RU2385682C2 - Method of treating osteoarthritis deformans - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, namely arthrology. A puncture is carried out from a typically external approach with simultaneous introduction of an arthroscope, and from a typically internal approach with simultaneous introduction of a shaver wherethrough a joint is washed and cleaned from pathological intraarticular inclusions. Thereafter its cavity is filled with physiological saline. Osteoperforation of proximal epiphysis of shin bone follows removal of the liquid remained in the joint and suturing of the puncture wounds by piercing an anterior cortical layer of the bone with a stylet pointed completely perpendicular to this layer at depth 4 cm in four points arranged in a horizontal plane at the distance from the central axis of shin bone. The first point is located 6 cm entoectad, the second - 4 cm entoectad, the third - 4 cm inward, the fourth - 6 cm inward. Each puncture breaks a spongy part of the bone by deflection of the stylet inward and entoectad by 10° in each side, then the stylet is removed, and the wounds are sutured. Osteoperforation according to the offered technique allows for the operative therapy without using postoperative immobilisation, special therapeutic exercises, and physiotherapeutic procedures. Motion activity is restored 3-4 weeks later for everyday load, and 2.5-3 months later for intense load.

EFFECT: method simulates a fracture without disturbing an external cortical layer and provides increase of blood flow in the given region that ensures increase of blood supply both to an articular cartilage and the whole joint.

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Description

And the invention relates to the field of medicine, namely orthopedics, and can be used in patients with deforming osteoarthritis of the knee joint of the II-III stage.

A known method of treating osteoarthritis of the knee according to the application of the Russian Federation No. 96100999, A61B 17/56, publ. 1998, including the tunneling of the articular ends of the femur and tibia in diverging directions with the capture of the entire area of the pathological rearrangement of bone tissue of the altered condyles and repeat it after the restoration of damaged sections of the spongy bone.

However, this method is very traumatic, since both the femur and the tibia are injured. In addition, it does not provide the possibility of joint reduction, and also does not allow to remove free chondromatous bodies and other pathological intraarticular inclusions from the joint cavity. The method requires repeated osteoperforation after a certain period of time, which lengthens the treatment period.

A known method of treating osteoarthritis of the knee according to the patent of the Russian Federation No. 2270629, A61B 17/56, publ. 2006, including decompression tunneling of the articular ends, insertion of a conjugated fixation screw and measurement of intraosseous pressure (VDK) through the fixation screw. Then, fluid is injected into the joint cavity and passive redression is carried out. After that, epimetaphyseal tunnels are performed with a spoke in the frontal plane from two sides (at least 5 on each side) at the level of transition of the cancellous bone into the tubular one, while the channels are fan-shaped in the form of a cone to the subchondral layer and they are evenly placed along the articular surfaces. Then, additional through tunneling is performed with the formation of at least 10 tunnels parallel to each other in the plane of the cross section frontally and perpendicular to the longitudinal axis of the bone, while the tunnels are placed at an equal distance in the projection of the medullary plane of the tibia.

The measurement of intraosseous pressure (VDK) through a fixative screw and injection into the joint cavity of fluid with passive joint reduction is repeated daily for at least five days after surgery.

This method requires the installation of a fixing screw for a long time, which creates a risk of infection of the bone. The joint cavity is not cleansed of pathological intraarticular inclusions. The method requires stationary monitoring for the entire period of use of the locking screw, which significantly increases the cost of treatment and increases its time.

A known method of treating pain with gonarthrosis according to the patent of the Russian Federation No. 2288658, A61B 17/56, publ. 2006, including decompression subchondral tunnelization of the articular ends and patella, perforation of the karticular layer, perpendicular to the tibial site, centrally, retreating distally by 1.5-2 cm from the tuberosity. Next, a conjugated screw-clamp is inserted and intraosseous pressure (VDK) is measured through the screw-clamp, as well as the administration of drugs in the bone marrow cavity of the tibia in case of hypertension: anesthetic and chimes.

Measurement of VDK and drug administration is repeated daily for at least five days after surgery. The treatment effect is evaluated by reducing the VDK.

However, this method does not purify the joint cavity from pathological intraarticular inclusions. The presence of an inserted fixation screw and repeated measurement of VDK leads to an increased risk of bone infection and requires the creation of sterile conditions.

The closest in technical essence is a method of treating deforming arthrosis of the knee joint according to the patent of the Russian Federation No. 2193363, A61B 17/56, publ. 2002, including the injection into the joint cavity of fluid with redress of the knee joint. Partial bilateral ligentotomy of the transverse support ligaments of the patella and pterygoid ligament is performed with a fan movement, then the joint is punctured at the upper, upper, and inner edges of the patella and the joint is washed with physiological saline and novocaine sequentially to clear waters. After the evacuation of fluid from the joint cavity, the needles are removed. Then, in the projection of the epiphyses of the femur and tibia, subchondral osteoperforation with a drill and tunneling with a spoke are performed frontally in mutually oblique directions, and at least three through tunnels are formed in the patella. A puncture needle is inserted into the medullary canal of the tibia for 4-5 days. Next, corrective osteotomy of the tibia in the upper third of the tibia, fixation of the fragments and subsequent correction of the axis of the limb using the transosseous apparatus to the fusion of bone fragments are carried out. The operation is completed by suturing and aseptic dressings on the wounds around the needles.

However, in this method, the joint is not cleansed of pathological intraarticular inclusions. Additional injuries are caused to the capsular-ligamentous apparatus of the patella and the patella itself, which lengthens the postoperative period. Installation of a puncture needle into the medullary canal of the tibia, for 4-5 days, dramatically increases the risk of infection of the bone and requires special sterility conditions. Osteotomy of the tibia with subsequent fixation of fragments by the Ilizarov apparatus is another additional trauma that complicates and increases the duration of rehabilitation treatment, which includes constant monitoring and removal of the apparatus after healing of the osteotomy zone.

The objective of the present invention is to provide a minimally traumatic method of surgical treatment of deforming osteoarthritis by reducing the number of surgical injuries, with a reduced risk of infection of the bone, eliminating open wounds after surgery, providing an easier and shorter postoperative period before restoration of the functions of the knee joint.

The problem is solved in that in the method of treating deforming osteoarthrosis, in which a puncture is performed, the joint is washed with its simultaneous redress, the joint cavity is filled with liquid, the joint is washed, then subchondral osteoperforation of the joint end of the tibia is performed, according to the invention, the puncture is performed with typically external access with the simultaneous introduction of an arthroscope and typically internal access with the simultaneous introduction of a shaver through which the joint is washed and cleaned from pathological intraarticular inclusions, followed by filling its cavity with physiological saline through an arthroscope under video control, and osteoperforation of the proximal epiphysis of the tibia is carried out after removal of the fluid remaining in the joint and suturing of puncture wounds, by piercing through the skin of the anterior cortical layer of the bone with a stylet directed strictly perpendicular to this layer to a depth of 4 cm at four points located in the horizontal plane at a distance from the central axis of the outer bones: the first - 6 cm outward, the second - 4 cm outward, the third - 4 cm inwards, the fourth - 6 cm inwards and with each puncture the spongy part of the bone is violated by deflecting the stylet to the nutria and outward by 10 ° each side, after which the stylet is removed and the wounds are sutured.

The destruction of the spongy-bone part of the bone simulates a fracture without disturbing the outer cortical layer and provides increased blood flow in this area, which helps to increase blood supply to the articular cartilage and the joint as a whole. Using the proposed method of osteoperforation allows for surgical treatment without the use of immobilization, special therapeutic exercises, physiotherapy in the postoperative period. Restoration of motor activity for household loads occurs after 3-4 weeks, and for increased loads - after 2.5 -3 months.

Figure 1 shows the location of punctures during osteoperforation of the proximal epiphysis of the tibia. Figure 2 - the path of movement of the tool during osteoperforation.

The method is as follows.

Surgical treatment is carried out under spinal anesthesia. After treatment of the lower extremity with an antiseptic, puncture is performed from typically external access - 2 cm below the lower pole of the patella and 2 cm outward, with the introduction of an arthroscope through the puncture hole. Through the arthroscope, the joint cavity is filled with saline, at least 100 ml. A puncture is also performed from a typical internal access - 2 cm inwards from the lower pole of the patella and 2 cm below the lower pole of the patella with the introduction of a shaver through the puncture hole of the internal access. The joint is washed through an arthroscope and cleaned of free chondrotic bodies, which are removed from the joint cavity through a shaver. Next, the joint is filled with not less than 100 ml of physiological saline and the joint is redressed by repeatedly bending and extending the joint. Produce the final washing of the joint cavity. Fluid is removed from the joint through an arthroscope. The arthroscope and shaver are removed and the puncture holes are sutured. Next, osteoperforation of the proximal epiphysis of the tibia is carried out 2 cm below the articular surface of the tibia. Osteoperforation is carried out by piercing to the depth of 4 cm of the anterior cortical layer of the bone with a sharp stylet with a diameter of 4 mm directed strictly perpendicular to the cortical layer. The piercing is carried out at 4 points at a distance from the central axis of the tibia: the first point is 6 cm outwards; the second - 4 cm outwards; the third - 4 cm inside; the fourth is 6 cm inwards. With the introduction of the stylet to a depth of 4 cm, it is sequentially rejected in the joint plane inwards and outwards by 10 ° in each direction to destroy the trabecular part of the bone. Then the stylet is removed and the operation is completed by suturing and antiseptic dressings on skin wounds.

An example of the method

Patient S., 53 years old. Complaints: pains in the knee joint when walking, lameness, "night pains" disturb. Clinical examination: swelling of the right knee joint without effusion in the joint cavity. On palpation, pain on the medial surface of the right knee joint, radiologically: the joint gap is unevenly narrowed mainly in the medial section, the joint surfaces are flattened, deformed, expanded due to marginal bone growths; reinforced subchondral sclerosis of the end plates. Flattened inner surface of the patella, osteophytes of the inner poles. Sealed menisci, ligamentous apparatus. Sesamoid bone on the posterior surface of the femoral condyles.

Conclusion: X-ray signs of deforming osteoarthrosis of the right knee joint 2-3 tbsp.

The patient underwent conservative treatment for 6 months with the use of intraarticular blockade with diprospan without a pronounced effect.

According to the proposed method, the patient underwent debridement arthroscopy with revascularizing osteotrepanation, namely, puncture from a typical external access - 2 cm below the lower pole of the patella and 2 cm outward, with the introduction of an arthroscope through the puncture hole. Through the arthroscope, the joint cavity is filled with physiological saline, at least 100 ml. A puncture was performed from a typical internal access - 2 cm inwards from the lower pole of the patella and 2 cm below the lower pole of the patella, with the introduction of a shaver through the puncture hole of internal access. The joint was washed through an arthroscope and cleaned of free chondrotic bodies that were removed from the joint cavity through a shaver. Next, the joint was filled with not less than 100 ml of physiological saline and the joint was redressed by repeated flexion and extension of the joint. The final washing of the joint cavity has been performed. Fluid from the joint removed through arthroscope. After that, the arthroscope and shaver are removed and the puncture holes are sutured. Next, osteoperforation of the proximal epiphysis of the tibia was performed 2 cm below the articular surface of the tibia by piercing the anterior cortical layer of bone with a sharp stylet 4 mm in diameter directed strictly perpendicular to the cortical layer to a depth of 4 cm. The piercing was carried out at four points at a distance from the central axis of the tibia: the first point - 6 cm outwards; the second - 4 cm outwards; the third - 4 cm inside; the fourth is 6 cm inwards. With the introduction of the stylet to a depth of 4 cm, it was sequentially rejected in the plane of the joint inwards and outwards by 10 ° in each direction to destroy the trabecular part of the bone. Then the stylet was removed and the operation was completed by suturing and antiseptic dressings on skin wounds.

The pain syndrome was stopped on the second day after the operation. The patient was discharged from the hospital a day after surgery. Sutures were removed after 7 days in the clinic. Full bit load on the foot - on the fourth day after the operation. The patient returned to work 2 weeks after surgery. Sports loads restored (skiing) 3 months after the operation. At the control examination after 7 months, the function of the knee joint is satisfactory, there are no pains at rest and during physical exertion.

Claims (1)

A method of treating deforming osteoarthrosis, in which a puncture is performed, the joint is washed with its simultaneous reduction, the joint cavity is filled with liquid, the joint is washed, then subchondral osteoperforation of the joint ends is performed, characterized in that the puncture is performed with typically external access with simultaneous introduction of an arthroscope and with typically internal access with the simultaneous introduction of a shaver through which the joint is washed and cleaned through the shaver from pathological intraarticular inclusions, with the next filling of its cavity with physiological saline through an arthroscope, and osteoperforation of the proximal tibia epiphysis is performed after removal of the fluid remaining in the joint and suturing of puncture wounds, by piercing through the skin of the anterior cortical layer of the bone with a stylet directed strictly perpendicular to this layer to a depth of 4 cm at four points, located in the horizontal plane at a distance from the central axis of the tibia: the first - 6 cm outward, the second - 4 cm outward, the third - 4 cm medially and fourth - by 6 cm medially and at each puncture violate the spongy part of the bone by the stylet deflection inwards and outwards by 10 ° in each direction, then the stylet is removed and the wound was sutured.

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