RU2758831C2 - Method for treatment of initial aseptic osteonecrosis of middle and posterior parts of foot due to pathological functional restructuring of bone tissue - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, it can be used in the treatment of aseptic necrosis of the middle and posterior parts of the foot caused by pathological functional restructuring of bone tissue. Tunneling of the posterior part of the foot is performed. Autoplasm enriched with platelets in a volume of 5 ml and autologous bone marrow aspirate in a volume of 5 ml are injected into the obtained channels. After 2 days and then every 5 days, a mixture of autoplasm with naropin in the ratio of 1:1 is injected 2-3 times into the fascial cases of the foot in the same volume. After that, after 4-5 days, orthopedic correction of the foot is performed.

EFFECT: method provides for a reduction in the risk of infectious and non-infectious complications, the possibility of outpatient management of the patient after tunneling, a reduction in pain during the procedure, a reduction in the financial component of the procedure, a reduction in the duration of treatment due to the activation of the vascularization process.

1 cl, 1 dwg, 1 ex

Description

The proposed invention relates to traumatology and orthopedics and can be used in the treatment of aseptic necrosis of the middle and hind parts of the foot caused by pathological functional rearrangement of bone tissue. The treatment of the initial stages of aseptic osteonecrosis, of various localizations, especially the middle and hindfoot, is a very difficult task that takes a long time. Manifestations of aseptic osteonecrosis on the foot consist in severe edema, pain and significant, up to complete loss, decrease in function. Aseptic necrosis is conventionally divided into two types: secondary aseptic osteonecrosis, as a consequence:

- systemic pathology (rheumatoid arthritis, systemic lupus erythematosus, etc.), leading to a violation of the vascular supply of intra and extravasal genesis; embolization of the vessels of the bone marrow and subchondral bone; hypercoagulation of primary and secondary genesis;

- long-term use of bisphosphonates; ionizing radiation (X-ray therapy); long-term intake of glucocorticoids, immunosuppressants, cytostatics, alcohol dependence.

The second type of aseptic necrosis is diseases that developed as a result of pathological functional rearrangement of the bones of the foot during excessive physical exertion (fatigue or stress fractures), they are distinguished by the absence of systemic concomitant pathology, a genetic predisposition to the development of stress fractures, peculiar manifestations of edema on MRI, and bone ischemia. brain and trabecular necrosis along the line of which a stress fracture occurs, as well as in connection with disturbances in bone blood flow.

The known method of two-stage surgical treatment of aseptic necrosis and chronic fractures of the talus (patent application RF 99127778 2001 Dolgopolov V.V., Shestakov A.V.).

1. At the first stage, under general anesthesia, the Ilizarov apparatus is applied to the ankle joint to restore the lost distance between the calcaneus and tibia by distraction.

2. At the second stage, without removing the apparatus, the fibula osteotomy is performed, the necrotic part of the talus is excised, the resulting defect is replaced with an autograft bone from the ilium.

Disadvantages of the method: both stages are performed in the operating room under general anesthesia. The use of an external bone fixation device increases the risk of infectious complications from the wound. Long-term presence of foreign bodies in the bone (metal pins) creates areas of aseptic inflammation and, as a result, ischemic fracture zones. Removal of aseptic areas of the talus leads to gross defects of the latter, disrupting the normal anatomy of the midfoot. The technical complexity of the operation. The need for specific care for the external bone fixation device.

The closest analogue is a method of surgical treatment for aseptic necrosis of the talus in patients with rheumatoid arthritis (R.A. Bakir, Ph.D. thesis abstract, Moscow, 2013).

1. Apply antero-median approach: perform a longitudinal incision along the anterior surface of the lower third of the leg and ankle joint.

2. The fascia is dissected along the line of the operative access. The tendon of the long extensor of the thumb is retracted inward, and the tendon of the long extensor of the fingers and the neurovascular bundle are retracted outward. The capsule is dissected, after which the foot is placed in a position of maximum flexion, which allows visualization of the joint.

3. The chisel is used to remove cartilage and sclerosed bone tissue from the talus and tibia block, move posteriorly and set at an angle of 100 degrees to the tibia axis. Bone fragments are fixed with 2 cancellous screws, held in a cross direction.

4. Two skin incisions, 5 mm long, are made in the projection of the distal tibia along the anteromedial and anterolateral surfaces, the canal is reamed, spoigious screws are inserted through the tibia into the body of the talus.

5. The bone marrow punctate obtained from the wing of the ilium is introduced into the body of the talus and the area of juxtaposition of the bone fragments.

Disadvantages of this method: the operation is performed using general anesthesia. The technical complexity of the operation. Large surgical trauma with a high risk of developing septic complications. The need for long-term anesthesia in the postoperative period. Leaving screws in the bone tissue after surgery as fixators. The normal anatomy of the midfoot is impaired. The high cost of the operation, the duration of medical and social rehabilitation.

Objectives: improving the reparative capacity of bone tissue, reducing the risk of intraosseous edema, increasing the effect of treating aseptic bone necrosis, preventing stress fractures, including:

• Ensuring the technical simplicity of the method.

• Reducing the risk of infectious and non-infectious complications.

• Ensuring the possibility of outpatient management of the patient after tunneling.

• Reduction of pain during the procedure.

• Reducing the financial component of the procedure.

• Reduced treatment time.

The technical result.

The advantages of this method of treatment of initial aseptic osteonecrosis of the middle and hind parts of the foot, caused by pathological functional rearrangement of bone tissue, is that the tunnel canals in the bones of the foot create conditions for ioangiogenesis, and platelet-rich plasma into the tunnel canals and fascial cases of the foot (PRP-therapy (Platelet-Rich Plasma)) stimulates regeneration processes due to cytokines and growth factors secreted from platelet α-granules. Platelet cytokines, contain TGF-β (producing growth factor β), PDGF (platelet growth factor), insulin-like growth factors IGF-I and IGF-II, FGF (fibroblast growth factor), VEGF (vascular endothelial growth factor), epidermal growth factor tissues and growth factor of endothelial cells. These techniques make it possible to eliminate the processes of hypertension in the bone tissue, to reduce the area of edema and ischemia, ensuring the processes of restoration (regeneration) of the bone tissue; reduce the risks associated with the development of infectious and non-infectious complications; autoplasma does not lead to allergic reactions from the body; low invasiveness of the procedure and a small volume of plasma provide minimal manifestations of pain syndrome; do not require hospitalization of patients, technically simple execution allows the entire course of treatment to be carried out on an outpatient basis, reducing the overall cost of treating a patient.

The essence of the invention lies in the fact that the process of vascularization is activated, while after local or intravenous anesthesia, tunnelization of the affected area of the foot is performed and autoplasma in a volume of up to 5 ml, enriched with platelets, is injected into the resulting channels, then, after 2 days, and then every 5 days Autoplasm is injected 2-3 times into the fascial cases of the foot in the same volume mixed with anesthetic in a 1: 1 ratio, after which orthopedic correction of the foot is performed.

The method is additionally demonstrated in the figure - a method of treating initial aseptic osteonecrosis of the middle and hind parts of the foot caused by pathological functional rearrangement of bone tissue is carried out as follows (see Fig. 1 - channel direction in aseptic necrosis of the middle and hind parts of the foot):

1. Under intravenous or local infiltration anesthesia in the zones of aseptic osteonecrosis (determined by MRI), tunneling of the affected parts of the foot (zones of edema, ischemia, trabecular necrosis of the bone marrow - in Fig., Item 1) is performed once, in order to reduce intraosseous pressure in bone marrow edema, creation of channels in the cancellous bone to ensure the possibility of vascular invasion into the avascular zones, delivery of stimulators of bone tissue regeneration directly to the zone of aseptic necrosis.

2. Up to 5 ml of platelet-rich plasma (PRP) obtained from 10 ml of the patient's blood is injected into the obtained tunnel canals by centrifugation for 5 minutes at a speed of 3000 rpm and aspirate of autologous bone marrow (BMAC) taken from the pelvic wing.

3. 2 days after tunneling, repeat the PRP procedure: inject platelet-rich plasma into the fascial cases of the foot, with prolonged local anesthesia drugs (naropin) with an antispasmodic effect, where hypertension was detected with an interval of 5 days, 2-3 procedures are performed in total.

4. After stopping the clinical manifestations of the disease (edema and pain), 4-5 weeks after the start of treatment, orthopedic correction of the detected dysplasia of the foot is performed, and the dosed load on the limb is allowed.

The proposed method has been tested in a clinical setting since 2018, on a total of 25 patients who were diagnosed with a marching fracture (stress fracture) of the midfoot.

Clinical example. Patient N., 41, fell ill after performing work unusual for a way of life associated with lifting and carrying weights. Within 2 months, treatment was carried out at the municipal trauma center with diagnoses: plantar fasciitis, achillobursitis. There was no effect of the treatment. Pain syndrome persisted. He walked with crutches. Based on the MRI performed at our site and the pressure measurement in the fascial fulles of the foot, the diagnosis was formulated: hollow foot, overload of the left foot, subchondral edema-ischemia of the calcaneus bone marrow, trabecular necrosis of the calcaneus (incomplete stress fracture), hypertension in the fascial cases of the foot. Tunnelization of the mid-posterior parts of the foot (talus, calcaneus) was performed under intravenous anesthesia, platelet-rich plasma (PRP) and autologous bone marrow aspirate 5 ml were introduced into the canals. Two days later, 10 ml of a mixture of enriched blood plasma (PRP) - 5 ml and naropin - 5 ml were injected into the case spaces of the foot. This procedure was repeated every 5 days - a total of 3 procedures. One month after the start of treatment, the patient began to walk independently without using crutches in orthopedically adjusted shoes. Control MRI 1.5 months after the start of treatment: positive dynamics, revascularization of the zone of incomplete stress fracture, the zone of trabecular edema is not determined.

Claims (1)

A method of treating initial aseptic osteonecrosis of the hindfoot, caused by pathological functional rearrangement of bone tissue, characterized in that intravenous anesthesia is performed, tunnelization of the hindfoot is performed, and platelet-rich autoplasm is injected into the resulting canals in a volume of 5 ml and an aspirate of autologous bone marrow in a volume 5 ml, then after 2 days and then every 5 days 2-3 times a mixture of autoplasma with naropin in a 1: 1 ratio is injected into the fascial cases of the foot in the same volume, after which orthopedic correction of the foot is performed after 4-5 days.

Images