RU2623316C1 - Method of plastic surgery on anterior cruciate ligament of knee joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: through oblique channels are formed in a medial condyle of tibia and a lateral condyle of femur. A synthetic transplant is led through the oblique channels. The transplant ends are fixed in the oblique channels using interference screws. Two through horizontally oriented channels are additionally formed: one - above the outer aperture of the femur oblique channel, the other one - lower from the outer aperture of the tibia oblique channel. Transplant ends remaining outside are placed into the corresponding horizontally oriented channels and fixated in the channels under the conditions of interference screws tension.

EFFECT: method eliminates the risk of transplant tension force weakening and prevents joint instability.

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Description

The invention relates to medicine, namely to traumatology. This technical solution is intended to restore the full function of the knee joint with its anterior instability by reconstruction of the anterior cruciate ligament.

Damage to the knee joint is a significant part of the total number of injuries of the musculoskeletal system. A significant place in the structure of injuries to the knee joint is occupied by damage to the anterior cruciate ligament, which, according to various authors, reaches 62%.

To date, more than 250 methods for plastic surgery of the anterior cruciate ligament have been developed, most of which are aimed at the formation of through channels in the tibia and femur, conducting transplants through them and fixing the latter through various structures of attachments, namely:

- fixing the free ends of the graft at the exit of the canals with a node, loop [Movshovich I.A. Operative orthopedics: (Manual for doctors). - M .: Medicine, 1983, p. 257-258; SU copyright certificates for inventions No. 990204, 1659030, RU patent for invention No. 2007137];

- fastening the free ends of the graft to the musculoskeletal system with silk ligatures [SU copyright certificate for invention No. 1228839, RU patent for invention No. 20022454];

- the use of wedge fixing implants [RU patent for invention No. 20177469];

- the use of folded tridents, revealing during their deepening into the trabecular bone [SU copyright certificate for invention No. 1335265].

The implementation of the primary fixation by means of the above-mentioned fasteners is aimed at ensuring tight adhesion and preventing the intra-channel displacement of the graft during cyclic loads, which helps to maintain stability of the knee joint in the process of patient rehabilitation until biological fixation occurs. However, regardless of the method of attachment, the ends of the graft can be fixed in the bone channels at different distances from the joint cavity, which leads to excessive transplant mobility in the longitudinal and transverse directions, causing the effects of a “piston”. The above phenomena have a negative effect on the strength of secondary fixation and lead to the expansion of bone channels [Mironov SP, Orletsky AK, Vetril B.C. The method of arthroscopic fixation of the cruciate ligaments of the knee joint during their acute damage // Bulletin of Traumatology and Orthopedics. N.N. Priorov. 2001, No. 3, p. 26-28]. The aperture method, which consists in introducing an interference screw into the space between the end of the graft and the channel wall, allows minimizing such negative effects. As a result, the stability of the knee joint increases, which is explained by a decrease in the total length of the graft and a decrease in its elastic deformation. The absence of the irritating effect of synovial fluid does not prevent consolidation [Kotelnikov G.P. Forms of post-traumatic instability of the knee // Orthopedics, traumatology and prosthetics. 1991, No. 3, p. 5-9].

At this time, methods of plasticizing the anterior cruciate ligament are used, including the formation of channels, transplants through them with intracanal fixation of its ends with interference screws, which is recognized as the “gold standard” in world practice [Arthroscopic reconstruction of the anterior cruciate ligament of the knee joint / G.D. Lazishvili, V.V. Kuzmenko, S.G. Girshin et al. // Bulletin of Traumatology and Orthopedics. N.N. Priorov. 1997, No 1, p. 23-27]. With this fixation technique, two anterior cruciate ligament plastic techniques are used, which, when comparing the long-term results of their use, noted comparable indicators in both groups, stating good functional achievements [Zaffagnini S., Bruni D., Muccioli G., Bonanzinga T., Lopomo N. , Bignozzi S., Marcacci M. Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction a prospective randomized study at 8-year minimum follow-up // Knee Surg. Sports Traumatol. Arthrose. 2011. No.19. P / 390-397].

The closest analogue to the claimed invention is the "single beam" plastic of the anterior cruciate ligament based on the technique of the proposed method with a synthetic graft with intracanal fixation of its ends by the interference screws in the femur - antegrade and in the tibia - retrograde, avoiding their ingress into the joint [Information materials see . http://www.artro-s.ru/metodika-odnopuchkovoy-plastiki-pks.html].

However, such a “classical” arrangement of screws with possible resorption of the formed bone channels, leading to an increase in their diameter, reduces the rigidity of fixation of the graft, ensuring the occurrence of a relapse of instability of the knee joint.

The task of the invention is to eliminate the risk of a weakening of the tension force of the graft by reducing the rigidity of fixation of its ends, leading to a relapse of instability of the knee joint.

The essence of the claimed invention lies in the fact that in the method of plastic surgery of the anterior cruciate ligament of the knee joint, which includes the formation of through oblique channels in the medial condyle of the tibia and lateral condyle of the femur, through which a synthetic transplant is carried out and its ends are fixed inside the oblique channels by means of interference screws, additionally two through horizontally oriented channels are formed: one is higher from the outer opening of the oblique femoral canal, the other is lower m external opening oblique channel of the tibia, the graft is placed outside the remaining ends to the corresponding horizontally oriented channels and produce them in-bore fixation under tension interference screws.

The technical result of the claimed invention.

The presence of additional fastening elements for the ends of the grafts allows to increase the rigidity, reliability and stability of their fixation, eliminating the possibility of developing the mobility of the graft along the oblique canals during exercise on the knee joint in the rehabilitation period, which occurs due to the slipping of the ends of the graft between the interference screw and the channel wall, and therefore , weakening the tension of the graft. This effect is achieved through the application of a technique that involves throwing the cortical layer through the site, using it as a persistent platform, the outside of the oblique canals of the free ends of the graft and their subsequent placement in two previously formed horizontally oriented channels in the femur and tibia, fixing the position of the data the ends of the graft under tension with an additional interference screw in each of the channels, moving it along them to a dense Ania to the walls. Performing horizontally oriented channels through allows you to stretch the free ends of the graft through the channels without any technical difficulties, make them the necessary tension and fix in the reached position.

The invention is illustrated using Fig., Which depicts an x-ray of the right knee joint of patient K. after surgery, visualizing the location of the formed channels with installed interference screws inside them.

The method of plastic surgery of the anterior cruciate ligament of the knee joint is as follows.

The patient is placed on an orthopedic table, lying on his back with lower limbs bent at an angle of 90 ° in the knee joints. A tourniquet is applied to the patient's thigh. After 3-fold treatment of the surgical field with an antiseptic solution, surgical approaches are performed: anterolateral and anteromedial. The place of anterolateral access is determined in the position of bending of the knee joint at a right angle by palpation of a depression limited by the medial-outer edge of the ligament of the patella, proximal by the apex of the patella and distally by the edge of the external condyle of the tibia. A skin incision 5 mm long is performed with a pointed scalpel approximately in the middle of the indicated area. The anteromedial access is located more medially than the ligament of the patella, symmetrically to the anterolateral access. After orientation in the joint and focus correction by the camera lens, the joint is revised. Inspect the intercondylar elevation. To clarify the integrity of the anterior cruciate ligament, the assistant pushes the lower leg forward, while the surgeon looks at the tension of the anterior cruciate ligament. After determining the rupture of the anterior cruciate ligament, topical points of the tibial canal are selected. On the plateau of the tibia, retreating 1/3 from its front edge, establish a crown of a foot connected to the arc of the guide. The rod mounted on the arch of the pedal device is abutted into the cortical of the inner condyle of the tibia, a sleeve is put on the rod. Through a hole in the tibial stock, a measuring needle is carried out until the drill stops in the sleeve. Then, by bending and extending the knee joint with a knitting needle through the tibial condyle, the intended entry point into the external condyle of the femur, which corresponds to the anatomical attachment of the anterior cruciate ligament, is outlined. A castellate foot of a special shape, fixed in the arc of the guide on the division of 55 degrees, is installed in the topical intraarticular point on the condyle of the thigh. The stem rests on the cortical from the outside in the supracondylar region of the thigh. The guide needle is carried out from outside to inside. The direction of the channels has a minimum deviation angle with respect to the axis of the limb. Bone channels with a diameter of about 7 mm are drilled on the needles from the outside inward. A synthetic graft is pulled through the formed bone channels. In parallel with the transplant, a needle is inserted into the channels. The graft is fixed by cannulated interference screws extra-articularly along this spoke. The thigh screw is installed antegrade from the hip, and retrograde on the lower leg. After installing the graft and fixing it with 2 interference screws, using a drill with a diameter of 7 mm, 5 mm above the outlet of the formed oblique channel of the femur in the transverse direction from the outside, a horizontally oriented through channel is made into which the proximal end of the graft is inserted and fixed with an additional interference screw in the direction from the outside to the inside under tension. Then, 5 mm below the outlet of the oblique tibial canal, from the inside out, using a drill with a diameter of 7 mm, a similar additional horizontally oriented through channel is formed, where the distal end of the graft is inserted and fixed with an additional interference screw from the inside outwards under tension. Perform joint lavage. Suture the wound.

Example

Patient K., 43 years old, was admitted to the trauma unit with a diagnosis of “Rupture of the anterior cruciate ligament of the right knee joint”.

After preoperative preparation, the patient underwent surgery: arthroscopic plastic surgery of the anterior cruciate ligament according to the method described above.

On the second day after surgery, the patient was allowed to walk with crutches without resting on a sore leg. However, external limb immobilization was not required. Dosed reliance on the limb was allowed 4 days after surgery. From the first days, active development of movements in the knee joint was carried out. At the control examination after three months noted: the range of motion is complete, there is no instability in the joint.

Claims (1)

The method of plastic surgery of the anterior cruciate ligament of the knee joint, including the formation of through oblique channels in the medial condyle of the tibia and the lateral condyle of the femur, conducting a synthetic transplant through them and fixing its ends inside the oblique channels using interference screws, characterized in that they additionally form two through horizontally oriented canal: one is higher from the external opening of the oblique canal of the femur, the other is lower from the external opening of the oblique canal olshebertsovoy bone graft is placed outside the remaining ends to the corresponding horizontally oriented channels and produce them in-bore fixation under tension interference screws.

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