RU2729935C1 - Diagnostic technique of dynamic imbalance of quadriceps muscle of thigh due to lateral dislocation of patella - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used for diagnosing dynamic imbalance of quadriceps muscle of thigh as a result of lateral dislocation of a patella. Performing surface electroneuromyography is performed. ENMG-examination is related to phase of the step. In determining additional reduction m. vastus medialis of quadriceps muscle in range of 60–80 % of step cycle is diagnosed by imbalance m. vastus medialis of quadriceps muscle of thigh as a result of lateral position patella.

EFFECT: method enables improving the therapy on the basis of objective criteria by determining in real time the occurrence of a modified walking stereotype.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used in the diagnosis of acute and chronic damage to the knee joint associated with dislocation of the patella for targeted controlled treatment and complete functional rehabilitation based on objective criteria. The medical, social and economic significance of the knee joint pathology is associated with its high proportion (31.2%) in the composition of the causes of primary disability [Kharchenko A.P. Clinical and organizational prospects for the development of minimally invasive surgery of the knee joint (on the example of a large administrative center of the Stavropol Territory): author. dis. ... cand. honey. Sciences / A.P. Kharchenko. - Novosibirsk, 2006. - 22 p.]. Acute injury to the knee joint occupies a fourth (10-25%) in the overall structure of childhood injuries in Russia. Dislocation of the patella is one of the most common injuries of the knee joint in children and adolescents: every fifth (15-20%) of all hospitalized patients with knee injury comes with this diagnosis. Intermediate retrospective analysis of data for a 20-year period indicates an increase in the primary dislocation of the patella by 2 times S.V. Arkhipov et al. 1985-1988 - 0.6-11.8% versus 15-20% Bykov VM, Timofeev IV, 2004 [Arkhipov S.V. Clinical picture, diagnosis and treatment of patellar dislocations in adults: author. dis. ... cand. honey. sciences / S.V. Arkhipov. - M., 1985. - S. 3-15; Bykov V.M. Diagnostics and treatment of traumatic dislocations of the patella in children: Dissertation for the degree of candidate of medical sciences: 14.00.35 - children's surgery - St. Petersburg, 2006. - P. 13. Timofeev I.V. Clinical picture, diagnostics and endoscopic methods of treatment of acute patellar dislocation: author. dis. ... cand. honey. Sciences: 14.00.35 - children's surgery - M., 2004. - 15 p.].

According to the results of monitoring studies I.G. Klimenko (2009), recurrent habitual patellar dislocation, the frequency of which ranges from 3 to 5% of all pathological conditions of the knee joint, leads to severe dysfunction of the lower extremities [Klimenko I.G. Surgical correction of dysplastic, recurrent patellar dislocation // Siberian Medical Journal. - 2009. - T. 89, No. 6. - S. 181-184]. A number of authors note that the imperfection and untimely diagnosis of damage to the structures of the knee joint and, accordingly, ineffective treatment - in 47-60% of cases lead to the development of various forms and degrees of joint instability, persistent disability of patients [Volokhovsky N.N., Kuznetsov I. AND. Chondromalacia with patellar instability // Coll. mat. Third Congr. Grew up. Arthroscope. islands. M., 2000. - S. 5-12, Bodne D., Quinn S.F., Murray W.T. et al. Magnetic resonance images of chronic patellar tendinitis // Sceletal. Radiol. 1988. - Vol.17. - P.24-28, Bryukhanov A.B. Magnetic resonance imaging in the diagnosis and evaluation of the effectiveness of treatment of hemophilic arthropathy: Author's abstract. dis. Cand. honey. sciences. Barnaul, 1996. - 28 p.]. At the same time, not only early diagnosis of patellar dislocation, (which arose both before the onset of patellar dislocation, and as a result of this injury), but also its correction during the operation is a significant component of effective treatment.

It is known from the analysis of the available literature that physical examination is most often used in practical health care to diagnose patellar lateolocation. Thus, the occurrence of severe pain in the anterior part of the knee joint after an indirect knee injury in combination with lateral dislocation of the patella is the basis for a diagnosis. However, in some cases, with spontaneous reduction of dislocation on the basis of only the clinical picture, it is impossible to accurately establish the very fact of dislocation in the anamnesis. In such situations, the picture of intra-articular hemorrhage comes to the fore in 62.8-90% of cases [Timofeev I.V. Clinical picture, diagnostics and endoscopic methods of treatment of acute patellar dislocation: author. dis. ... cand. honey. sciences: 14.00.35 - children's surgery - M., 2004. - 15 p.], which is not a strictly specific picture of dislocation, but is observed with most injuries of the knee charter, as a result of which diagnostic difficulties arise in determining the nature of the damage, and as a result, mistakes in patient management tactics.

When analyzing the history of trauma, less than half of patients describe the very fact of patellar displacement, especially when it concerns children and adolescents. The children's contingent of patients cannot accurately state the very moment of receipt and the nature of the injury [Vybornoe D.Yu. Arthroscopy in trauma and diseases of the knee joint in children / D.Yu. Vybornov, M.A. Petrov, I.N. Isaev // Pediatric surgery. - 2012. - No. 5. - S. 29-34].

Also, due to the frequent self-regulation of dislocation during forced straightening of the leg still at the site of injury, together with some properties of the child's body: edema is more pronounced than in adults, massive hemarthrosis, pain contracture - all this complicates the clinical examination of the patient, and the very fact of displacement does not proves.

Standard X-ray examination, with its objectivity, accessibility and availability of non-invasiveness, the possibility of diagnosing concomitant injuries of bone structures, makes it possible to diagnose a “fixed” patellar dislocation, but does not allow indicating a dislocation in the event of its spontaneous reduction, since it does not take into account the “functional” component of the injury. With combined damage to the patella and femoral condyles, X-ray examination allows visualizing only the violation of bone structures, however, with perichondral injuries, it remains uninformative, which in 66% leaves these injuries undetected [Clinical manifestations and differential diagnosis of intra-articular pathology of the knee joint in childhood / M. A Gerasimenko // Military medicine. - 2014. - No. 3 (32). - S. 108-112]. The disadvantages of X-ray examination include the impossibility of diagnosing spontaneously set dislocations of the patella, additional radiation exposure to the patient, the impossibility of diagnosing concomitant soft tissue and perichondral injuries, and the impossibility of assessing the recovery of the knee joint during rehabilitation.

It is known in the art to use ultrasound to assess the knee joint in such a lesion. This is an affordable, non-invasive way to visualize lesions, which does not lead to additional radiation exposure to the subject. However, as with the previous method, ultrasound can only reveal indirect signs of a spontaneously retracted patellar dislocation, such as damage to the medial stabilizers of the patella in the form of diffuse thickening of soft tissues, an uneven increase in echogenicity with a loss of clarity in differentiation of the structures of the medial part of the joint, thickening of the synovial membrane, and these signs could be detected only in the acute period of the injury.

In addition, the USV method does not allow for a functional assessment of the state of the knee joint during the rehabilitation process, it remains largely subjective.

One of the most informative ways to visualize damage to the soft tissues of the knee joint is magnetic resonance imaging (MRI), the sensitivity and specificity of which for injuries of the menisci and cruciate ligaments is higher than 80%, and in some studies 90% and higher, which puts MRI in the first place in diagnostic plan. Another of the advantages of MRI is the spatial image, which makes it possible to fully assess all structures [Pitsyn I.A. The use of arthroscopy and the principle of specialists' feedback to assess the true effectiveness of ultrasound in the differential diagnosis of pathology of the intra-articular structures of the knee joint: author. dis. ... cand. honey. sciences. - Yaroslavl, 2016. - 18 p.].

The disadvantages of MRI are its subjectivity, high cost; persistent edema in the acute period can distort the picture of intra-articular injuries, does not allow assessing the functional state of the muscles involved in the movement and kinematic stabilization of the knee joint. These circumstances limit the use of MRI in clinical practice in the acute period and in assessing the effectiveness of treatment and rehabilitation in patients with patellar laterolocation.

According to the data of the patent information search, methods for the diagnosis and treatment of patellar dislocation are known - according to patent No. 2674918 dated December 27, 17, "Method for the surgical treatment of recurrent patellar dislocation in children", in which the method of multilayer spiral computed tomography produces spatial visualization of the bone structures of the knee joint, determine the degree of damage to the cartilage of the patella and femur. Magnetic resonance imaging is used to assess the degree of damage to the medial patellar ligament, trans- and osteochondral damage to the femoral surface of the patella and the external condyle of the femur, and the condition of the surrounding soft tissues, including the state of their vasculature. According to patent No. 2343862 dated 06.12.06, "Method for autoplasty of the patella's own ligament after knee arthroplasty," one of the technical solutions indicates the possibility of the patellar lateroposition, in which the autograft is fixed with a medial displacement of its tendon part. The general disadvantages of these methods is their exclusively anatomical component, which does not assess the functional efficiency of new structures.

The use of arthroscopy of the knee joint is the most informative method for diagnosing patellar dislocation and associated injuries. This method allows not only to visualize the damage, but also to carry out early surgical correction. The disadvantages of the method include high invasiveness, in comparison with previous methods, the need for a highly qualified surgeon, the availability of equipment, the need for hospitalization of the patient, the inability to assess the condition of the muscles stabilizing the knee joint, the inability to use the method to assess the treatment and rehabilitation of patients.

Closest to the proposed method is the use of electroneuromyography (ENMG) in patients with dislocation of the patella [Electroneimiography in the diagnosis of pathology of the patellofemoral joint in young patients / M.A. Gerasimenko, O. I. Shalatonina, E.V. Zhuk, S.I. Tretyak // Kazan. honey. zhurn. - 2011. - No. 4. - S. 503-508]. The use of this method involves ENMG at rest (control) and during flexion and extension of the knee joint, which led to a change in excitability in the arc of the monosympathetic reflex, both in the motor and sensory part, in comparison with the intact limb. Dysfunction of the neuromuscular apparatus manifested itself on both limbs (generalization of disorders) with predominance on the side of the injury. An assessment was made of the ratio of the amplitudes of the lateral and medial vastus muscles, the biceps and lateral vastus muscles, as well as the muscles of the lower leg that perform antagonistic motor functions in normal conditions and on the affected limb. Thus, the ratio of the amplitude of ENMG of the broad medial muscle to the amplitude of the lateral was 0.86 in healthy individuals, on the side of the affected joint below 0.75; for the biceps femoris and lateral head - 0.84 and 1.3, respectively; biceps and medial wide - 0.97 and 1.7, respectively; for the gastrocnemius and broad lateral muscle - 0.9 (N) and 1.5, for the gastrocnemius and broad medial muscle - 1.1 (N) and 2.0, respectively. The results obtained indicated a change in the physiological balance between the vastus muscles with a predominance of the activity of the lateral head of the quadriceps muscle, biceps femoris muscle and calf muscle. This ratio of the activity of the lateral and medial portions of the quadriceps muscle of the thigh and other muscles is not strictly stable - it can change after repeated injuries of the knee joint, surgical treatment, and in the process of rehabilitation. The observed higher activity of the lateral vastus and gastrocnemius muscles on the side of the syndrome of lateral patellar hypertension suggests the possibility of their participation in excessive homolateral tension of the patella. The disadvantages of the method include its laboriousness and the impossibility of using it in motion, which significantly reduces the sensitivity of the method itself. This method is adopted as a prototype.

The technical result of the proposed method for diagnosing the dynamic imbalance of the quadriceps femoris muscle due to laterodislocation of the patella is achieved by the fact that our method used a gait research apparatus (in this case, the computer complex "Stadis" LLC "Neurosoft", Ivanovo), which allows registering ENMG in the dynamics of walking, comparing the ENMG envelopes with the step cycle, and when an additional contraction wave m appears. vastus medialis of the quadriceps femoris muscle in the interval 60-80% of the stride cycle - a dynamic imbalance of the quadriceps femoris muscle is diagnosed due to laterodislocation of the patella.

The pathogenetic basis of the proposed method is the biomechanical hierarchy of motor acts of the musculoskeletal system, and when anatomical relationships change, compensation occurs due to the musculo-ligamentous apparatus of the ipsilateral limb.

Our proposed method is performed as follows:

To register walking parameters, 2 wireless biometric sensors "Neurosens" are installed on the patient's lower leg above the ankles and one sensor on the lower back. Each biometric sensor allows registration of up to two differential channels of surface EMG.

The main muscle of the anterior group is m. quadriceps femoris. Of the four heads of this muscle, only three are available for examination by surface EMG: m. rectus femoris, m. restus lateralis, m. vastus medialis, while M. vastus lateralis and m. vastusmedialis is synergistic and can only affect the knee joint. Cutaneous electrodes are placed on motor points along muscle fibers according to the standard technique The SENIAM project (Surface ElectroMyoGraphy for the Non-Invasive Assessment of Muscles) is a European concerted action in the Biomedical Health and Research Program (BIOMED II) of the European Union [Electronic resource ... Access mode: http://www.seniam.org/].

The patient walks on a flat surface without means of support, in comfortable shoes (without heels, tight to the foot) at a comfortable pace for two minutes. The program automatically registers temporal, phase and kinematic parameters of walking, comparing them with the ENMG envelope of the muscles. For each ENMG, two quantitative parameters are calculated:

1) amplitude (μV) - the highest value of the ENMG envelope per step cycle (CS), used to assess the strength of muscle contraction;

2) phase (% TS) - the moment of the TS, which corresponds to the maximum value of the ENMG envelope, to assess the timeliness of the inclusion of the muscle in the TS.

The study was conducted on the basis of the Ivanovo Regional Hospital for War Veterans in February - May 2019. 40 people were examined, aged from 10 to 17 years (average age 13.5 ± 2.3 years) with traumatic dislocations of the patella as after conservative (20 people) and after surgery (20 people) treatment. The control group consisted of almost healthy 40 volunteers (1st year students of the Ivanovo State Medical Academy of the Ministry of Health of the Russian Federation and the Ivanovo Fire and Rescue Academy of the State Fire Service of the Ministry of Emergencies of Russia). Inclusion criteria were: persons under 18 years of age inclusive, living in the Central Federal District, with a body mass index from 21 to 24, no bad habits, with the main group in physical education, no pathology and a history of knee injury, no fractures of the pelvic bones, hip, lower leg , feet.

Normally the maximum for m. vastus medialis occurs in 12% of the CN. (Fig. 1). In the course of the study, in adolescents with patellar dislocation, both after surgical and conservative treatment, an imbalance in the bioelectric activity of m. vastus medialis in the step cycle on the side of the dislocation, which consists in its additional stress during the period of transfer (60% -80% of the CV), compared with the respondents in the control group.

A new dynamic walking stereotype is being formed, in which an additional, compensatory contraction of m is observed. vastus medialis during the period of walking, when there is a loss of contact with the support - at the moment of separation of the toe from the support during the period of transfer, which compensates for the stabilization of the knee joint during flexion, when there is a "tendency" of the patella to dislocate.

Examples of screen shots of ENMG screens of clinical application of the developed method are shown in Fig. 2-4.

FIG. 2. ENMG m. vastus medialis in the step cycle in the experimental group. Teenager B., 17 years old with dislocation of the patella on the left after conservative treatment in 1.5 months. after injury: a strong additional muscle contraction is observed, which is necessary to stabilize the patella with max = 68.5% during the transfer period.

FIG. 3. ENMG m. vastus medialis in the step cycle in the experimental group. A 17.5-year-old teenager with a history of dislocation of the patella on the left after conservative treatment 2 years after the injury. There is a second wave of contraction of the medial head of the quadriceps femoris muscle with an onset at 45% of the CV at the end of the support period and with a maximum at the beginning of the transfer period in 60% of the CV.

FIG. 4. ENMG m. vastus medialis in the step cycle in the experimental group. A 16-year-old girl with dislocation of the patella on the right after surgical treatment one year after the injury: there is an additional muscle contraction during the transfer period with a maximum at the beginning of the transfer period in 60% of the CP, necessary to stabilize the patella.

Thus, in adolescents with patellar dislocation, changes in the bioelectric activity of m. vastus medialis compared with the control group, which consists in its additional contraction during the transfer period, at the moment when the patella stabilization is necessary.

Claims (1)

A method for diagnosing a dynamic imbalance of the quadriceps femoris muscle due to laterodislocation of the patella, including performing surface electroneuromyography, characterized in that the ENMG study correlates with the phases of the step, and in determining the additional contraction of m. vastus medialis of the quadriceps femoris muscle in the range of 60-80% of the stride cycle, an imbalance of m. vastus medialis of the quadriceps femoris muscle due to the lateroposition of the patella.

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