Method of arthroscopic reconstruction of posterior cruciate ligament and set of instruments for protection of popliteal artery in course of its realisation

FIELD: medicine.

SUBSTANCE: group of inventions relates to traumatology and orthopaedics. A set of instruments for the protection of the popliteal artery in the operation of arthroscopic reconstruction of the posterior cruciate ligament includes a guide-pin, which is sharpened from both ends, with a sharpening from one end being trihedral; the device for the protection of the popliteal artery, consisting of a working part and a handle, rigidly fixed at the right angle to each other, with the working part representing a cylindrical rod, which at the free end has a flattened section with through holes, located at an equal distance from each other, at an angle to the longitudinal axis of the working part, the flattened section of the working part is smoothly curved at an obtuse angle; a limiter on a cannulated drill, representing hollow cylinders of the different height with an internal diameter, corresponding to the drill diameter. A step-by-step formation of the tibial bone tunnel is realised. The operated extremity is bent in the knee joint at the right angle. Beginning of the tibial tunnel is determined more laterally and lower than the tibial tuberosity and formed at an angle of not less than 55° to the articulate surface of the tibia. The guide-pin is passed with the sharp trihedral sharpening forward, then removed and introduced with the other end forward. After that, the device for the protection of the popliteal artery is introduced through the posterior-medial access, and the guide-pin is wedged in the closest to it hole of the flattened section of its working part. Limiters are successively put on the drill, with the number of limiters being selected in such a way that the part of the drill, free from the limiters, corresponds to the tibial tunnel length. The cannulated drill is passed along the guide-pin, fixed in the device for the protection of the popliteal artery, and the tibial tunnel is formed.

EFFECT: group of inventions makes it possible to reduce a risk of injuring the popliteal artery, reduce a risk of purulent-inflammatory complications.

2 cl, 1 ex, 10 dwg

 

Group of inventions relates to medicine, namely to traumatology and orthopedics, and can be used in arthroscopic reconstruction of the posterior cruciate ligament (PCL) as measures to prevent and reduce the risk of trauma of the popliteal artery (PA).

Arthroscopic one-beam auto - and alloplasty is the most commonly used option restore PGS. When performing arthroscopic PCL reconstruction one of the main problems is the proximity of the location and, as a consequence, the high risk of injury to the popliteal neurovascular bundle in the formation of tunnels for carrying out the transplant, especially in the tibia. In recent years the published results of various studies aimed at establishing the methods, allowing to reduce the possibility of damage to the popliteal artery (1-4). However, none of the proposed methods surgery cannot completely eliminate the possibility of injury of the vessel.

The closest analogue is spezialitaten (wire catcher) produced by Artrex (5). According to the standard technique of introducing him into the knee joint is performed through an anterior approach, which significantly reduces the manipulative capabilities of the surgeon. The tunnel formed in the tibia at an angle of 45° to the plateau and the beginning of his Nachod�tsya medial to the anterior edge of the tibia. When conducting spokes-guide wire and drill in this case there is a high probability of intersecting the direction of the tibial bone tunnel and running PA. In addition, a significant drawback of specealitatea is that it is inserted through the anterior-medial or anterior-lateral "working" accesses, which significantly limits the manipulative capabilities of the surgeon, and the working part is fixed on the end of the spokes-the Director, almost blindly. The latter, in turn, increases the risk of slipping off the needles with the working part of specealitatea and the migration outside the joint cavity, leading to a risk of injury to the PA.

The technical result is to optimize conditions for performing arthroscopic PCL reconstruction with minimal trauma intervention and to minimize the risk of complications.

- Reliable fixation of the spokes in the device to protect the PA and the possibility of visual control over her situation makes it impossible for her to shift into soft tissue and wound her PA.

- The optimal direction of the tibial bone tunnel and the angle of flexion of the knee joint, identified in the topographic-anatomical experiment (6) such that the probability of crossing conducted spokes-guide wire with the progress of the PA is extremely low.

- The inability to move the drill into the area of the PA is achieved �and through the use of limiters, reduces the working part of the drill to the length of the forming tunnel.

- Reduces the risk of purulent-inflammatory complications in the area of the tibial tunnel, since the beginning it is formed lateral to and below the tibial tuberosity, and this area is sufficiently pronounced an array of muscle tissue, wound closure creates preconditions for better healing.

- Improved visualization during the formation of the channel and increase the manipulative capabilities of the surgeon reduces the overall duration of the surgical intervention.

The result is achieved due to the application of the developed set of tools for the protection of the PA, namely, devices for protection of PA, spokes-guide wire with extra sharpening on the opposite end of the type of "knitting needles", the required number of stops on with cannulated drill bit, and use of, and also determining the direction of the tibial tunnel in the experiment, which gradually formed at a certain angle of flexion of the lower limb in the knee joint. Device for protecting the PA injected through an additional postero-medial access (the main front accesses remain free for manipulation of the surgeon), hole in the working end of the device to protect the PA under visual control lock the working end of the spokes-guide wire, having�th special sharpening (like "knitting needles").

In the figures shown:

Figure 1. The analogue and the prototype of the protective device. PCL elevator and wire catcher (Artrex), where 1 is the working part of the device.

Figure 2. Device for protecting PA, where 2 is the working part, 3 - knob, 4 - flattened portion of the device, 5 - openings in the working section.

Figure 3. The needle-guide, where 6 is a General view, 7 - sharpening the type of "knitting needles"; 8 - standard triangular sharpening.

Figure 4. End sharpening spokes-guide wire, where 7 - sharpening the type of "knitting needles".

Figure 5. End sharpening spokes-guide, where 8 is the standard triangular sharpening.

Figure 6. A set of constraints on the drill bit, with 9 - cylinder, 10 mm width, 10 - cylinder with a width of 5 mm, 11 is a cylinder with a width of 2.5 mm.

Figure 7. The position of the stops on the drill bit, where 12 is the length of the drill in a limited set of constraints.

Figure 8. The direction of the tunnel in the tibia, front view, where 13 is the inlet of the tunnel.

Figure 9. The direction of the tunnel in the tibia, a side view, where 14 is the angle of channel inclination relative to the horizontal plane.

Figure 10. Fixing spokes-guide wire in the working part of the device to protect PA (scheme method), where 15 is the last part of the spokes are fixed in the working part of the device to protect PA (zone of contact needles and devices), 16 - direction holding the spokes.

P�redlagaemyi a set of tools are made of medical steel and consists of defender of the popliteal artery (figure 2), spokes-guide wire (figure 3, 4, 5) and the required number of stops on the drill bit (figure 6, 7).

Device for protecting the PA has the working part 2 of flattened section 4 and the handle 3. The working part 2 and the handle 3 is rigidly fixed at an angle of 90° to each other through serial adhesions. The working part 2 is a cylindrical rod with a diameter of 6 mm, flattened-to-end and having a smooth curve at an obtuse angle. For example, in the present specimen, the bending angle of 170° and the vertex angle of the bend is located at a distance of 10 mm from the end of the working part. Flattened section 4 of the working portion is one third of its total length and has a through hole 5 with a diameter of 2 mm and held at an angle of 65° to its longitudinal axis. The openings 5 are located on the flattened portion at an equal distance from each other. For example, nine holes at a distance of 3 mm from each other in the present sample, the first of them is located at a distance of 5 mm from the end of the working part.

The angle the holes, the bending angle of the working part and all the parameters measured we developed the design identified by the authors as a result of a targeted search in the experiment, the anatomical preparations, which confirmed and justified according to the anatomical features of the knee joint and the arrangement operational to�Tupou.

The needle-guide wire (figure 3) has a diameter of 2.4 mm and different sharpening both ends (figures 4, 5). At one end is made of a standard triangular sharpening 8, on the opposite - sharpening type "knitting needle" 7.

Limiters on with cannulated drill bit (figure 6, 7) are uneven hollow cylinders with an inner diameter corresponding to the outside diameter with cannulated drill bit from the standard set for plastics MCS, such as 9 mm and, respectively, an outer diameter of 12 mm. the Set is, for example, five cylinders 9 height 10 mm, two cylinders 10 height 5 mm and two cylinders 11 with a height of 2.5 mm.

The group of inventions is as follows.

According to the standard technique, surgery is performed through four access - standard Antero-medial and Antero-lateral and more posterior-medial access for instrumentation and access below and medial to the tuberosity of the tibia, corresponding to the entrance formed in a tibial bone tunnel. In our proposed method the first three access form without distinction, but the last one not define medial and lateral to and below the tibial tuberosity. After preparing the bed for the formation of the tibial tunnel (figure 8) is injected into the joint Director from the standard set �La plastique PGS. With it, hold the needle-guide wire 6 three-sided grinding 8 forward bending of the operated limb at an angle of 90° in the knee joint. The needle-guide wire 6 is carried out until it stops in the target pointer on the working side of the guide wire. However, the beginning of the tibial tunnel 13 is formed lateral to and below the tibial tuberosity (figure 8). The angle of the tunnel 14 to the tibial plateau at least 55° (figure 9). When these conditions are met, the risk of crossing the direction of the spokes and stroke PA is minimized. The needle-guide wire 6 is carried out initially sharp three-sided grinding 8 forward, then remove and re-enter on the same channel, but forward the sharpening on the type of "knitting needles" 7. The guide wire is removed. As a result of these manipulations after removing the guide wire, the end of the spokes 7 is located in the posterior intercondylar area of the tibia (area intercondyllaris posterior). Device for protecting PA popliteal artery enter the working part 2 in the rear section of the knee joint through an additional postero-medial access. Then under arthroscopic control by the end of the spokes 7 "put" on the most close to it is located the hole 5 of the working parts of the device to protect the PA popliteal artery 4. Due to the difference in the diameter of the hole 5 and the original sharpening needles last 6 reliably jams in the backcourt. T�Kim, the contact zone 15 (jamming) needles and devices to protect PA area corresponds intercondyllaris posterior.

The optimal direction of the tibial bone tunnel and the angle of flexion of the knee joint revealed in the topographic-anatomical experiment. The angle of inclination of not less than 55° identified by the group of authors as the best when conducting experimental work on the anatomical material. Than vertical direction of the tunnel, the lower the risk of injury to the PA, however, it increases its length. Thus, the authors consider the optimal formation of a tunnel under an angle of 55° to the tibial plateau.

On with cannulated drill bit successively strung limiters, starting with 9 and maximum to a minimum height of 11 (figure 7), picking up their numbers so that the remaining free portion of the drill fit the length of the tibial tunnel. Next on the needle-wire is carried out with cannulated drill bit to form the tibial tunnel. Thereby eliminating the possibility of penetration of the needles and drills beyond the posterior capsule of the knee joint and iatrogenic damage to the PA.

Clinical example

Patient A., age 20, with damage to the posterior cruciate ligament of the right knee joint. Range of motion (flexion of 80 degrees, extension 130°), the symptom back of a drawer 6 mm, Lachmann t�St ++.

Made alloplasty posterior cruciate ligament using the proposed methodology, with application of the developed Toolkit. Operation time 1 h 10 min, Intraoperative blood loss of 50 ml In the early postoperative period vascular complications not revealed. Postoperative rehabilitation by the standard technique. As a result managed to achieve increased range of motion: flexion 45°, extension 180°, the symptom back of a drawer after 3 months. after surgery 2 mm, Lachmann test is negative.

References

1. Ahn J. H. Increasing the distance between the posterior cruciate ligament and the popliteal neurovascular bundle by a limited posterior capsular release during arthroscopic transtibial posterior cruciate ligament reconstruction: a cadaveric angiographic study / J. H. Ahn, J. H. Wang, S. H. Lee, J. C. Yoo, W. J. Jeon // Am J Sports Med. - 2007. - vol.35(5) - p.787-792.

2. Cosgarea, A. J. Proximity of the popliteal artery to the PCL during simulated knee arthroscopy: implications for establishing the posterior trans-septal portal / A. J. Cosgarea, D. E. Kramer, M. S. Bahk, W. G. Totty, M. J. Mata // J Knee Surg. - 2006 - vol.19(3) - p.181-185.

3. Pace J. L., Arthroscopy of the posterior knee compartments: neurovascular anatomic relationships during arthroscopic transverse capsulotomy / J. L. Pace, S. J. Wahl // Arthroscopy - 2010 - vol.26(5) - p.637-642.

4. Yoo J. H. The location of the popliteal artery in extension and 90 degree knee flexion measured on MRI / J. H. Yoo, C. B. Chang // Knee - 2009 - vol.16(2) - p.143-148.

5. Noyes F. R., PCL Reconstruction with the Acufex® Director™ Drill Guide using the Noyes All-Inside and Tibial Inlay Techniques with a Double-Bundle Quadriceps Tendon Graft / Frank R. Noyes, Jeffrey D. Harrison // Cincinnati Sportsmedicine and Orthopaedic Center, Cincinnati, Ohio. - http://metodebok-ortopedi.ihelse.net/Metodobok_legr/Pdf/V1-plc.pdf.

6. Kuznetsov I. A. Topographic-anatomical approaches to the development of the system of protection of the popliteal artery when performing arthroscopic grafting posterior cruciate ligament / I. A. Kuznetsov, N. F. Fomin, D. A. Shulepov // Traumatology and Orthopedics of Russia - 2012 - 4(66) - p. 26-32.

1. A set of tools to protect the popliteal artery in arthroscopic reconstruction of the posterior cruciate ligament, including a needle-guide wire having a shank with two ends, with one end sharpened triangular; a device to protect the popliteal artery, consisting of a working part and a handle rigidly fixed at right angles to each other, wherein the working part is a cylindrical rod, which at the free end has a flattened section with through holes, spaced at equal distance from each other, at an angle to the longitudinal axis of the working portion, the flattened portion is smoothly bent at an obtuse angle; limiters on with cannulated drill bit, which represents an uneven hollow cylinders with an inner diameter corresponding to the diameter of the drill.

2. Method of arthroscopic reconstruction of posterior cruciate ligament using the kit according to claim 1, including a gradual formation of a tibial bone tunnel, for which the operated limb bend in the knee at right corner�Ohm, the start of the tibial tunnel determines lateral to and below the tibial tuberosity and form an angle of at least 55° to the articular surface of the tibia, the needle-guide wire carried a sharp three-sided grinding forward, then extracted and injected it forward the other end, then through the posterior-medial access enter a device to protect the popliteal artery and wedge the needle-guide wire in most closely located to her hole flattened portion of its working parts, then a drill consistently strung constraints, the number of which is adjusted so that free from the constraints part of the drill fit the length of the tibial tunnel, then the needle-guide wire fixed in the device to protect the popliteal artery, performed with cannulated drill bit to form the tibial tunnel.



 

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