RU2821146C1 - Method of treating pain syndrome and accelerated rehabilitation of patients with ankle arthrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to rehabilitation, traumatology and orthopaedics, and can be used for treating pain syndrome accompanying ankle joint arthrosis. Cryoanalgesia of nerves innervating an ankle joint capsule is performed provided that a sensory response is obtained and there is no motor response. Procedure is performed with monitoring of blood pressure, ECG, Sat and etCO2. After the cryoanalgesia procedure, non-steroidal anti-inflammatory preparations are additionally used in combination with therapeutic exercises.

EFFECT: method enables accelerating the rehabilitation of the patients with ankle arthrosis by eliminating the pain syndrome and restoring the range of motion of the ankle joint.

1 cl, 1 ex

Description

The invention relates to medicine, namely to anesthesiology-reanimatology, pain treatment, rehabilitation, orthopedics and traumatology, and can be used for the treatment of pain and accelerated rehabilitation of patients with ankle arthrosis.

The concept of arthrosis is a general name for all manifestations of non-inflammatory joint lesions, the causes of which can be completely different. Arthrosis of the ankle joint occurs - in contrast to arthrosis of the large joints of the knee and hip - as a result of previous injuries to the ankle joint. In most cases, deforming arthrosis is a consequence of a severe injury to the ankle joint, which results in damage to the articular cartilage tissue, which leads to impaired gliding of the articular surfaces and their additional trauma during movement. The classification of arthrosis into three degrees is justified primarily by the X-ray picture of the deformation of cartilage tissue. However, depending on the degree of damage to the joint and the individual characteristics of the patient, the pain syndrome can be quite pronounced even in the first degree of damage to the joint, which does not require surgical treatment, but requires intervention to improve the patient’s quality of life. For arthrosis of the third degree, surgical intervention was considered the only solution at the moment.

1. Therapeutic and diagnostic sanitation arthroscopy is a modern type of surgical treatment. This operation is a high-tech minimally invasive intervention. During the operation, the doctor has the opportunity to examine the cavity of the affected joint, remove destroyed cartilage, adhesions in the joint, pieces of cartilage lying freely in the joint cavity (the so-called “chondromic bodies”).

2. Arthrodesis of the ankle joint - surgical immobilization of the ankle joint. During the operation, the articular surfaces of the ankle joint are removed, the treated surfaces of the tibia and talus are compared, and they are fixed. After 3-4 months, complete fusion of these bones occurs. After the operation, movement in the joint becomes impossible and pain in the ankle joint stops. However, the range of motion is partially compensated by the forefoot.

3. Endoprosthetics of the ankle joint (endoprosthesis) - complete replacement of the ankle joint with an artificial one. This is a complex, high-tech operation. During the operation, the surgeon completely replaces the rubbing surfaces of the joint with metal ones. A polyethylene liner is installed between the metal surfaces.

However, there are many contraindications for such operations, including from a surgical point of view:

1. Young age.

2. Severe degree of osteoporosis of the bones of the leg and/or foot.

3. Varus and valgus deformity with a deviation angle of more than 10°.

4. Instability of the ankle joint.

5. Aseptic necrosis of the talus.

6. Any inflammatory diseases in the joint area.

7. Rough deforming scars in the ankle area.

8. History of arthrodesis surgery, which led to the formation of pseudarthrosis.

9. Traumatic destruction (destruction) of the joint.

10. Long-term therapy with glucocorticosteroids, which can lead to osteoporosis.

From an anesthesiological point of view:

1. Severe cardiac pathology, reduced ejection fraction.

2. Coagulopathy of any origin.

3. Severe hemodynamically significant arrhythmias.

4. Diabetes mellitus with unstable glycemia.

5. Severe forms of respiratory disorders (COPD, severe asthma).

It is worth considering that some patients independently refuse to undergo surgery.

Currently, much attention is being paid to cryoanalgesia of large joints, such as the hip, knee, and shoulder. Interest in cryoanalgesia of these structures is due to the fact that not all patients can receive adequate orthopedic care. Prosthetics of these joints is associated with anesthetic and surgical risks. In case of refusal of prosthetics for one reason or another, cryoanalgesia remains the only option for returning a normal quality of life.

There is a known method of using a cryoanalgesic technique at the level of the ankle joint - the work of L Hodor 1, K Barkal, L D Hatch-Fox Cryogenic denervation of the intermetatarsal space neuroma, performed back in 1997, which showed the successful use of this technique in the treatment of neuroma of the metatarsal space.

The technical result of the present invention is to increase the effectiveness of pain relief and accelerate rehabilitation for arthrosis of the ankle joint.

The technical result is achieved due to the fact that we denervate the ankle joint with cold and restore range of motion, after which the joint protects itself.

The cold denervation procedure (cryoanalgesia) is one of the effective interventional methods for treating pain syndrome, providing high-quality long-term pain relief through low-temperature destruction of the nerve sheaths of sensory or mixed nerves. The cryoanalgesia procedure is performed locally in the area of pain, under local anesthesia (in the form of an injection). During the procedure, a small incision is made to insert a cryoprobe, which consists of a hollow tube with a smaller diameter tube inside, into which gas cooled to -75°C is supplied. Once the patient feels stimulation at the point of maximum pain, the stimulation is reduced and the nerve is frozen. Conduct several 2-3 minute freezing sequences with 30 second thawing intervals before each cycle. Usually at the beginning of the first freezing cycle there is a burning sensation, which may be repeated, but this goes away after about 30 seconds, otherwise the procedure is completely painless.

The cold denervation procedure is carried out under conditions of monitoring blood pressure, ECG, Sat and etC02. Additionally, therapy with non-steroidal anti-inflammatory drugs and therapeutic exercises are prescribed. Exercise prevents the destruction of articular cartilage. It has long been observed that physiological mechanical loading reduces the inflammatory response in numerous cell types, including articular chondrocytes, but the mechanism responsible has long remained unclear.

A study was published in 2019 that demonstrated the mechanism by which exercise may reduce the risk of osteoarthritis. Researchers have studied the role of primary chondrocyte cilia and their associated intraflagellar transport (IFT) in the mechanical regulation of interleukin-1b (IL-1b) signaling. They subjected chondrocytes to cyclic mechanical stress in the presence and absence of the cytokine IL-1b.

Wherein:

- Nitric oxide (NO) and prostaglandin E2 (PGE2) release were used to monitor IL-1b signaling.

- Release of sulfated glycosaminoglycan (sGAG) provided a measurement of cartilage degradation.

- Measurements of HDAC6 activity, tubulin polymerization and acetylation were also carried out.

It was found that:

- Mechanical loading suppressed the release of NO and PGE2 and prevented cartilage degradation. Under this load, HDAC6 is activated and tubulin acetylation and cilia elongation caused by IL-1β are disrupted.

- Inhibition of HDAC6 by tubacin blocked the anti-inflammatory effects of loading and restored tubulin acetylation and ciliary elongation.

- The hypomorphic IFT88 mutation reduced IL-1B signaling and abolished the anti-inflammatory effects of exercise, suggesting an IFT-dependent mechanism.

- Loading decreased the pool of unpolymerized tubulin that was replicated by taxol, which also mimicked the anti-inflammatory effects of mechanical loading and prevented ciliary elongation.

Simply put, this study shows that mechanical loading activates the HDAC6 protein, which leads to suppression of inflammatory signaling and ultimately prevents cartilage breakdown.

Example:

Clinical case:

Patient K is 65 years old. Weight 85 kg, height 161 cm, went to the clinic on 06/29/21. A pensioner who has been suffering from arthrosis of large joints for a long time, previously underwent cryoanalgesia of the right knee joint for grade 3 arthrosis; full range of motion has been restored with minimal pain. The patient suffers from arterial hypertension, diabetes mellitus, chronic heart failure with reduced ejection fraction, and walks with the support of a cane. Complaints about the inability to lean on the foot, constant pain in the right ankle joint. A diagnosis of grade 3 arthrosis of the right ankle joint was made. The patient was refused surgery due to severe concomitant pathology. The joint is enlarged in volume, the skin around the joint is changed, hyperemic, active movements in the joint are sharply limited (extension 5 degrees, flexion 15 degrees), causing pain. Compression of the joint in both the frontal and sagittal planes is painful.

Anatomical studies have confirmed the thesis that all the main nerves of the lower leg - the saphenous, tibial, gastrocnemius, superficial peroneal nerve and deep peroneal nerve - are involved in the sensory innervation of the ankle joint. All of these nerves are involved in the innervation of both the ankle joint and the talocaleonavicular joint. Previous anatomical studies illustrate extensive inter- and intra-individual variations in nerve distribution. These features make it difficult to perform denervation of this structure.

It is reliably known that the ankle is innervated by 3 superficial and 2 deep nerves; it was decided to perform cryoablation in the projection of the two deep nerves closest to the ankle joint capsule.

The deep peroneal nerve is denervated in the area of the trochlea of the talus, the deep branches of the tibial nerve are blocked at the level of the scaphoid.

This procedure took place under conditions of monitoring blood pressure, ECG, Sat and etC02. In the supine position under the control of ultrasound and a neurostimulator, the patient underwent denervation of the articular branches of the tibial nerve targeting the scaphoid bone and denervation of the branches of the deep peroneal nerve at the level of the talus trochlea. Only after making sure that a sensory response was received and a motor response was absent could cryoanalgesia be performed to avoid damage to the motor fibers of these nerves. The patient was observed by clinic staff for a week and noted a significant improvement in his health, a gradual increase in range of motion and a decrease in pain levels. Additionally, therapy with non-steroidal anti-inflammatory drugs and therapeutic exercises were prescribed. After 3 months, a telephone call was made to assess the quality of pain management and the patient's condition. The pain has decreased by 70% (subjectively), movement is complete, and it is now possible to rest on the foot.

At the moment, 5 denervations of the ankle joint have been performed at our clinic, which is small to form an opinion about the success of this technique, but with an increase in the sample size, an assessment may be made about the success or insufficient effectiveness of this author’s technique. However, we can say with confidence that this technique is minimally invasive and can be useful in a certain category of patients.

This clinical case shows that not only large joints are subject to denervation, and with further development of the technique, it can be actively used. This will lead to an increase in the quality of life for many patients. At the moment, the technique has been applied to 5 patients with good clinical results.

Claims (1)

A method for treating pain syndrome due to arthrosis of the ankle joint, which consists in performing a cold denervation procedure - cryoanalgesia - of the nerves innervating the capsule of the ankle joint, subject to the receipt of a sensory response and the absence of a motor response to prevent limitation of movement, the procedure is performed while monitoring blood pressure, ECG, Sat and etC02 , after the cryoanalgesia procedure, non-steroidal anti-inflammatory drugs are additionally used in combination with therapeutic exercises.