Method for treating posterior-external rotation instability of knee joint

FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: one should form a transplant out of femoral biceps' tendon, form an oblique-cross-sectional transfemoral canal in isometric area upon external femoral condyle, right to the front against insertion fibular collateral ligament, apply proximal end of crossed femoral biceps' tendon through this canal, fix the end of crossed femoral biceps' tendon upon internal femoral condyle. The method enables to prevent tendinous rupture at the site of its new fixation and avoid the loss of articular bending function.

EFFECT: higher efficiency of therapy.

2 dwg, 1 ex

 

The invention relates to medicine, namely to traumatology, orthopedics, and can be used for the treatment of chronic back-outer rotational instability (SNR) of the knee joint, characterized by the outer hyperacusia tibia with posterior subluxation of external tibial plateau relative to the outer condyle of the femur. SNR occurs when the damage to the arcuate complex, functionally combining the arcuate ligament, fibular collateral ligament, aponeurotic and the tendinous part of the popliteal muscle and the lateral head of the gastrocnemius muscle.

Known methods of treatment SNRN the knee joint include the "deepening" formed in the channel of the outer condyle of the thigh to the popliteal tendon muscle (1) or transposition of the femoral insertions of the tendons of the knee muscles and the fibular collateral ligament few dorsal and anteriorly (2). However, these surgical intervention aimed at limiting the outer hyperlocal tibia, technically impossible when damage to the popliteal tendon of the muscle in its middle part or in the muscle-tendon transition.

Known methods of plastic reconstruction of the damaged tendon popliteal muscle, provide static stabilization of the joint, imply formation at the rear outer corner stake the aqueous joint ligament substitution patterns of the distal part Iliotibial tract or the front third of the tendon of the biceps femoris (3).

The disadvantages of these methods include:

- formation of persistent flexion contractures after the formation of the tibial bone tunnel and surgical manipulation of the soft tissues at the rear outer corner of the knee joint;

- stretching over time relatively weak grafts.

The closest in terms of its technical solution to the claimed method adopted for the prototype, is the method proposed by Clancy (4).

The method consists in the transposition of the tendon of the biceps femoris to the outer maselko of the femur with the formation of tenodesis. The resulting new collateral ligament helps to keep the leg in a predetermined position, limiting its outer rotation and back-outer subluxation. Thanks to close aponeurotic communication between the distal part of the displaced tendon of the biceps femoris and the arcuate complex (5) is the tension in the distal part of the arcuate complex, which further contributes to the stabilization of the joint.

The disadvantages of the method adopted for the prototype should include the complexity of isometric positioning of the tendon of the biceps femoris on the outer myselt of the femur, resulting in loss of flexion of knee function. Occurs when the movements of the cutting efforts in their PTS who lived, can lead to tendon rupture at the site of his new mount.

The essence of the invention lies in the combination of distinctive features is sufficient to achieve the desired technical result, namely the elimination of back-outer rotary instability of the knee joint and improve treatment outcomes by eliminating the disadvantages inherent in the known methods.

This objective is achieved in that in an isometric zone on the outer myselt of the femur, immediately anterior to the insertions of the fibular collateral ligament form the oblique femoral bone canal, through him spend the proximal end of the cross tendon of the biceps femoris and carry out its fixation on internal myselt of the femur.

Thus:

1. The location of the graft in isometric zone and the tension in the position of internal rotation of the tibia prevents rear-outer subluxation of the tibia without limitation Shebalino-extensor movements in the joint.

2. Leveled functional activity of the biceps femoris as an external rotator of the tibia.

The layout of anatomy of the knee joint before and after the operation of the proposed method is depicted in figure 1 and figure 2, which shows the head of the fibula 1, the later is supplemented flax head of the gastrocnemius muscle 2, the fibular collateral ligament 3, the tendon of the biceps femoris 4, Iliotibial tract 5, the transplant of tendon of biceps femoris 6, Razmyslov bone tunnel 7.

The method is as follows.

Make a longitudinal incision of the skin and fascia length of 12 cm on the back edge contuinuing Iliotibial tract from the lower third of the thigh to the head of fibula. The tendon of the biceps femoris release scriptorum from muscle fibers and spurs to the lateral head of the gastrocnemius muscle. The outer condyle of the femur naked in isometric area immediately anterior to the insertions of the fibular collateral ligament. In this place the drill bit is formed through oblique Razmyslov channel equal to the diameter of the tendon of the biceps femoris. The tendon of the biceps muscle cross 12-15 cm above the head of fibula. The proximal end of the tendon stitched with thread of non-absorbable material. The transplant for the thread carried through the formed bone channel and taut, in the position of flexion and internal rotation of the tibia is fixed to the screw, put in the internal condyle of the femur. After the suturing of postoperative wounds limb immobilized plaster Longuet in the position of internal rotation of the leg and flexion of the knee joint under glom 150° . Two weeks after removal of skin sutures drumstick from a position of internal rotation is transferred to a neutral position with the extension of the immobilization period for another 4 weeks.

Patient Muranov E. A., 27 years old, was admitted in NIZH “WTO” with a diagnosis of chronic post-traumatic rear-outer rotary instability of the right knee joint severe (case history No. 2184). Due to severe lameness caused by posterior subluxation of the outer condyle of the tibia, the patient was forced to constantly use a cane and splint. Severe instability of the knee joint was the cause of the restriction of motor activity of the patient and led to the termination of his career. The patient made a quick intervention by the proposed method. In the beginning was performed diagnostic arthroscopy. When revision of knee joint were diagnosed with concomitant damage to the posterior cruciate ligament. From outdoor access made of plastic reconstruction of the ligaments of the knee joint according to the method described above. The total period of immobilization of the knee joint in the postoperative period was 6 weeks. After removing the bandage, the patient was hospitalized for rehabilitation treatment. A course of fizioterapii with full recovery of the volume of movements in the joint. Examined again in two months. The result of the operation the patient was satisfied: active, walking instability in the joint, not the notes.

The discussed method can be recommended in clinical practice.

Sources of information

1. Jacob R.P., H. Hassler, Staeubli H.U. Observations on rotatory instability of the lateral compartment of the knee. Experimental studies on the functional anatomy and the pathomechanism of the true and the reversed pivot shift sign // Acta Orthop Scand Suppl. - 1981. - p.191.

2. Hughston J.C., Jacobsen K.E. Chronic posterolateral rotatory instability of the knee // J. Bone Joint Surg.-1985. - 67-A., p.351.

3. Muller We. The knee: Form, function and ligamentous reconstruction. Springer, Berlin Heidelberg, New York. - 1983.

4. Clancy W.G. Repair and reconstruction of the posterior cruciate ligament // In: Chapman M, ed. Operative orthopaedics. Philadelphia: JB Lippincott.-1988. - p.1651-1665.

5. Marshall J.L., Girgis F.G., Zeiho R. The biceps femoris tendon and its functional significance // J. Bone Joint Surg. - 1972. - 57-A. - p.1444.

A method of treating post-traumatic rear-outer rotary instability of the knee joint, including the formation of transplant of tendon of biceps femoris and its transpose, characterized in that isometric zone on the outer myselt of the femur, immediately anterior to the insertions of the fibular collateral ligament, forming an oblique lateral femoral canal, and through him spend the proximal end of the cross tendon of the biceps femoris and carry out its fixation on internal myselt of the femur.



 

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