RU2368342C1 - Method of compressive arthrodesis of ankle joint in case of traumatic osteoarthrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to orthopedics and can be applied in treatment of patients with consequences of severe chronic injuries of ankle joint. Before arthroscopic resection Ilizarov apparatus is superposed on foot and shin in such way that distal support is placed lower than ankle joint fissure. Subcutaneous ligamentotomy of collateral ligaments of ankle joint is performed. Distraction at the ankle joint level is realised until 6-8 mm diastasis is formed, subcutaneous ligamentotomy of collateral ligaments of ankle joint is performed, and in process of arthroscopic resection in upper-exterior and upper-interior angles of ankle "fork" by means of shvaver notches in sagittal plane on the whole tool diametre are made into stratum of joint site of shin bone and outer ankle from one side and into stratum of joint site of shin bone and inner ankle from opposite side.

EFFECT: method eliminates technical difficulties in process of operation.

1 ex, 5 dwg

Description

The invention relates to medicine, in particular to orthopedics, and can be used in the treatment of patients with the consequences of severe chronic injuries of the ankle joint.

There is a method of treating the consequences of chronic injuries of the ankle joint by creating arthrodesis of the articular surfaces, providing for a wide dissection of soft tissues, resection and their fixation with two knitting needles (Movshovich I. A. Operative orthopedics. M .: Medicine, 1983. - S.285-286).

The disadvantages of this method are:

- injuries;

- does not provide sufficient fixation;

- involves the prolonged use of plaster casts in the postoperative period.

There is also known a method of compression arthrodesis of the ankle joint, providing for the resection of the articular surfaces and the creation of rigid fixation and compression between them using the transosseous apparatus (Ilizarov G.A., Okulov G.V., Popova L.A. Compression arthrodesis of the ankle and other joints of the foot: Method recommendations KNIIEKOT. - Kurgan. - 1981. - 19 p.).

However, the known method has the following disadvantages:

- the invasiveness of surgery;

- the method involves an open resection of arthrodesis surfaces, which significantly increases the risk of postoperative complications;

- long stay of the patient in a hospital.

Closest to the proposed method is a compression arthrodesis using an arthroscopic technique, involving endoscopic resection of the ankle bones with their subsequent fixation and the creation of compression between them by an external fixation device (Loskutov A.E., Golovakha M.L., Lushnik S.L. arthroscopic technique for ankle arthrodesis // Orthopedics, traumatol. and prosthetics. - 2001. - No. 1. - 77-79).

The disadvantages of the prototype are:

- a limited list of indications for arthroscopy in severe degenerative-dystrophic lesions of the ankle joint due to significant technical difficulties associated with gross changes in the joint and paraarticular tissues, leading to a sharp narrowing of the joint gap;

- in the conditions of limited space and poor visibility of the operating area, it is not possible to complete the coaptation of arthrodesis surfaces without clear guidelines.

The aim of the proposed method is to expand the indications for arthrodesis of the ankle joint using arthroscopic techniques for severe deformations and severe degenerative-dystrophic lesions of the joint.

The object of the invention is achieved by the fact that before the arthroscopic resection, the Ilizarov apparatus is placed on the foot and lower leg so that the distal support of the apparatus is located below the ankle joint gap, subcutaneous ligamentotomy of the lateral ligaments of the ankle joint is performed, distraction is performed at the level of the ankle joint until the formation of diastasis 6-8-8 mm, and in the process of arthroscopic resection in the upper-outer and upper-inner corners of the “fork” of the joint, the saws are cut with a shaver in the sagittal plane at the entire diameter of the instrument in the thickness of the joint area of the tibia and outer ankle on one side and in the thickness of the joint area of the tibia and inner ankle on the opposite side.

The method consists in the fact that the compression arthrodesis of the ankle joint using arthroscopic techniques is performed in three stages as follows.

At the first stage, Ilizarov’s distraction transosseous apparatus is applied to the lower leg and foot by the generally accepted method for creating diastasis between the arthrodesized bones. The apparatus is composed of two rings and one half ring, elongated by two plate consoles connected by threaded rods. The connection of the half ring with plate consoles is strengthened by an additional half ring. An additional half-ring is mounted in the frontal plane so that its concave surface faces the plantar area of the foot. The proposed arrangement of the apparatus allows you to create significant distraction efforts in the system "apparatus-limb" and does not limit the manipulation of instruments during the arthroscopic stage of surgery.

Spokes on the lower leg are carried out in the upper third and on the border of the middle and lower third, taking into account the topography of the neurovascular formations. After tensioning the needles are fixed in the rings. In this case, the distal ring is located 6-8 cm above the ankle gap to facilitate arthroscopic manipulations. Through the calcaneus, two intersecting spokes are carried, which, in a tense state, are attached to the distal support of the apparatus.

After applying the Ilizarov apparatus, a subcutaneous ligamentotomy of the lateral ligaments is performed at the place of attachment to the ankles, which allows creating diastasis during bone distraction, which is necessary for the correct insertion of an arthroscope and ensuring adequate operative space. At the ankle joint, distraction is performed by tightening the nuts on the threaded rods between the distal ring on the lower leg and the supporting structure on the foot. The distraction of the bones forming the ankle joint is continued until the formation of diastasis of 6-8 mm, which is controlled radiologically. Such diastasis provides intraarticular space sufficient to perform the next stage of surgery.

The second stage of the operation consists in the removal of articular cartilage of articulating surfaces and bone resection for better coaptation of arthrodesis surfaces. On the front surface of the ankle joint, two punctures of the skin and a joint capsule 0.5 cm long are formed with a scalpel. An arthroscope is inserted through the anterolateral access, and a probe is examined through the anteromedial one and the joint is examined consecutively, from its anteromedial to the anterolateral and from the posterolateral to the posteromedial. During joint revision, all adhesions and scars intersect, preventing an adequate view of the ankle joint cavity. Then, the articular cartilage is uniformly removed from the distal articular area of the tibia of the talus block and from the inner surface of both ankles with a shaver. Resection of the talus block involves the removal of its convex and lateral surfaces until the bone marrow spaces of the cancellous bone are exposed. Coaptation of the resected talus block in the ankle “fork” is facilitated by the following technique in the preparation of the tibia bone bed. In the upper-outer and upper-inner corners of the “fork” of the ankle joint, they make a shaver a saw cut in the sagittal plane for the entire diameter of the instrument in the thickness of the joint area of the tibia and outer ankle on one side and in the thickness of the joint area of the tibia and medial ankle on the opposite side. This method of bone resection allows you to freely immerse the talus in the “fork” of the tibia and achieve good contact between the arthrodesis surfaces. The correct position of the arthrodesized bones while maintaining the biomechanical axis of the limb is controlled by x-ray. One puncture suture is applied to the skin punctures.

The third stage of the operation consists in fixing and compressing the arthrodesized bones with the compression version of the Ilizarov apparatus. To maintain coaptation of the arthrodesis surfaces, the talus is temporarily fixed to the tibia with three knitting needles, which are passed through the heel from the plantar surface. The distraction version of the Ilizarov apparatus previously applied to the lower leg and foot is transferred to the compression version.

For this, the supports of the Ilizarov apparatus on the foot are dismantled. Crossing spokes are additionally drawn through the talus in the horizontal plane, which are mounted on an elliptical support. The ellipsoidal support consists of two half rings connected by plate strips. The proximal ring and the distal support are interconnected by threaded rods, with the help of which moderate compression is performed in the arthrodesis zone. Knitting needles held transarticularly from the plantar surface of the foot are removed.

Postoperative management of a patient with compression arthrodesis of the ankle joint is to provide rigidity and stable fixation by creating additional compression of the ankle bones 1 mm every 7-10 days, in early functional therapy. Early walking begins on day 2 after surgery with a gradually increasing load on the leg. In the first week after surgery, the patient first walks with crutches, then with a cane and from the second week no longer uses additional support. Therapeutic exercises are indicated from 3-4 days after surgery. Control radiography is performed at least 1 time in 4 weeks.

The dismantling of the Ilizarov apparatus is carried out after the formation of ankylosis, which is determined on a radiograph and after a clinical test is performed (on average after 2 months). They recommend a gradually increasing load on the operated limb, which can be brought to full 2-3 weeks after removing the Ilizarov apparatus.

The essence of the invention is illustrated by drawings, where:

Fig. 1 - radiographs of patient B. before surgery,

Fig. 2 - radiographs of patient B. after surgery,

Fig. 3 - Radiographs of patient B. during treatment,

Fig. 4 - radiographs of patient B. after the dismantling of the Ilizarov apparatus,

Fig. 5 - Radiographs of patient B. 2 years after surgery.

The proposed method was successfully tested during 2004-2007. in the traumatology department of the NUZ “MSCh” in Astrakhan and at the department of traumatology, orthopedics and the ICH of the Astrakhan State Medical Academy for 9 patients.

The following are the results of the practical use of the method.

Example

Patient B., born in 1961, turned to the traumatology department of the NIH MCH in March 2004 with complaints of severe pain in the right ankle joint while standing and walking, and the inability to perform professional duties (forwarding agent in a trading company).

Objectively: the patient moves with crutches. The right ankle joint is deformed, swollen, there is a hallux valgus installation of the foot. Palpation in all sections of the ankle joint is moderately painful, there is a sharp local pain during palpation of the posterior edges of both ankles. Joint movements are painful. Range of motion in the joint - back flexion 90 °, plantar -125 °. Relative and absolute shortening of the right lower limb was not detected. On radiographs of the right ankle joint (Fig. 1) dated 03.02.04, the false joint of the inner ankle, synostosis of the tibia syndesmosis, fused fracture of the lower third of the fibula, significant narrowing of the joint gap with the presence of marginal growths, valgus installation of the talus (up to 20 ° from the horizontal plane ) due to the impression of the outer parts of the joint area of the tibia.

From the anamnesis, it was found that 4 years ago she underwent osteosynthesis with an knitting needle and fixation of the tibiofibular syndesmosis with a bolt-coupler for fractures of the ankle and lower third of the fibula, rupture of the tibiofibular syndesmosis of the right ankle joint. The fracture of the inner ankle did not grow together (Fig. 1), the fixators were removed 6 months after the operation (Fig. 1). Further symptomatic conservative treatment was ineffective.

On March 30, 2004, a patient under anesthesia underwent compression arthrodesis of the right ankle joint using the arthroscopic technique according to the proposed technique in the traumatology department of the medical institution Medsanchast. The patient was placed a distraction version of the Ilizarov apparatus, performed a subcutaneous ligamentotomy of the lateral ligaments of the ankle joint, arthroscopically removed the articular cartilage from the arthrodesis surfaces and, taking into account the existing deformation in the upper-outer and upper-inner corners of the “fork” of the joint, made a shaver cutting into the entire sagus plane in the thickness of the joint area of the tibia and outer ankle on one side and in the thickness of the joint area of the tibia and inner ankle with ivopolozhnoy hand, performed wedge resection of the tibia, the compression created between bones artrodeziruemymi external fixation apparatus (Fig.2, 3). She was discharged from the hospital on April 4, 2004.

In the postoperative period, to ensure rigidity and stable fixation, additional compression of the ankle bones was supported by 1 mm every 7-10 days, early functional therapy was performed. The patient was recommended early walking from 2 days after surgery with a gradually increasing load on the leg, and from the second week without additional support (Fig. 3). Therapeutic exercises were prescribed from 3 days after the operation.

The Ilizarov apparatus was removed after 9 weeks of fixation after a clinical test and determination of bone ankylosis on a radiograph (Fig. 4).

No complications were noted during the entire treatment period. The total fixation period of the apparatus was 9 weeks.

When assessing the long-term result (after 2 years), it was found out that the arthrodesis is well-to-do (Fig. 5), the patient has no complaints. The installation of the right foot is correct. The range of motion of the foot was 3-4 °. The patient performed the previous work associated with long walking.

The proposed method of compression arthrodesis of the ankle joint in patients with the consequences of severe trauma to the ankle joint achieves the following positive effect:

- allows you to expand the indications for the use of arthroscopic techniques for resection of arthrodesis surfaces in case of gross deformations and severe degenerative-dystrophic joint lesions;

- facilitated the implementation of full coaptation of arthrodesis surfaces;

- reduced trauma surgical intervention;

- the risk of early and late postoperative complications is reduced;

- allows you to early activate the patient in the postoperative period;

- allows you to carry out an early load on the operated limb;

- provides the formation of bone ankylosis between arthrodesis surfaces in a shorter time;

- improves cosmetic results of surgical treatment;

- reduced the length of stay of the patient in the hospital.

Thus, the advantage of the proposed method of compression arthrodesis of the ankle joint for traumatic osteoarthritis is the reduction in morbidity, the expansion of indications for arthrodesis of the ankle joint using arthroscopic techniques in the case of severe deformations and severe degenerative-dystrophic lesions, the improvement of cosmetic results of surgical treatment, and the reduction of hospital treatment time.

The implementation of this method will improve the quality of surgical treatment of patients with the consequences of severe ankle injury.

Claims (1)

The method of compression arthrodesis of the ankle joint for traumatic osteoarthritis, which consists in arthroscopic resection of the ankle bones with their subsequent fixation and the creation of compression between them by the Ilizarov apparatus, characterized in that before the arthroscopic resection, the Ilizarov apparatus is placed on the foot and lower leg so that the distal support of the apparatus is located lower cracks in the ankle joint, perform subcutaneous ligamentotomy of the lateral ligaments of the ankle joint, carry out the distraction at a ram of the ankle joint to the formation of diastasis of 6-8 mm, and in the process of arthroscopic resection in the upper-outer and upper-inner corners of the “fork” of the joint, they bring shavings in the sagittal plane over the entire diameter of the instrument into the thickness of the joint area of the tibia and outer ankle with one sides and in the thickness of the joint area of the tibia and inner ankle on the opposite side.

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