Low-traumatic surgical technologies in the diagnosis and treatment of injuries and diseases of the knee joint

The dissertation is devoted to the development and clinical substantiation of low-traumatic surgical technologies for the diagnosis and treatment of injuries and diseases of the knee joint. The prevalence of this pathology in a large industrial centre is examined, the limitations of traditional conservative and open surgical interventions, as well as the possibilities of arthroscopy, are analysed. The author designed a specialized set of instruments and proposed a surgical tactic for operations through a small access, including in combination with arthroscopy, which makes it possible to shorten the duration of hospitalization and rehabilitation, to reduce the number of complications, and to improve the quality of life of patients. The work also presents organizational and medical-diagnostic algorithms of rehabilitation and an evaluation of the economic effectiveness of the proposed technologies.

Injuries of the knee joint account for 4.9% of all injuries of the musculoskeletal system and for 50% of all intra-articular traumatic disorders (Trachuk A.P., 2000). Injuries of the capsular-ligamentous apparatus constitute from 43% to 80% of cases (Chemeris A.I., 2000; Baker P., 2003). This type of injury is observed more frequently among men of working age. Not infrequently, injuries of this localization lead to persistent loss of working capacity due to the development of deforming osteoarthrosis in 9%–11% of cases (Gelber A.C., Hochberg M.C., 2000; Sutton A.J., Muir K.R., Mockett S., 2001). Among the diseases that determine long periods of temporary disability are meniscopathy, Hoffa's disease, chronic synovitis of various etiologies with frequent entrapment of synovial villi, pigmented villonodular synovitis, bursitis or tendinosis in the region of the lower pole of the patella, lateral patellar compression syndrome with or without subluxation of the patella, and the presence in the cavity of the knee joint of free cartilaginous and osteocartilaginous bodies of various origins (Bollen S., 2000). They affect persons of mature and advanced age, limiting their working capacity and reducing their quality of life. The principal method of treatment of injuries and diseases of the knee joint is the traditional conservative method, based on puncture treatment followed by immobilization, physiotherapeutic procedures, and balneotherapy (Tavernier T., Dejour D., 2001; Lobenhoffer P., 2002; Hjelle K., Solheim E., 2002). Its use does not allow achieving a stable remission of the disease and complete restoration of function in 43% of cases (Calla M., Lobenhoffer P., 2003), which ultimately determines the indications for the operative method. Classical surgical interventions through large accesses with wide opening of the joint cavity and restoration of the damaged anatomical structures (Gudas R., 2004; Movshovich I.A., 1994) require a long rehabilitation period and are accompanied by the development of deforming arthrosis, formation of scars and contractures (Tkebuchava G.I., 2000), and also determine a high percentage of postoperative complications, from 7% to 16.4% (Chemeris A.I., 2000; Gill T.J., Steadman J.R., 2002). Arthroscopy reduces the invasiveness of the intervention, produces a good cosmetic effect, and decreases the number of postoperative complications (Loskutov A.E., Golovakha M.L., 2002). It makes it possible not only to establish an exact diagnosis but also to substantially broaden the understanding of the character and type of pathology. However, each of the known methods has a number of limitations, and therefore the development of new technologies that preserve the advantages and eliminate the shortcomings of both directions in the surgery of the knee joint is a relevant task.

Aim of the investigation

To develop alternative low-traumatic surgical technologies as a method of choice in injuries and diseases of the knee joint.

Tasks of the investigation

1. To study the character and prevalence of injuries and diseases of the knee joint in a large industrial centre.

2. To design and select instruments for the surgical treatment of injuries and diseases of the knee joint through low-traumatic accesses.

3. To investigate the expediency of using alternative low-traumatic surgical technologies in the comprehensive treatment of pathology of the knee joint.

4. To carry out an evaluation of the effectiveness of the application of low-traumatic technologies in the surgery of the knee joint in comparison with traditional methods of treatment.

5. To develop organizational and medical-diagnostic algorithms for the rehabilitation of patients after low-traumatic interventions on the knee joint.

Scientific novelty

The prevalence of injuries and diseases of the knee joint in a large industrial centre has been studied. For the first time, sets of instruments have been developed (license No. 64/2002-0216-0561 of 18 October 2002, Ministry of Industry, Science and Technology of the Russian Federation; utility model certificate No. 27296, registered in the State Register of Utility Models of the Russian Federation on 20 January 2003; utility model patent No. 56158, registered in the State Register of Utility Models of the Russian Federation on 10 September 2006; intellectual product No. 73200400212, registered by FGUP VNTITS on 3 December 2004) and a surgical tactic has been proposed for the optimization of surgical manipulations in the cavity of the knee joint through a small access (intellectual product No. 73200400211, registered by FGUP VNTITS on 3 December 2004). The terms, indications, and expediency of using alternative low-traumatic surgical technologies in the comprehensive treatment of patients with injuries and diseases of the knee joint have been substantiated. Organizational and medical-diagnostic algorithms for the rehabilitation of patients after operations performed through a small access have been developed (certificate of intellectual product "System of rehabilitation of patients operated on the knee joint through a mini-access" No. 73200400213, registered by FGUP VNTITS on 3 December 2004). An evaluation of the effectiveness of the application of low-traumatic technologies in the surgical treatment of patients with pathology of the knee joint in comparison with traditional methods of treatment has been carried out.

Practical significance of the work

The level of prevalence of pathology of the knee joint in a large industrial centre has been determined, which made it possible to calculate the bed capacity required for patients of this profile.

A set of instruments and a surgical tactic for operative intervention on the knee joint through a small access have been developed and introduced, allowing the optimization of functional results; serial production on an industrial scale has been established. Their introduction made it possible to reduce the duration of hospital stay and temporary disability, to lower disability rates, and to increase the socio-economic effectiveness of treatment.

Implementation of the results in practice

The results of the investigation have been implemented in the practical activity of the municipal institution "Central City Hospital No. 23" of Yekaterinburg, as well as in orthopaedic clinics of the cities: the district hospital of the Urals Federal District of the Ministry of Defence of the Russian Federation in Yekaterinburg, Izhevsk, Orenburg, Chelyabinsk, Perm, Nizhny Novgorod, Magnitogorsk, Zlatoust, Tambov, Ufa, Berezovsky, Nizhny Tagil, Serov, and Pyt-Y, in the teaching process for interns, clinical residents and traumatologists at the Department of Traumatology of the Faculty of Advanced Training and at the Ural State Medical Academy, and also in the Ministry of Social Protection of the Population of the Sverdlovsk Region.

Approval of the work

The materials of the work were reported and discussed at a meeting of the Society of Traumatologists-Orthopaedists on 18 December 2003 at the Ural Research Institute of Traumatology and Orthopaedics named after Chaklin (Yekaterinburg); at the Russian conference "Topical Issues of Minimally Invasive Surgery" (Perm, 2003); at the Russian conference "New Technologies in the Treatment of Injuries of the Musculoskeletal System" (Revda — Yekaterinburg, 2003); at a meeting of the Scientific Council of SPC "Bonum" (Yekaterinburg, 2004); at the I Congress of Traumatologists-Orthopaedists of the Urals Federal District (Yekaterinburg, 2005); at the conference of rationalizers and inventors of the Sverdlovsk Region (Yekaterinburg, 2005); at the regional surgical conference "Minimally Invasive Technologies in Surgery" (Nizhny Novgorod, 2005); and at the Interregional Traumatological Conference (Yekaterinburg, 2006).

Publications

On the topic of the dissertation, 12 works have been published, of which 1 in the central press, 1 utility model certificate, and 1 utility model patent.

Volume and structure of the work

The dissertation is set out on 151 pages and consists of an introduction, a review of the literature, 3 chapters of original research, a conclusion, conclusions, practical recommendations, a list of references, and appendices. The work is illustrated with 37 figures and 11 tables. The bibliography contains 69 domestic and 174 foreign sources.