RU2717369C1 - Repair method for anterior cruciate ligament of knee joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopedics, and can be used for plasty of an anterior cruciate ligament of knee joint. Method involves forming the canals in the shinbone and femoral bones, carrying a transplant from an external part of the tendon of the long fibular muscle through the transplant and fixation thereof. Under the control of the arthroscope a guide is formed along the guide in the external condyle of femur and internal condyle of the tibia. Then, free autograft 27–30 cm long is isolated, and an overlay suture with two open cuts is made on the repaired table on the ends of the tendon. For this purpose, one end of the tendon is applied on the other one; at that, the outlet of the end of the lower end is 5–6 mm. After that, the sewn-in end is turned to the shear and a second row of sutures along the width of the tendon is applied. Further, the autograft is folded in half so that a transplant of four bundles is obtained, and 1.0–1.5 cm blanket is used to suture it at two ends. Thereafter, under the control of an arthroscope, one of the stitched ends of the autograft is inserted into a formed canal in an external condyle of the femur and fixed, and the other stitched end of the autograft is made in a tibial canal and fixed. At that, autograft fixation and tension is performed with the help of Tightrope buttons.

EFFECT: method provides higher effectiveness and earlier rehabilitation of patients ensured by intensified internal sutures of the autograft.

1 cl, 5 dwg, 1 ex

Description

The alleged invention relates to medicine, namely to traumatology and orthopedics, and can be used to treat anterior instability of the knee joint

A known method of preparation and installation of a four-beam autograft from the tendon of the semitendinosus muscle during plastic surgery of the anterior cruciate ligament (Pat 27647613, Russian Federation, IPC АВВ 17/00 / Slastinin V.V., Fine AM; applicant and patent holder: State budgetary health institution of the city of Moscow Scientific Research Institute of Emergency Medicine named after N.V. Sklifosovsky of the Moscow Department of Health - No. 2017114415; Claim. 04.25.2017; Publish. March 16, 2018; Bull. No. 8).

Plastic surgery of the anterior cruciate ligament is characterized by the installation in the bone tunnels of the knee joint of a four-beam autograft from a tendon of a semitendinosus muscle prepared as follows. The ends of the tendon are first sutured to form a two-beam graft, then one of the ends of the obtained two-beam graft is rotated 180 ° relative to the other end to obtain a figure in the form of the number 8 and then align the ends to form a four-beam graft. Four pairs of sutures are formed in the obtained four-beam graft using separate threads. The first pair of sutures is formed from the distal and proximal ends of the graft, threading the threads into loops formed by tendon bundles for subsequent transplantation through the tibial and femoral tunnels and its temporary tension during plastic surgery. The second pair of sutures is a proximal and distal circular sutures that form at least 2 cm from the ends of the graft, stitching the graft bundles with a transverse suture, followed by tying the graft and forming a knot between the ends of the threads. A third pair of sutures is formed close to the proximal and distal circular sutures from the side of the central part of the graft to ensure the final cortical fixation of the graft on the femur and tibia, respectively, for which the graft is stitched through two bundles of tendon located in a diagonal cross section. A fourth pair of “corrugating” sutures is formed at the ends of the graft so that when the strands are tensioned during plastic surgery, the diameter of the distal and proximal ends of the graft is increased by at least 20%. After preparation of the autograft, plastic surgery of the anterior cruciate ligament is performed. The graft is pulled through the tibial and femoral tunnels due to traction for the proximal thread threaded into a loop formed by tendon bundles. At the same time, pulling on the proximal thread is fixed, fixed to one of the holes of the cortical fixator. The proximal thread threaded into a loop formed by tendon bundles is removed. Due to traction for the distal thread, threaded into the loop formed by the tendon bundles, the graft is tensioned and the femoral cortical fixator is finally installed on the outer surface of the femur. Over the cortical tibial fixator, the threads of the proximal corrugating suture are tied after they have been previously sipped. Filaments are tied over a cortical tibial fixator with constant tension for final distal cortical fixation. Remove the distal thread threaded into a loop formed by tendon bundles. Above the cortical tibial fixator, the strands of the distal corrugating suture are tied after their preliminary pulling.

The disadvantages of this method include a shortage of flexion of the knee joint in the late postoperative period due to the use of a tendon muscle as a transplant, which is its flexor.

The disadvantages of this method include the possibility of poor integration of the tendon and bone due to the use of a significant amount of suture material.

The closest in technical essence to the proposed one is a method for plastic surgery of the cruciate ligaments of the knee joint (Pat 2631107, Russian Federation, IPC A61B 17/00 / Umkhanov Kh.A., Umkhanov Kh.Kh .; applicant and patentee: Federal State Budgetary Educational Institution of Higher Education "Chechen State University" - No. 2016117782; declared 05/05/2016; publ. 09/18/2017; Bull. No. 26).

The known method includes exposure, stratification in half along the tendon of the long peroneal muscle and cutting off part of the outer portion. Then, an autopsy of the knee joint is performed with an external parapatheral incision and a channel is formed from the center of the intermuscular space towards the lateral surface of the external condyle. Then a tendon graft is brought to the lateral surface of the external condyle and fixed with bone-periosteum sutures, after which the distal end of the graft is brought out through the formed channel to the tibial tuberosity and fixed to it with bone-periosteal sutures.

The disadvantages of this method include the high invasiveness of surgical intervention due to arthrotomy of the knee joint and, as a result, a long rehabilitation, as well as the presence of a cosmetic defect.

In addition, the authors of the proposed method believe that in the known technical solution there is insufficient strength of the graft, which is associated with both the formation of a two-beam graft and its fixation.

The objective of the proposed technical solution is to develop a method of plastic surgery of the anterior cruciate ligament of the knee joint.

The technical result of the proposed method is to increase the effectiveness of treatment by preventing stretching and weakening of the autograft during the functional load of the knee joint, as well as simplifying its implementation and reducing trauma.

The technical result of the proposed method for plastic surgery of the anterior cruciate ligament of the knee joint is achieved by the fact that the method includes the formation of channels in the tibia and femur, conducting a graft through them from the outer part of the tendon of the long fibular muscle with a reinforcing internal suture and its fixation.

Distinctive techniques of the proposed method are that under the control of an arthroscope, a channel is formed along the guide in the external condyle of the femur and the internal condyle of the tibia. A free graft of 27-30 cm long is isolated. On the preparation table, on the free ends of the tendon, a false suture with two open sections is performed. To do this, one end of the tendon is applied to the other, while the release of the cut of the lower end is 5-6 mm, after which the stitched end is turned on the cut and a second row of sutures along the width of the tendon is applied. Next, the autograft is bent so that a graft of four beams is obtained and it is sutured from both ends by 1.0-1.5 cm with a twisted seam. After that, under the control of an arthroscope, one of the stitched ends of the autograft is carried out into the formed channel in the external condyle of the femur and fixed. The other stitched end of the autograft is carried out in the tibial canal and is also fixed, while the fixation and tension of the autograft are carried out using Tightrope buttons.

A comparative analysis of the proposed method and the prototype shows that the claimed method differs from the known above methods. These differences allow us to conclude that the claimed technical solution meets the criteria of the invention of "novelty."

The analysis of patent and medical literature has shown that the proposed method contains features that distinguish it from known technical solutions.

The proposed method allows to increase the effectiveness of treatment due to minimally invasive access and to prevent stretching and weakening of the autograft with the functional load of the knee joint.

This is confirmed by experimental studies of the authors of the proposed method. So, the value of the force and length at which the graft was broken from the tendon of the long peroneal muscle (according to the proposed method) was 1113.81 N / mm, in comparison with the known method of forming an autograft using the prototype of two bundles, the value of force and length was 833, 41 N / mm.

The results of an experimental study indicate greater mechanical strength of the transplant prepared by the proposed method.

The above allows us to conclude that the proposed technical solution meets the criterion of "inventive step".

The method comprising the claimed invention is intended for use in surgery. The possibility of its implementation is confirmed by the techniques described in the application, therefore, the claimed invention meets the condition of patentability "industrial applicability".

The essence of the proposed method for plastic surgery of the anterior cruciate ligament of the knee joint is illustrated by figures 1-5. So in FIG. Figure 1-3 shows the graft preparation scheme, where 1 is the “lower” end of the graft, 2 is the “upper” end of the graft, 3 is the first row of suture, 4 is the second row of sutures.

In FIG. Figures 4-5 show MRI of the knee joint, where: 5 is an autograft.

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

Under aseptic conditions of the operating room, in the patient’s supine position with fully extended large joints of the lower extremity and internal rotation of the lower leg by 30-45 degrees, the tendon of the long fibular muscle at the ankle joint level, behind the fibula, is palpably palpated, retreating posteriorly by 1.5 cm. For the collection of tendon material, one incision of the skin with a size of at least 3.5 cm and not more than 5.0 cm and a depth of about 0.5 cm is sufficient. The outer half of this tendon is selected, which is taken to the holder, then with a highlighter in the proximal direction, secrete, cut off and lead to the wound. When taking a tendon, use the tool from the set for plastic PKS Arteks (Germany). The resulting autograft from the tendon of the long peroneal muscle should have a length of at least 27 cm.

After taking the tissue, they begin to reinforce the ends of the tendon. The material for reinforcing is a durable dacron thread No. 4, which grows with scar tissue and which, in turn, further increases the strength of the connection. On the preparation table at the ends of the tendon perform a false joint with two open sections. To do this, one end of the tendon is applied to the other, while the release of the cut of the lower end is 5-6 mm. Then the stitched end is turned away to cut and a second row of sutures is applied along the width of the tendon. Next, the autograft is bent in half so that a graft of four beams is obtained and stitched with a twisted seam 1.0-1.5 cm from both ends.

After that, under the control of an arthroscope, one of the stitched ends of the autograft is carried out into the formed channel in the external condyle of the femur and fixed. The other stitched end of the autograft is carried out in the tibial canal and is also fixed. The autograft is fixed and tensioned in the femoral and tibial canals using Tightrope buttons according to the “all inside” technique.

The proposed method for plastic surgery of the anterior cruciate ligament of the knee joint is illustrated by an example of a specific implementation.

Patient K., 34 years old, was admitted to the clinic for planned surgical treatment with a diagnosis of In-depth complete damage to the anterior cruciate ligament of the left knee joint. Anterior post-traumatic instability of the left knee joint of the III degree. Injured damage to the medial meniscus. Left-sided gonarthrosis of the II degree. Combined contracture of the left knee joint. Pain syndrome.

Complaints of pain and instability in the left knee joint, of the inability to fully use the left lower limb.

Anamnesis of the disease: the injury was received six months ago during a training in martial arts - received a blow to the upper third of the left leg. He turned to the emergency room at the place of residence, where he was diagnosed with hemarthrosis, damage to the capsule-ligamentous apparatus of the left knee joint. The prescribed conservative treatment is ineffective and the patient was referred for consultation to the clinic of the Federal State Budget Scientific Institution "Scientific Center for Advanced Chemistry and Health", where he underwent a clinical examination of the injured knee joint, an X-ray examination, and an MRI of the left knee joint. A preliminary diagnosis is made: Complete damage to the anterior cruciate ligament (PCL) of the left knee joint. Anterior post-traumatic instability of the left knee joint 3 degrees. Further surgical treatment is recommended - PCS plastic surgery as planned.

09/25/2017 the patient was hospitalized in the traumatology and orthopedic department of the Federal State Budget Scientific Institution "Scientific and Technical Center".

09/26/2017, the operation was performed (operation code A 04/16/015.002) - "plastic surgery of the anterior cruciate ligament using an autotendoendoprosthesis from half the tendon of the long fibular muscle on the left using the all inside technique using Arthrex® fixators with a TightRope fixation system."

Postoperative MRI of the knee of patient K. is shown in FIG. 4, where position 5 is an autograft.

On the 3rd day after the operation, the patient complained of minor pain in the area of surgical intervention. The operated lower limb is fixed with a brace in the position of full extension.

On the 6th day after surgical treatment, the patient was discharged in satisfactory condition for outpatient treatment with recommendations.

By the time of discharge, the general condition of the patient met the following requirements:

1. There was no persistent pain syndrome, both in the area of tendon sampling, and in the area of directly plastic surgery;

2. Body temperature within the age norm;

3. Complete restoration of the supporting ability of the operated lower limb under conditions of fixation of the operated joint with an official brace in the position of full extensia;

4. The absence of clinically significant venous thrombosis;

5. The absence of clinically significant synovitis or hemarthrosis of the operated joint.

At the follow-up examination, 1.5 years after the operation, the patient does not have any manifestations of pain and discomfort in the operated knee joint and in the area of the long fibular muscle (ankle joint), test “front drawer”, Lachman, Pivot-shift the tests are negative, the phenomena of hypotrophy of the quadriceps, gastrocnemius muscles of the operated lower limb were not observed, pronation and supination of the foot on the side of the operated lower limb in full.

MRI control 1.5 years after autologous autoplasty of the PCS (Fig. 5, autograft 5) made it possible to determine the anatomical location of the autograft in the knee joint.

Thus, the proposed method allows to increase the effectiveness of treatment by strengthening the internal suture of the autograft, as well as providing the possibility of early rehabilitation of patients, since there is no stretching and weakening of the autograft with early functional loads of the operated lower limb. The use of the outer part of the tendon of the long peroneal muscle as an autograft does not weaken the capsule-ligamentous apparatus of the ankle joint and impaired function of the ankle joint and foot.

The inventive method can be recommended for use in clinical practice with plastic surgery of the anterior cruciate ligament of the knee joint.

Claims (1)

The method of plastic surgery of the anterior cruciate ligament of the knee joint, including the formation of channels in the tibia and femur, conducting a graft through them from the outer part of the tendon of the long fibular muscle and its fixation, characterized in that under the control of an arthroscope, a channel is formed along the guide in the external condyle of the femur and internal the tibial condyle, then a free autograft 27-30 cm long is isolated and a false suture with two openings is performed on the preparation table at the ends of the tendon sections, for this, one end of the tendon is laid on the other, while the outlet of the lower end section is 5-6 mm, after which the stitched end is turned on the section and a second row of sutures is applied along the width of the tendon, then the autograft is folded in half so that a graft four beams, and they are stitched from both ends by 1.0-1.5 cm with a stitching seam, then under the control of an arthroscope one of the stitched ends of the autograft is carried out into the formed channel in the external condyle of the femur and fixed, and the other stitched the end of the autograft is carried out in the tibial canal and fixed, while the fixation and tension of the autograft is carried out using Tightrope buttons.

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