RU2754506C1 - Method for treatment of partial damage to the anterior cruciate ligament of the knee joint - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used in the treatment of subsynovial partial injuries of the anterior cruciate ligament. Arthroscopy is performed in an aqueous medium at a pressure of 60-80 Pa. The knee joint is bent at an angle of 100-120°. Through the anteromedial port, a laser conductor with a diameter of 2 mm is inserted subsynovially into the thickness of the ligament and, following the course of the fibers, the conductor is carried to the site of ligament damage with the distal end of the conductor placed in the area of ligament damage. The laser is applied to the damage area simultaneously with two wavelengths of 0.97 mcm with a power of 3W and 1.56 mcm with a power of 5W at a speed of 1-2 mm/sec until the fibers are compressed. Then the conductor is removed from the joint.EFFECT: provides complete restoration of the ligament and stability of the knee joint, the exclusion of irradiation of the synovial membrane and other structures of the knee joint, as well as a reduction in the time of manipulation compared to the standard method for laser exposure due to intra-articular exposure simultaneously with two wavelengths in the declared modes.1 cl, 3 dwg, 2 ex

Description

The technical field to which the invention relates

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used in the treatment of sub-synovial partial injuries of the anterior cruciate ligament (ACL) in patients of different sex and age who are shown arthroscopic surgical treatment.

State of the art

The knee joint is one of the largest joints of the human musculoskeletal system. Stable joint work is ensured by all elements of the capsule-ligamentous apparatus. One of the main stabilizing elements of the knee joint is the anterior cruciate ligament. Injury to the anterior cruciate ligament leads to knee instability. Instability of the knee joint can lead to the development of gonarthrosis.

Trauma is one of the main causes of injury to the cruciate ligaments of the knee. Damage to the ACL can be partial or complete. Restoration of complete damage to the ACL with its rupture is possible by the method of classical prosthetics with a synthetic prosthesis or an autograft from the patient's tendons. Partial damage to the ligament often remains without surgical treatment, with partial loss of anteromedial stability. Conservative methods of treatment of partial damage to the anterior cruciate ligament, such as restriction of movement or plaster mobilization, physiotherapy, do not lead to its complete recovery. With repeated loads, further dislocation of the intact part of the ligament occurs, with the gradual involvement of other components of the joint in the process. Based on this, in case of partial damage to the ligament, it is necessary to achieve its restoration.

From the prior art, a method of cold plasma coblation is known for arthroscopic treatment of post-traumatic intra-articular pathology of the knee joint (Mironov S. P. et al. Echography of pathology of the knee joint // SonoAce international. - 2006. - No. 14. - P. 78-89.), according to which cold-plasma treatment of the affected tissues is carried out using the Atlas apparatus equipped with electrodes. With cold plasma treatment, the intraoperative temperature is reduced to 50-55 ° C. Plasma is formed between the electrode contacts made according to the bipolar scheme. Due to this, the depth of tissue damage does not exceed 100 microns.

However, when using this method, there is a risk of compaction of the intact ligamentous apparatus or a stretched joint capsule, as well as the removal of unaffected cartilage tissue.

A known method of treatment for ACL injuries, with preserved intact stump of the anterior cruciate ligament without the use of grafts (McWilliam JR, Mackay G. The internal brace for midsubstance Achilles ruptures // Foot & ankle international. - 2016. - T. 37. - No. 7 - pp. 794-800.), According to which the torn ligament stump is reinserted (sewn to its anatomical attachment site) after preliminary special treatment of the bone bed, and then with an "internal brace" (seat belt, InternalBrace), passed through a microchannel in the stump itself ACL, create an independent structure to stabilize the knee joint and conduct early rehabilitation. The known method allows you to maintain your own stability receptors (proprioceptors) in the native ligament of the knee joint. During the procedure, there is no need to harvest the own tendons of the thigh or lower leg for the formation of the graft, as well as to drill out the thick intraosseous canals. The method allows to reduce the postoperative pain syndrome.

The disadvantages of this method include: the possibility of re-injury, which can lead to re-plasty by the classical technique; making more than one puncture; long time to perform the manipulation, as well as the impossibility of removing the implants used in this method.

Closest to the proposed invention is a method for treating partial damage to the anterior cruciate ligament of the knee joint (RF patent No. 2320383). According to the method, arthroscopy is performed in an aqueous medium at a pressure of 60-80 Pa. The knee joint is bent at an angle of 140-160 °. Marks are made at the boundaries of damage. The optical fiber conductor is positioned at a distance of 2-4 mm above the damage site and irradiated with a laser with a wavelength of 0.97 μm, a power of 10.0-11.9 W, a speed of 2-4 mm / s. After that, free fibers are removed and coagulated. Then, a mosaic effect is carried out on the sections of the partially stretched fibers until visible compression with a wavelength of 0.97 microns, a power of 10.0-11.9 W. The method allows to restore the anatomical integrity of a partially damaged anterior cruciate ligament and stability of the knee joint, is a trigger mechanism for the regeneration of damaged fibers by the type of wound healing by primary intention.

However, in accordance with the known method, the effect is exerted only on the surface fibers of the ligament, without affecting part of the damaged fibers located in the center of the trunk of the ligament, incl. in cases of sub-synovial ruptures, when the ligament is completely covered by the synovial membrane, which does not ensure complete restoration of the ACL and does not exclude the risk of developing knee instability.

The technical problem to be solved by the claimed invention is the development of a method for the treatment of sub-synovial partial injuries of the anterior cruciate ligament, leading to a complete restoration of its anatomical integrity and stability of the knee joint.

Disclosure of the essence of the invention

The technical result to be achieved by the claimed invention is to ensure complete restoration of the anatomical integrity of the anterior cruciate ligament and stability of the knee joint due to intra-barrel introduction of a laser guidewire into the anterior cruciate ligament and exposure to the laser in the stated modes exclusively on the rupture site. The invention makes it possible to exclude irradiation of the synovial membrane and other structures of the knee joint, as well as to reduce the time of performing the manipulation in comparison with the standard method of laser exposure (from 45 minutes to 20-25 minutes).

The technical result is achieved by developing a method for arthroscopic treatment of partial subsynovial damage to the anterior cruciate ligament of the knee joint, according to which arthroscopy is performed in an aqueous medium at a pressure of 60-80 Pa, the knee joint is bent at an angle of 100-120 °, a laser guide is inserted through the antero-medial port with a diameter of 2 mm sub-synovially into the thickness of the ligament and, following the course of the fibers, the guidewire is passed to the site of the ligament injury with the placement of the distal end of the guidewire in the area of the ligament injury, followed by the action of the laser on the damaged area simultaneously with two wavelengths of 0.97 μm with a power of 3 W and 1, 56 microns with a power of 5 W at a speed of 1-2 mm / sec until the fibers are compressed, then the conductor is removed from the joint.

The introduction of the guidewire sub-synovially first into the ligament and its subsequent introduction along the fibers provides the most accurate positioning of the distal end of the guidewire in the area of rupture and laser action directly on the area of damage. In this case, the combined effect of the laser on the damaged area at the same time with two wavelengths of 0.97 microns and 1.56 microns allows collagen fibers of the anterior cruciate ligament to be collected, as a result of which the ligament is stretched. The use of a laser guidewire with a diameter of 2 mm, as well as the speed of movement of its distal end of 1–2 mm / s, make it possible to exclude damage to the adjacent structures when the guidewire is moved.

Brief Description of Drawings

The invention is illustrated by illustrations, where FIG. 1 shows a photo of a ligament with a partial rupture in the region of the middle third, in Fig. 2 - a photo of a ligament after treatment with the proposed method; figure 3 - the stage of introduction of the conductor through the synovium into the middle third of the ligament.

Implementation of the invention

The proposed method is carried out as follows.

After the performed spinal anesthesia, the lower limb is placed and fixed with a tourniquet. In this case, the knee joint is bent at an angle of 100-120 °, visually controlling the onset of twisting of the ACL fibers. Arthroscopy is performed in an aqueous medium using a pump at a pressure of 60-80 Pa. From standard arthroscopic ports (antero-lateral, antero-medial), revision of articular structures is performed. After performing the revision, a fiber-optic conductor (light guide) with a diameter of 2 mm is introduced through the anteromedial port. The guidewire is inserted through the synovial membrane into the ligament thickness using a trocar (Fig. 1). The introduction of the conductor is carried out in the area of either the upper third, or the middle third, or the lower third of the ligament, depending on the location of the rupture. Most often, a partial rupture occurs in the region of the middle third of the ligament (about 92% of cases), therefore, it is preferable to inject in the middle third, while the injection point should be at least 1-2 mm from the edge of the ligament. Further along the fibers, the conductor is carried out to the place of damage - the rupture of the fibers of the ligament (intra-barrel introduction), setting the distal edge of the conductor to the place of rupture, followed by exposure to the rupture site with a laser (Fig. 2). The exposure is carried out in a pulsed or continuous mode simultaneously with 2 wavelengths of 0.97 microns with a power of 3 W and 1.56 microns with a power of 5 W, with a speed of movement of the distal end of the conductor (light guide) of 1-2 mm / sec (translational movements). The exposure is carried out for 4-7 minutes until visible compression of the fibers of the ligament under the control of arthroscopy (remodeling of the ligament occurs with its tension). Then the guidewire is removed from the ligament and joint.

As a result of simultaneous exposure to two wavelengths in the stated modes, laser remodeling of the ligament with its tension occurs.

An increase in the power of the laser exposure, as well as the exposure time above the stated values, can lead to trauma to the fibers of the ligament; with a decrease in the radiation power, the use of single-wave radiation or a decrease in the exposure time, the therapeutic effect is not achieved.

To implement the method, a semiconductor diode laser of LLC NTO "IRE-Polyus" with a pulsed and continuous mode of radiation generation and the following technical characteristics can be used: with 2 wavelengths 0.97 μm with a power of 3 W and 1.56 μm with a power of 5 W, an optical diameter fibers 300 microns, maximum continuous operation time ≥ 30 min, green backlight, weight 7-9 kg.

In accordance with the claimed method, 18 patients with subsynovial partial damage to the anterior cruciate ligament were treated. Of these, a good result was achieved in 13 patients, which manifested itself in relieving pain and returning to previous loads, complete restoration of the anatomical integrity of the anterior cruciate ligament and stability of the knee joint was achieved, satisfactory - in 4 patients who, with increased load on the damaged joint, developed pains of a “aching” nature that disappeared after a decrease in loads, 1 patient had an unsatisfactory result, which manifested itself in pain when flexing at rest due to non-compliance with the recommendations of the attending physician in the postoperative period.

Clinical examples of the invention are presented below.

Example 1. Patient C., 31 years old, slipped and fell from a height. There was swelling of the joint, pain when bending. She turned to the clinic for medical help. A course of physiotherapy was prescribed. Instability in the knee joint, pain during flexion and axial load, and swelling were often noted over the next 5 months. Repeated visit to the doctor for ultrasound, MRI revealed partial damage to the ACL, the anterior horn of the medial meniscus, and the posterior horn of the lateral meniscus. Hospitalized in a hospital for surgical treatment. In the study: clinically, ultrasound, MRI, tensometry confirmed partial damage to the ACL, the initial manifestations of post-traumatic gonarthrosis.

The treatment was carried out according to the proposed method.

After the performed spinal anesthesia, a water pump was turned on at a pressure of 60 Pa, the knee joint was bent at an angle of 120 °, visually monitoring the onset of twisting of the ACL fibers. During arthroscopic surgery, partial damage to the anterior cruciate ligament (partial rupture in the middle third) with increased mobility was determined.

Through the antero-medial port, a 2 mm diameter conductor was passed sub-synovially into the thickness of the middle third of the ligament. Following the course of the fibers, the guidewire is carried directly to the site of the ligament rupture. Then, the laser was exposed in a continuous mode with two wavelengths simultaneously for 4 min 45 seconds until the fibers were visibly compressed (at a speed of 1 mm / s). Then the conductor was removed from the joint. The operation time was 23 minutes.

In the postoperative period, the lower limb is immobilized in the splint. A 3-week rehabilitation course of treatment was carried out. At the end of the rehabilitation period, the patient noted the absence of swelling, pain during flexion, instability in the knee joint, and could start full-fledged loads of the joint.

Clinical, MRI, ultrasound, strain gauge control was carried out within 1 month, 3, 6 months to 2 years. There were no signs of ACL damage, no symptoms of knee joint instability in the patient.

Example 2. Patient V. 40 years old, when playing hockey, felt a crunch and pain in the right knee joint. I went to the doctor after 7 days, when the pain in the knee joint increased, a feeling of discomfort appeared. Was admitted to a hospital for examination and surgical treatment. In the study: clinically, ultrasound, MRI, partial damage to the ACL was revealed.

The treatment was carried out according to the proposed method.

During arthroscopic surgery, partial damage to the anterior cruciate ligament was determined, with the presence of loose fibers in the form of looseness. After the performed spinal anesthesia, a water pump was turned on at a pressure of 80 Pa, the knee joint was bent at an angle of 100 °, visually monitoring the onset of twisting of the ACL fibers. Through the antero-medial port, a 2 mm diameter conductor was passed sub-synovially into the thickness of the middle third of the ligament. Following the course of the fibers, the conductor was led to the place of partial rupture, and then a laser was applied to the region of the rupture in a pulsed mode simultaneously with two wavelengths with a pulse duration of 0.5 ms and a pause duration of 0.01 ms for 5 min until the visible compression of the fibers (at a speed of 2 mm / s). Then the conductor was removed from the joint. The operation time was 24 minutes.

A 2-week rehabilitation course of treatment was carried out. At the end of the rehabilitation period, the patient noted the absence of pain, discomfort and was able to start full-fledged loads of the joint.

In terms of 1 month, 3, 6 months to 2 years, clinical, MRI, ultrasound, stabilometric control were carried out. There were no signs of ACL damage, no symptoms of knee joint instability in the patient.

Thus, the proposed method allows you to restore the anatomical integrity of a partially damaged anterior cruciate ligament due to exposure to laser radiation in the stated modes directly on the ligament at the site of its injury, thereby triggering the regeneration of damaged fibers by the type of wound healing by primary intention, with restoration of knee joint stability. In addition, the method excludes irradiation of the synovium and other structures of the knee joint. The method can be used for partial ruptures, straining and stretching, when the continuity and mechanical integrity of the ligament is preserved.

Claims (1)

A method for arthroscopic treatment of partial sub-synovial injury of the anterior cruciate ligament of the knee joint, characterized by the fact that arthroscopy is performed in an aqueous medium at a pressure of 60-80 Pa, the knee joint is bent at an angle of 100-120 °, a laser guidewire with a diameter of 2 mm is inserted sub-synovially through the antero-medial port into the thickness of the ligament and, following the course of the fibers, guide the conductor to the place of the ligament damage with the placement of the distal end of the conductor in the area of the ligament injury, followed by the laser action on the damaged area simultaneously with two wavelengths of 0.97 μm with a power of 3 W and 1.56 μm with a power of 5 W at a speed of 1-2 mm / s until the fibers are compressed, then the conductor is removed from the joint.

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