RU2391065C1 - Method of treatment of old lacerations of extensor apparatus of knee joint - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely to traumatology and can be used for treatment of old lacerations of extensor apparatus of knee joint. The mobilisation of lateral heads of quadriceps muscle of thigh is carried out. An autoplasty of tendinous defect, mobilisation and elongation of knee ligaments are conducted. In addition transverse channels in the patella, tendinous rectus, additionally in the tibial spine and the upper third of the tibia are formed. Plastic material is inserted through the channels forming two closed systems in the form of ovals: patella, tibial spine and tendinous rectus - the upper third of the tibia. ^ EFFECT: method allows to prevent the development of deforming arthrosis at old lacerations. ^ 1 ex, 4 dwg

Description

The invention relates to medicine, in particular to traumatology, and can be used in the surgical treatment of chronic injuries of the extensor apparatus of the knee joint.

Known methods for treating chronic injuries of the extensor apparatus of the knee joint both in the tendon of the quadriceps femoris and in the patellar ligament, including surgical replacement of the tendon defect with the help of plastic material from patient’s autotissues (SU 1097286, 1984; RU 2144800, 2000), allotisses ( Sukhonosenko V.M. Diagnostics and treatment of chronic injuries of the extensor apparatus of the knee // Tomsk State University of Surgery named after I.I. Grekov. - 1978. - T. 121, No. 7. P. 64-69; Nikitin G.D., Kornilov N.V., Linnik S.A., Efimov N.V. Allote Ndoplasty in the treatment of muscle, tendon and ligament injuries // St. Petersburg, 1994. - 256 p.), less often synthetic materials (Movshovich I.A. Operational orthopedics // M .: "Medicine", 1982 - 416 p .; Levitsky F .A., Trufanov IM Diagnosis and treatment of injuries of the extensor apparatus of the knee // Diagnosis and treatment of injuries of large joints: collection of scientific articles / NRITO named after R.R. Vreden. - St. Petersburg, 1991. - С .116-119).

However, simultaneous stitching of the diverged ends of the quadriceps femoris muscle with its chronic injury leads to the formation of extensor contracture of the knee joint in the postoperative period. Extensor contracture of the knee joint is the result of retraction of the quadriceps femoris, fibrotic changes in it and in the sliding apparatus, which develop due to the lack of normal function of this muscle for many months, and sometimes years after damage. Overcoming extensor contracture of the knee joint during rehabilitation, as a rule, requires considerable effort and a long time, drastically increasing the period of postoperative rehabilitation. In addition, with chronic ruptures of the quadriceps femoris, retraction and ligaments of the patella are often expressed, resulting in its low standing. Surgical restoration of the quadriceps femoris muscle in the presence of retraction of the patellar ligament does not eliminate its low location, which leads to discongruence in the femoral-patella joint. If relationships in the femoral-patella joint of any genesis are violated, both traumatic and dysplastic, deforming arthrosis develops in it, which leads to pain, limitation of movement in the knee joint, and impaired limb function (Simenach B.I. et al. Violation syndrome equilibrium of the patella of dysplastic origin (conceptual model) // OTP. - 1985. - No. 10. - P.18-23; Dejour D. et al. Postoperative low patella. Treatment by lengthening of patellar tendon // Rev. Chir. Orthop. Appar. Mot. 1995 - 81 (4) - P.286-295).

A known method for the treatment of chronic injuries of the quadriceps femoris muscle (RU 2161925, 2001), by muscle myolysis with the formation of a channel in the patella and autoplasty of the tendon defect, in addition to the channel in the patella above the damage in the rectus muscle form a transverse channel, plastic material is passed through the channels, for example, an allograft, the ends of which are sutured to form a closed system in the form of an oval, the quadriceps is fixed to the plastic material along its perimeter, and the lateral heads of the muscle are pre-alternated proximal. The created closed system additionally strengthens the reunited stump of the tendon, and the fixation of the quadriceps muscle to the plastic material along its perimeter increases the strength of the recreated tendon.

However, the reconstruction of the extensor apparatus of the knee joint according to this method does not provide the anatomical position of the patella in cases of retraction of its ligament, which leads to disruption of the relationship in the femoral-patella joint and the development of deforming arthrosis in it.

The technical problem - the restoration of congruency in the femoral-patella joint while maintaining the strength of the recreated tendon, is solved as follows.

In the method of treating chronic injuries of the extensor apparatus of the knee joint, including mobilization of the lateral heads of the quadriceps femoris, autoplasty of the tendon defect, the formation of transverse channels in the patella and in the tendon of the rectus muscle, the use of plastic material, for example, allotendin to form a closed system in the form of an oval, according to the invention mobilization and elongation of the ligament of the patella and additionally form the transverse channels in the tuberosity and in the upper third of the tibia bone, and plastic material is passed through the channels with the formation of two closed systems in the form of ovals: patella-tuberosity of the tibia and tendon of the rectus muscle - the upper third of the tibia.

Mobilization and lengthening of the patellar ligament allows to normalize the position of the patella and restore congruence in the femoral-patella joint. The formation of two oval closed systems provides reliable duplication of the place of rupture (corrugating suture) of the tendon and the elongated patellar ligament with an allotendin, ensuring the preservation of the anatomical position of the patella and normal relationships in the femoral-patella joint.

Thus, the use of the proposed method allows to restore congruency in the femoral-patella joint, to ensure the preservation of its normal function, which prevents the development of deforming arthrosis.

The method is as follows.

Figure 1 presents a diagram of the reconstruction of the extensor apparatus of the knee joint.

Surgical access - an incision along the anteroposterior surface of the thigh from the middle third of it to the lower edge of the patella. Tissues are dissected in layers, the skin-fascial flap is removed outside, the place of the damaged tendon is exposed. The quadriceps femoris is divided into its constituent portions, dissecting the adhesions between them, the lateral heads are mobilized. The quadriceps tendon together with scars in the lesion area is isolated, a corrugating suture is applied to them, combining both tendon stumps and cicatricial regenerate. This technique restores the integrity of the tendon and eliminates the defect. The ligament of the patella is mobilized and its Z-shaped elongation is performed. In the central part of the patella in the frontal plane, a channel with a diameter of 4-5 mm is formed with a drill or a milling cutter. Then also in the transverse direction form a channel in the tuberosity of the tibia. Any plastic material, for example, allotendinum, is passed through the formed channels, its ends are pulled and sutured, and a closed oval-shaped system is formed. For the second closed system, the transverse channels in the tendon of the rectus muscle are similarly formed 3-4 cm above the zone of its damage and the upper third of the tibia, through which plastic material is passed, for example, allotendin, its ends are pulled and sutured, and a closed oval shape system is formed: the rectus tendon is the upper third of the tibia. The wound is sutured in layers, tightly.

Example. Patient B., 63 years old, was admitted to the hospital 1 year 5 months after an injury with complaints of lack of active extension of the left lower leg, instability when walking, restriction of movement in the knee joint, fatigue and lameness.

Diagnosis: chronic full rupture of the tendon of the quadriceps muscle of the left thigh. On radiographs, the low position of the patella is determined: the left patella is located 2 cm lower than the right. The Insall-Salvati Index is below normal.

The operation was performed: revision of the extensor apparatus of the knee joint, a rupture of the quadriceps femoris, diastasis over 6 cm, filled with scars. The retraction of the patellar ligament and the low standing of the patella were determined.

Figure 2 presents the x-ray of the right (healthy) knee joint; Figure 3 - x-ray of the left knee joint before surgery; Figure 4 - x-ray of the left knee joint after surgery.

Surgical separation of all portions of the quadriceps femoris was performed. The patellar ligament was mobilized and its Z-shaped extension of 2 cm. The tendon of the rectus and intermediate muscles, together with the scar tissue filling the rupture area, was reduced to the patella. A mattress suture was placed at the ends of a torn tendon with corrugating scar tissue in the gap zone. In the tuberosity of the tibia and the upper third of the leg (at a distance of 3 cm), as well as in the patella, transverse channels with a diameter of 5 mm are formed. Through the patella and canal, a 29 cm long allograft transplant was made in the tuberosity, its ends are stretched and stitched, forming a closed system in the form of an oval (internal). The second allograft (connected from two, 48 cm) is inserted through the canal in the upper third of the leg and the transverse canal in the tendon of the quadriceps femoris muscle, formed above the lesion zone. The ends of this allograft are taut and sutured. The wound is sutured tightly. Gypsum tire for 4 weeks.

Congruency in the femoral-patella joint restored. The Insall-Salvati index is within normal limits. Recovery treatment after removal of the cast was carried out for 4 weeks. The function of the active extension of the lower leg was restored after 8 weeks, the range of motion in the knee joint was 75-165 (active), 75-180 (passively). The support ability of the operated limb is fully restored.

Thus, the use of the proposed method for the surgical treatment of chronic injuries of the extensor apparatus of the knee joint provides:

- the formation of a single functional block from the tendon of the rectus and intermediate muscles, scars and plastic material;

- reliable duplication of the suture area of the recreated tendon and ligament of the patella;

- restoration of congruency in the femoral-patella joint.

This allows you to restore the integrity of the extensor apparatus of the knee joint, to ensure functional rehabilitation of the patient with the exception of the possibility of repeated rupture of the extensor apparatus of the knee joint, to normalize the relationship in the femoral-patella joint and prevent the development of deforming arthrosis in it.

Claims (1)

A method of treating chronic injuries of the extensor apparatus of the knee joint, including mobilization of the lateral heads of the quadriceps femoris, autoplasty of the tendon defect, the formation of transverse channels in the patella and in the tendon of the rectus muscle, the use of plastic material to form a closed system in the form of an oval, characterized in that they mobilize and lengthening of the ligament of the patella and additionally form transverse channels in the tuberosity and in the upper third of the tibia, and plastic Methods and material carried through the formed transverse channels to form two closed systems in the form of ovals: patella - tibial tuberosity and tendon rectus muscle - the upper third tibia.

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