RU2300337C1 - Surgical method for treating exacerbated anterior knee joint cruciform ligament injuries cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out knee joint arthrotomy. Canal is formed in internal femoral condyle and a through canal in tibial condyle. Lavsan implant is brought through the formed canals and fixed. Blind canal is formed in external femoral condyle. An additional blind canal is formed in the internal tibial condyle. Lavsan vascular prosthesis is introduced through the formed canals. Spherical fixing member manufactured from bone cement. Proximal prosthesis end is introduced into the formed blind canal of the external femoral condyle and conical bone cement plug is hammered into it in pulling the prosthesis in uninterrupted manner. Then it is brought through the canal formed through the tibial condyle and the prosthesis is fixed with the like plug in bent knee joint state position. Then, the like fixing member is sutured in distal prosthesis end lumen and introduced into the blind canal of the femur. The prosthesis end is fixed with the like plug.

EFFECT: reliable prosthesis fixation; reduced risk of traumatic complications; accelerated treatment course.

Description

The invention relates to medicine, in particular to orthopedics, and in particular to methods for treating chronic injuries of the ligamentous apparatus of the knee joint.

Known methods for surgical reconstruction of the anterior cruciate ligament (PCL) of the knee joint by using various artificial materials. A wide range of surgical techniques and materials for prosthetics (nylon, lavsan, perylene, dacron, polyester, vitlan, etc.) is presented in the domestic literature (Z. Mironova, Errors and complications in the diagnosis and treatment of patients with intraarticular injuries and diseases of the knee joint / Z. S. Mironova, A. S. Martens, T. I. Inagamjanov. - Tashkent: Medicine, 1977. - 100 pp .; Movshovich I. A. Operative orthopedics: A guide for doctors / I. A. Movshovich. - M .: Medicine, 1994. - S.298-302, 448 p .; Malygina M.A. Restoration of the cruciate ligaments of the knee joint a / M.A. Malygina, V.P. Okhotsky, O.P. Filippov, J.F. Laboureau // Annals of Traumatology and Orthopedics. - 1997. - No. 2. - S.14-19).

A common disadvantage of these methods is that the grafts are fixed by hemming or knotting, which does not provide sufficiently reliable fixation of the graft.

As a prototype for the closest technical essence, we have chosen the method of restoration of the anterior cruciate ligament of the knee joint with lavsanoplasty, described by IA Movshovich (Movshovich IA Operational orthopedics. A guide for doctors. Second ed., Revised and supplemented. M., "Medicine", 1994, 445 p., S.299).

The method is as follows.

After arthrotomy of the knee joint, through channels are formed, one in the external condyle of the thigh, the second in the metaphysis of the tibia. An lavsan ribbon is passed through the formed channels. The tape is fixed on the external condyle of the thigh using a knot, and on the tibia it is sutured to the surrounding tissues.

The method has the following disadvantages.

Insufficiently reliable fixation of the lavsan ribbon by tying the knot, since in some cases it may be untied or, over time, the knot may decrease in volume due to its constant tension, which can lead to its penetration into the formed channel, which may lead to instability of the restored knee ligament. The method is traumatic, as additional cuts are required on the thigh and in the area of the tibial tuberosity.

The high probability of the above complications does not allow the early development of movements in the knee joint in the postoperative period and requires immobilization of at least 3-4 weeks, which leads to excessive scarring and the occurrence of stiffness of the knee joint, which leads to an increase in rehabilitation time to 3 months (I. Movshovich A. Operative orthopedics. A manual for doctors. Second ed., Revised and supplemented. M., "Medicine", 1994, 445 pp., S.300).

The objective of the invention is to develop a method that improves the reliability of fixation of the prosthesis, reduce the invasiveness of the operation and reduce treatment time.

The problem is solved in that they perform arthrotomy of the knee joint, form a blind canal in the external condyle of the thigh, as well as a blind and through channel in the internal condyle of the tibia, conduct a lavsan vascular prosthesis through the formed channels, and the fixator is sewn into the lumen of its proximal end spherical bone cement with a diameter of 2-3 mm, after which the proximal end of the prosthesis is immersed in the formed blind canal of the external condyle of the femur and hammered into conical bone cement plug with a diameter of 7.8-8.2 mm and a height of 20-25 mm, while the prosthesis is constantly pulled, then it is passed through the formed through canal of the tibia and the prosthesis is fixed in the knee joint with a similar plug, then A similar fixative is sewn into the lumen of the distal end of the prosthesis and the prosthesis is immersed in the blind canal of the tibia, after which the end of the prosthesis is fixed with the same stopper.

The method is as follows.

The operation is performed under spinal anesthesia or endotracheal anesthesia. The patient lies on his back, the knee joint is bent at an angle of 90 degrees on a special stand. It is possible to perform an operation under a tourniquet or using a pneumatic cuff (which is preferable).

Medial access by Payra. A revision of the knee joint is performed. If necessary, remove the damaged menisci, and also excise the stumps of the anterior cruciate ligament.

A thin (3 mm) and wide (7 mm) awl (sweeps can be used) form the blind canal (up to 3-4 cm deep) in the external condyle of the femur. The entry intraarticular point in the condyle of the femur is 3-4 mm anterior to the edge of the posterior intercondylar notch, on the medial surface of the lateral condyle (approximately 11 hours for the right knee joint). The direction of the channel should correspond to the course of the ligament so that there are no excesses of the prosthesis. Flare the edge of the canal with a 9 mm drill to prevent grinding of the prosthesis against the edge of the canal. A through channel is formed in the medial condyle of the tibia, passing it through the metaepiphyseal zone. Also, the channel is flared up to 9 mm from the side of the cavity of the knee joint.

A ligament prosthesis is prepared from a vascular prosthesis 20 cm long. A pre-prepared spherical fixer of bone cement - polyacrylamide (diameter 2-3 mm) is sewn into the lumen of the proximal end of the prosthesis. This end of the prosthesis is immersed in the blind canal of the femoral condyle and the pre-prepared bone cement plug (diameter 8 mm, height 20 mm) is driven into it, while constantly stretching the prosthesis. The latch must be firmly jammed with the side surface of the plug. Stitch the distal end of the prosthesis with lavsan ligatures. Using a special conductor, a prosthesis is passed through the through channel in the tibia at the ends of the threads.

Pull the prosthesis at an angle of 160 degrees of flexion of the knee joint, fixing it with another plug. For complete adaptation of the prosthesis, it is necessary after fixing it on the condyle of the thigh and before fixing it on the condyle of the tibia to produce 15-20 flexion-extensor movements in the knee joint.

A blind canal is formed in the tibia 3-4 cm deep. The fixative is sewn into the distal end of the prosthesis so that it can be lowered into the blind canal. The end of the prosthesis is fixed in the channel with a stopper. Control the stability of the knee joint and the tension of the prosthesis. Install active drains in the upper inversion area. Layered stitches on the wound. Immobilization of the knee - with an orthosis or plaster cast for 10-12 days.

Distinctive essential features of the claimed method are:

1. The formation of two blind canals, in the external condyle of the femur and additionally in the internal condyle of the tibia, which reduces the invasiveness of the operation, since it eliminates the need for additional incisions on the femur and tibia.

2. The use of lavsan vascular prosthesis, which is more durable compared to other implants, and its tubular shape allows the latch to be sewn into the lumen.

3. The use of a spherical shape clamp made of bone cement (polyacrylamide) for fastening the ends of the prosthesis due to the effect of mechanical jamming increases the reliability of fixing the end of the prosthesis between the blind channel wall and the cork.

The set of distinctive essential features is new and allows to increase the reliability of fixation of the prosthesis, reduce the invasiveness of the operation and reduce the duration of treatment.

Examples of specific performance.

Example No. 1

Patient K., 38 years old. And / b No. 287. Diagnosis: Injury damage to the right side of the knee joint.

Operated in Lokb in 2005. The operation was performed under endotracheal anesthesia. The patient was lying on his back, the knee joint was bent at an angle of 90 degrees on a special stand. The operation was performed under a tourniquet. Medial access was made according to Payr. The revision of the knee joint.

A thin (3 mm) and wide (7 mm) awl formed a blind canal 4 cm deep in the external condyle of the femur. The entry intraarticular point in the condyle of the femur was 4 mm anterior to the edge of the posterior intercondylar notch, on the medial surface of the lateral condyle (approximately 11 hours for the right knee joint). The direction of the channel corresponded to the course of the ligament. The edge of the canal was flared with a 9 mm drill to prevent grinding of the prosthesis against the edge of the canal. A through channel has been formed in the medial condyle of the tibia, passing it through the metaepiphyseal zone. Also, the channel was flared up to 9 mm from the side of the cavity of the knee joint. A ligament prosthesis was prepared from a vascular prosthesis 20 cm long. A pre-prepared spherical fixer of bone cement - polyacrylamide (diameter 3 mm) was sewn into the lumen of the proximal end of the prosthesis. This end of the prosthesis was immersed in the blind canal of the femoral condyle, and a pre-prepared bone cement plug (diameter 8 mm, height 20 mm) was hammered into it, while the prosthesis was constantly pulled. The latch was firmly jammed with the side surface of the cork. We stitched the distal end of the prosthesis with lavsan ligatures. Using a special conductor, a prosthesis was passed at the ends of the threads through the through canal in the tibia.

The prosthesis was pulled at an angle of 160 degrees of flexion of the knee joint, fixing it with another plug. To fully adapt the prosthesis after fixing it on the condyle of the thigh and before fixing it on the condyle of the tibia, 18 flexion-extensor movements in the knee joint were made.

A blind canal was formed in the tibia 4 cm deep. A fixative was sewn into the distal end of the prosthesis so that it could be lowered into the blind canal. The end of the prosthesis was fixed in the canal with a stopper. We performed control of the stability of the knee joint and the tension of the prosthesis. Active drains were installed in the upper inversion area. Layered stitches on the wound. Immobilization of the knee - with an orthosis or plaster cast for 10 days.

4 weeks after surgery, the patient walks on his own, the full amount of flexion-extension of the knee joint, the absence of pain. The patient is completely satisfied with the result of the operation. Duration of treatment is 35 days.

Example No. 2 (by the prototype method)

Patient S., 46 years old. And / b No. 3480 Diagnosis: Injured damage to the right side of the knee joint.

Operated in the Lokb in 2001 according to the method of Movshovich I.A. 6 weeks after surgical treatment, there is flexion-extensor contracture of the knee joint associated with forced prolonged immobilization of the joint with a plaster splint for 4 weeks. Duration of treatment - 70 days.

Example No. 3

Patient T., 45 years old, and / b No. 6244. She was treated at the Lokb in 2002 with a diagnosis of Deforming osteoarthrosis of the II degree, chronic damage to the PCS, relapse of instability of the left knee joint. Lavsanoplasty of PKS according to the prototype method in 1981.

The operation was performed in the Lokb: Arthrotomy. Revision of the knee joint. During the audit revealed instability of fixation (separation) of the proximal end of the mylar prosthesis. Made repeated reconstruction of the PCS lavsan vascular prosthesis (by the present method). Achieved a positive result. 3.5 weeks after the operation, the patient walks on her own, there is no pain, the full range of movements in the knee joint is achieved, there is no instability of the anterior cruciate ligament. Duration of treatment is 40 days.

By the method of Movshovich A.I. the authors operated on 46 patients. In 9 (19.6%) patients, at different times after the operation, complications were observed in the form of instability of the prosthesis.

According to the claimed method was operated on 92 patients. Complications were observed in 5 (5.4%) patients.

When using the prototype method, additional external immobilization of the operated limb with a plaster cast for 4-6 weeks is required. After which, naturally, stiffness arises, requiring an even longer recovery treatment. And the proposed method allows starting 2-3 days after the operation to begin the passive development of movements in the knee joint and, therefore, reduce the treatment time. According to our own data, the treatment time for the prototype method is 70-90 days, and for the claimed method is 34-40 days, that is, the claimed method allows to reduce treatment time by 36-50 days.

Claims (1)

A method for surgical treatment of chronic injuries of the anterior cruciate ligament of the knee joint, including arthrotomy of the knee joint, the formation of a canal in the external condyle of the thigh and the through canal in the internal condyle of the tibia, its fixation through the formed channels of the dacron implant, characterized in that in the external condyle of the femur form a blind canal, and also additionally form a blind canal in the inner condyle of the tibia, passing through the formed channels a lavsan vascular prosthesis, and before the prosthesis is carried out, a spherical bone cement retainer is sewn into the lumen of its proximal end, after which the proximal end of the prosthesis is immersed in the formed blind canal of the external condyle of the femur and the cone-shaped bone cement plug is hammered into it, while pulling the prosthesis, then it is passed through the formed through canal of the tibia and in the position of flexion in the knee joint the prosthesis is fixed with a similar plug, then into the lumen the corresponding end of the prosthesis is sewn with a similar fixative and the prosthesis is immersed in the blind canal of the tibia, after which the end of the prosthesis is fixed with the same stopper.