RU2845795C1 - Method of treating early osteochondral lesions of lower extremities - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used for treating early osteochondral involvements of the lower extremities. Affected extremity is unloaded for at least 3 months. Drug therapy is started with the osteotropic therapy involving the daily administration of calcium and vitamin D. Zoledronic acid is administered once a year. Osteotropic therapy is combined with a course of electroneurostimulation of gastrocnemius muscles of both lower extremities in the form of three procedures of 20 minutes daily for 10 days. Further, a course of prolonged epidural analgesia is carried out for 7 days in courses up to 4 times a year every three months, after which on the day of removing the catheter, a course of vascular therapy is started, including the administration of tolperisone 450 mg once daily with course of 1 month, clopidogrel 75 mg in a single daily dose for three months and diosmin 500 mg twice a day for three months.

EFFECT: method enables interrupting the pathological process at the early stages of osteonecrosis before cartilage collapse due to the integrated effect on the vascular and resorptive components of the pathogenesis of the disease with managing the pain syndrome.

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Description

The invention relates to medicine, namely orthopedics, and can be used in the treatment of osteonecrosis of bones. The method is applicable in the early stages as an independent treatment, and in the later stages it can be an addition to surgical intervention.

Etiopathogenetic theories of osteonecrosis are similar to avascular necrosis of the femoral head, due to the pathophysiological similarity of the diseases [Ahuja S., Bullough P., 1978; Fisher D., 1978, Yamamoto, 2000]. Regardless of the underlying causes of the disease, a cascade of reactions is triggered that causes a vicious circle, where arteriole occlusion causes bone marrow edema, leading to compression of the sinuses, resulting in the development of vascular stasis. Local increase in the resorptive activity of osteoclasts and inhibition of the activity of mesenchymal cells and osteoblasts are noted, bone loss occurs, the strength properties of trabeculae decrease, a cascade of microfractures occurs, which contributes to mechanical compression of the venous bed, and as a consequence - vascular stasis and ischemia, which leads to the development of osteonecrosis.

Conservative treatment is effective in early forms of the disease before the collapse of the articular surface in combination with subchondral bone and cartilage. Interruption of the pathological process at these stages is possible due to complex treatment, which is aimed at improving blood supply in the area of the affected ankle joint, affecting vascular stasis, and reducing local bone resorption.

A method for treating aseptic necrosis of the femoral head is known, carried out against the background of orthopedic unloading (Patent RU No. 2392942 C1, IPC A61K 31/663 - 27.06.2010, Bulletin No. 18), including the administration of the drug Curantil, characterized in that ibandronate, an active metabolite of vitamin D3 and an ossein-hydroxyapatite complex are additionally administered, wherein ibandronate is administered intravenously at a rate of 2-4 mg / 2-4 ml once every three months, and the other drugs are administered orally daily in the following quantities: active metabolite of vitamin D3 - 0.5-1 μg / day, ossein-hydroxyapatite complex - 0.6-3.6 g / day and dipyridamole - 75-400 mg / day.

The disadvantage of the method is its low efficiency in terms of relieving pain and vascular stasis.

A method for persistent relief of pain in degenerative-dystrophic diseases of the joints of the lower extremities is known (Patent RU No. 2465926, IPC A61M 19/00, A61H 31/02, A61K 31/165, A61K 31/02, A61K 31/4468, A61K 31/045, A61P 23/00 - 11/10/2012, Bulletin No. 31), including the introduction of 0.2% Naropin into the epidural space, which allows for relief of pain and temporary stabilization of the pathological process due to sympathetic blockade.

The disadvantage of this method is the single-use nature of the course of therapy, i.e. the absence of a systemic effect on the vascular component of the formation of osteonecrosis.

A method is known that allows interrupting the pathological process at the early stages in osteochondropathy of the femoral head, which is a form of osteonecrosis in children (Patent RU No. 2608135 C1, IPC A61M 19/00, A61K 31/167, A61P 19/00 - 13.01.2017, Bulletin No. 2). The child is given long-term epidural analgesia using a catheter installed in the lumbar spine. A medicinal mixture of 0.2% naropin solution with 0.2 mcg/ml adrenaline is administered through the catheter in a dosed manner, 12 hours a day, for at least 120-180 hours, while the rate of administration of the drug is individually measured from 2 to 8 ml per hour.

This method is taken as a prototype.

Treatment of patients with osteonecrosis using this method does not relieve venous stasis and subchondral bone resorption.

The objective of the claimed invention is to develop a method for treating osteochondral lesions of the talus and metadiaphyseal sections of long bones of the extremities, starting from the early stages of development.

The usefulness of the claimed method lies in the complex effect on the vascular and resorptive components of the pathogenesis of the disease with the relief of pain syndrome.

The technical result of the claimed invention is the interruption of the pathological process in the early stages of osteonecrosis before the collapse of the cartilage layer.

The technical result is achieved through a comprehensive approach and includes multiple courses of long-term epidural analgesia, electrical neurostimulation of the gastrocnemius muscles of the lower extremities, carried out against the background of osteotropic and vascular therapy.

The advantage provided by the given set of features is: removal of spasm from the microcirculatory bed, which improves arterial blood supply to the pathology zone; relief of venous stasis in the osteonecrosis zone; antiresorptive effect of therapy; reduction of pain syndrome and restoration of the patient's functional capabilities.

Implementation of the invention.

After diagnosis, patients with preserved articular cartilage of the affected joint are prescribed to follow an unloading orthopedic regimen for at least three months. Unloading of the limb is carried out using crutches or a cane. Drug treatment begins with osteotropic therapy, based on the level of calcium in the blood and D-hormone (25OHD3). The dose of the drug cholecalciferol is 1000-1500 ME/day, and ossein-hydroxyapatite complex is one tablet twice a day for the entire treatment period. The dosage of zaldronic acid is 5.0 once intravenously once a year.

In parallel with osteotropic therapy, a course of electroneuromyostimulation is prescribed with the application of electrodes to the gastrocnemius muscles of both lower extremities. Three stimulation procedures are performed daily for 20 minutes with the patient individually selecting the strength of the stimulating impulse. The course is 10 days.

Next, the first course of extended drug sympathectomy is performed. In aseptic conditions, under local anesthesia, in a lateral position with knees bent and brought to the chest, catheterization of the epidural space is performed at the L2-L3 level. After checking the correct position of the catheter, a system for dosing solutions is connected to it and the introduction of 0.2% naropin and 0.2 mcg/ml adrenaline begins. The rate of administration is adjusted individually from 2 to 8 ml per hour, taking into account the relief of pain syndrome, but maintaining the motor activity of the lower extremities. Then, for 7 days, the drugs are administered 12 hours a day.

The treatment is repeated in 7-day courses up to four times a year with an interval of three months. The criteria for stopping treatment are the stage of subchondral bone tissue restoration on MRI scans performed before each course of therapy.

Immediately on the day of removal of the catheter from the epidural space, the patient is prescribed a course of vascular therapy consisting of a centrally acting muscle relaxant - Tolperisone, 450 mg once daily for a course of one month, an anticoagulant - Clopedogrel 75 mg once daily for a course of three months, and a drug with a venotonic and angioprotective effect, Diosmin, 500 mg twice a day for a course of three months (until the next course of extended epidural analgesia).

Clinical example.

Example 1

Patient M., 32 years old, came in May 2022 complaining of pain in the right ankle joint, which intensified when walking, and lameness. According to the patient, the first symptoms appeared six months after the COVID-19 infection. After laboratory and instrumental examination, the diagnosis was established: osteonecrosis of the talus, stage II, without damage to the bone-cartilage layer.

The patient received a single intravenous injection of Aclasta 5.0 and was prescribed calcium carbonate at a dose of 800-1000 mg once a day in combination with the active metabolite of vitamin D in the form of alphacalcidol at a dose of 0.5-1.0 mcg once a day. In parallel, a course of electrical neurostimulation of the calf muscles of both lower extremities was carried out three times a day for 20 minutes using an individual Venoplus device.

In a hospital setting, under aseptic conditions, local anesthesia, in a lateral lying position with knees bent and brought to the chest, catheterization of the epidural space at the L2-L3 level was performed. After checking the correct positioning of the catheter, a system for dosing solutions was connected to it and the introduction of 0.2% naropin and 0.2 mcg/ml adrenaline was started. At an introduction rate of 4 ml per hour, pain relief was achieved with preserved motor activity in the lower extremities. Then, for 7 days, the drugs were administered 12 hours a day.

After removal of the epidural catheter, the patient was prescribed vascular therapy with Tolperisone 450 mg per day, Clopidogrel 75 mg per day and Diosmin 500 mg twice a day. The entire course of therapy was carried out on an outpatient basis for three months. In parallel, the patient was prescribed a course of therapeutic exercise daily against the background of unloading the affected limb (walking with crutches).

Three months later, the patient was invited back to the clinic. The patient noted a significant reduction in pain and the absence of lameness. Objectively: movement in the right ankle joint is in full range, painless. Comparison of MRI images showed stabilization of the affected area of the talus. It was decided to conduct a repeated course of prolonged epidural analgesia for 7 days. The patient was discharged for outpatient treatment. Drug vascular therapy, as in the first stage of treatment, lasted for three months.

Example 2

Patient Zh., 35 years old, came in February 2023 complaining of pain in the left knee joint, increasing with physical exertion, and lameness for the last three months. History: the first symptoms appeared three months after the COVID-19 infection. After laboratory and instrumental examination, the diagnosis was established: osteonecrosis of the distal femur in the second stage.

The patient received a single intravenous injection of Aclasta 5.0 and was prescribed calcium carbonate at a dose of 800-1000 mg once a day in combination with the active metabolite of vitamin D in the form of alphacalcidol at a dose of 0.5-1.0 mcg once a day. In parallel, a course of electrical neurostimulation of the calf muscles of both lower extremities was carried out three times a day for 20 minutes using an individual Venoplus device.

In a hospital setting, under aseptic conditions, local anesthesia, in a lateral lying position with knees bent and brought to the chest, catheterization of the epidural space at the L2-L3 level was performed. After checking the correct position of the catheter, a system of metered solution supply was connected to it and the introduction of 0.2% naropin and 0.2 mcg/ml adrenaline was started. At an injection rate of 5 ml per hour, pain relief was achieved with preserved motor activity in the lower extremities. Then, for 7 days, the drugs were administered 12 hours a day.

After removal of the epidural catheter, the patient was prescribed vascular therapy with Tolperisone 450 mg per day, Clopidogrel 75 mg per day and Diosmin 500 mg twice a day. The entire course of therapy was carried out on an outpatient basis for three months. In parallel, the patient was prescribed a course of therapeutic exercise daily against the background of unloading the affected limb (walking with crutches).

Three months later, the patient was invited back to the clinic. The patient noted a significant reduction in pain and the absence of lameness. A control MRI of the knee joint showed signs of stabilization of the pathological process in the distal femur.

The full course of treatment was repeated twice more, three months each time.

Claims (1)

A method for treating early stages of osteochondral lesions of the lower extremities, including unloading the affected limb for at least 3 months, drug treatment begins with osteotropic therapy, including daily intake of calcium and vitamin D preparations, a single annual administration of zoledronic acid, parallel to osteotropic therapy, a course of electrical neurostimulation of the gastrocnemius muscles of both lower extremities is carried out in the form of three procedures for 20 minutes daily for 10 days, then a course of extended epidural analgesia is carried out for 7 days in courses up to 4 times a year with an interval of three months, after which, on the day of catheter removal, a course of vascular therapy is started, including tolperisone 450 mg once daily for 1 month, clopidogrel 75 mg once daily for three months and diosmin 500 mg twice a day for three months.