RU2363408C1 - Method of treating osteoarthrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: extraarticular subcartilaginous decompression tunnelling of epiphyses of knee joints and knee cap is done. Contents of the medullary canal of shin bone are subcartilaginously put into the groove of a bone perforator. Not less than 16 zones for active remodelling are formed in the subcartilaginous layer of articular sections.

EFFECT: possibility of potentiating reparative chondrogenesis.

2 cl, 1 ex, 3 dwg

Description

The invention relates to medicine, in particular to orthopedics, namely to extra-articular methods of treating heterogeneous gonarthrosis, 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 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 biological effect on the subchondral zone of the condyles of the femur and tibia with potentiation of reparative tissue genesis.

A known method of surgical treatment of deforming arthrosis of the knee joint with tube 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. The method also does not provide for biological potentiation of reparative chondrogenesis.

Known bone perforator (patent No. 50101 of the Russian Federation, MKI A61B 17/56. Bone perforator. / Makushin VD, Chegurov OK, Biryukova M.Yu. - No. 2005116553; claimed. 05/30/05; publ. 12/27/05 d.), which is used for trabecular tamponade of the spoke canals with the aim of stimulating reparative processes. However, this bone perforator was not used for subchondral injection of tissue contents from the bone marrow cavity.

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 of the Russian Federation. Method of treating deforming arthrosis of the knee joint. / V.D. Makushin, O.K. Chegurov, V. I.Kazantsev, B.V. Kamshilov (RF), No.20026047 / 14; claimed on 10/16/2000. Published on 11/27/2002. Bull. 33).

However, in the known method, reparative chondrogenesis is not potentiated by the introduction of intravital biologically active substances of the bone marrow and stromal cells from the bone marrow cavity into the subchondral parts of the bones.

The objective of the present invention is the possibility of potentiation of reparative chondrogenesis by the introduction of intravital biologically active substances of the bone marrow and stromal cells from the bone marrow cavity into the subchondral parts of the bones with the formation of sites of active remodeling.

The problem is solved in that in the method of treating osteoarthritis, including fan subchondral decompression tunneling of the articular ends and patella, tissue fluid is taken from the bone marrow cavity of the tibia, which is diluted 1: 6 with sterile physiological saline immediately after collection, a needle is drawn into the final zone of each tunnel attached to the syringe, and injected subchondrally at least 0.3 ml of diluted tissue fluid, apply aseptic dressings to the wounds, during the period of recovery For treatment, walking with crutches is recommended, followed by a gradually increasing load on the leg.

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

figure 1 - radiographs of the left knee joint of a patient P., 58 years old: a) in direct projection - before treatment; b) in direct and lateral projections - 6 months after treatment;

figure 2 - MRI tomograms (T1 mode) of the left knee joint: a) before surgery; b) 6 months after treatment;

figure 3 - MRI tomograms (T2 mode) of the left knee joint: a) before surgery; b) 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 solution in the projection of the upper part of the bone marrow cavity of the tibia, the anterior cortical layer of the tibia is perforated with a drill. A cannulated fixation screw with a mandrel for osteosynthesis M 16.10.004.000 with a length of 65 mm is screwed into the formed channel. Immerse its end in the bone marrow cavity of the bone. The mandrin is removed, instead an injection needle connected to the syringe is inserted into the channel of the fixative screw.

Then carry out the sampling of tissue fluid, by creating a vacuum in the cavity of the syringe, extract the contents from the bone marrow cavity of the tibia in an amount of 1.0 ml, which is immediately after the fence is diluted with sterile saline 1: 6. The locking screw is removed. A suture and an aseptic dressing are applied to the wound.

Then, a bone perforator performs fan subchondral tunnelization of the condyles of the femur and tibia, and oblique longitudinal tunneling of the patella. At least three tunnels are performed in the patella. In each condyle of the femur and tibia, at least 4 tunnels are formed subchondrally.

After the formation of each of the 16 tunnels with a depth of up to the subchondral layer, a needle attached to the syringe is drawn along the perforator groove into the final zone of the tunnel, and at least 0.3 ml of diluted 1: 6 tissue fluid containing intravital biologically active substances of the bone marrow and stromal cells is injected from the bone marrow cavity of the tibia.

The operation is completed by the application of aseptic dressings.

After surgery for the period of rehabilitation treatment, walking with crutches is recommended, followed by a gradually increasing load on the leg.

An example implementation of the method.

Patient P., 58 years old, diagnosis: Left-sided idiopathic gonarthrosis of stage II with pain. The disease is 2 years old. It was treated conservatively, taking analgesics and chondroprotectors. The treatment effect was mild. She experienced severe pain at rest and when walking.

During a clinical examination: there is no varus deviation of the left lower leg when standing. Flexion-extensor contracture of the left knee joint 90 ° -165 °. On palpation on the inner surface of the left knee joint, pain was noted. On the radiograph of the left knee joint in a direct projection there are signs of gonarthrosis characterizing the II stage of the degenerative-dystrophic process (subcompensated form) (Figure 1, a). On the MRI tomogram (T1 mode) of the left knee joint (Figure 2, a) the articular cartilage before treatment is summarized: in the medial section of the joint - 0.27 cm, in the lateral section - 0.33 cm. Trabecular edema of the subchondral sections is determined tibia. According to the MRI tomogram (T2-mode), evaluating blood circulation before treatment (Figure 3, a), in the anteroposterior and lateral projections in the area of the knee joint, subcompensated blood circulation with a poor arterial network and rare short collaterals is determined. The vascular network is partially reduced, the main vessels are spasmodic. Synovial inversion of the joint is increased.

Under epidural anesthesia after processing the surgical field, the conjunctive fixation screw was screwed into the upper part of the bone marrow cavity of the left tibia after perforation with a drill of the cortical plate from the planum tibia side and the end was immersed in the bone marrow cavity. The mandrin was removed and, using a syringe connected to a needle, 1.0 ml of content was obtained from the bone marrow of the tibia, which was diluted with an isotonic sodium chloride solution in a ratio of 1: 6. The locking screw has been removed.

A suture and an aseptic dressing were placed on the wound.

The oblique longitudinal tunneling of the patella was performed with the formation of three tunnels. Then, fan subchondral tunneling of the condyles of the femur and tibia was sequentially performed and, using a needle connected to the syringe, subchondral dilution of the bone marrow containing intravital biologically active substances of the bone marrow and 0 stromal cells was introduced subchondrally into the groove of the bone perforator using a syringe connected to a syringe , 3 ml to the final zone of each tunnel. The total number of tunnels in the subchondral sections was 16 (zones of active remodeling). Aseptic dressings were applied to the wounds.

On the second day after the operation, the patient started walking with crutches with a gradually increasing load on the operated limb. 1.5 weeks after the operation, the patient noted the absence of pain at rest and a sharp decrease in the intensity of pain during movement. The range of motion in the left knee joint increased (70 ° -180 °). The term of inpatient treatment was 35 days.

During the clinical examination of the patient after discharge from the clinic after 6 months, all types of pain syndrome are absent. Positive biological dynamics of structural elements in subchondral zones was noted. Joint function increased: painless full extension and flexion to 50 °. A distance of stable painless walking up to 3 km. The patient is satisfied with the treatment and notes an improvement in the quality of life.

When x-ray examination 6 months after surgery (Figure 1, b), the bone structure in the projection of the subchondral layer of the condyles of the articular parts of the femur and tibia is improved, the cartilaginous surface is flat, the sclerosis of the subchondral layer is reduced. On the MRI tomogram (T1 mode) of the left knee joint (Figure 2, b), the articular cartilage is summarized: in the medial section of the joint - 0.33 cm, in the lateral section - 0.38 cm. A decrease in trabecular edema of the subchondral divisions of the tibia bones. When assessing blood circulation on an MRI tomogram (T2 mode) in the anteroposterior and lateral projections in the area of the knee joint, compensated blood circulation with many developed collaterals of various calibers is determined (Figure 3, b). Reduction and spasm of the vascular network is absent. Synovial inversion of the joint is normal.

The proposed method for the treatment of osteoarthrosis allows using less traumatic surgical techniques to stimulate reparative chondrogenesis and potentiate regional blood flow. The trophic effect in the subchondral zone is enhanced. The configuration of the articular surfaces and the structure of the subchondral bone tissue are restored by remodeling tissue structures with intravital biologically active substances and stromal cells from the bone marrow cavity of the tibia of the patient.

The biological effect of local subchondral potentiation of reparative chondrogenesis in vivo by biologically active substances of the bone marrow and stromal cells from the bone marrow cavity of the tubular bone is as follows. A microcirculatory disorder with gonarthrosis causes a decrease in capillary circulation and ischemia in the subchondral bone. Under the influence of circulatory disorders, venous stasis and hyperemia occur, blood oxygen saturation in the subchondral layer of the bone decreases, morphological changes in bone trabeculae occur, and bone metabolites activating proteolytic activity accumulate. The metabolism of the subchondral layer and cartilage nutrition are disturbed. The destruction of cartilage proteoglycans occurs, leading to its degradation. When tunneling the subchondral zones of articulating surfaces of the joint, potentiation of reparative chondrogenesis by intravital biologically active substances of the bone marrow and stromal cells from the bone marrow tubular bone with the formation of sites of active remodeling leads to the restoration of the constancy of interstitial and intraorgan homeostasis. In the areas of the subchondral bone opened during tunneling, blood vessels (capillaries) are formed again. Through the walls of blood vessels, a substance is exchanged between blood and tissues (water, ions, micro and macromolecules of cells, tissue medium and lymph). The microcirculatory network of the subchondral layer is restored. There is a trophic cooperative effect of activation of the reparative genesis of all tissues, including cartilage. Recovery of trophism leads to regression of degenerative-dystrophic processes in the joint. Partial resorption of calcified cartilage in the cartilage component creates normal biological contact with the adjacent bone.

Positive biological dynamics of the restructuring of the structure of the cartilage and subchondral bone tissue, a pronounced analgesic effect and an increase in joint function in the postoperative period indicate the effectiveness of surgical benefits and the stability of the result.

The proposed method is used in the clinical departments of FGU "RRC" WTO "them. Academician G.A. Ilizarov. Rosmedtehnologii ".

Claims (2)

1. A method of treating osteoarthritis, including fan subchondral decompression tunneling of the articular and patella, characterized in that the contents of the bone marrow cavity of the tibia are sampled, which is immediately diluted with sterile saline solution 1: 6, and a needle attached to the tunnel is attached to the tunnel syringe and injected subchondrally at least 0.3 mm, apply aseptic dressings to the wounds, during orthopedic walking is recommended during rehabilitation joint unloading and then gradually increasing the load on the leg. 2. The method according to claim 1, characterized in that at least 16 zones of active remodeling are formed in the subchondral layer of the articular regions.

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