Remedy reservatio knee joint, dislocation and subluxation of the tibia posterior

 

(57) Abstract:

Usage: medicine, orthopedics and traumatology. The inventive perform nadbugskoye osteotomy of the tibia and, as necessary, fibula on the border of the upper and middle thirds of the proximal fragments of the tibia rootroot in the sagittal plane to restore the slope of the tibial articular surface of the posterior, distal fragments move forward and implement the back top edge to the proximal fragments, after which the arm is fixed in the apparatus of external fixation, and then gradually move forward to the desired value, eliminate consistently dislocation or subluxation of the tibia backwards, reservatio and deformation of the tibia to restore the normal anatomic correlations in the knee joint, which eliminates the looseness in the joint, LLD and prevents the recurrence of a laser epimetaphyseal deformation. 1 C.p. f-crystals.

The invention relates to medicine, in particular for orthopedics and traumatology, and can be used to restore the relationship of the articular surfaces of the knee joint for the rear subluxations and dislocations, reservaciones and friends who olsevicova bones (BBK). Such epimetaphyseal deformation develops after suffering osteomyelitis periarticular localization, as the effects of injuries of the proximal zone of growth BBK premature and uneven its closure as a consequence of skeletal dysplasia and systemic diseases, etc.

Restoring articular ratios in such cases is achieved with great difficulty, and most approaches is, in our opinion, palliative in nature. Known attempts to recover in such situations, ligaments and thereby prevent further dislocation of the tibia. In another approach, redistribute direction and the thrust force of the quadriceps femoris and create obstacles to be careful. So, there is a method of eliminating reservatio knee replacement, which increase the volume of the patella and thus improve control biomechanics of the knee joint (Kutuzov, A. P., Jones A. C., RF application 97114830, 1999). However, to fully resolve the deformation is not possible, increasing patello-femoral conflict, remains a bone component deformation and conditions for further dislocation of tibia.

The closest solution in this field is the solution of the deformation at which Vyborny base anteriorly, while restoring the slope of the tibial articular surface of the posterior additionally perform plastic ligaments (A. P. Chernov, A. C. 1398846 from 01.02.1988, prototype). However, such restoration of ligamentous structures is antimigration character, in normal anatomy not found a similar localizations of attachment of ligaments. In addition, rough subluxations and dislocations of the lower leg in such a way that you cannot resolve, relapse remain conditions for the development of contractures and instability of the knee joint, there is a loss of correction in the process of rebuilding the transplant. Elimination of reservatio and subluxation of the tibia backwards with other related multiplanar deformities of the proximal epimetaphyseal BBK in this way is also impossible. Secondary changes of the tendon-muscular and capsular-ligamentous structures do not allow in this way simultaneously to correct for gross subluxation of the tibia backwards. In addition, the limitations for the application of bone grafts arise after suffering osteomyelitis.

The invention is directed to solving objectives: increase the efficiency of the method by the most complete repair of the support ability at one - and, recurvata knee, gross violations of biomechanical axis, looseness of the joints and shortened limbs.

When the execution of the method is achieved correction of violations of congruency, restored anatomically correct relationship of the articular ends of the bones and their dynamic articulation, stability and axial ratio in the knee joint, the maximum amplitude of movements.

This is achieved by conducting nabulikovat osteotomy of the tibia and, as necessary, fibula (IBC) on the border of the upper and middle thirds, while the proximal fragments of the tibia rootroot in the sagittal plane to restore the slope of the tibial articular surface of the posterior, distal fragments move forward and implement the back edge at the proximal fragments, after which the arm is fixed in the apparatus of external fixation, gradually move forward to the desired value, while still directional rotation of the proximal fragment, the distraction of the posterior tendon-ligament structures and capsule of the knee joint, eliminate consistently dislocation of tibia posterior, reservatio knee joint and deformity of the tibia in fron the Ave and biomechanical axis of the tibia.

The method is as follows.

Spend a few spokes with intersection, 2 of them with napaam in the opposite direction, through nadbugskoye region of the tibia, secured in the annular support external fixation device, the plane of which is chosen in view of the subsequent correction. The most preferred application of the apparatus, A. Ilizarov. Additionally spend spokes from the intersection through the distal tibia and through BBK slightly below the tuberosity. The spokes at the bottom is fixed in the annular support, and in the upper third of the leg in the ring or semi-ring apparatus, depending on the associated deformations. When rough dislocation of tibia posterior to require installation of a temporary upper femoral base apparatus 2 or 2.5-ring abutments on the spokes with a sibling and remote intersection. Perform through 2 small incisions on both sides of the own of the patellar tendon nadbugskoye osteotomy of the tibia. Section BBK spend close to a horizontal plane, perpendicular to the long axis of the tibia, which provides an inclined direction of the osteotomy relative to the plane of the tibial plateau and leaves sufficient for stable fixation of the device the weight of costno apparatus, when rotation is stretched and stably fixes Misaki of the tibia, which allows you to do in the future without plastic cords. When coarse dislocation of tibia and posterior deformities of the tibia in the other planes are osteotomy of the fibula on the border of the upper and middle thirds. The proximal fragment BBK rootroot in the sagittal plane in such a way as to restore the slope of the tibial articular surface of the posterior. Thus, the proximal metaphys BBK is very important geometric parameter that reproduces normal anatomy, and creates an obstacle for moving the buoyancy of the lower leg backwards with the support. The distal fragment BBK move a bit forward and implement in the proximal. At small subluxations fragments of the tibia is fixed and fixed in the apparatus, linking the middle and upper bearing lower hinge distraction device, hold the metered ocorrencia and restore the biomechanical axis, and stretching the back of the tendon-ligament-capsule structures realized in the process of further rehabilitation.

When coarse dislocation of the tibia using a temporary base on top of the thigh, in re licevyh feet, fixing the proximal and proximal fragments Department distal fragment BBK. The rear part of the upper ring support lower link articulated distraction device with a base at the hip, allowing you to continue stretching the back of the tendon-ligament-capsule structures, to continue the rotation of the proximal fragment to the desired correction in the dynamics. Such a move helps to ensure the elimination of any dislocation of tibia and posterior dynamic ocorrencia in the apparatus. Rotational displacements of decorsia is provided by the intersection of MLK, a momentary reversal of the fragments in the horizontal plane. After elimination of subluxation of the tibia posterior to eliminate deviations anatomical axis of the knee joint in the frontal plane through the mounting articulated distraction device on the shank between the upper and lower annular bearings apparatus of external fixation. When the dislocation of the tibia posterior to the dismantling of the subsystem on the thigh spend 3-4 weeks. In the process of moving and fixation of bone fragments in matlakala space occurs good regenerate, and bone grafting is not required.

Example 1. Patient I., aged 14, history 245. He enrolled in the Department of pediatric orthopedics and t the tion, dislocation of tibia posterior instability of the knee joint. At the age of two moved epiphyseal osteomyelitis. Repeatedly operated on this occasion. Last fistula was closed at 7 years of age. Developed rough rozpolcenost of the knee joint in all planes. By relying passively closes the joint in the position of reservatio arise rough cutting efforts, has developed a rough tikoobraznye deformation in the region of the knee joint. On the radiograph dislocation of tibia backwards, regional moving contact of the rear surface of the condyle of the femur in the unsampled portion with the front edge of the tibia occurs only when reservaciones installation tibia; varus deformity of the tibia, the slope of the tibial articular surface anteriorly to 40 degrees, dystrophy condyle; zone growth is not traceable. The relative shortening of the right leg 3 see the action proposed method. Mounted apparatus 5 ring supports, 3 of them in the Shin. Made nabulikovat corrective osteotomy BBK, osteotomy of the IBC on the border of the upper and middle thirds. The proximal fragment retiremen in the sagittal plane. Mounted beams, for which the fragments gradually displaced anteriorly, acacia epimetaphyseal the fragment in the process of correction. Due to the articulated distraction device and traction relative to the beams metered fixed varus deformity of the tibia. After elimination of the continued dislocation fixation of the device, removal of temporary repositional subsystem on the thigh conducted 4 weeks after the operation, which began the movement in the knee joint. The total period of fixation of the tibia in the apparatus 8 weeks. Restored articulation in the knee joint, fixed dislocation of tibia, the axis of the limb and the stability of the knee joint. When viewed in 2.5 years, the joint is stable, functionally no different from a healthy, full range of motion, excellent cosmetic effect, no pain. Recurrence of the deformity has not come, the length of the legs is the same, the anatomic axis is correct.

Example 2. Patient S., 16 years old, medical history, 233. Was admitted with a diagnosis of chronic hematogenous osteomyelitis, left tibia, dislocated tibia backwards, recurvation-torsion-varus deformity of the tibia, multiplanar deformity of the proximal metapelite of the tibia. Sick 3 years of age. During tibiae rough ingrown scars, crater depressions in the region of the proximal metapelite BBK. The unstable joint, dislocation of tibia posterior slope is about detected clinically and radiographically. Repeatedly operated in larger centres. Managed to achieve closure of the fistula, in the last 3 years acute osteomyelitis was not. In terms of preoperative preparation conducted immunoprophylaxis staphylococcal toxoid. The action above described method. On the hip mounted repositional subsystem of the 2 rings and arcs of Ilizarov, Shin - subsystem of 3 rings from which the top 2 after nabulikovat osteotomy BBK and osteotomy of the IBC on the border of the upper and middle thirds used for dynamic movement and correction. Decorsia after osteotomy performed simultaneously. Bone fragments contiguous because of rough scars. Acute osteomyelitis in the proximal tibia. Bone wound in the crater deepening somknuti to heal conducted intensive antibiotic therapy. Varus and residual deformation was eliminated gradually in the process of vzaimoperesechenie fragments and move them to the normal articulation. The dismantling of the subsystem on the thigh after 4 weeks. In the process of formation of bone regeneration and loss of correction occurred. Restored the anatomical axis of the limb, the slope of the tibial articular posterior sites, sources in the apparatus, which amounted to a total of 8 weeks. Examined 1 year after surgery. No complains. The anatomical axis of the operated limb is correct, deformation, subluxation, instability no, the range of motion in the operated joint, practically does not differ from the healthy, the length of the legs is the same. Pain, jet phenomena in the joint does not occur, walks over long distances. Satisfied with the result.

Just made 5 transactions on the proposed method. In 2 cases, installation of the subsystem at the hip and osteotomy of the IBC is not required, subluxation was able to eliminate almost simultaneously with a small ocorrencia residual deformations in the postoperative period is metered and hold the shank from dislocation and distraction stretching the posterior soft tissue structures of the joint was performed in the rehabilitation process on the Balkan frame, in particular a traction force on the tibia axis for the device, by means of pilings, active and passive exercise therapy was also applied loads on the front surface of the knee joint and the lower third of the thigh in combination with electrical stimulation of the quadriceps muscle. In these cases, the period of fixation of the tibia in the apparatus was 5 weeks. That was enough for the formation of costno all cases the range of motion in the joint is not lost.

The positive effect from the use of this method compared to known is that it allows you to correct subluxation, dislocation, reservatio and other related deformation of the tibia combined with instability of the knee joint without loss of correction in the early and late postoperative period, does not require plastic ligaments, gives a reliable long lasting effect. The viability of the ligaments by its tension during rotation of the proximal fragment BBK after osteotomy, the formation oriented in the direction of the distraction efforts pericapsular fibrous tissue during fixation device. According to our observations deformation after the application of the proposed method is not recurs in comparison with the prototype, at least, for 2 reasons: in the early period does not occur resorption of the bone graft, and in the remote - there are no conditions to weaken the stability of the plastically restored, with some anatomically unreasonable amended, ligaments, as suggested earlier in combined methods.

In the result of the operation in the process of correction and fixation megalomania space replaces the bone regenerate, and inost knee.

The proposed method is quite universal, in comparison with the original traumatic pathology, eliminates virtually all pathogenic mechanisms of relapse of the deformity, allows dynamic ocorrencia in the device for external fixation of all related elements disturbances of bone and joint structures. The method is applicable in the most severe deformities BBK epimetaphyseal localization, dislocation of the posterior tibia, including previously deferred due to the destructive processes of osteomyelitis.

1. Remedy reservatio knee joint, dislocation and subluxation of the tibia backwards by high osteotomy of the tibia with the change in the slope of the tibial articular surface, wherein performing nadbugskoye osteotomy of the tibia, while the proximal fragments of the tibia rootroot in the sagittal plane to restore the slope of the tibial articular surface of the posterior, distal fragments move forward and implement the back top edge to the proximal fragments, after which the arm is fixed in the apparatus of the breast fixation, then gradually move forward to the desired value, continue directional rotation proximaldistal dislocation or subluxation of the tibia backwards, reservatio and deformation of the tibia in the frontal and horizontal planes to restore the normal anatomic correlations in the knee joint.

2. The method according to p. 1, characterized in that when coarse dislocation of tibia and posterior deformities of the tibia in the other planes are osteotomy of the fibula on the border of the upper and middle thirds.

 

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