RU2283050C2 - Method for treating knee joint cartilage for local injuries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves grafting bone and cartilage autotransplants from less loaded areas of external and internal femoral condyles to articulation cartilage destruction zone positioned in stress concentration zone. Donor dimples are restored using cylindrical ceramic spongious bone substitutes of required diameter and height prepared in advance.

EFFECT: enhanced effectiveness in restoring cartilage on tibial condyles in femoro-patellar articulation.

Description

The invention relates to the field of medicine, namely to orthopedics and traumatology.

A method of treating local injuries of cartilage of the knee joint, accompanied by exposure of the subchondral bone, which has been used in clinical practice for a long time, is the resection of its unstable areas and subsequent tunneling of the subchondral bone (Pridie, 1959; Ogilvie-Harris, Jackson, 1984). In recent years, a technique has been developed that has undergone a number of technical changes in terms of the depth of the tunnels in the subchondral bone and the distance between them, aimed at creating the so-called “superbunch” with its subsequent transformation into cartilaginous tissue (Steadmen et al., 2001). The main disadvantage of these methods is that they lead to the formation of scar tissue or fibrous cartilage in the area of destruction, which are significantly inferior in their functional properties to hyaline cartilage.

There is a method for replacing extensive defects of the cartilaginous surface of the knee joint in young patients by replacing orthotopic bone-cartilage allografts of identical sizes (Newman, 1998).

However, this method has several disadvantages. The potential for transmission of hepatitis C and B viruses or HIV infection limits its widespread clinical use (Buck et al., 1990). A discussion continues about the methods for preoperative preparation of transplants: freshly picked transplants have high chondrocyte viability and low bone fusion potential due to a pronounced immunogenic reaction, while their freezing, reducing bone immunogenicity, has an extremely negative effect on cartilage cells (Manlin et al., 1994).

In recent years, mosaic cat-cartilaginous autoplasty has been increasingly used in clinical practice (Hangody et al., (1998)). Most authors believe that this technique makes it possible to ideally replace a portion of the affected articular surface in the load concentration region with a cylindrical bone-cartilage autograft taken from the less loaded part of the external and internal femoral condyles or intercondylar fossa anterior to the site of attachment of the anterior cruciate ligament (Ahmad et al ., 2001). Long-term arthroscopy and histological findings show that the resulting cartilage is identical to hyaline cartilage (Cole, 2002).

A disadvantage of existing methods of mosaic bone-cartilaginous autoplasty is the presence of defects in the articular surface at the sites of graft collection. Currently used methods include filling donor wells with autografts from the lesion zone, however, the sizes of these grafts often do not correspond to donor ones in height and diameter, which does not allow for stable fixation and adequate replenishment of plastic material intake sites. In a number of patients, pain in the joint persists for a long time in the postoperative period, slow bone filling of large holes can be seen on radiographs, and femoropatellar arthrosis develops.

The technical result of the invention lies in the fact that the spongy bone is restored more quickly and completely at the places of graft collection, for which donor holes are filled with ceramic spongy bone substitutes of the required size, pre-made and stored under sterile conditions in the operating room (Utility Model Certificate No. 25996 from November 10, 2002 - "An implant for contour plastics, restoration, correction, repair or replacement of defects, injuries or deformations of bone or cartilage Ani "). The use of ceramic cancellous bone substitutes can significantly accelerate the reconstruction of the femoral condyles of the femur at the site of autograft collection, which is confirmed by the improvement of clinical results and radiographic data of the knee joint.

The result of the invention is achieved by the fact that the donor wells are filled with cylindrical ceramic cancellous bone substitutes of the required diameter and height made earlier.

The method is as follows.

Arthroscopy of the knee joint is performed from standard anteroposterior and anteroposterior approaches, during which the state of all intraarticular structures is determined, the localization and area of the cartilage destruction site are determined, free intraarticular bodies are removed, and existing damaged menisci are resected.

Autograft collection and transplantation was performed using a special Arthrex tool kit (OATS - osteochondral autograft trasfer system).

After completion of endoscopy, the surgical field was re-treated and an arthrotomy was performed. If autografts were transplanted on the external condyle of the femur, anterior external access was used, and anterior-internal one was used to localize the destruction site on the internal condyle. After arthrotomy, the size and number of grafts necessary for the most complete replenishment of the joint surface defect was determined by special meters. Mills of the required diameter were used to take cylindrical bone-cartilage autografts with a height of 15-20 mm from the unloaded part of the external condyle of the femur. In the zone of destruction of the articular surface, the cutter formed holes in which bone-cartilage autografts were placed, driving them tightly and forming an even articular surface of the condyles. A small difference in the diameters of the cutters for drilling and graft collection provides a pressfit for transplanted autografts, without requiring additional fixation. In the same sequence, the required number (up to 5) of autografts was transplanted.

The next step was to replenish defects in the articular surface at the sites of autograft collection. Wells of small diameter (5-8 mm) were left empty or autografts were placed in them from the cartilage damage zone, and holes with a diameter of 10-13 mm were filled with cylindrical ceramic cancellous bone substitutes. Alignment of the walls of the donor well and determination of its depth were carried out using impactors of various diameters available in the set. Next, a ceramic cancellous bone substitute is selected, having a diameter of 1 mm larger than the hole and 3 mm shorter than its depth, which is embedded in the hole. The indicated difference in the diameter and height of the hole and the ceramic cylinder ensures its firm fixation and allows to fill the existing deficiency of the spongy bone to the level of hyaline cartilage.

Having restored defects in the articular surfaces, we checked the stability of fixation of autografts and cylindrical ceramic cancellous bone substitutes during passive movements in the knee joint. The joint was washed, drained, the wound was sutured in layers, the limb was immobilized with a posterior plaster cast.

Drainage was removed after 24-48 hours, walking with additional support on crutches without load on the operated leg was allowed after the drainage was removed.

Limb immobilization was maintained for 2-4 weeks. After the immobilization was completed, a comprehensive rehabilitation treatment was carried out, including physiotherapy exercises aimed at strengthening the muscles of the limbs and restoring the range of motion in the joint, massage, water and physiotherapeutic procedures. Dosed load was allowed after 4-6 weeks, full - after 7-8 weeks after surgery. For two to three months, patients were advised to use a cane when walking, to fix the joint with an elastic bandage or knee pad.

Clinical example.

Patient I., 37 years old (medical history No. 9730/2002), was hospitalized in the clinic as planned.

Upon receipt, complains of moderate pain, restriction and soreness of movements in the right knee joint. These complaints worry about six months, did not seek medical help. Symptoms of synovitis, palpation tenderness in the projection of the internal condyle of the femur, limitation of flexion of the lower leg by 20 degrees and extension by 10 degrees are clinically determined. On radiographs of the knee joint - a defect in the medial condyle of the femur, below it in the projection of the joint space is a bone-cartilage fragment.

4 days after hospitalization, arthroscopy of the knee joint was performed, during which it was established that the menisci and the anterior cruciate ligament were not damaged, in the inner part of the femoral-tibial joint, the osteo-cartilaginous body was oval in size 1 × 1.5 cm, connected by a cartilaginous bridge with the femoral condyle bones. After removal of the intraarticular body on the loaded surface of the internal condyle of the femur, the defect of the articular surface is 1 × 1.5 cm in size with uneven edges, the bottom of the “niche” is the spongy bone.

Three anterior-cartilaginous autografts with a diameter of 13, 6 and 5 mm were transplanted from anteroposterior access from the unloaded part of the external and internal femoral condyles to the destruction zone. The donor hole with a diameter of 13 mm on the external condyle is filled with a cylindrical ceramic sponge bone substitute, and the other two are filled with bone-cartilage autografts obtained during the formation of recipient holes. During control movements in the knee joint, the grafts and the ceramic cylinder are fixed stably, the articular surface is even.

The postoperative period was uneventful, the sutures were removed on the 12th day, gypsum immobilization after 4 weeks. Dosed load is allowed after 6 weeks, full - after 12 weeks.

During the follow-up examination 6 months after the operation, the patient does not show complaints of pain in the knee joint, joint function has fully recovered. On radiographs of the operated joint, complete bone fusion and autograft rearrangement in the region of the internal condyle of the femur are determined, the articular surfaces of the condyles are congruent, there are no signs of gonarthrosis. In the projection of the external condyle of the femur, a cylindrical shadow from the ceramic substitute of the cancellous bone is traced.

Bibliography

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Claims (1)

A method for treating local injuries of the cartilage of the knee joint, including transplantation of bone-cartilage autografts from less loaded sections of the external and internal condyles of the femur into the area of destruction of the articular cartilage located in the stress concentration zone, characterized in that previously made cylindrical sponge ceramic substitutes are introduced into the donor wells bones, firmly fixing them to the level of hyaline cartilage.