due to the pressure along the rod's axis and fix this thread rod in the support of Ilizarov's apparatus. On the 5^th d it is necessary to conduct a dosed traction of the thread rod along its axis at the rate of 1 mm daily till transplant's movement - the fragment of cortical plate up to its initial position. The innovation enables to decrease traumatism, shorten terms of therapy and prevent the onset of contractures.

EFFECT: higher efficiency of therapy.

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Description

The present invention relates to medicine, namely to traumatology and orthopedics, and can be used to treat deforming arthrosis of the knee joint, especially accompanied by pain.

There is a method of treating arthrosis of the knee in the form of an exhaustive osteotomy of the proximal pineal gland of the tibia (1). From the skin incision along the inner surface of the proximal tibial epiphysis, through the hole in the cortical plate with a diameter of 8 to 18 mm, scabius bone is scooped around the circumference of the pineal gland. A curved rod inserted through the same opening simultaneously carries out free communication of the pineal gland with the bone marrow canal.

The main disadvantage of this method is that weakening of the bone in the metaepiphysis area as a result of full scooping up against the background of osteoporosis, a common companion of arthrosis of the knee joint, can lead to a compression fracture of one of the tibial condyles.

Closest to the proposed is a method of distraction stimulation of the proximal tibia with arthrosis of the knee joint (2). The essence of the method is that from the tibia, on the intervention side, 2 autografts of 5 cm × 1 cm are taken. The grafts are inserted into the channels made by a drill in the thickness of the metaphysis of the femur from the outside and in the proximal metaphysis of the tibia from the inside, at a distance of 2-3 cm from the level of the joint and parallel to it in the frontal plane. The outer ends of the grafts are introduced, as a rule, with some deepening (by 0.5-1.0 cm) and fixed with Kirschner spokes, which in turn are connected to the “tie rods” on the rings of the Ilizarov two-section apparatus, applied at the same level. After 2-3 weeks, slow traction begins at a speed of 0.25-0.5 mm per day for 1.5-2.5 months. Using the same Ilizarov apparatus, moderate decompression of the knee joint (with a force of 5-8 kg) lasting up to 3-4 months is performed. Full load on the limb was allowed 1-2 months after removal of the apparatus.

However, the known method has significant disadvantages:

1. Taking two free bone autografts with dimensions of 5 cm × 1 cm leads to significant additional trauma, an increase in the duration of surgery and, as a result, increases the risk of infectious complications.

2. The need to fit autografts after they are taken to the size of the holes made with standard drills also lengthens the operation time.

3. The use of two mini-distraction systems in one Ilizarov apparatus makes it difficult for patients to independently perform transplant distraction, especially at the outpatient stage of treatment.

4. Fixation of the knee joint against the background of degenerative-dystrophic changes characteristic of osteoarthritis within 3-4 months, as a rule, leads to the formation of persistent extensor contracture, completely leveling the effect of unloading of the knee joint. In this case, the duration of the recovery period for eliminating contracture is equal to the duration of knee fixation in the Ilizarov apparatus, which significantly increases the patient’s total treatment period.

To correct the identified shortcomings, the task was set:

- to increase the effectiveness of the treatment of deforming arthrosis of the knee joint by reducing the invasiveness of the method, the risk of infectious complications and shortening the treatment time.

The task is achieved as follows.

Treatment of deforming arthrosis of the knee includes the introduction of a graft into the canal, made from the inner surface of the proximal tibia epimetaphysis at a distance of 2-3 cm from the joint level and parallel to it in the frontal plane, followed by fixation of the graft in the Ilizarov apparatus. New in solving the problem is that the graft is formed from a cortical plate taken in the channel formation zone. After that, a threaded rod is inserted into the graft and pressure along the axis of the rod compactes the spongy bone to a depth of at least 35 mm, followed by fixation of the threaded rod in the support of the Ilizarov apparatus. Then, on the 5th day, metered traction of the threaded rod along its axis is performed at a rate of 1 mm per day until the fragment of the cortical transplant plate moves to its original position.

We explain the significant distinguishing features of the proposed method of treatment.

The formation of a graft from a cortical plate taken in the channel formation zone ensures the rejection of free autografts from additional incisions, as well as the absence of the need for precise fitting of grafts to the formed openings. The use of a cortical plate of the inner condyle of the tibia significantly reduces the time of surgical intervention and anesthetic management, minimizing the risk of anesthetic and infectious complications.

The insertion of a threaded rod into the graft and compaction of the cancellous bone by pressure along the axis of the rod to a depth of at least 35 mm, followed by fixation of the threaded rod in the support of the Ilizarov apparatus, allows only the tibia to be regenerated in the metaepiphysis without affecting the femur, which, together with maintaining the function the knee joint during treatment is not inferior to the prototype in stimulating effect. Moreover, the use of one support of the Ilizarov apparatus allows patients to maintain motor activity at the outpatient stage of treatment, which significantly improves the quality of life during treatment.

Performing metered traction of the threaded rod along its axis at a rate of 1 mm per day, starting from 5 days from the operation to the advancement of the fragment of the cortical transplant plate to its initial position, is necessary for the formation of a distraction regenerate. This corresponds to the concept of the stimulating effect of tensile stress on the blood circulation of the operated limb according to Ilizarov (3), and, on the whole, shortens the patient’s treatment by this method by 2 times.

Conducted patent information studies have shown that the proposed method is new and industrially applicable, since it does not require exceptional funds for its implementation. The interconnection of essential techniques ensures the achievement of a new technological result and has an inventive step.

The essence of the proposed method is as follows.

Under general anesthesia, under aseptic conditions, in the patient’s position on the back, along the inner surface of the proximal tibia epimetaphysis, retreating from the joint gap by 2-3 cm, a skin incision is performed, followed by layer-by-layer access to the cortical plate. A chisel having a width of 15 mm and oriented parallel to the joint in the frontal plane forms a window in the cortical plate measuring 15 mm × 15 mm with a bit recess of at least 35 mm. A threaded rod with a diameter of 6 mm is inserted into the middle of the square bone graft flap, and the end of the shaft should not stand more than 3 mm inward from the cortical plate (see the appendix to the description, Figure 1, a).

After that, pressure along the axis of the rod compactifies the spongy bone to a depth of not less than 35 mm. 3-4 cm distal of the threaded rod mount the ring support of the Ilizarov apparatus and two mutually intersecting spokes with a diameter of 1.8 mm stretched in it. Next, the threaded rod is fixed to the base support using a bracket and two nuts (see the appendix to the description, Fig. 1, b), while the nut that is closer to the lower leg is a lock nut, and the second nut is the main one. The postoperative wound is sutured with interrupted sutures.

On the 2nd day after the operation, the patient is allowed to load on the operated limb, which he brings to full load no later than 7 days after the operation. Simultaneously with the beginning of the load, the patient is prescribed physiotherapy exercises on the knee joint. On the 5th day after the operation, the formation of a distraction regenerate begins by dosed traction of the threaded rod along the axis at a rate of 1 mm per day, which is achieved by loosening the lock nut and rotating the main nut 360 degrees around the longitudinal axis of the rod, after which they tighten the lock nut. Distraction is continued until a fragment of the cortical transplant plate reaches its original position (see the appendix to the description, FIG. 1, c). The period of distraction, which the patient performs first under medical supervision, and later independently, is equal to the depth of the initial compaction of the cancellous bone of the tibia metaphysis, i.e. not less than 35 days. Throughout the entire period of distraction, the patient moves with full load and preserves the static-dynamic function of the knee joint. After the transplant is installed in the mother bed of the cortical condyle of the tibia, which is periodically monitored by x-ray, the external fixation system and the threaded rod are removed, the wounds are healed by secondary intention.

The period of treatment of the patient by the proposed method consists of separate periods: preoperative period - 3 days, pre-distraction - 5 days, distraction period - 35-40 days. Thus, the period of inpatient and outpatient treatment of a patient before returning to everyday life is 45 days.

This method treated 2 patients with deforming arthrosis of the knee joint with severe pain.

The result of the treatment of these patients was a complete relief of pain, including nighttime, an improvement in the static-dynamic function of the knee joint, assessed using the Leken scale (Leqens MG, 1997) (4), in the form of a decrease in pain syndrome with a pronounced (8-10 points) to mild (1-4 points), a subjective improvement in the quality of life associated with the expansion of motor activity.

The essence of the proposed method is illustrated by a clinical example.

Patient M., 59 years old, was admitted to the clinic GU SC RCVSC VSNS RAMS 05/13/2003 Diagnosis: bilateral post-traumatic osteoarthritis of the knee joints, left III degree, right I degree; varus deformity and extensor contracture of the left knee joint (see the appendix to the description: Figure 2, a, b). The range of motion in the left knee joint, measured by the “0” passing method, was: flexion / extension = 100/5/0. The severity of pain on the Leken scale is 10 points, which corresponds to a pronounced degree.

May 15, 2003 under spinal anesthesia performed surgery. Under aseptic conditions, in the patient’s position on the back, along the inner surface of the proximal tibia epimetaphysis, 2.5 cm from the articular gap, a skin incision was made, followed by layer-by-layer access to the tibial cortical plate. A bit having a width of 15 mm and oriented parallel to the joint in the frontal plane forms a window in the cortical plate with dimensions of 15 mm × 15 mm with a bit indentation of at least 35 mm. A threaded rod 6 mm in diameter was inserted into the middle of a square bone graft graft (see the appendix to the description: Fig. 3 a, b).

After that, pressure along the axis of the rod compacted the spongy bone to a depth of 35 mm. An annular support of the Ilizarov apparatus was mounted 4 cm distal to the threaded rod and two mutually intersecting spokes with a diameter of 1.8 mm were pulled in it. Next, the threaded rod was fixed to the base support using a bracket and two nuts. The postoperative wound was sutured with interrupted sutures.

On the 2nd day after the operation, the patient is allowed to load on the operated limb, which he brought to full load on the 7th day after the operation. Simultaneously with the beginning of the load, the patient was prescribed physiotherapy exercises of the knee joint. On the 5th day after the operation, the formation of a distraction regenerate began by dosed traction of the threaded rod along the axis at a rate of 1 mm per day. The distraction was continued until the fragment of the cortical transplant plate reached its initial position (see the appendix to the description: Fig. 4 a, b). The period of distraction, which the patient performed first under medical supervision, and later on his own, is 35 days. Throughout the entire period of distraction, the patient moved with full load and maintaining the static-dynamic function of the knee joint. After the graft was placed in the mother bed of the cortical condyle of the tibia, the external fixation apparatus was removed and the wounds healed by secondary intention (see the appendix to the description: Fig. 5 a, b).

The term of treatment of the patient by the proposed method was 40 days.

The result of treatment of the patient was the relief of the pain syndrome - the Leken index in dynamics decreased from 10 to 3 points (weakly expressed), the increase in the range of movements in the left knee joint was: flexion / extension = 140/0/0.

When examining the patient in dynamics 1 month after dismantling the AVF, the Leken index did not decrease and the range of movements did not change, the control x-ray revealed filling of the bone cavity with the formed bone regenerate (see the appendix to the description: Fig.6 a, b).

Thus, the proposed "Method for the treatment of deforming arthrosis of the knee joint" in comparison with other known technologies has improved the efficiency of treatment of patients, reduce the morbidity and risk of infectious complications, reduce treatment time by 2 times (from 3-4 months to 40-45 days), stop pain, and also increase the range of motion in the knee joint.

Sources of information taken into account

1. Paskachev A.B. Exhaustive osteotomy in the treatment of patients with deforming arthrosis of the knee joint stage 1-2 // Abstract of Cand. honey. sciences. - Moscow. - 1987. - 17 p.

2. Prokhorov V.P., Murugov B.C. Distraction biostimulation in the treatment of gonarthrosis // Orthopedics, traumatology and prosthetics. - 1991. - No. 11. - S.23-25.

3. Ilizarov G.A. Some theoretical and clinical aspects of transosseous osteosynthesis from the perspective of general biological patterns that we discovered // Clinical and theoretical aspects and experimental justification of transosseous osteosynthesis in bone and soft tissue distraction. - Kurgan, 1986. - S.7-12.

4. Kovalenko V.N., Bortkevich O.P. Osteoarthrosis. A practical guide. - Kiev, 2003. - P.399.

Claims (1)

A method of treating deforming arthrosis of the knee joint, including the introduction of a graft into the canal, made from the inside in the proximal tibia epimetaphysis at a distance of 2-3 cm from the joint level and parallel to it in the frontal plane, fixation in the Ilizarov apparatus, characterized in that the graft is formed from a cortical plate taken in the zone of channel formation, a threaded rod is inserted into the graft, pressure along the axis of the rod compaction of the spongy bone to a depth of not less than 35 mm, fix the threads the fifth rod in the support of the Ilizarov apparatus, on the 5th day, metered traction of the threaded rod along its axis is performed at a rate of 1 mm per day until the graft — a fragment of the cortical plate — moves to its initial position.

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