Optimization of the Tactics of Surgical Treatment of Chronic Knee Joint Injuries in the Presence of Concomitant Varicose Disease of the Veins of the Lower Extremities

The dissertation is dedicated to the optimization of surgical treatment tactics for chronic knee joint injuries in patients with concomitant varicose disease of the veins of the lower extremities. The investigation analyzes the frequency and structure of traumatic knee joint injuries in this patient category, develops an examination algorithm, and determines indications for performing simultaneous arthroscopic and venous surgical interventions. The scientific novelty of the work lies in the comparative analysis of the results of sequential and simultaneous operations, as well as in the development of a comprehensive approach to preoperative and postoperative patient management.

Relevance

The problem of trauma and morbidity of the musculoskeletal system represents one of the priority issues not only of healthcare but of the entire state [78]. Knee joint injuries belong to the group of the most frequently encountered pathologies of the human locomotor system. The frequency of injuries is explained by the fact that the knee joint is one of the largest joints in the human body, has a complex configuration, and endures significant, sometimes extreme, physical loads [62].

Among all injuries of the musculoskeletal system in military personnel, their share amounts to 17.4% of the personnel. Among hospital patients, those with surgical pathology of large joints, injuries, and diseases of this location are encountered in 30.8% of cases. Their average age is 25.3 years, of whom 81% are cadets and students of higher educational institutions. In this context, meniscal tears account for 39.8%, damage to the capsuloligamentous apparatus for 38.1%, and patellar instability for 5.5% [144].

Among the civilian population, there are 255 persons with injuries and diseases of the knee joint per 10,000 adult inhabitants, which constitutes 9.8% of all musculoskeletal pathology. Sports activities are the cause of knee joint injuries in 16% of cases [44, 78].

Varicose disease (VD) is one of the diseases long known to humanity. It is regarded as the 'price humanity pays for the ability to walk upright.' The relevance of the varicose disease problem is evidenced by the fact that half of the adult population of developed countries have minor signs of venous disease (women - 50-55%, men - 40-50%), and no less than half of them manifest varicose disease (women - 20-25%, men - 10-15%) [179, 273].

In our country, every second woman and every fourth man suffer from varicose disease [60], while in the United States 15-20% of the population suffers from this disease [275]. Various complications of varicose disease (superficial thrombophlebitis, deep vein thrombosis, trophic disorders) serve as the cause of disability in no less than 10% of patients, which substantially reduces the quality of life of people of the most productive age — 20-50 years [101, 153].

Knee joint injuries are also most frequently encountered among the most productive age group. The generally accepted practice for treating chronic knee joint injuries is arthroscopic surgical treatment, which involves the use of a tourniquet [62]. In this regard, without prophylaxis, venous thrombosis of deep or superficial veins of the lower extremities occurs in 3.1% to 17.9% of cases during arthroscopic operations [212, 251]. When prophylaxis is conducted but without consideration of thrombosis risk factors, deep thromboses of the calf and thigh veins occur in 3.5% of patients [218, 238].

Scientific and technological progress has elevated surgery to a qualitatively new level. Therefore, simultaneous operations on organs located in one anatomical area have become widely applied. Synonyms of the term 'simultaneous' (simultaneus — from Latin simul — together) are 'concurrent' and 'synchronous.' At the same time, the term 'synchronous' (synchronus — from Greek chronos — time) is identical to the term 'concurrent,' as well as 'occurring at the same time.' It is recognized that 'simultaneous' should designate surgical interventions performed at the same time on two or more organs due to different diseases.

In the case of combined diseases, staged surgical correction of one organ, separated by a certain interval of time, in the nearest postoperative period may be accompanied by severe complications from the other, unoperated, pathologically altered organ. Therefore, the frequency of performing simultaneous operations in clinical practice is increasing, along with their necessity.

In patients with chronic knee joint injuries, a sufficiently large number have various stages of varicose disease of the lower extremities requiring surgical or conservative treatment. In such cases, varicose disease requires planned phlebectomy, after which a break in surgical treatment of 3-6 weeks is necessary. In the case of knee joint injuries, arthroscopy is required, but the risk of arthroscopy in the context of varicose disease is sufficiently high despite prophylaxis. Thus, both diseases enter into a certain contradiction and require surgical treatment [201].

The treatment tactics for chronic knee joint injuries with concomitant varicose disease of the lower extremities have not been fully developed. This work is dedicated to the optimization of the tactics of surgical treatment of combined surgical pathology of the lower extremities, which determines the goal of the investigation.

Goal of the work: to develop an optimal tactic for surgical treatment of chronic knee joint injuries in the presence of varicose disease of the veins of the lower extremities.

Tasks of the investigation:

1. To conduct an analysis of the frequency and structure of various traumatic injuries of the knee joint in patients with concomitant varicose disease of the veins of the lower extremities.

2. To develop an algorithm for examining patients with traumatic injuries of the knee joint who have concomitant varicose disease of the veins of the lower extremities.

3. To determine indications for simultaneous arthroscopic surgical interventions and surgical operations on the veins of the lower extremities.

4. To develop a tactic and technique for surgical treatment in the case of knee joint injuries and concomitant varicose disease of the veins of the lower extremities, and to study the results of these surgical interventions.

Scientific Novelty

1. An analysis has been conducted of the frequency of the combination of knee joint injuries and varicose disease of the veins of the lower extremities; an algorithm for examining patients has been determined, as well as the frequency and structure of various complications.

2. The necessity and possibility of performing simultaneous operations — arthroscopy of the knee joint and various types of phlebectomy — have been established.

3. The results of sequential arthroscopic operations on the knee joint and phlebectomies have been analyzed and compared with the results of simultaneous operations.

4. An analysis has been conducted of the frequency of various complications during sequential and simultaneous operations, and their comparison has been made.

Practical Significance

1. A technology for the simultaneous performance of arthroscopy of the knee joint and various types of phlebectomy has been developed.

2. Indications, contraindications, and the effectiveness of simultaneous arthroscopic surgical interventions and surgical operations on the veins of the lower extremities have been determined.

3. Based on the analysis of the results of simultaneous operations on the knee joint and veins of the lower extremities, an algorithm for examining patients, preparing for surgery, and managing patients in the postoperative period has been developed.

4. Practical recommendations have been developed for the occurrence of various complications in the postoperative period, their diagnosis, and measures for their prevention and treatment.

Implementation of Results

Simultaneous arthroscopic operations on the knee joint and veins of the lower extremities have been implemented in clinical practice in the traumatology department of the 32nd Central Naval Clinical Hospital (Zheleznodorozhny, Moscow Oblast) and the surgery department of City Hospital No. 1 in Kaliningrad.

Research materials are used in the educational process during lectures with listeners, resident physicians, clinical ordinands, and adjuncts in the departments of surgery and military-field surgery at the State Institute for Advanced Training of Physicians, Ministry of Defense of the Russian Federation.

Two certificates of rationalization proposals have been obtained on the topic of the dissertation.

Main Propositions of the Dissertation for Defense

In the presence of traumatic changes of the knee joint in combination with varicose disease of the lower extremities, specialized examination is necessary for developing a treatment tactic.

In the presence of significant meniscal injuries requiring arthroscopic debridement, in combination with varicose disease of the veins of the lower extremities, it is possible to perform a simultaneous operation: arthroscopy and phlebectomy.

Patients require special preparation and postoperative care before a simultaneous operation.

When performing a simultaneous surgical intervention, with preoperative and postoperative patient management, the duration of restoration of function of the operated extremity and the number of complications are less than with sequential operations.

Dissertation Validation

Research materials were reported at: the scientific-practical conference of the 32nd Central Naval Clinical Hospital (2004); the XXV Scientific-Practical Conference of Surgeons of the Republic of Karelia (Petrozavodsk, 2005); the First Congress of Traumatologist-Orthopedists of the Ural Federal District (Yekaterinburg, 2005); the IV Congress of the Russian Arthroscopic Society (Saint Petersburg, 2005).

The dissertation work was validated at a session of the section of military-field surgery of the Moscow and Moscow Oblast Surgical Society (2006).

Publications

Five scientific works have been published on the topic of the dissertation, of which three are in central medical journals, in collections of proceedings of scientific-practical conferences, and also in books: 'High Technologies in Traumatology and Orthopedics: Organization, Diagnosis, Treatment, Rehabilitation, Education' (Yekaterinburg, 2005), 'Current Issues of Traumatology and Orthopedics' (Saint Petersburg, 2006).

Volume and Structure of the Dissertation

The dissertation is presented on 141 pages of typed text and consists of an introduction, 3 chapters of own observations, discussion of the obtained results, conclusion, conclusions, practical recommendations, and a bibliography of 279 sources (151 domestic and 128 foreign authors). The work is illustrated with 23 figures and 15 tables.