RU2633277C2 - Method for anatomic single-beam plasty of anterior cross-shaped ligament by patellar ligament transplant - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: "bone-tendon-bone" autotransplant is taken from the patient: a bone block from the middle part of the lower pole of the patella and from the tibia at the site of the patella ligament attachment to the tuberosity of the tibia and the patellar ligament between these bones from the middle third of the patellar ligament. Through transverse apertures are made through each bone block of the autotransplant for filaments for autotransplantation. Channels are made in the tibia and femur. The femoral canal is formed from a point defined as follows: the point of intersection of the lateral intercondylar and lateral bifurcation edges is determined, a retreat is made from this point along the bifurcation margin at a half distance to the articular surface of the condyle and 2 mm posterior and further in a plane parallel to the lateral bifurcation margin by the thickness of the patellar ligament between the bone blocks of the bone-tendon-bone autotransplant. Bone blocks of the autotransplant are sequentially placed in the channels in the tibial and femur bones and fixed to the walls of the channels after connecting ligament tension.

EFFECT: method increases transplant fixation stability.

1 cl

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for arthroscopic anatomical single-beam plastic surgery of the anterior cruciate ligament of the human knee joint with an autograft from the patellar ligament.

A known method of arthroscopic anatomical plasty of the anterior cruciate ligament of the knee joint (see van Eck CF, Lesniak B.P., Schreiber VM, Fu FH Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart // Arthroscopy. - 2010. No. 26 . - P. 258-268), which consists in taking a bone-tendon-bone autograft from a patient: a bone block from the middle part of the lower pole of the patella and from the tibia at the site of attachment of the patellar ligament to the tibial tuberosity and the patellar ligament between these bones from the middle third of the ligament of the patella, sub Preparations autograft to plastic, performing in each block bone graft through lateral openings yarns for autograft execution channels in the tibia and femur bones. The implementation of the canal in the tibia is carried out using a guide with a fixed extra-articular arch in position 55 °. The intraarticular leg is set at a point located 7-8 mm anterior to the anterior fibers of the posterior cruciate ligament and on a line extending along the posterior edge of the anterior horn of the external meniscus. The center of the femoral canal is determined from the additional anterolateral supramiscal approach, established using the “injection needle” technique, located at a distance of 2-2.5 cm posterior to the standard anterolateral approach, for which the intersection point of the lateral intercondylar and bifurcation edges is determined, depart from of this point along the bifurcation margin half the distance to the articular surface of the condyle and 2 mm posteriorly, which corresponds to the anatomical center of the thigh area nnogo attachment of the anterior cruciate ligament. Set the guide needle and form the femoral canal. To install an autograft, an autograft is passed through the canal in the tibia through the canal and placed with the help of threads one bone autograft block in the canal in the femur, fixing it to the canal wall, then the autograft is pulled and another autograft graft is placed in the canal in the tibia, fixing it by fixing to channel wall.

The disadvantage of this method is the non-isometric arrangement of the autograft in the intercondylar fossa of the femur, which occurs due to its vertical position. This can cause the tendon of the autograft to collide with the roof of the intercondylar fossa or the external condyle of the femur, restriction of movement in the joint or weakening of fixation, or, conversely, overstretching, and possibly graft rupture during rehabilitation of the patient. Ultimately, this can lead to an adverse outcome of surgical treatment.

The present invention solves the problem of developing a new method of anatomical single-beam plastic surgery of the anterior cruciate ligament with a graft from the patellar ligament. The technical result obtained in this case consists in a more stable guaranteed fixation of the implantable graft due to its anatomical location. This is due to the fact that when plasticizing the anterior cruciate ligament with an autograft from the patellar ligament, the asymmetry of the tendon part of the used graft is taken into account and taking into account this, the center of the femoral canal is determined, the location of which will differ from the anatomical center of the natural site of attachment of the anterior cruciate ligament by the thickness of the patellar ligament between bone blocks of the bone-tendon-bone autograft. When installed in such a channel formed in the femur, the intraarticular orientation of the graft corresponds to the location of the native ligament. A consequence of the aforementioned positioning of the femoral canal is the optimal spatial location of the ligament graft in the intercondylar fossa of the femur, leveling the risk of damage in the process of early active rehabilitation of patients. In addition, the anatomical method of plasty allows to obtain superior indicators of the anterior and rotational stability of the knee joint.

The specified technical result is achieved by the fact that in the method of anatomical single-beam plastic surgery of the anterior cruciate ligament by a graft from the patellar ligament, which consists in taking a bone-tendon-bone autograft from a patient: a bone block from the middle part of the lower patellar pole and from the tibia at the site of attachment of the ligament the patella to the tuberosity of the tibia and ligament of the patella between these bones from the middle third of the ligament of the patella, performing an autograft in each bone through transverse openings for threads for carrying out an autograft, performing canals in the tibia and femur, which determines the anatomical center of the anterior cruciate ligament attachment area and the center of the femoral canal, sequential placement of autograft bone blocks in the canals in the femur and tibia and fixing them to the canal walls after tension of the tendon connecting them to each other, to determine the center of the femoral canal from the anatomical center of the attachment area the legs of the anterior cruciate ligament retreat in a plane parallel to the lateral bifurcation margin by the thickness of the patellar ligament between the bone blocks of the bone-tendon-bone autograft.

The method of anatomical single beam grafting of the anterior cruciate ligament with a graft from the patellar ligament is as follows.

The patient is placed in a supine position, the patient’s lower leg freely hanging from the orthopedic table, while the knee joint is in the flexion position at an angle of 90 °. After performing spinal anesthesia or endotracheal anesthesia, an air cuff is applied to the upper third of the thigh of the operated limb to prevent possible blood loss. The surgical field is treated with antiseptic solutions. To take an autograft, a longitudinal midline incision is made of the skin and underlying soft tissues up to 7 cm long from the lower pole of the patella downward over the patellar ligament to the tibial tuberosity. From the middle third of the patellar ligament, which is 3 cm wide, using a scalpel with two longitudinal cuts along the entire length from the place of attachment of one end of the ligament to the lower pole of the patella to the place of attachment of its other end to the tibial tuberosity and the entire thickness of the ligament, cut a strip of patellar ligament with a width equal to 1/3 of the width of the ligament. Then, from the middle part of the lower pole of the patella, at the place of attachment of the patellar ligament to it, a bone block up to 3 cm long, a width equal to the width of the cut ligament, and a thickness of at least 1 cm is cut using a surgical saw. The bone block is cut out similarly on the opposite end of the patellar ligament in the place of its attachment to the tuberosity of the tibia. Thus, a bone-tendon-bone autograft up to 10 cm long is obtained, which contains two bone blocks connected by a ligament. Through transverse openings for the threads for the autograft and channels in the tibia and femur are performed in each bone of the autograft. The implementation of the canal in the tibia is carried out using a guide with a fixed extra-articular arch in position 55 °. I install the intraarticular leg at a point located 7-8 mm anterior to the anterior fibers of the posterior cruciate ligament and on a line extending along the posterior edge of the anterior meniscus anterior horn. To perform the canal in the femur, the anatomical center of the anterior cruciate ligament attachment area is determined and after that the center of the femoral canal is determined from the additional anterolateral supramenculal access established using the “injection needle” technique located at a distance of 2-2.5 cm posterior to the standard front-internal access. The anatomical center of the area of the femoral attachment of the anterior cruciate ligament on the inner surface of the external condyle of the femur is determined at the intersection of the lateral intercondylar and lateral bifurcation edges, departing from this point along the bifurcation edge half the distance to the articular surface of the condyle and 2 mm posteriorly. To determine the center of the femoral canal from the anatomical center of the anterior cruciate ligament attachment area, they retreat in the plane parallel to the lateral bifurcation margin by the thickness of the patellar ligament between the bone blocks of the bone-tendon-bone autograft. Through the received center of the femoral canal, a guide needle is installed and a femoral canal is formed. After preparation of the autograft for plastic, bone blocks of the autograft are sequentially placed in the canals in the tibia and femur and fixed to the walls of the canals after tension of the ligament connecting them to each other. The autograft is fixed, movement in the joint without restrictions and obstacles. The wound is sutured in layers, taking into account all the rules of asepsis and antiseptics. Apply an aseptic dressing. The lower limb is immobilized with a plaster cast from the upper third of the thigh to the lower third of the lower leg for better wound healing and engraftment of the autograft.

Clinical example

Patient K., 26 years old, asked for help at the traumatology and orthopedic department of the State Health Institution KB No. 12 for advice on dysfunction of the right knee joint.

Complaints: pain during movement, instability, limitation of the function of the right knee joint.

From the history of the disease, it is known that the patient was injured as a result of a fall when skiing about a year ago, the mechanism of injury is rotational-flexion, he turned for help to the trauma center, where the X-ray of the right knee joint was performed in 2 projections on which the bone-traumatic pathology is not revealed. A puncture of the knee joint was performed, about 60 ml of hemorrhagic contents were aspirated, after which immobilization was imposed by the posterior plaster cast for a period of 3 weeks. After removing the gypsum immobilization, the patient was engaged in physical therapy, as a result of which the range of movements in the knee joint was completely restored. After some time, with the resumption of training, pain appeared in the right knee joint during physical exertion, the inability to perform the usual load, there were episodes of instability in the right knee joint, accompanied by severe pain and swelling of the joint. As a result of magnetic resonance imaging of the right knee joint, damage to the inner meniscus and the anterior cruciate ligament was revealed. During a physical examination, the right knee joint is moderately edematous, palpation determines local pain in the projection of the inner meniscus, positive symptoms of Chaklin, Perelman, Steinman-Buchard, the symptom of the “front drawer” is positive, Lahman test +++, no patellar ballot, axial load slightly painful, the range of motion in the right knee joint is 0-0-140 degrees. An objective study on a KT-1000 arthrometer showed an anterior displacement of the lower leg of 10 mm (with a maximum permissible border of up to 4 mm).

Based on complaints, medical history, clinical presentation, X-ray data, magnetic resonance imaging, knee arthrometry, the diagnosis was made: chronic damage to the inner meniscus and the anterior cruciate ligament of the right knee joint. Chronic anterior instability of the right knee joint.

The patient is offered surgical treatment. After obtaining consent, the patient is hospitalized in the traumatology and orthopedic department in a planned manner for surgical treatment.

A partial resection of the inner meniscus of the right knee joint and anatomical single-beam plastic surgery of the anterior cruciate ligament by a graft from the patellar ligament were performed using our proposed method. After performing spinal anesthesia with 0.5% - 4 ml Naropin solution, a pneumatic cuff was placed on the upper third of the thigh of the operated limb to prevent possible blood loss. The surgical field was treated with Kutasept's solution. To take the autograft, a longitudinal midline incision was made of the skin and underlying soft tissues 7 cm long from the lower pole of the patella downward over the patellar ligament to the tibial tuberosity. From the middle third of the patellar ligament, the width of which is 3 cm, using a scalpel with two longitudinal cuts along the entire length from the place of attachment of one end of the ligament to the lower pole of the patella to the place of attachment of its other end to the tibial tuberosity and the entire thickness of the ligament, cut a strip of patellar ligament with a width 1 cm. Then from the middle part of the lower pole of the patella in the place of attachment of the ligament of the patella to it using a surgical saw, a bone block 2.5 cm long, with a width equal to the width of cut ennoy ligament, and a thickness of at least 1 cm. Similarly have cut bone block at the opposite end of the patellar ligament in place of its attachment to tibial tuberosity. Thus, a 9 cm long bone-tendon-bone autograft was obtained, which contains two bone blocks connected by a ligament. In each bone block of the autograft, transverse transverse openings were made for the threads for the autograft and channels in the tibia and femur. The implementation of the canal in the tibia was carried out using a guide with a fixed extra-articular arch in position 55 °. An intraarticular pedicle was set at a point 7 mm anterior to the anterior fibers of the posterior cruciate ligament and on a line extending along the posterior edge of the anterior meniscus anterior horn. To perform the canal in the femur, the anatomical center of the anterior cruciate ligament attachment zone was determined and after that the center of the femoral canal was determined from the additional anteroluminal supramencular access, established using the “injection needle” technique, located at a distance of 2-2.5 cm posterior to the standard front-internal access. The anatomical center of the area of the femoral attachment of the anterior cruciate ligament on the inner surface of the external condyle of the femur was determined at the intersection of the lateral intercondylar and lateral bifurcation edges, departing from this point along the bifurcation edge half the distance to the articular surface of the condyle and 2 mm posteriorly. To determine the center of the femoral canal from the anatomical center of the anterior cruciate ligament attachment area, they retreated in the plane parallel to the lateral bifurcation margin by the value of the thickness of the patellar ligament between the bone blocks of the bone-tendon-bone autograft. Through the center of the femoral canal, a guide needle was installed and the femoral canal formed. After preparation of the autograft for plastic, bone blocks of the autograft were sequentially placed in the canals in the tibia and femur and fixed to the walls of the canals after tension of the ligament connecting them to each other. The autograft was fixed, movement in the joint without restrictions and obstacles. The wound was sewn up in layers, taking into account all the rules of asepsis and antiseptics.

Immobilization was imposed by a brace for the knee joint, on the 5th day early passive movements in the right knee joint were started, and on the 10th day the patient was discharged from the clinic for outpatient treatment with recommendations to continue physiotherapy exercises to heal the wound and remove sutures. 8 weeks after surgical treatment, the full range of movements in the knee joint was restored, while moving the patient, additional support was not required. After 6 months, the patient returned to sports. After 9 months after the operation, the patient regained his level of physical activity and did not notice instability in the knee joint.

Claims (1)

The method of anatomical single-beam grafting of the anterior cruciate ligament with a graft from the patella ligament, which consists in taking a bone-tendon-bone autograft from a patient: a bone block from the middle part of the lower patellar pole and from the tibia at the site of attachment of the patellar ligament to the tibial tuberosity and between these bones from the middle third of the ligament of the patella, performing in each bone block of the autograft through transverse openings for threads for wires autograft grafting, performing canals in the tibia and femur, sequential placement of autograft bone blocks in the canals in the tibia and femur and fixing them to the canal walls after tension of the ligament connecting them, characterized in that the femoral canal is formed from the point determined by the following way: determine the intersection point of the lateral intercondylar and lateral bifurcation edges, deviate from this point along the bifurcation edge by half a distance to the condyle of the condyle and 2 mm posteriorly and further, they retreat in a plane parallel to the lateral bifurcation edge by the size of the thickness of the patellar ligament between the bone blocks of the bone-tendon-bone autograft.