RU2353314C2 - Therapy of gonarthrosis complicated with aseptic femur condyle necrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method refers to medicine, particularly to orthopaedics, and to be applied for therapy of gonarthrosis accompanied with aseptic femur condyle necrosis. Substance of the method involves subchondral decompression tunnelling of articular ends and patella. It is accompanied with parallel tunnelling within a pathological site of condyle thus destroying the modified bone structure. Then bone chips are tunnelled from unmodified sites of the opposite femur condyle.

EFFECT: invention allows stimulating reparative regeneration of tissues and regional blood flow herewith draining a pathological change site, recovering organ structure and configuration after destructing a zone of pathological subchondral site, providing decompression of intraosseous hypertension, reducing operative extent and injuries, providing possibility for early operated limb loading and rapid recovery of joint movements.

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Description

The invention relates to medicine, in particular to orthopedics, namely to extraarticular methods of treating gonarthrosis complicated by limited subchondral aseptic necrosis of the femoral condyle (Koenig disease), and can be used in clinical departments specializing in the treatment of joint diseases.

A sanitizing operation in the treatment of gonarthrosis is known, consisting in arthrotomy through parapatellar approaches with revision of the joint cavity and removal of the destroyed menisci and osteophytes, destroyed portions of the articular cartilage and other pathological formations (Slobodskaya AB, Osintsev E.Yu. Sanitizing operation for gonarthrosis and rehabilitation of patients after it // VI congress of traumatologists and orthopedists: Abstracts - N-Novgorod, 1997. - P.872).

This intraarticular operation is highly traumatic due to massive dissection of the soft tissues of the joint and is not aimed at stimulating reparative processes in the area of aseptic subchondral necrosis of the femoral condyle.

A known method of arthroscopic treatment of Koenig's disease with the surgical removal of bone-cartilaginous bodies from a niche, followed by osteoperforation of the subchondral portion of the bone using a Kirchner needle. In cases of large dissect sizes, arthroscopy is supplemented by arthrotomy (Monakhov V.V., Kuznetsov I.A., Bashurov Z.K. Arthroscopic treatment of Koenig's disease // Collection of materials of the Third Congress of the Russian Arthroscopic Society. - M., 1999. - S. 91-92).

However, the implementation of intraarticular surgery does not provide for replacement plastics of the resulting defect in the articular surface with bone chips displaced from unchanged portions of the femoral condyles, which lengthens the time of organotypic reconstruction of the bone-cartilaginous structure.

Known is the arthroscopic method for mosaic chondroplasty of defects in articular surfaces in case of gonarthrosis with cartilaginous autografts taken in the same joint from non-loaded areas of the joint (Kuzmenko V.V., Lazishvili G.D., Lunsaga PM Experience of autotransplantation of articular cartilage // Collection of materials of the Third Congress of Russian Arthroscopic Society. - M., 1999. - P.119).

However, the operation is also performed intraarticularly and does not include plastic bone structures of the pathological zone of the required depth, which reduces the rehabilitation effect of treatment of the patient. In addition, according to A.Yu. Kayumova et al. (2006) when using arthroscopic operations at the third and fourth stages of deforming arthrosis of the knee joint (according to the Outerbridge classification, 1961), relapse and disease progression are observed in 30% of cases (Features of surgical treatment of various stages of deforming arthrosis of the knee joint using arthroscopic technique / A.Yu. .Kayumov, E.E. Chernyak, E.A. Trudzinskaya, N.V. Kochetova // Nizhny Novgorod Medical Journal (Traumatology, Orthopedics, Combustiology), 2006. - P.108-110).

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

The application of this method is very traumatic. Tunneling of the subchondral condyles is performed with a large diameter drill (8 mm) in the sagittal direction after preliminary sections of soft tissues. In addition, the method does not provide a targeted effect on the area of pathological reconstruction of the condyles of the femur.

There is a method of surgical treatment of deforming arthrosis of the knee with tubal scalpels (Surgical treatment of deforming osteoarthritis / Yu.M. Yushenin, M.M. Fedorov, I.S. Valitov and others // Singral surgery. - 2000. - No. 1. - S.25-30).

However, after staged tunneling of soft tissues in the joint area and drilling with hollow drills of bone-forming elements of the knee joint in 16.9% of cases, the pain syndrome intensifies and leads to an unsatisfactory result of the operation.

A known method of treating deforming arthrosis of the knee joint, in which subchondral knitting needles form tunnels through the bones of the knee joint through mutually oblique directions (Patent 2193363 RF Method for the treatment of deforming arthrosis of the knee joint / V.D. Makushin, OK Chegurov, V.I. Kazantsev, B. .V.Kamshilov (RF), No.2000126047 / 14; Declared 10/16/2000. Published on 11/27/2002. Bull. 33).

However, in the known method, they do not locally affect the entire area of the site of pathological rearrangement of the femoral condyle and do not produce plastic defect bone tissue from healthy areas of the bone, which reduces the effect of treatment.

The objective of the present invention is the destruction of the area of the pathological subchondral region, the restoration of its structure and configuration of the articular surface.

The problem is solved in that in the method of treatment of gonarthrosis. the condyle of the femur complicated by aseptic necrosis, including subchondral decompression tunneling of the articular ends, patella, tunneling is performed within the pathological section of the condyle, while the altered bone structure is destroyed, then subsequent bone grafting is performed with shavings that are moved along the tunnels from the unchanged sections of the opposite condyle.

It is advisable to form at least 8-10 tunnels parallel to each other passing through the pathological zone for maximum coverage of the focus of pathological restructuring.

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 left knee joint of the patient D., 61 years old in direct projection: a) before treatment; b) in the process of tunneling the pathological zone; c) 6 months after treatment;

figure 2 - Computer tomograms of the left knee joint: a, b) before treatment; c, d) 6 months after treatment.

The method is as follows.

Surgical treatment is carried out under epidural anesthesia. After treatment of the lower extremity with an antiseptic bone perforator (Patent No. 50101 of the Russian Federation, MKI А61В 17/56. Bone perforator / Makushin V.D., Chegurov O.K., Biryukova M.Yu. - No. 2005116553; filed 30.05.05; publ. . 12/27/05.) Perform tunneling of the changed condyle of the femur. A bone perforator is administered subchondrally from the side of the opposite condyle of the femur through a pathological focus. Using a pusher from the longitudinal groove of the bone perforator, before its removal, the bone chips formed from the unchanged part of the condyle are pushed out into the pathological reconstruction zone. At least 8-10 plane-parallel tunnels are formed, passing through the pathological focus, with its maximum coverage in volume.

In the projection of the condyles of the femur and tibia, where there are no pathological rearrangement zones, frontally, fan, subchondral tunneling of the articular ends is performed with the formation of at least 4-6 tunnels in each condyle. Frontally in mutually oblique directions, 3-4 channels are formed subchondrally with a spoke in the patella. After surgery for the period of rehabilitation treatment, walking with crutches without a load on the leg is recommended. 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.

The positive x-ray dynamics of the reconstruction of the area of aseptic necrosis with the restoration of the configuration of the articular surface and the structure of the subchondral bone tissue in the postoperative period indicates the effectiveness of the surgical aid and the stability of the result.

An example implementation of the method.

Patient D., 61 years old. Diagnosis: Bilateral idiopathic gonarthrosis stage II with pain more on the left. Aseptic necrosis of the internal condyle of the left femur. The disease is 2 years old. It was treated conservatively, taking analgesics and chondroprotectors. The treatment effect was mild. I had difficulty walking up the stairs.

Clinical examination: varus deviation of the left lower leg when standing at 5 °, flexion-extensor contracture of the left knee joint 90-165 °. On palpation on the inner surface of the right knee joint, pain was noted. On a radiograph of the left knee joint in a direct projection there are signs of gonarthrosis characterizing stage II of the process, in the internal condyle of the left femur, a bone-cartilaginous defect of an inhomogeneous structure with a sclerotic border around the site of destruction and discontinuity of the line of the cartilaginous surface of the condyle (Figure 1a). On computed tomograms, the pathological focus is located in the posterior part of the internal condyle of the femur. The defect in area was half the contact surface of the condyle (Figa, b).

After treating the surgical field with an antiseptic under epidural anesthesia from the unchanged condyle of the femur, a bone perforator is subchondrally inserted through the pathological focus of the opposite condyle of the femur. Using a pusher from the longitudinal groove of the bone perforator, before its removal, the bone chips formed from the unchanged part of the condyle were pushed into the pathological reconstruction zone. Similarly, 10 parallel tunnels were formed, passing through the pathological focus, with its maximum coverage in volume (Fig.1b). In the projection of the condyles of the femur and tibia, where there are no areas of pathological rearrangement, a fan, subchondral tunnelization of the articular ends was frontally performed with the formation of 6 tunnels in each condyle. Frontally in mutually oblique directions, 3 channels are formed subchondrally by a spoke in the patella.

On the second day after surgery, the patient began walking with crutches without loading the operated limb. 1.5 weeks after the operation, the patient noted a decrease in the intensity of pain during movement and an increase in the amplitude of movements in the left knee joint (70-180 °). The term of inpatient treatment is 45 days.

During the clinical examination of the patient, 6 months after discharge from the clinic, the intensity of the pain syndrome decreased significantly, when climbing the stairs to the 4th floor notes slight pain. Joint function increased: painless full extension and flexion to 50 °. The distance of stable painless walking is up to 2 km. Believes that the quality of life has improved. Satisfied with the treatment.

During an X-ray examination 6 months after the operation (Fig. 1c), the bone structure in the projection of the pathological focus of reconstruction is uniform, the continuity of the cartilaginous surface is restored, and sclerosis is absent. According to computed tomography of the knee joint, restoration of the bone structure is noted in the posterior part of the internal condyle of the femur, structurally, the bone defect is actively restored (Fig.2c, d).

The proposed method allows, using less traumatic surgical techniques, to stimulate reparative tissue regeneration and regional blood flow with drainage of the pathological reconstruction site. The resorbing effect in the subchondral zone of the necrotic elements of the pathological focus is enhanced, the configuration of the articular surfaces and the structure of the subchondral bone tissue are restored by means of the replacement “bone chip repair” of the reconstruction zone with the areas of “healthy” condyle bone beams.

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

Claims (1)

A method of treating aseptic necrosis of the condyles of the femur, including subchondral decompression tunneling of the articular ends, patella, characterized in that they produce parallel tunneling within the pathological section of the condyle, destroying the altered bone structure, then move the bony bone along the tunnels from unchanged portions of the opposite condyle of the femur.

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