RU2288658C2 - Method for treating pain syndrome at gonarthrosis - Google Patents

Abstract

FIELD: medicine, orthopedics.

SUBSTANCE: it is necessary to carry out subchondral decompression tunnelization of articular ends of a knee joint and a patella along with measuring intraosseous pressure (IOP). Moreover, one should apply a cannulated screw-fixator by perforating cortical layer being perpendicular against tibial platform centrally by stepping about 1.5-2 cm distally. Then on should measure IOP and in case of hypertension one should introduce successively anesthetic and curantyl into tibial medullary cavity for the period of 5 d, not less and according to its decrease it is possible to evaluate the efficiency of therapy conducted. Application of the present method enables to decrease intraosseous pressure and, also, enhance and prolong analgesic effect in treating pain syndrome at gonarthrosis.

EFFECT: higher efficiency of therapy.

3 dwg, 1 ex, 1 tbl

Description

The invention relates to medicine, in particular to orthopedics, and in particular to methods of treating gonarthrosis, accompanied by severe pain, in the elderly and senile, and can be used in clinical departments specializing in the treatment of joint diseases.

A known method of surgical treatment of deforming arthrosis of the knee, which consists in subchondral tunneling of the articular ends (M.Kh. Khaddadin. Surgical treatment of deforming arthrosis of the knee joint // Orthopedics, traumatology and prosthetics. - 1981. - No. 3. - P.27-29) .

However, with this method in 23% of cases the pain in the knee joint does not disappear, which reduces the effect of rehabilitation treatment. In addition, the method does not provide for control of the reduction of intraosseous pressure (VCD) in the bone marrow cavity of the tibia.

The well-known method of Yushenin in the treatment of deforming arthrosis of the knee joint with tube scalpels (Surgical treatment of deforming osteoarthritis / Yu.M. Yushenin, M.M. Fedorov, I.O. Valitov, etc. // Singral surgery. - 2000. - No. 1 - S.25-30).

However, after the staged tunneling of soft tissues in the joint area and drilling with hollow drills of bone-forming elements of the knee joint in 44% of cases, the pain syndrome remains pronounced and reduces joint function. In 16.9% of cases, as a result of treatment, the pain syndrome intensifies and leads to an unsatisfactory result of the operation. The technique does not provide for decompression of the bone marrow cavity of the tibia.

A characteristic symptom of intraosseous hypertension in osteoarthritis of the knee is constant aching pain at rest and at night, which is due to a violation of intraosseous microcirculation. Intraosseous pressure is an integral indicator of hemodynamics, therefore there are suggestions for its reduction for pain relief (OA Ushakova. Diagnostic value of intraosseous pressure in case of deforming gonarthrosis. (Responsible editor A.Zh. Abrakhmanov). - Alma-Ata: Joint damage. - 1982. - S. 72-75).

However, with a single decrease in GVD, the analgesic effectiveness of the surgical procedure remains low and there is no prolonged effect on the angio-, barroreceptors and osteoreceptors of the bone marrow cavity of the tibia.

Known hydraulic lavage of the knee joint using arthroscopic technique in combination with tunneling of the articular and patella (Shevtsov V.I., Karaseva T.Yu., Soldatov Yu.P. Experience in treating patients with pathology of large joints in the RTC "WTO" using arthroscopic technology // Modern problems of medicine and biology: materials of the XXXI scientific-practical conference. - Kurgan, 1999. - P.120).

However, when using this method, it is not provided for a decrease in VCD in dynamics, which does not allow for objective control of the analgesic effect.

A known method of treating deforming arthrosis of the knee joint, in which the tunnels are formed subchondrally in the bones of the knee joint through mutually oblique directions and reduce intraosseous pressure (Patent 2193363 RF, MKI ⁷ A 61 B 17/56. Method for the treatment of deforming arthrosis of the knee joint / V.D. Makushin, OK Chegurov, V.I.

However, in the known method, after measuring the VCD, they do not actively affect the angio-, barroreceptors and osteoreceptors of the bone marrow cavity of the tibia using topical anesthetics and vascular preparations, which reduces the analgesic effect of the treatment.

The objective of the present invention is to develop a method for the treatment of pain with gonarthrosis, which allows to strengthen and prolong the analgesic effect.

The problem is solved in that in a method of treating a pain syndrome with gonarthrosis, including subchondral decompression tunneling of the articular ends of the knee joint and patella with the measurement of intraosseous pressure, a cannulated fixation screw for osteosynthesis is installed, perforating the cortical layer perpendicular to the longitudinal axis in the center 1.5-2 cm in the distal direction from the tuberosity, after which the VKD is measured in the bone marrow cavity of the tibia sequentially anesthetic (0.5% solution of novocaine 5.0 ml) and a vascular preparation (2% solution of pentoxifylline 5.0 ml; 0.5% solution of persantin 2.0 ml) are introduced, which have anticoanulant, angioprotective, immunomodulatory effect, and then, within five days after the operation, the VCD is additionally measured and the anesthetic with the vascular preparation is sequentially administered and, according to the magnitude of the decrease in the VCD, which is compared with the clinical intensity of the pain syndrome, the prolongation of the analgesic effect is evaluated.

The present invention is illustrated in a detailed description with reference to a specific example of the method, on a photocopy of x-rays, in which:

figure 1 - x-ray of the right knee joint of the patient G., 62 years old in direct projection before treatment;

figure 2 - x-ray of the right knee joint in a lateral projection during treatment;

figure 3 - x-ray of the right knee joint in the direct and lateral projections after treatment;

Table 1 - a map of the dynamics of the VKD and the nature of pain in the joint.

The method is as follows.

Surgical treatment is carried out under epidural anesthesia. After treatment of the lower extremity with an antiseptic in a plane perpendicular to the tibial site, a cannulated fixation screw set for osteosynthesis M 16.10.004.000 with mandrin is set centrally, departing distally by 1.5-2 cm from the tuberosity. The mandrin is removed, the cavity of the fixing screw is filled with an isotonic sodium chloride solution and connected through a hydraulic system to a pressure sensor. VCD recording is carried out on the "Minograph-4" company "Siemens-Elema". VKD is recorded in mmHg Then, a rubber plug is placed on the cannulated screw-clamp and the planned surgical intervention is performed.

In the projection of metaepiphyses of the femur and tibia, frontally, fan, subchondral tunneling of the articular ends with a spoke (6-8 tunnels) is performed. Frontally in mutually oblique directions, 3-4 channels are formed subchondrally with a spoke in the patella. In cases of violation of the biomechanical axis of the limb, corrective osteotomy of the tibia in the upper third of the leg is performed with correction of deformation and fixation by the Ilizarov apparatus. Immediately after surgery, the VCD is measured on the operating table, having previously removed the plug, after which an anesthetic with a vascular preparation: anticoagulant, angioprotector and immunomodulator is sequentially injected through the cannulated screw-clamp, a plug is put on the clamp-screw. Control is the result of a study of VCD before surgery.

The VKD is subsequently measured daily, ending with the administration of an anesthetic in combination with a vascular drug (anticoagulant, angioprotector and immunomodulator). The obtained VCD data is compared with the control. The value of the GVD is correlated with the average values obtained in the clinic of the RTC "WTO" in a group study in patients with gonarthrosis before and after decompression operations. The decrease in VVD on the fifth day after surgery to normal values indicates the effectiveness of surgical benefits and the stability of the result.

An example implementation of the method.

Patient G., 62 years old. Right-sided exchange-dystrophic gonarthrosis II Art. with severe pain. The disease is 8 years old. It was treated conservatively, taking analgesics, chondroprotectors, physiotherapy. The treatment effect was mild. Concerned about the constant painful pain in the knee when walking and at rest. The aching night pains are especially disturbing.

Clinical examination: varus deviation of the lower leg when standing at 5 °, flexion contracture 170 °. On palpation on the inner surface of the right knee joint, pain was noted. On radiographs of the right knee joint there are signs of gonarthrosis that characterize stage II of the process, the joint gap in the medial section of the joint is moderately narrowed. (Figure 1).

After treating the surgical field with an antiseptic under epidural anesthesia centrally, in a plane perpendicular to the tibia, 2 cm from the central bone tuberosity, a cannulated fixation screw for osteosynthesis M 16.10.004.000 is installed through the cortical layer. The mandrin was removed and the VKD measurement was made, which amounted to 15 mm Hg. (100%) (hypertension, 3 times higher than the normal numbers of VKD, with a norm of 4-5 mm Hg). Put on a rubber stopper on a clamp. Then, fan with the capture of the metadiaphyseal sections, tunneling was carried out with a spoke with a diameter of 1.8 mm with the formation of 6-8 channels in each bone and three mutually oblique channels in the patella (Figure 2). A 0.25% solution of novocaine 5.0 ml and pentoxifylline 2% - 5.0 ml, which pharmacodynamically improve microcirculation and rheological properties of the blood, cause a vasodilating effect, reduce platelet aggregation and blood viscosity, are introduced into the bone marrow cavity of the tibia. Block adenosine receptors.

On the operating table after the operation, the VKD was measured, the value of which was 12.5 mm Hg. or 83% of the original numbers. Put a cap on the locking screw. The patient received analgesics for 2 days.

The day after surgery (the first day) in the dressing room again measured VVD, which decreased to 10 mm RT.article. (67%). The patient noted a decrease in the intensity of pain at rest and at night. 0.25% solution of novocaine 5.0 ml and 0.5% solution of persantin 2.0 ml were introduced into the bone marrow cavity of the tibia according to the instructions. Persantine (curantyl, dipyridamole) is an antiplatelet agent, angioprotector, immunomodulator and has a local and general therapeutic effect.

2nd day after surgery: VKD - 12.5 mm Hg (83%). An anesthetic (0.25% solution of novocaine 5.0 ml) and a vascular preparation (0.5% solution of persantin 2.0 ml according to the instructions) were injected intraosseously.

Subjectively, the night pains disappeared, at rest during the day minor, weak, periodic pains were noted. Patient G. walked, resting on her leg, there were lungs, pain passing at rest.

3rd day after surgery: VKD - 12 mm Hg (80%). 0.25% solution of novocaine 5.0 ml and a vascular preparation (0.5% solution of persantin 2.0 ml) were injected intraosseously. At rest, there are no night pains. The patient noted minor pain in the knee joint by the end of the day, when she walked a lot. Analgesics were not prescribed in the following days.

4th day after surgery: VKD - 12.5 mm Hg (83%). An anesthetic and a vascular preparation were introduced intraosseously according to the above procedure. The patient is very pleased that the leg hurts slightly periodically when she walks a lot.

5th day after surgery: VKD - 5 mm Hg (33%), which is normal. Intracranial injected drugs according to the above method. The pain syndrome was completely and stably eliminated (Figure 4), regardless of function.

The patient was discharged from the clinic after 30 days with the absence of pain. On x-ray is not installed progression of degenerative-dystrophic signs in the tissues of the knee joint (Figure 3). The joint gap is not narrowed. No knee flexion contracture.

The proposed method allows to obtain the biological effect of the treatment, which consists in the fact that an active, directed effect on hypertension by lowering VCD in combination with intraosseous blockade by anesthetic (novocaine) and an anticoagulant, angioprotector, immunomodulator allows for pathogenetically based treatment of pain due to changes in the ischemic cycle of the disease , eliminating the violation of metabolic processes in the tissues of the knee joint. Unblocking local blood circulation, draining the venous stasis and anticoagulant, angiprotective effect of the used dipyridamole reduces thrombus formation in the smallest intraosseous vessels both in the subchondral bone and adjacent spongy bone of the articular ends.

The proposed method for improving subchondral microcirculation in clinical practice, it is advisable to combine with the restoration of the most correct biomechanical relationships of the articular ends in gonarthrosis.

The proposed method is used in the clinical departments of the RRC "WTO" named after academician G.A. Ilizarov.

Day Before surgery After operation day 2 days 3 days 4 days 7 days VKD fifteen 12.5 10 12.5 12 12.5 5 % one hundred 83 67 83 80 83 33 The presence of pain Painful, aching at rest and at night. Pain when walking - A sharp weakening of all types of pain No pain at rest. Mild pain while walking No pain at rest. Mild pain while walking No pain at rest. Periodic walking Complete disappearance of pain at rest in the joint and during movement

Claims (1)

A method of treating a pain syndrome in gonarthrosis, including subchondral decompression tunneling of the articular ends, patella, characterized in that through the cannulated fixative screw, which is installed by perforating the cortical layer perpendicular to the tibia area centrally, retreating 1.5-2 cm distal from the tuberosity, measure intraosseous pressure (VCD) and with hypertension, anesthetics and chimes are sequentially injected into the bone marrow cavity of the tibia for at least five days after surgery tion, the additional measurements carried EVA daily reduction which evaluate treatment efficacy.

Images