RU2746974C1 - Method for determining achievement of correction of flexion contracture in knee joint among children with spastic forms of infantile cerebral paralysis when performing anterior hemiepiphysiodesis among children aged 7-12 years - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.SUBSTANCE: radiography of the child is carried out every three months on an outpatient basis at the place of residence in the direct and lateral projection of the operated limb with the capture of the hip and lower leg, in the position of the maximum passive extension of the limb in the knee joint. The results are sent to the attending physician. When the extension of 180º in the knee joint is reached, the child is subjected to goniometry of the operated limb in the prone position with passive extension and in the standing position with active extension of the lower leg, as well as radiography in the prone position with maximum passive extension of the lower leg. When the amount of passive extension, according to goniometry in the prone position of 7º to 3º of recurvation, and of 18º to 12º of recurvation, according to x-ray of the knee joint in lateral projection in prone position, as well as the amount of the active extension of 6º to 2º of recurvation in the standing position, according to goniometry, are reached, the removal of the plates is recommended.EFFECT: method makes it possible to achieve a physiological volume of movements in the knee joint for this age group, in which the energy consumption of the patient's vertical adjustment will be optimal, as well as to delay the recurrence of flexion contracture in the knee joints among children with a large growth potential due to the combination of techniques of the claimed invention.1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, in particular to orthopedics, and can be used for surgical correction of flexion contractures of the knee joint in children with spastic forms of cerebral palsy (cerebral palsy).

Flexion contractures and deformities of the knee joints occur against a background of various diseases, including cerebral palsy, in which this pathology is progressive and is based on both an arthrogenic component and a tendon-muscular component. In the process of a child's growth, these types of deformities of the lower extremities can lead, among other things, to regression, inhibition of development or a complete loss of vertical movement skills. Conservative methods of treatment of formed persistent deformities in these pathologies are ineffective in most cases. Open surgery is associated with high invasiveness and a high risk of complications. The minimally invasive technology of guided growth, or controlled growth, promotes gradual correction by temporarily blocking the growth zone. The technology is based on the application of the Hueter-Volkmann law, according to which an increase in the load on the growth plate leads to a slowdown in bone growth. Apoptosis and autophagy of chondrocytes, which are reversible after elimination of stress on the growth zone, play an important role in growth inhibition. This technology has been popular for the last 20 years.

A known method of correcting flexion contractures of the knee joints in children with spastic forms of cerebral palsy using metal implants located on the surface of the knee joint, while on the anterior surface of the distal epiphysis of the femur in the peripatellar zone of the knee joint, two metal plates are fixed using screws installed on 1- 2 cm above and below the growth zone, for which two peripatellar skin incisions are performed along the lateral and medial sides of the patella in the projection of the growth zone up to 3.5-5.0 cm long along the thigh axis, then the subcutaneous tissue, capsule and synovium of the knee joint are dissected to visualize the epimetaphyseal region, under the control of an image intensifier, the growth zone is verified, it is marked with an injection needle and channels are formed for screws, parallel to each other and the growth zone lines in the anteroposterior direction, in the epiphysis and metaphysis above and below the growth zone, and the length of the screws must correspond 1/3 of the bone diameter, and place the plates on the anterior surface of the femur medially and laterally from the patella, then the wound is washed, sutured in layers and a plaster splint is applied in the position of maximum extension for up to one week (RF Patent No. 2698218).

The question remains, what target values of extension in the knee joint should be achieved when performing anterior hemiepiphysiodesis of the distal femoral metaepiphysis.

N. Stiel et al. Recommend that correction be performed until about 5 ° recursion is achieved only for patients with significant growth potential at the time of implant removal in order to avoid deformity recurrence. Recurvation of the knee joint (hyperextension) is an extension of more than 180 ° in the knee joint. It can be physiological and pathological. The parameter was chosen empirically by the authors. (Stiel N., Babin K., Vetto-razzi E., Breyer S., Ebert N., Rupprecht M, Spiro AS Anterior distal femoral hemiepiphysi-odesis can reduce fixed flexion deformity of the knee: a retrospective study of 83 knees. Acta orthopedica. 2018: 89 (5), 555-559). Klatt, Stevens, on the other hand, emphasize that they remove the plates, avoiding recurvation in the knee joint. (Klatt J, Stevens RM. Guided growth for fixed knee flexion deformity. J Pediatr Orthop. 2008; 28: 626-631. Doi: 10.1097 / BPO.0b01 3e3 18183d573.).

It is known to bring the volume of extension in the knee joint to 180 ° (Zaid Al-Aubaidi, Bjarne Lundgaard, Niels Wisbech Pedersen. Anterior distal femoral hemiepiphysi-odesis in the treatment of fixed knee flexion contracture in neuromuscular patients. J Child Orthop (2012) 6: 313 -318). In all the examples presented, the physiological extension in the knee joint in children is not taken into account, which is the most optimal for the lowest energy consumption during verticalization.

For surgical methods of treating axial deformities of the extremities in the sagittal plane, based on controlled blocking of growth in the metaepiphyseal zones of the child's bones - anterior hemiepiphysiodesis, the scientific literature does not know specific indications for removing the plates and the method for their determination. Also, the normal values of active and passive extension in the knee joints in children by age have not been described. In the scientific literature, there are data on the refractory values of passive and active extension in the knee joint only in adults. So, according to Bukup K., the normal volume of hyperextension in the knee joint in adults is 5-10 ° (which is a physiological recurvation) (Klaus Bukup Johannes Bukup Clinical study of bones, joints and muscles. M .: Medical literature, 2018. ). According to V.O. Marks. from the extended position of the knee joint, it is passively possible to obtain overextension within 12 °. The beginning contractures of the knee joint are detected by the loss of additional movements of the lower leg. These include hyperextension of the lower leg (Marks, V.O. Orthopedic diagnostics: Guidebook 1978). At the same time, hyperextension in the knee joint ≥10 ° is already one of the five criteria for determining joint hypermobility according to R. Beighton, that is, it refers to pathological recurvation (Rejeb A, Fourchet F., Materne O., Johnson A., Horobeanu C, Farooq A., et al. Beighton scoring of joint laxity and injury incidence in Middle Eastern male youth athletes: a cohort study.BMJ Open Sport Exerc Med. 2019; 5: e000482.doi: 10.1136 / bmjsem-2018-000482).

The objective of the invention is to develop a method for determining the achievement of correction of flexion contracture in the knee joint in children with spastic forms of cerebral palsy when performing anterior hemiepiphysiodesis in children 7-12 years old.

The technical result of the implementation of the task is to determine the target volume of passive and active extension in the knee joint in children 7-12 years old with a diagnosis of cerebral palsy when performing temporary anterior hemiepiphysiodesis.

To achieve the technical result of the task, a reference group of 40 children (60 knee joints) was recruited, including 21 boys and 19 girls. The group included patients without pathology affecting the range of motion in the knee joint, one or two limbs. The age of the children in the selected group was from 7 to 12 years old. The group included children with diagnoses: inequality in the lengths of the lower extremities due to hemihypoplasia, Legg-Calve-Perthes disease at the stage of outcome, tumor neoplasm of the metaphysis, spastic hemiplegia with cerebral palsy (unilateral form of lesion); as well as with a diagnosis of injury to one knee joint. Exclusion criteria from the reference group: the presence of joint hypermobility syndrome, determined by P. Beighton's criteria, the presence of exostous chondrodysplasia, as well as regular exercises in the sports section, affecting the ligamentous apparatus of the knee joint. All children from the reference group underwent radiography of the lower extremities during the examination for the underlying disease. Radiography of a healthy limb was performed in the supine position with maximum passive extension. Goniometry was performed using a protractor-goniometer according to the method described by V.O. Marks. Laying was used in the supine position with the determination of the maximum passive extension in the knee joint and in the standing position with the determination of the maximum active extension (Marks, V.O., 1978. Orthopedic diagnostics: Guidebook). Among the patients of the reference group, the average angle of extension in the knee joint in the supine position with passive extension of the lower leg was 5 ° recurvation (± 2 °) (or from 7 ° to 3 ° recurvation) according to goniometry and 15 ° recurvation (± 3 °) ( or from 18 ° to 12 ° recursion), according to X-ray data. There was no statistically significant relationship between the extension angle according to the results of X-ray and goniometry and the age of the child in the group (p> 0.05). These parameters are suitable for children from 7 to 12 years old. The average angle of active extension in the standing position according to goniometry was 4 ° recursion (± 2 °) (or from 6 ° to 2 ° recursion). Based on the results of the reference group, we determined the target volume of passive extension in children 7-12 years old with a diagnosis of cerebral palsy when performing temporary anterior hemiepiphysiodesis, which, according to goniometry in the supine position, is from 7 ° to 3 ° of recurvation and from 18 ° to 12 ° of recurvation according to X-ray data of the knee joint in lateral projection in the supine position. The target volume of active extension in children aged 7-12 years with cerebral palsy when performing temporary anterior hemiepiphysiodesis is from 6 ° to 2 ° recurvation in the standing position according to goniometry data. Smaller values of the tibial-femoral angle according to goniometry in the standing position and maximum passive extension according to X-ray and goniometry data can serve as clinical and X-ray criteria for flexion contracture of the knee joints in children of this age group and a reason to postpone the removal of metal structures when performing anterior hemiepiphysiodesis.

Thus, the method for determining the achievement of correction after performing anterior hemiepiphysiodesis is as follows. In the postoperative period, every 3 months, on an outpatient basis, at the place of residence, patients undergo X-rays in the frontal and lateral projection of the operated limb with the capture of the thigh and lower leg, with the center on the knee joint, in the position of passive extension, and sent to the attending physician. Taking into account the specific styling for children with cerebral palsy when performing X-ray (the position of passive extension of the limb in the knee joint in the lateral projection in the presence of spasticity, panic in the child, often reduced cognitive abilities against the background of the underlying disease), and the technical difficulties in performing such styling, upon reaching extension about 180 ° in the knee joint, the child is examined directly by the attending physician. Radiography is performed in the direct and strictly lateral projection of the operated limb with the capture of the thigh and lower leg, with the center on the knee joint, in the supine position with maximum passive extension in the knee joint. Examination and goniometry of the operated limb are performed in the supine position with passive extension and in the standing position with active extension of the lower leg (for patients with cerebral palsy who are able to verticalize with active extension of the lower leg).

Upon reaching the target values of the studied parameters: the volume of passive extension according to goniometry in the prone position from 7 ° to 3 ° of recurvation and from 18 ° to 12 ° of recurvation according to the X-ray of the knee joint in the lateral projection, in the supine position, the volume of active extension from 6 ° up to 2 ° recurvation in the standing position according to goniometry, the child is shown the removal of the plates.

Clinical example of the implementation of the method. Child L., seven years old, has been observed at the place of residence by a neurologist since birth with a diagnosis of cerebral palsy, spastic tetraparesis. GMFCS IV. Repeatedly underwent inpatient treatment in the neurological department. Does not support weight on its own, does not stand, does not walk. It is verticalized only with support by the hands and with the help of orthopedic additional support means. Botulinum therapy has been regularly carried out since 2016. In 2018, at the age of 7, the child developed complaints of limitation of movement and soreness in the knee joints. Conservative therapy had no effect. In December 2018, he entered the neuro-orthopedic department of the National Medical Research Center of Children's Health of the Ministry of Health of Russia. Appearance before surgery (Fig. 1). The child underwent goniometry to determine the angle of maximum passive extension in the knee joint, which was 142 ° on the left and 150 ° on the right. The child underwent radiography of the lower extremities in lateral (Fig. 2) and frontal (Fig. 3) projections before surgical treatment in the supine position with passive extension of the knee joint before surgical treatment. The angle of maximum passive extension in the knee joint was determined, which was 142 °, in the right knee joint - 150 °. Anterior hemiepiphysiodesis of the distal epiphysis of the right and left femur was performed. In the interhospital period, with an interval of 3 months at the place of residence, radiography of the knee joints in frontal and lateral projections in the position of maximum passive extension was performed; radiographs were sent to the attending physician. In September 2018, a 180 ° extension was achieved based on lateral X-ray at the site of residence. The child was admitted to the hospital for examination. Goniometry was performed to determine the angle of maximum passive extension in the knee joint. The appearance before removing the plates is shown in (Fig. 4). The volume of passive extension in the knee joint, according to goniometry data, is 6 ° of recurvation on the right and 5 ° of recurvation on the left. Radiography of the lateral projection was performed to determine the angle of maximum passive extension in the knee joint (Fig. 5), which was 12 ° of recurvation on the left and right. Performed radiography in direct projection (Fig. 6). Based on the results of the survey, a decision was made to remove the metal structures.

Using the proposed method allows you to accurately achieve the physiological range of motion in the knee joint for a given age group, at which the energy consumption of verticalization of the patient will be optimal, as well as to delay the recurrence of flexion contracture in the knee joints in children with high growth potential.

Claims (1)

A method for determining the achievement of correction of flexion contracture in the knee joint in children with spastic forms of cerebral palsy when performing anterior hemiepiphysiodesis in children 7-12 years old, including determining the values of active and passive extension in the knee joints, characterized in that the child is carried out every three months on an outpatient basis at the place of residence X-ray in frontal and lateral projection of the operated limb with the capture of the thigh and lower leg in the position of maximum passive extension of the limb in the knee joint and sent to the attending physician, when reaching 180 ° extension in the knee joint, the child is examined by the attending physician, the child is goniometry of the operated limb in the supine position with the maximum passive extension and in a standing position with active extension of the lower leg, as well as X-ray of lying with maximum passive extension of the lower leg and, upon reaching the volume of passive extension according to goniometry data in the prone position, from 7 ° to 3 ° of recurvation and from 18 ° to 12 ° of rivers urvation according to X-ray of the knee joint in lateral projection in the prone position and the volume of active extension from 6 ° to 2 ° of recurvation in the standing position according to goniometry, the child is shown removal of the plates.

Images