RU2611913C1 - Method for treatment and prevention of deforming osteoarthritis of ankle joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: under the EOC control a K-wire is conducted intramedullary and a cannulated drill is used to form a channel where an artromedullar shunt is installed flush with an internal channel under the cartilage until total immersion flush with the bone front edge of the tibia, linking the intraosseous space, forming the medullary cavity of the tubular bone with joint cavity. After K-wire removal, the shunt channel is cleaned from possible bone chips contamination and the cartilage is treated in the outlet area by a countersink.

EFFECT: accelerated recovery of joint cartilage to prevent their deterioration.

2 cl, 3 dwg, 1 ex

Description

The invention relates to traumatology and orthopedics, and in particular to methods for the prevention and treatment of lesions with deforming osteoarthrosis of the ankle joint.

Prevention, as well as the treatment of various joint injuries are relevant trends in modern traumatology and orthopedics.

Degenerative and inflammatory diseases affect the joints of different age groups, and after 60 years of age - in about 60% of men and 70% of women. In this case, the joints of the lower extremities, constantly under load of body weight, are affected much more often than the joints of the upper limbs. The incidence of deforming osteoarthritis (hereinafter OA) of the ankle joint (crusarthrosis) is up to 25% in the structure of the incidence of OA (Zavgorodniy N.V., Tereshkova V.P., 2008), while in 60% of cases OA develops after various injuries, occupying the third the place after arthrosis of the knee and hip joints (Plotkin G.L. et al., 2006, Yezhov M.Yu., 2011), occurs mainly in people of young working age and is most severe due to the maximum weight load on these departments. Cruzarthrosis is a progressive disease, which is characterized by a decrease in the amplitude of movements, an increase in pain, especially during physical exertion, swelling of the joint, foot and lower leg. Subsequently, trophic disturbances join. According to intraosseous phlebography, pronounced signs of impaired venous outflow are detected. Normally, intraosseous pressure in the body of the talus is 10 mm aq. Art., in the distal tibia and fibula 26 and 23, respectively. With OA, the pressure in the talus increases 4 times, in the tibia - 3 times.

All this leads, as a rule, to severe damage to the articular cartilage, subchondral bone and capsule-ligamentous apparatus of the joints.

An important role in the pathogenesis of diseases is played by unfavorable changes in the tribological characteristics of articular cartilage, disrupting their sliding and proper functioning. The inflammatory reaction developing as a result of these diseases also causes a sharp increase in free radical processes with the formation of toxic products that exacerbate joint tissue damage.

The processes providing adequate biological lubrication and maintaining the physiological level of free radical processes in the joints in the world are not fully understood. The causes and pathogenesis of these disorders in the functioning of the joints have not yet been established, which prevents the development and search for pathogenetically substantiated methods of treatment and prevention of joint diseases.

Currently available methods of treatment are not aimed at eliminating the underlying causes of the disease and often provide only symptomatic treatment.

It is also known that the intra-articular administration of hyaluronate-based preparations proposed in the invention is not able to fully restore the tribological parameters of diseased joints (US Pat. US No. 5143724).

The use of phospholipids is also problematic, due to the uncertainty of the participation of phospholipids in articular friction (US Pat. No. 6133249).

For the treatment of inflammatory joint diseases, in particular for pain relief, the use of a synthetic catalyst is disclosed that accelerates the elimination of toxic oxygen radicals. However, this approach does not eliminate the causes of the activation of free radical processes in the affected joints (US Pat. US No. 6980620).

For the treatment of arthritis, plant lipid extracts have been proposed that have a beneficial effect due to the natural antioxidants contained in them, which is, in fact, a compensatory treatment that compensates for the lack of endogenous antioxidants present in the joint tissues (US Pat. No. 6346278).

The use of inhibitors of cyclooxygenase-2, induced nitric oxide synthase - iNOS, as well as inhibitors of cytokine activity reduces the inflammatory response in diseased joints (US Pat. No. 6,248,745, US No. 6492516). However, in these sources of information, the causes of the occurrence of an inflammatory reaction are not eliminated.

So there is a method of treating articular cartilage defects by injection of embryonic tissue (US Pat. RF No. 2195940). The disadvantages of this method are the risks associated with the use of allogeneic tissue - possible rejection, infection, there are problems with the presence of donor material.

A known method for the implantation of autologous chondrocytes (AO), cultured in vitro, then transplanted into the defect zone and secured using the periosteum, or artificial membrane. The disadvantages of this method include: the long time to obtain a cell culture (about 3 weeks), the expansion of surgical aggression when taking the periosteum, in addition, the artificial membrane is a foreign material, and the cost of such treatment is high (Brittberg M. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation / M. Brittberg, A. Lindahl, A. Nilsson et al. // N. Engl. J. Med. - 1994. - Vol. 331, No. 14. - P. 889-895).

Currently, there is no doubt that the source of embryonic development of cartilaginous tissues is the mesenchyme, in the composition of which the leading role is played by multipotent mesenchymal stem cells. A number of studies have been devoted to mesenchymal stem cells, from which it follows that the descendants of this cell population in the adult human body are multipotent mesenchymal stromal bone marrow cells. They differ from hematopoietic stem cells, since they do not express hematopoietic cell antigens - CD34, CD14, CD45. Part of the multipotent mesenchymal stromal cells, under certain conditions (appropriate microenvironment, cytokine effect, growth factors, etc.), can differentiate along the chondroblastic pathway into chondrogenic cells - prechondroblasts, chondroblasts, chondrocytes (Mazurov V.M. Joint diseases. Spetslit, 2008 , 397 p.).

A number of researchers have shown that stromal-vascular phenotype cells derived from adipose tissue can be the source of cartilage tissue progenitor cells. Adipose tissue stromal cells are a population of cells with a high degree of plasticity and high proliferation rate (Traktuev D.O. Adipose tissue stromal cells - a plastic type of cell with a high therapeutic potential / D.O. Traktuev, E.B. Parfenova, V .A. Tkachuk, KL March // Cytology. - 2006. - V. 48, No. 2 - p. 83-93).

A known method of repairing defects in hyaline cartilage of the knee joint, including the introduction of mesenchymal stem cells obtained by liposuction of subcutaneous fat from various tissues, followed by enzymatic treatment, after abrasive chondroplasty and microfracturing by arthroscopy (A. Stadnikov, etc. New methods for treating defects hyaline cartilage of the knee joint in patients with gonantrosis. Scientific and Practical Rheumatology, 2009, No. 3, pp. 1-5). In this method, it is only about the restoration of the knee joint.

A known method of repairing defects of hyaline cartilage of the articular surfaces of the ankle joint, in which injection of a mixture of stromal vascular fraction cells is used simultaneously with fibrin glue without opening the joint under the control of an electron-optical transducer under local or general anesthesia, which allows to achieve accurate delivery of the mixture to the defect zone and reliable fastenings (US Pat. RF No. 2559089).

In the later stages of the disease and severe joint damage, implantation of artificial joints is a common way to repair affected joints. The main disadvantage of arthroplasty is a more traumatic surgical method. In addition, it destroys all structures of the joint (articular surfaces, joint capsule), does not give the joint a chance to restore reparative processes in it.

To maximize the use of the patient’s body resources, minimize surgical intervention, as well as expand the ability to treat joint diseases, restore and create arthromedullary communication, various cannulated devices are used to select and supply the liquid fraction of the bone marrow (bone fat) from the intraosseous space to the articular cavity for lubrication of the articular surfaces (US Pat. RF. No. 2323775).

There are also various options for arthromedullary implants (US Pat. Of the Russian Federation at PM No. 91843, 92320, 92321), made cannulated, which provide a connection between the bone cavity and the articular cavity for bone fat from the intraosseous space to the joint cavity, which reduces the coefficient of friction of the articular surfaces .

None of the sources of information indicated the installation of cannulated arthromedullary implants specifically in the ankle joint to lubricate the articular surfaces with bone fat, which is part of the bone marrow, due to its anatomical features.

Ankle joint - an articulation of the bones of the lower leg with the foot - a mobile connection of the tibia, fibula and talus of a person. Complex in structure, blocky in shape, formed by the articular surfaces of the distal epiphyses of both tibia, covering the talus block with a “fork”. The tibia is adjacent to the upper articular surface of the talus, and the articular surfaces of the outer and inner ankles are on the sides. The following movements are possible in the joint: frontal axis - flexion and extension of the foot; the sagittal axis - supination and pronation, the vertical axis - abduction and reduction. Axial movements are conjugated and performed along a component line.

The technical result aimed at achieving this technical solution is the creation of such methods for the prevention and treatment of joint injuries and the development of ankle joint treatment methods that would provide lubrication and restoration of the affected joints, excluding small bones and soft parts from entering the bone marrow into the joint cavity tissue when drilling bone tissue. In addition, they would contribute to the restoration of tribological characteristics, normalization of oxidative and inflammatory processes in them using the patient’s bone fat with the help of minimally invasive established cannulated devices using arthroscopic or open methods.

The technical result is achieved through the use of a method for the treatment and prevention of deforming osteoarthritis of the ankle joint, characterized in that a longitudinal skin incision is made when accessing along the front-inner surface of the tibia in the projection of the ankle joint, then the incision is made in the projection of the joint gap along the inner contour of the medial ankle, then an access zone is identified at the base of the inner ankle along the front edge of the tibia, under the control of the image intensifier, a Kirchner needle is inserted in form a canal with a ramedullary and cannulated drill, into which an arthromedullary shunt with an internal canal is inserted flush under the cartilage until it is completely submerged with the anterior bone edge of the tibia, connecting the intraosseous space that forms the medullary bone cavity of the tubular bone with the articular cavity, from possible ingress of bone chips and process cartilage in the area of the outlet with a countersink.

You can also access along the front-outer edge of the tibia in the projection of the ankle joint, then the incision is made along the inner contour of the lateral ankle and an access area is identified, forming an artificial fossa at the base of the outer ankle along the front edge of the tibia.

From the above comparative analysis, it follows that the claimed method meets the patentability criterion of “novelty”, since no similar solution was found for the ankle joint from the information sources, the procedure for the operation of installing the arthromedullary hollow shunt in the ankle joint is not described.

The method comprising the claimed invention is intended for use in healthcare. The possibility of its implementation is confirmed by the methods and means described in the application. The claimed method ensures the achievement of the technical result perceived by the applicant, namely ensuring a high reparative ability to regenerate articular cartilage and shorten the rehabilitation time for patients with joint diseases, there is no likelihood of small bones and parts of soft tissues getting into the bone marrow when drilling.

From the above it follows that the claimed invention meets the condition of patentability "industrial applicability".

In the analysis of known methods, it was revealed that they lack information on the influence of the distinguishing features of the method on the achievement of a technical result, therefore, the invention meets the requirement of "inventive step".

Thus, at present, there is no effective, less traumatic method for treating degenerative-dystrophic diseases of the ankle joint using the bone marrow of the patient, constantly coming to the surface of the affected joints.

Prevention and treatment of lesions of the ankle joint (GSS) in the initial and subsequent stages of joint damage is carried out by connecting the intraosseous space that forms the joint of the bone filled with bone marrow with the joint cavity. This ensures that bone marrow components, including bone fat, enter the articular cavity due to increased intraosseous pressure as a result of elastic deformation of the bone during loading on the bone, including that arising from movement. In addition, with OA, the pressure in the talus increases 4 times, and in the tibia - 3 times. The bone marrow is able to constantly and fairly easily penetrate through the created channel into the joint space. Due to the difference in pressure, a pressure gradient arises, providing a direction for the fluid to move from the area with high pressure to the area with lower pressure. This eliminates the possibility of spontaneous squeezing of the bone marrow into the bloodstream, which could cause fat embolism.

Components of the bone marrow, including bone fat, also enter the friction surfaces of the joint and provide lubrication, thereby reducing friction between them. To do this, use a minimally invasive device installed by arthroscopic or open methods - an implant, or a cannulated device made in the form of a tube or made in the form of a shunt.

The installation of the devices used is carried out in various ways using the tool kits used in surgery, minimally invasively, and / or using arthroscopic techniques.

Operation Technique

During the operation, both front-inside access and front-outside access are possible.

The operation is performed using regional anesthesia (spinal, conduction, epidural). The position of the patient lying on his back.

Carrying out an operation with anterior-internal access. After triple treatment of the surgical field with an antiseptic solution and laying with sterile sheets, the forefoot is placed in the position of maximum pronation and abduction of the foot outward.

A longitudinal skin incision is made up to 3.5 cm when accessed along the front-inner surface of the tibia in the projection of the ankle joint, then the incision is continued in the projection of the joint space along the inner contour of the medial ankle. Stupidly and sharply we select the access zone at the base of the inner ankle along the front edge of the tibia, where there is its own anatomical fossa or notch.

Under the control of the image intensifier, the Kirschner needle is carried out, intramedullary (bottom-up, front-back, inside-out), until the sensation of "failure". A cannulated drill of 0 4.5 mm forms a channel into which an arthromedullary shunt is screwed (“flush” under the cartilage) until it is completely submerged flush with the bone anterior edge of the tibia. The types and sizes of the shunt are selected in advance or determined intraoperatively with a measuring ruler.

After removing the spokes, the shunt channel is cleaned of possible ingress of bone chips and other inclusions. The appearance of bone fat in the area of the shunt head indicates the proper installation of the shunt. The final stage is the processing of cartilage in the area of the outlet (countersink) in order to prevent channel overgrowth. Hemostasis. In layers - stitches on the wound.

In the postoperative period: cold - topically, painkillers according to indications, physiotherapy. Exercise therapy in the absence of pain. Dosed load on the limb from 1 day, with continuation in the next 2-3 days and full support on the leg from 3-4 days.

Performing surgery on the anterior-outer edge of the tibia

The operation is performed by anteroposterior access, under regional anesthesia (spinal, conductor, epidural). The position of the patient lying on his back.

After triple processing of the surgical field with an antiseptic solution and laying sterile sheets over the front of the foot with the hands of the surgeon, we bring, support and bring the entire foot to the position of the sole flexion. A longitudinal skin incision is made up to 3.5 cm, access is provided along the front-outer edge of the tibia in the projection of the ankle joint, then the incision is made along the inner contour of the lateral ankle. Stupidly and sharply we select the access zone, at the base of the outer ankle along the front edge of the tibia we create an artificial anatomical fossa.

Under the control of the image intensifier, the Kirschner needle is carried out, intramedullary (bottom-up, front-back, inside-out), until the sensation of "failure". A cannulated drill ∅ 4.5 mm forms a channel into which an arthromedullary shunt is screwed (“flush” under the cartilage) until it is completely submerged flush with the bone anterior edge of the tibia. The types and sizes of the shunt are selected in advance or determined intraoperatively with a measuring ruler.

After removing the spokes, the shunt channel is cleaned of possible ingress of bone chips and other inclusions. The appearance of bone fat in the area of the shunt head indicates the proper installation of the shunt. The final stage is the processing of cartilage in the area of the outlet (countersink) in order to prevent channel overgrowth. Hemostasis. In layers - stitches on the wound.

In the postoperative period: cold - topically, painkillers according to indications, physiotherapy. Exercise therapy in the absence of pain. Dosed load on the limb from 1 day, with continuation in the next 2-3 days and full support on the leg from 3-4 days.

INDICATIONS:

- osteoarthrosis of the I-II, II-III stages;

- prolonged pain syndrome (more than 6 months);

- impediment syndrome of the anterior and posterior parts of the ankle joint;

- waiting period for prosthetics;

- Patients who cannot or do not want to have a prosthesis.

Clinical example. Patient N., 76 l. DZ: Post-traumatic deforming osteoarthrosis (DOA) of the left ankle joint, 2 tbsp., The state after the operation of metal osteosynthesis of n / a lower leg bones (according to primary indications).

Complaints on admission: pain when walking, fatigue, swelling in the ankle joint.

Case history: household trauma, a fall on the street 01/15/2014, they first contacted the City Clinical Hospital No. 12, X-rays, the diagnosis was made of a fracture of the lower third of the bones of the left leg. Operation 01/30/2014 - open osteosynthesis of the bones of the left lower leg, fixation with plates and screws.

Local status: walks without additional support, limping on his left leg. The skin of both legs is clean. Right shin and foot without pathology. On the left lower leg there are postoperative scars at the level of the lower third. The skin color in this area is changed. Extension and flexion in the left ankle joint are limited, about 25 °. Sensitivity saved.

On the R-gram: bone growths along the edges of the articular surfaces of the tibia and neck of the talus, consolidated fracture of the ankles. A biomechanical study revealed latent lameness, a pronounced asymmetry of time parameters (7%, with a norm of less than 5%), and the time of double support was increased. The step frequency and walking speed are also clearly reduced. In addition, as compensation for the function of the ankle joint, the amplitude of the flexion-extensor movements in the knee joint, its recurrence, and the intrapronatal installation of the hip joint are sharply reduced.

The patient, after removing the positional screws from the lower leg, underwent an operation according to the method described above on the front-inner surface of the ankle joint, and the installation of an arthromedullary shunt. The postoperative period without features. Wound healing by primary intention.

At the control examination after 3 months: no pain. The gait is ordinary, does not limp. The range of motion in the ankle joint increased to normal. On the R-gram, the position of the arthromedullary shunt (AMS) is stable, migration of the implant and resorption of the inert tissue around it is not determined.

A repeated biomechanical study revealed that the asymmetry parameters returned to normal (3%), the periods of support were leveled, and the strength of the back push of the left foot increased. At the same time, the step frequency and walking speed increased. In addition, varus deviation of the left foot, recurrence of the left knee joint, and intrapronatal installation in the hip joint were reduced. The almost normal range of motion in the knee and hip joints was restored.

The proposed method of treatment is intended for the prevention and treatment of the ankle joint and allows you to maintain the range of motion in the ankle joint, extend for many years (tens of years) the person’s ability to move independently without pain, in addition, in some cases replacement of the endoprosthetics with treatment of the affected joint is possible due to the use of internal reserves of the body, such as lubricity and the ability to restore reserves of grease in the bones.

The proposed method of treatment will be widely used in clinical practice.

In fig. 1, an cannulated device is presented as an implant, made with a through channel, with inlet and outlet openings, a sheath made of materials used in orthopedics and equipped with threaded elements, perforations of various shapes and configurations. The sizes of the device allow selection for a specific option based on data such as, for example, the width of the joint space, stage of the disease. To achieve the specified technical result, it is possible to use various known devices installed invasively, namely a cannulated device made in the form of a tube or made in the form of a shunt.

In fig. Figures 2 and 3 show schematically the procedure of the operation, respectively, according to option 1 (performing an operation with anteroposterior access) and option 2 (performing an operation along the anteroposterior edge of the tibia).

The above method provides an acceleration of the recovery process of the affected cartilage tissue of the joint, the friction surfaces of the joints by lubricating the friction surfaces of the joints with components of the bone marrow, including bone fat.

The proposed method will prevent or significantly slow down the development of various joint lesions, including post-traumatic arthrosis, improve the recovery of affected human joints, including those affected by arthrosis of the ankle joint, in the initial and subsequent stages of lesions, including injuries or diseases, to delay the timing of a possible subsequent joint replacement and thereby extend the functioning of the person’s own joints. The invention uses the special properties of bone fat, which is part of the bone marrow, which have unique lubricating properties, as well as the fact that bone fat contains an antioxidant - vitamin E, which blocks the radical-forming activity of wear particles on rubbing surfaces.

Thus, a technical result was achieved that contributed to the restoration of the tribological characteristics of natural and artificial joints, normalization of oxidative and inflammatory processes in them to ensure long-term proper functioning of natural and artificial joints.

Claims (2)

1. The method of treatment and prevention of deforming osteoarthritis of the ankle joint, characterized in that a longitudinal skin incision is made when accessing along the front-inner surface of the tibia in the projection of the ankle joint, then the incision is continued in the projection of the joint gap along the inner contour of the medial ankle, then an access area is identified at the base of the inner ankle along the front edge of the tibia, under the control of the image intensifier, a Kirchner needle is inserted intramedullary and a canal is formed with a cannulated drill, into which the arthromedullary shunt with the internal canal is flush under the cartilage until it is completely submerged flush with the bone anterior edge of the tibia, connecting the intraosseous space that forms the bone marrow cavity of the tubular bone with the articular cavity, after removing the spokes, the shunt channel is cleaned of possible ingress of bone chips cartilage in the area of the outlet with a countersink. 2. A method for the treatment and prevention of deforming osteoarthritis of the ankle joint, characterized in that a longitudinal skin incision is made when accessing along the front-outer edge of the tibia in the projection of the ankle joint, then the incision is made along the inner contour of the lateral ankle and an access area is formed, forming an artificial fossa at the base external ankle along the front edge of the tibia, under the control of the image intensifier, the Kirchner needle is inserted intramedullary and a cannula is formed into the canal into which an arthromedullary shunt with an internal canal is pushed flush under the cartilage until it is completely submerged flush with the bone anterior edge of the tibia, connecting the intraosseous space that forms the bone marrow cavity of the tubular bone with the articular cavity, after removing the spokes, the shunt channel is cleaned of possible ingress of bone chips and area of the outlet with a countersink.

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