Operations on the knee joint in hemophilia. What is knee hemarthrosis, what are its causes, symptoms and treatment? Physical activity and rehabilitation

(5th medical Komsomol kagan, kneeling. R. R. Vre. 109 STATE COMMITTEE ON INVENTIONS AND DISCOVERIES OF THE SCST OF THE USSR WRITING IMAGES AND VTORIOMS OF EVIDENCE (71) Altai State Institute named after Leninskog (56) Injury and disease joint. Sat. Proceedings of LITOden L 1981, Issue 8, S. 108 - The invention relates to medicine, in particular to orthopedics and hematology, can be used in the treatment of hemophilic osteoarthropathy, accompanied by hemorrhages in the joints. as follows, Before the operation, the patient is administered treatment dose cryoprecipitate, determine the level of factor 8 of blood coagulation. With a sufficient correction of the level of factor 8 of blood coagulation, the patient is taken for surgery and a hinge-distraction apparatus is applied, for example, Volkov-Oganesyan. On the operating table, one-stage distraction is carried out, aimed at the forcible separation of the articular ends with the formation of a gap of 2-3 mm, X-ray control is carried out, registering the size of the formed joint gap. In the postoperative period, distraction is continued by 1 mm per day until the formation of an interarticular gap of 15 - -20 mm. 2(54) METHOD OF TREATMENT OF THE KNEE JOINT IN HEMOPHILIA(57) The invention relates to medicine, namely to orthopedics in the treatment of hemophilic osteoarthropathy knee joint. In order to reduce the likelihood of repeated hemorrhages, cryoprecipitate is administered intravenously into the joint, 18–25 units. per 1 kg of the patient's weight per day, simultaneously stretching the articular surfaces up to 2 - 3 mm, and then in postoperative period continue stretching 1 mm per day until the formation of the articular sheath 15 - 20 mm, halve the dose of cryoprecipitate during the development of motion. zheny in the joint. Simultaneously with the distraction, they begin to restore the range of motion in the joint using a hinge-distraction apparatus, the dose of cryoprecipitate during the period of distraction and recovery of movements is halved, Example 1. Patient Sh., 13 years old, suffers from hemophilia A. From the age of 2, hemorrhages began in the joints. with the subsequent formation of osteoarthropathies and contactures in the knee joints, at the age of 6, redrawing was performed plaster bandages . Contractures were eliminated, but hemorrhages in the joints did not stop. Due to non-compliance with orthopedic prophylaxis, there was a recurrence of contractures in the knee joints. At the age of 8, under the cover of cryoprecipitate, the Volkov-Oganesyan hinge-distraction apparatus was applied to the left knee joint and Ilizarov to the right one. On the operating table, one-stage distraction was performed with the formation of an interarticular gap of 2–3 mm. Complete elimination of contractures was achieved on the right on the 10th day, on the left 1540809 Compiled by P. Filippov Editor N. Tupitsa Tekhred I. Veres Proofreader O. Kravtsova Order 242 Circulation 542 , d. 4/5Production. Publishing plant Patent, Uzhhorod, st. Gagarina, O on the 14th day. After applying the apparatus, along with the restoration of movements in the joints, a gradual distraction of 1 mm per day was carried out. The dose of cryoprecipitate during this period was halved. The size of the gap in both knee joints reached 20 mm. Over the next 5 years, hemorrhages in the joints were not observed. There is no looseness in the joints. Diastasis between the articular surfaces spontaneously decreased to 1 - 2 mm. The patient began to walk without crutches. Example 2. Patient W, 13 years old, was admitted to the Altai Hematology Center in 1981 about hemophilic osteoarthritis and contractures in both knee joints. On admission, the patient was put on distraction devices: on the right Ilizarov, on the left Volkov. Oganesyan, The patient underwent distraction of both knee joints according to the proposed method. On the left knee joint, an increase in the gap between the articular surfaces by 15 mm was achieved. Right - 16 mm. The patient over the next 7 years came annually for a consultation at the hematology center. There were no hemarthroses in the knee joints during seven postoperative years. Before surgery, hemarthroses were observed 2 to 4 times a year. Example 3, Patient. K., aged 16, was admitted to the hematology center in 1982 for hemophilic osteoarthritis of the left knee joint. Before admission, the patient had hemarthroses in the knee joint 3-5 times a year. Upon admission, the Volkov-Oganesyan apparatus was applied. Carried out the treatment according to the proposed method with education. gaps between articular surfaces 17 mm. Examined in 1986. There were no hemorrhages in the knee joint. Re-examination in 1987. Hemorrhages in the joint were still not noted. intravenous administration cryoprecipitate, stretching of the articular surfaces up to 2 - 3 mm, followed by a decrease in the dose of cryoprecipitate during the development of movements in the joint, differ 4 in that, in order to reduce the likelihood of repeated hemorrhages in the joint, 25 stretching of the articular surfaces is continued in the postoperative period by 1 mm per a day before the formation of the joint space 15 - 20 mm.

Application

4334224, 23.11.1987

ALTAI STATE MEDICAL INSTITUTE IM. LENIN KOMSOMOL

CHANTSEVA EVGENIA ALEKSEEVNA, BARKAGAN ZINOVIY SOLOMONOVICH, KUZMINYKH ALEXANDER PETROVICH, CHANTSEV ALEXANDER VENIAMINOVICH

IPC / Tags

Link Code

The method of treatment of the knee joint in hemophilia

Related Patents

And fix the graft to cuboid bone with simultaneous longitudinal compression of closed joints. 4644/5 Branch of PPP "Patent", Uzhhorod, street, Projectnaya, 4 1 1 The invention relates to medicine, in particular to reconstructive surgery, and can be used in the treatment of orthopedic patients with paralytically loose feet, The purpose of the invention is to reduce the invasiveness of the operation at one-, . temporary closure of several joints of the foot. The method is carried out as follows. The outer ankle is cut off ...

The study revealed E. coli, Proteus and pathogenic staphylococcus up to 50 million units in 1 ml). It filled all sections and pockets of the abdominal cavity, but was concentrated in greater quantities in the right lateral canal and in the right iliac region. In the same place, a perforated gangrenous process, located medially, and an accumulation of pus in the interloop space, where the apex of the process was located, were revealed. The peritoneum is hyperemic. small intestine, it is covered with petechial hemorrhages in all places, in some places there are fibrin raids, Abdomen dried with electric suction and napkins. An appendectomy was performed. The abdominal cavity was washed with 3000 ml of 0.02 R solution of chlorhexidine to clear water (with bacteriological ...

In the metacarpophalangeal joints. Gradually eliminating contracture in all joints, which also leads to stretching of the muscles and tendons of the hand and fingers, 1616630 claims. , distraction of the articular ends, development of movements in the joints, differing from the fact that, in order to ensure movements in the radiocarpal joint, the needles are additionally passed through the distal forearm and the main phalanx of the first finger, the nail phalanges are fixed in the position of extension during flexion in other joints, distraction is carried out first in the wrist joint, then in the joints of the fingers, ...

Hemarthrosis is called a hemorrhage in the joint. Pathology can affect any area - the knee joint, temporomandibular, finger joints, and so on. It develops due to rupture of blood vessels that supply intra-articular structures with blood. It is most often observed in the knee area, since a large load is placed on this articular joint. Hemarthrosis of the knee joint most often occurs as a complication after exposure to other factors - injuries or diseases. The development of hemarthrosis is accompanied by an increase in the affected area in volume (the knee becomes spherical), fluctuation (that is, fluctuations in the fluid inside the joint) and severe pain.

Pathology is divided into traumatic and non-traumatic type. Traumatic appears as a result of external mechanical impact, that is, due to fractures, rupture of ligaments, meniscus, bruise. Non-traumatic develops against the background of pathologies of the blood or vessels associated with reduced coagulability blood or increased fragility of the walls of blood vessels. Typical diseases in which such a complication becomes possible are scurvy, hemorrhagic diathesis, hemophilia. Pathology is diagnosed on the basis of a survey of the patient and an external examination. To clarify the reason, apply hardware examination: radiography, CT, .

Hemarthrosis is the accumulation of blood in the joint cavity. Most often it develops against the background of traumatic impact or with hemophilia. Due to the peculiarities anatomical structure knee joint, blood cannot flow out of it.

Important! With hemarthrosis of the knee joint, they are not taken into the army only if there are significant complications, or the pathology often recurs. In other cases, treatment is carried out until complete recovery.

Causes of hemarthrosis

There are not so many factors that provoke the development of this pathology:

• trauma (fall, blow, operation in this area);
• diseases of the blood and blood vessels.

To summarize, the main factor in any case is the traumatic impact on the joint from the outside. Diseases of the blood, blood vessels are considered the root cause, but in this case, hemarthrosis will occur only when even a minor injury is applied to the affected area to the patient. Moreover, patients are often unable to even remember the fact of the traumatic impact, since it was minimal.

Symptoms of hemarthrosis of the knee joint

Hemorrhage into the joint can have three degrees of severity, which manifest themselves in different ways:

1. With minimal bleeding (up to 15 ml). The joint is only slightly enlarged. The symptoms of the underlying injury predominate. Pain is present only at the site of injury. Reliance on the limb can be both limited and free.
2. Blood outpouring up to 100 ml. The joint is visually enlarged, the contours are smoothed, the formation of a spherical silhouette is observed at the junction of the bones. On palpation, the doctor determines the fluctuation. A significant accumulation of blood is accompanied by bulging from the patella from the inside and in the region of the anterolateral surfaces of the joint. Leg support is limited.
3. Ongoing bleeding with a clot volume greater than 100 ml. Skin becomes bluish in color soft tissues become tight and tense. Pronounced deformity of the knee. Sometimes there is an increase in temperature in the area of ​​damage. There is a syndrome of "floating patella". Leaning on a limb and walking are difficult.

With hemarthrosis of the first degree of severity, moderate pain syndrome bursting character. The greater the volume of blood that has been shed, the stronger discomfort. Reliance on the limb becomes either limited or remains full.

If post-traumatic hemarthrosis is caused by severe injuries, then the symptoms typical of the injury predominate. If the ligaments are damaged, then there is instability of the damaged area; fractures are characterized by intense sharp pain with the inability to stand on a diseased limb, and so on. Sometimes fragments of bone tissue or particles of the meniscus are present in the joint cavity. The consequences of severe hemarthrosis of the knee joint can be observed in the patient all his life.

FIND OUT MORE:

Complications and consequences

It is difficult to predict the consequences of hemarthrosis of the knee joint. With absence timely treatment the accumulation of blood leads to tissue compression. As a result, blood circulation is disturbed. This leads to the beginning of the development of dystrophic processes.

Due to the development of stagnation, blood cells begin to disintegrate and penetrate into the tissues near the joint and directly into its very structure. Such an influence negatively affects the knee capsule, as well as hyaline cartilage. An accumulation of hemosiderin, a pigment, is formed, which is released from the destroyed red blood cells. The result is a decrease in the elasticity of the cartilage, capsule, ligaments.

Foci of destruction appear on the surface of the cartilage tissue. As a result, the cartilage becomes not so smooth and gradually begins to break down under the influence of further trauma and stress during movement. The result is arthrosis (gonarthrosis).

Important! Many are interested in how long they give sick leave with hemarthrosis of the knee. It all depends on the severity of the injury that caused the pathology. Therefore, only a doctor can answer this question.

Sometimes the breakdown of blood cells leads to inflammation of the synovial membrane lining the joint cavity from the inside. Aseptic synovitis develops. If pathogenic bacteria enter the inflamed area with blood or lymph, then the disease is classified as infectious. When the infectious-inflammatory process spreads to the fibrous membrane in the area of ​​the capsule and surrounding tissues, purulent arthritis develops.

To possible complications also includes the development of intra-articular adhesions and scars, which leads to limited range of motion in the joint.

Diagnostics

Diagnosis of the disease is based on a survey and examination of the patient. To clarify the diagnosis and identify the cause of hemarthrosis, hardware studies are used:

• arthroscopy;
• joint puncture;
• radiography;
• and etc.

If a non-traumatic type of pathology is suspected, a consultation with a hematologist is necessary. Accordingly, additional analyzes may be required.

Treatment of hemarthrosis

If symptoms of hemarthrosis of the knee joint appear, then after examination and detection of pathology, treatment should be started. The consequence of the lack of therapy may be complete defeat cartilaginous tissues of the knee with the need to replace the joint with an implant.

In the prehospital period of the diseased limb, complete rest must be ensured. The patient should be placed in horizontal position, and place a small roller or pillow under the affected knee. Dry cold should also be applied, for example, a heating pad with chilled water, a bag of ice cubes, which is pre-wrapped in a cloth.

If the first degree of pathology is detected, then in most cases a puncture is not required. blood clot will resolve without intervention from the outside, but a plaster splint is applied to the leg. For a couple of days, you need to apply cold, while remaining calm with an elevated position of the knee. The load is limited. When the main symptoms subside, UHF therapy is prescribed. Recovery time depends primarily on the severity of the initial injury.

If there is more than 25 ml of blood in the joint, a decision is already made to perform a puncture, i.e. removal of accumulated blood from the affected area. Make her under local anesthesia. With the help of a thick needle inserted into the joint, excess blood is removed, and the joint cavity is washed with novocaine. Further, the doctor, based on the situation, may decide on the introduction of an anti-inflammatory agent on a hormonal basis.

Then apply a tight bandage and a plaster splint. Sometimes there is a repeated hemorrhage at the site of the lesion, and therefore a second examination of the doctor is required after a couple of days. If required, the process of eliminating blood clots is repeated. Usually 1-3 procedures are enough. The patient is advised to give the leg rest for the duration of therapy and rehabilitation, to keep it elevated. Walking is carried out with the support of crutches or a cane. The average treatment time is 2-3 weeks.

Simultaneously applied local treatment using ointments, creams, gels, folk remedies. Effective anti-inflammatory, painkillers - Traumeel, Deep Relief and so on. If infection is suspected, systemic antibiotics are prescribed.
At the end of the acute period, the patient is prescribed exercise therapy and physiotherapy (magnetotherapy, laser, etc.).

It always accompanies serious traumatic situations. The victim needs to be hospitalized. In the Department of Traumatology, in addition to removing blood from the joint cavity, surgical elimination of the resulting disorders (rupture of ligaments, meniscus, bone fracture, etc.) is carried out. Whenever possible, operations are performed by arthroscopy.

If grade 3 hemarthrosis has developed without severe injuries, then hospitalization of the patient is also mandatory. A hematologist and other specialists are consulted. Diagnostics is carried out with blood sampling to determine clotting disorders,

Kiev specialists performed a unique joint replacement surgery on a 27-year-old patient suffering from a severe form of hemophilia (blood clotting disorder)

“The patient's own joint was completely deformed. When it was removed, there was a risk of damaging the vascular bundle, which would cause bleeding.

27-year-old Andrey waited for this operation for three years. In people with hemophilia, due to periodic hemorrhages, the knee joints eventually collapse and lose mobility. It is very difficult for a person with such problems to move around. For many, the only treatment is surgery, during which their own "petrified" joint is removed and an artificial endoprosthesis is placed.

A few years ago, such patients had to be sent for treatment to Moscow, St. Petersburg or to foreign clinics, - says the director of the Kiev Hemophilic Center, researcher at the Department of Surgical Hematology and Hemostasiology of the Institute of Hematology and Transfusiology of the Academy of Medical Sciences of Ukraine Evgeny Averyanov. - Treat surgical methods patients with hemophilia is not easy. There is a risk heavy bleeding during the operation or within the next 10-12 days after it. To prevent such complications, patients are given large doses of a blood clotting drug - factor VIII (for hemophilia A) and factor IX (for hemophilia B). In Ukraine, these drugs are purchased by the state, but they are not enough. Therefore, it is necessary to save on prevention and provide medical care only in patients with acute bleeding.

At the beginning of this year, the World Federation of Hemophilia (USA) sent humanitarian aid to the All-Ukrainian Hemophilia Society - seven boxes of factor VIII drugs. Some of them went to the operation for Andrey. And the president of the Eurolab Foundation, Andrey Palchevsky, helped the guy buy an endoprosthesis.

Before surgical intervention we thought over and calculated every movement, because surgeons have no right to make a mistake, - Evgeny Averyanov continues. - To carry out this complex operation invited one of the leading Ukrainian orthopedic specialists, Professor Igor Zazirny from the Center for Orthopedics, Traumatology and sports medicine clinical hospital Feofaniya. The patient's own joint was severely deformed. Therefore, when it was removed, there was a risk of damaging the vascular bundle, and this could result in fatal bleeding. The operation was successful. Now the patient feels well, he can already bend his leg, stand on it, and walk. He no longer experiences pain, because of which he suffered greatly and was forced to constantly take strong painkillers. Thanks to the introduction of factor VIII preparations, the wound healed without complications and artificial joint fully settled down.

“A patient with hemophilia will not even have a tooth pulled out without the opinion of a hematologist”

As a child, I often had hemarthrosis (bleeding into the joints), - says Andrey. - I was born in Nova Kakhovka, Kherson region, and was the only child in the city with hemophilia. Doctors knew practically nothing about this disease. When, due to hemorrhages in the ankle joints, I could not get out of bed, my parents took me to Kherson, to the department of pediatric hematology, where mostly children with oncological diseases lay. There I was given intravenous injections of cryoprecipitate (a drug made from human blood), which temporarily helped stop the bleeding. What can I say, because for such patients as me, they won’t even pull out a tooth just like that - you need to bring a conclusion from a hematologist about the introduction of blood clotting drugs. Only after that the dentist agrees to work.

Andrei's parents worked as translators. When foreigners came to the city on friendly visits, the father and mother told them about their son's illness, asked how such children were treated abroad.

Soon they began to send us literature on hemophilia through delegations, - Andrei recalls. - In books and booklets it was said that in case of hemarthrosis it is necessary to introduce a preparation of factor VIII, which at that time no one had even heard of. I first saw this medicine at the age of 13. Parents were given boxes with factor VIII from France. My father studied the instructions for a long time and said that I should inject the medicine myself through a “butterfly” (a miniature catheter needle that is inserted into a vein). The first few times it was difficult, but then I got used to it. Thanks to prevention, I began to lead an active lifestyle and was not much different from my peers: I went to school for classes (before that, because of frequent hemorrhages, I was at home schooling), enrolled in the basketball section and, secretly from my parents, took up powerlifting. Now, no one really believes in it. After all, many patients with a severe form of hemophilia in Ukraine, due to a shortage of drugs, can only move with the help of crutches, or even on wheelchairs.

After graduating from school, Andrei decided to become a computer scientist. He entered the correspondence department at the institute and got a job in a company selling computer equipment.

I understood that I couldn’t go on sick leave, - says the guy. - However, one day the leg swelled up, the knee began to hurt. The drug at that time I had already finished. I had to go to the hospital. After spending a couple of days in the hospital, he was discharged home so as not to miss work. But the next day he woke up from the fact that he could not move a limb. The knee joint became three times larger and looked like a soccer ball. The skin on it was so stretched that, looking at the leg, I saw my own reflection. Hospital again! For two months I had punctures every three days (blood was taken from the joint). Doctors said that articular cartilage and bone tissue had already been destroyed.

Because of constant pain Andrei could not walk and moved to wheelchair. Physiotherapy and pain medication did not help. To reduce suffering, the guy periodically injected himself with strong painkillers.

It is simply impossible to endure such pain, - says Andrey. “Sometimes I didn’t have the strength to endure this torment. Now the most important thing is to recover after the operation. In this, my beloved girl Olga, with whom we have been together for two years, helps me. I am very grateful to the people who helped me - the president of the Eurolab Foundation Andrey Ivanovich Palchevsky, Professor Igor Mikhailovich Zazirny and surgeon Evgeny Valentinovich Averyanov. If patients with hemophilia had preventive drugs, then such consequences could be avoided. But blood clotting drugs are not sold in pharmacies, factor VIII can only be bought on the black market for $50-100 per vial. It is very expensive. And since we need medicines all the time, it is clear that we simply cannot do without the support of the state. In Russia, for example, such a problem practically does not exist. There, hemophiliacs, as in developed Western countries, social security. They get enough factor VIII and can lead a full life. I hope that over time something will change in Ukraine. It is sad to realize that the world has long had means to prevent hemorrhages, but they are not available to us.

The severe course of hemophilia is manifested by articular lesions. Mostly suffer large joints, on which it turns out more load. Hemorrhages in the bone and cartilage tissue occur due to a violation of blood clotting, which is based on an incorrect ratio of elements. Pathology is accompanied by severe joint pain, which is aggravated by movement, as well as swelling skin in the affected area.

Causes and symptoms of hemophilia

This is a disease of the hematopoietic system associated with a violation of blood clotting. Refers to hereditary diseases. Since the genes that are responsible for the development of pathology are distributed along with the X chromosome, hemophilia is transmitted only through female line but only men are affected.

There are rare cases when girls are born with blood pathology.

If it is established that the mother is a carrier of hemophilia, then in newborn boys the disease is diagnosed by examining the umbilical cord blood plasma. Otherwise, the diagnosis is made childhood when signs of bleeding appear. The first pronounced symptom of the disease is the development of hemarthrosis in children under the age of 1 year. Manifestations of symptoms are associated with the onset of active mobility of the baby. You can notice the signs during the first injections, which end in hemorrhage into the muscle tissue. The severe form appears spontaneous bleeding that occur several times a week for no apparent reason.

Mild and moderate forms of the disease are diagnosed at an older age. This is due to the insignificant level of factors that provoke it. At mild form hemorrhages are noted after surgical interventions or serious injury. Medium - manifests itself even with the slightest damage to the skin.

Joint damage in hemophilia

Most often, hemarthrosis affects the knee joints.

Articular hemorrhages occur as a result of exposure to synovial vessels or when the capsule itself is damaged, which is typical for. Large joints are mainly affected, on which the greatest pressure is exerted. These include:

• knee;
• elbow;
• hip;
• ankle;
• shoulder.

The patient feels a hemorrhage even before the formation visual signs in the form of swelling and pigmentation disorders of the periarticular skin. As fluid accumulates, pain and stiffness appear in the affected areas. Under the action of leukocytes in the cartilage tissue, the production of enzymes is noted, which acts destructively on the cartilage. Further, the synovial membrane suffers, which loses its integrity, thereby provoking further hemorrhage. At the same time, it is noted atrophic processes in muscle tissue which only exacerbates the situation. In the case of frequent relapses in one joint, its structure undergoes severe degenerative processes.

Hemophilic arthropathy

Severe pathology, which is caused by degenerative-dystrophic changes in the joint, due to recurrent hemorrhages, which leads to inflammatory response. The cause of the development of arthropathy is bleeding in the joint space, which occurs spontaneously or under the influence of minor injuries. Hemophilic hemorrhages are accompanied painful sensations in the affected joints, hyperemia of the skin and swelling of the affected areas.

In the case of relapses, the pain intensifies, and articular mobility is impaired.

Repeated hemorrhages in the articular cavity may result in ankylosis.

Development pathological condition takes place in several stages. Initially, a hemorrhage occurs in the joint, which leads to the formation of a diffuse hematoma and affects the synovial membrane. Next, inflammation begins on the background of panarthritis. Excess fluid is absorbed by the blood vessels, which leads to their supersaturation and causes swelling in the affected area. With recurrent hemorrhage, active destruction of cartilage occurs due to the production of harmful enzymes. At the final stage, the destroyed areas of the synovial membrane are replaced fibrous tissue. Under the influence of negative factors in the joint, there is an excess of enzymes and iron, which lead to degenerative structural changes in the cartilage. This condition can cause the development of arthritis and ankylosis.