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THE CHAPTER I. THE LITERATURE REVIEW

Damages svjazochno-kapsulnyh structures make 69-76 % of cases from all traumas of a knee joint (KS) (Mironova Z.S. from co-workers., 1973-1983; Suhonosenko V. M, 1974; Shojlsv D.P., 1986; Mironov S.P., 1997; Orletskij A.K., 1998; Henning S.E.

et al., 1991). By results of research in sample of 280000 persons within 3 years, spent in Kaiser Permanent Medical Center (San Diego, California), frequency of damages of a knee joint has made 0,038 % a year, of them of 61 % - sports traumas (football, basketball, skiing - 78 % of all sports damage KS). Nielsen A.V. And Yde J. (1991), studying an hour і otu damages of a knee joint, have found out, that in sample of 25000 persons there were 76 cases of damages of forward crosswise ligament (PKS). At sportsmen of damage of the copular apparatus, being the reason postgravmaticheskoj instability of a knee joint, take the second place among, so-called it of "internal damages” and 32 % (make Zhuravleva L.B. from co-workers., 1996). According to Zhuravlevoj L.B. (1996) from all damages of the copular apparatus of a knee joint at sportsmen of 30 % fall to ruptures of the forward crosswise ligament, leading to instability development. Souryal T.O. And Freeman T.R. (1993) have studied 902 sportsmen and have found, that damage PKS has arisen in 3 % of cases, that in 50 times above, than in the general population. Thus, there is a risk of damage PKS between 15 and 30 years, at high level of employment by such kinds of sports, as football, basketball, skis that is bound to jumps and braiding movements. At women of damage KS meet less often, that is bound to their smaller participation in kinds of sports with the raised risk (Clarke K.S. et al., 1980; Zclisko J.A. et al. 1982; Ferrctti A. et al., 1992). Andersson C., Gillgust J. (1992) have taped at 38 % of the surveyed sportsmen damage of a knee joint to a consequence

Functional overstrain svjazochno-kapsulnyh structures (at shtangistov - 50,5 %; volleyball players - 48,7 %; basketball players - 38,3 %).

Last decades representations about damages of a knee joint "have considerably changed Has changed, - according to the French traumatologist - orthopedist Trillata A (1972), - philosophy of our representations about a knee joint - about its functionality and stabilising mechanisms, our approach to restoration of its damages" has changed.

While ligaments are the static structure stabilising a joint in the course of movement, muscles are dynamic structure (Krasnov A.F., Kotelnikov G. P, Izmalkov S.N., 1992). Damage of ligaments leads to a progressing lesion of muscles, chronic instability of a knee joint, premature degenerate changes (to Chemeris A.I., 1982; Komogortsev I.E., 1988; Chepoj V. M, Jakovenko V. N, 1989; Levenets, Century N, Kotelnikov G. P, 1998, Puddu G. et al., 2001).

Instability of a joint is an impossibility of its normal functioning owing to loss of ability to short circuit in a leg without additional external or compensatory adaptations (Krasnov A.F., Kotelnikov G. P, 1989; Fridland L.B., 1993). The made definition has the expressed functional character. Therefore posttravmatnchsskaja instability of a knee joint is surveyed as a condition at which conformity of the functional basic areas of a hip and an anticnemion as a result of damage svjazochno-kapsulnyh structures of a knee joint after a trauma is broken.

Some authors consider, that a risk factor of damages PKS are anatomic features of intercondylar space. So Anderson A.F. et al. And Houseworth S.W. et al. (1987) have informed, that at patsiyoentov with damage PKS the intercondylar space is narrowed. It measured on the computer tomogram and the roentgenogram. Narrowing more than on 0,2 sm raises risk of damage PKS.

Diagnostics

Efficiency of treatment of traumatic damages kolejnogo a joint is in many respects defined by modern highly skilled diagnostics.

The clinical picture of damages PKS of the knee joint which is the reason of development posttravmaticheskon of instability of a knee joint (Voronovich I.R. „1971 is now full enough described; Simsnach B.I., 1978; Kotelnikov G. P, 1998; Hasslcr N, Jakob L.B., 1981). Nevertheless at anybody does not raise the doubts importance of timeliness and accuracy of diagnostics of this pathology. According to Fowler P.J. (1980) accuracy diag nostiki has made 50 %, on Warren R.F. (1990) - 55 %. Diagnostic mistakes make from 14,2 % to 40 % (Bodul_sh V.V., 1975; Klimenko G. S, 1991; Suhonossnko V. M, 1991; Girshin Of this year, 1992; Lisitspn M. P, 1996; Bems J.S. et al., 1992; Bray P.C.ctal., 1992).

Full rupture of forward crosswise ligament is accompanied, as a rule, acute bolyo and sensation of a crunch in a joint, there is a puffiness and gsmatroz (Fedoseyev M. M, 1985; Kuzmenko V.V. from co-workers., 1996). In revealing of clinical symptoms at inspection of patients with fresh damages PKS of a knee joint many authors bind difficulty to presence of the painful syndrome causing a muscular spastic stricture (Bodulin V.V., 1975; Mironova Z.S., Martene A.S., Inagamdzhanov T.I., 1977; Kotelnikov G. P, Dexcl M, Suezawa G., Rodriguez M, 1982). However, the great bulk of patients addresses to the doctor in late terms after a trauma from 2-6 months to 6-Ю years (Remizov V. V, 1987,1988; Jones K.G., 1980; Dejour N, Walch G., 1987; Ewans P.D. et al., 1987). The majority of patients by this time has instability of a gait, unsteadiness, uncertainty, a lameness, pains (Artemeva A.S., 1965; Borodino AA., Merkulov R. I, 1972; Schiesslcr W. Trabold Hempfling H., 1985; Sherman O.H. et al., 1987), the atrophy of muscles of a hip (by Voronovich I.R., 1966, 1971 is taped; Mjakotina L.I., Poles of Century JU, Strukova E.V., 1987; Gilliquist J.C., Hamberg R, I., 1982). The oligotrophy of muscles of a hip can meet at 9 %
Patients, basically at professional sportsmen (Poles of Century JU, 1986). The symptom is applied To check patoloshcheskoj mobility in a knee joint at damages of forward crosswise ligament of "a forward drawer" - promotion of proximal department of an anticnemion to front at incurvated under an angle 90 ° the bottom extremity (Bodulin V.V., 1975; Sitonko M. I, 1977; Nikitin V.V., 1985; Orletskij A.K., 1988; Suhonosenko V. M, 1991; Loch D.A., Lewis I.L., 1992). However it can be positive and at the kept crosswise ligaments, but its size will be much less (Stamashn S.I., Manja A.A., 1988; Lsvenets V. N, Linko J.V., 1989; Tsurkpn A.M., Deekeljuk I.H., 1989; Tretjakov V. B, Smiths In A., Kotelnikov M. G, 1998).

In this connection the most effective at manualnom research is application «Lachman test» (Torg). It is checked at a flexion in a knee joint till 20-30 °, in so-called "comfort positions" at which protective reduction of muscles is eliminated and full diagnostics in 85 % of cases is provided. Under a narcosis it makes 100 % of cases (Whether A.D., 1966; Merkulov R. I, 1973; Smille, 1962; Franke J., 1981; Gruber J., Wolter D., 1986; Sandberg R., Balkforst B., 1988).

Now one of the most modern and informative technologies of reception of diagnostic data at damage PKS is the magnitno-resonant tomography of a knee joint (Petroff V, 1999; Abdulhabirov M. A from co-workers., 2002). For the best visualisation PKS at MPT-diagnostics the flexion in a knee joint on 10 - 20 ° (Schils J.P is recommended. et and., 1990). The diagnosis is put on the basis of following signs: disturbance of a continuity of ligament (full cross-section rupture), wavy irregular its forward edge (regional partial rupture), signal strength rising in regimen Т2 (subsnnoviapnyj rupture) and a sharp strangulation of back crosswise ligament (ZKS), that can a life is bound to forward shift of a tibial bone (Heron C.W., Calvert River T, 1992).

Diagnostic value MRT can be estimated variously. Clinical practice has shown, that at MPT-diagnostics of damages PKS there are difficulties because of a difficult spatial locating of crosswise ligaments knee eye gava. Polly D.W. (1988) has informed on bad visibility PKS at 12 patients from 50. At good visualisation was 6 istinopozitivnyh and 31 nstiionsgativnyh, 1 lozhnopozitivnyj and was not lozhnonegativnyh cases. Jackson D.W. (1988) has informed on 86 patients (87 knee joints) with MRT n artroskopicheskim research which had 70 % of preliminary positive takes on damage PKS.

In diagnostics of ruptures of forward crosswise ligament it is possible to apply ultrasonic methods of research, reliability of diagnostics by these methods makes only 30 - 48 % as ultrasonic cannot be used when between ulgrazvukovym the analyzer and studied structure there is an osteal tissue (Ohotsky Century P, Malygin M. V, 1996).

Lachman-tsst It is considered the best among clinical symptoms of insufficiency PKS. Test Lachman gives 95 % sensitivity, providing the most simple clinical estimation. Dale Daniel and Larry Malcolm have offered for its measurements device KT-1000 (MedMetric Corpotation). Sensitivity of test КТ-1000 makes 97 % at 3 mm and 100 % at 2 mm (Liu S.H. et al., 1995). Anderson A.F. (1991) has compared data KT-1000 and other arthrometers - Stryker knee laxity tester, Acufex knee signature system, Dionics dynamic cruciate tester and Genucom. It is shown, that KT-1000 gives 82 % istinopozitivnyh results, that above, than at other arthrometers. Bach B.R. (1990) specifies, that the difference between both well-cared joints in case of rupture PKS makes more than 3,0 mm, and at healthy faces it - 0,9 mm. Anderson A.F. And Lipscomb And. (1986) data of clinical survey and testing by arthrometers КТ-1000 and Stryker have compared and have come to conclusion, that the arthrometry yields less exact results, than clinical researches.

nesmotrja a pas the big variety of physical techniques and radiological methods, diagnostics of ruptures IKS still causes difficulties. Sensitivity at revealing of ruptures of crosswise ligaments of a knee joint at MRT it is appreciable above, than at artroskopni (93,3 % and 70,0 %), specificity - above at MRT (98,7 % and 92,6 %), and accuracy is identical at MRT and artroskopni (on 93,7 %) accordingly.

artroskopija is an informative method in diagnostics of damages PKS of a knee joint and considerably raises accuracy of diagnostics (Mironov S.P. from co-workers., 1999). Without performance artroskopni, diagnostics guaranteeing high accuracy, in 14 - 20 % of cases of damage PKS remain not distinguished (Mironova Z.S., Fpleh F.J., 1982; Lsvenets V. N, Pljatsko V.V., 1989; Zar V.V., 1995; David Emmanuel, 1996; Lisitsyn M. P, 1996; Grigoriev Of this year, Tretjakov V. B, 1997; Mironov S.P., 1998).

Treatment of damages of ligaments of a knee joint

The question on a choice of tactics of treatment of patients with posttraumatic nestabilyjusgju a knee joint at damage of forward crosswise ligament remains till now to the most difficult. Researchers of nanosecond of a distance of the definitive answer to a question on a choice of a conservative or operative method of treatment at traumas of the kapsulno-copular apparatus of a knee joint (Whether A.D., 1966; Zhukov P. P, Bulatova O. N, 1977; Hughston I.C. et al., 1983).

Conservative treatment by an immobilisation within 4-6 weeks with the subsequent aftertreatment provides necessary stability of a joint only at 50 % of patients, at the others the instability excluding possibility of realisation in it vysokokoordinirovannyh of movements develops. While at the patients treated operatively, it is possible to restore stability in 80-95 % (Mironova Z.S., Bogutskaja E.V., Merkulova A.I., 1983; Lisitsyn M. P, 1996; Soionen K.A. ct. al., 1986; Hempfling N, 1995).

The history of operative treatment of damages of forward crosswise ligament of a knee joint totals more than 100 years. The French surgeon

Scgond in 1879 g has in detail described a clinical picture of rupture PKS, including a crash in a knee at the moment of rupture, a hemarthrosis and movement disturbance in a joint. Value PKS for a flexion of a knee and restriction of forward shift has been noted for the first time in 1836 Weber, Nolis in 1875, and subsequently Lachman have described semiology.

Mayo Robson for the first time has executed ligation of the broken off lobby of crosswise ligament in 1895, but has described this case in 1903 In 1902 Hogarth Pringle has established into place the part of the bone which have come off with PKS, and neu Grooves informed, that by 1913 Goetjcs has described 30 cases of ruptures of forward ligament. In 1913 of Greeks I.I. Has made a plasty of forward crosswise ligament from a wide fascia of a hip (Kotelnikov G. P, 1998). But at that time conservative treatment was in most cases spent, attempts of operative restoration PKS was a little. Now is more than 250 kinds of stabilising operations, but results often happen unsatisfactory.

The technics of the basic operations on reconstruction of forward crosswise ligament consists in a wide arthrotomy with use peredneyomedialnogo or S-shaped on Kuzmin-Pajru of accesses which provide high-grade audit of a joint, performance of interventions on interfacing articulate structures, formation of isometric channels in bones and bracing of graft PKS (Kotelnikov G. N, 1998). However artrotomicheskis operations travmatichny, quite often lead to development of rasping functional disorders, promote a forwardness deforming argroza (Movshovich I.A., 1966). Therefore constant search reliable malotravmatnchnyh operations which will allow to begin in short terms early active movements in a joint and walking with a full load on feet (Grishin Of this year, 1993 is clear; Mironov S.P. from co-workers., 1994, 1997; Shelboume K.D. et al., 1990; Puddu G. et al., 2002).

In 1976 Dendy D. Has executed artroskoiicheskuju plasty PKS, and it was an incitement to rapid development artroskopicheskih technologies in
Restoration of damages of forward crosswise ligament of a knee joint Development artroskopii has allowed to eliminate the basic disadvantages inherent artrotomicheskim in ways plastics of forward crosswise ligament, to carry out more high-grade inspection of a joint and an operative measure at sochetannyh damages of a knee joint, to keep integrity of covers of a joint, almost nanosecond to break blood supply and an innervation, to alter principles of conducting the postoperative and rehabilitational periods (Mironova Z.S. from co-workers., 1982; Shojlev D.P.,

1986; Ushakov O. A from co-workers., 1991; Malygin M. A, 1999; DeHaven K.E., 1980; Dandy D.J. et al., 1982; Johnson R.J. et al., 1984; Johnson L.L., 1986; Gilquist J. et al., 1991). Application standard napravitslsj allows under the control artroskona is isometric to form correctly channels in tibial and a femur, thereby to exclude possibility of damage of a graft and instability development at its wrong equipment and bracing (Mironov S.P., Arsnberg A.A., Orlstsknj A.K., 1991; Klimenko G. S from co-workers., 1996). The art Roskopichesky surgery allows to look in a new fashion essentially at tactics of treatment of patients with an acute trauma and inveterate damages of forward crosswise ligament of a knee joint (Ohotsky Century P from co-workers., 1996; queens A.V. From co-workers., 1997; Lazishvili GD. From co-workers., 1997). Therefore last years the majority of surgeons began to prefer artroskopicheskim to methods of reconstruction of forward crosswise ligament, refusing from open ways of plasty PKS.

Now in medicine a wide circulation have received following artroskopicheskie techniques of reconstruction of forward crosswise ligament: classical "chrezbolshebertsovaja" a technique (Dandy D., 1976),

transfemoralnaja a technique with use raznovelikih osteal blocks (Nikitin V.V., 1985). As a graft for artroskopicheskoj plastics PKS are used autogenous tissues, allotkani, synthetic materials.

The major element artroskopicheskoj technicians of reconstruction of forward crosswise ligament is maintenance of stable bracing
Graft which provides possibility of early regenerative treatment and excludes instability of a graft in places of bracing till the moment of its growing. Bracing is mainly used vnu§rikanalnaja with the help иіггсрфсреіпиьіх planned vshgtov and stirrups (Lisitsyn M. P, 1996; Lazishvili GD from co-workers., 1997). Bracing by osteal pegs (Ivanov V. I, Chemeris A.I., 1989), by a method compression impaktsin (Nikitin V.V. is made., 1985), are widely used various updatings of suspending variants of bracing of grafts, are with that end in view offered various kinds of fixatives (Trans-Fix, Endobutton) (Queens A.V. From co-workers., 1999). Use for bracing traispla§ggata various resolving materials (Lazko F.L., 1999 is perspective; Lazishvili G. D, 1999). At the analysis of results auditing artroskopy dependence of functionality of graft PKS on a kind and quality of its bracing is proved. The best results are received at jamming of the proximal osteal block of a graft and any bracing distal (Lazishvili GD, 1999). Minimum travmatichiost artroskopicheskoj plastics of forward crosswise ligament, strong bracing of a graft or synthetic implantata allow patients to start in early terms active regenerative treatment.

Carrying out terms artroskopicheskoj plastics PKS depend on many factors. Till now there is no common opinion concerning optimum time of reconstruction PKS after a trauma. About 15-20 years ago пракпіковалось urgent (within 1 week) restoration of rupture PKS (Karlsson J. et al., 1999). Some researchers consider, that at fresh damages of forward crosswise ligament of a knee joint artroskopicheskaja reconstruction PKS undertaken in the acute period, is more high-grade restores a joint bodily machinery, improves stability of a knee and warns development kompsnsatorno-prisposob_ggsln§h mechanisms (Lisitsyn M. P, 1996; Lazishvili GD from co-workers., 1997; Malygin MA. From co-workers., 1997; Rehn Y., 1973; Bomer M ct al., 1986; Hempfling H., 1995). On the other hand, a number of authors
Believe, that early operation within 2 first weeks after a trauma can raise risk of a painful syndrome, stability of a graft, artrofibroza and deficiency of a range of movement in a joint. Therefore the assumption has been come out, that the delay of surgical restoration reduces frequency and intensity of postoperative complications, such as a pain, artrofibroz and a syndrome of a contracture of a whirlbone (Shelboume K.D. et al., 1991).

Karlsson J. (1999) has found out, that sportsmen by whom plasty PKS in a subacute stage (has been made 21 day and more the ambassador of a trauma), in 2-5 years after operation reached higher level of loads, than the hardware sportsmen at whom reconstruction has been postponed for 12 24 months.

It specifies that reconstruction PKS of a knee joint does not depend on operation time, at least, within 2 years after a trauma. Therefore restoration of forward crosswise ligament can be postponed, if the patient agrees reduction of level of loads. Emergency reconstruction PKS in the first weeks after a trauma can be spent to patients who wish to return quickly to intensive sports loads. Hence optimum term of operative treatment is individual for each patient.

Grafts

Now for reconstruction of forward crosswise ligament of a knee joint the most various materials are used: auto - allotransplants and various synthetic implanty (Goncharov N.G., 2001; QDonoghue D.H., 1966; Hughston J.C., 1976). These materials can take root artroskopicheski or through artrotomichesky a cut.

The history of reconstruction of forward crosswise ligament has begun with use iliotibialnoj tapes in 1913 I.I.Grekovym. For today there is a big variety of kinds of the autografts used in surgery of damages PKS: from a wide fascia of a hip (Whether

A.D., 1958,1966; O’Donoghuc D.H., 1966); from whirlbone ligament (Thunders of M. V, 1968; Mironov S.P. from co-workers., 1986,1996); from a tendon the four-head of a muscle of a hip (Sgamatin S.I. from co-workers., 1986); from tendons of semitendinous and gentle muscles (Fedoseyev M. M, 1985; Kotelnikov G. P, 1987; Fedoruk G. V from co-workers., 1999); meniscuses (the Rostov M. P, 1968; Kotelnikov G. P, 1983).

Now plasty PKS with use central трелі whirlbone ligaments is most extended artroskopicheskaja; this method is often mentioned as «the gold standard» in endoscopic surgery of a knee joint, despite lacking any data the remote results. To the most high-grade demands shown to grafts of forward crosswise ligament answers block (a bone - ligament - a bone) an autograft from the central portion of ligament of a whirlbone. Durability makes it 168 % from durability of forward crosswise ligament then, as durability of tendons m. semitendinosus - only 70 %, a fascia lata - 36 % (Noyes F.R. et al., 1984; Butler D.L., 1989). At use of an autograft from whirlbone ligament rigidity of bracing that is a weak link at application suhozhilnyh grafts is provided. Presence of osteal blocks provides an optimality of integration of a graft. The great value has a histological structure of an applied graft. A normal histological picture of ligament of a whirlbone: fibroblasts; collagenic character of construction; absence of blood vessels, inflammatory tissues, it is similar to a normal structure of forward crosswise ligament (RougiafT V, 1997). But, despite the doubtless advantages, the given autograft possesses disadvantages. From whirlbone ligament it is necessary to carry necessity of drawing of an additional operational trauma to disadvantages of an autoplasty of forward crosswise ligament (additional cuts for an autogenous tissue fence), quite often arising thereof functional and sensory disturbances (Mironov With. P from co-workers., 1999; Bonamo JJ. et al., 1990).

The fence of an autograft of ligament of a whirlbone quite often leads to complications: fractures and abruptions at a fence (McCanol J.R., 1983), development in
The postoperative period patsllo-femoralnogo an arthrosis, a painful syndrome and leg disturbance on a knee. For last 2 decades the set of the researches devoted to reconstruction PKS by grafts of tendons that has allowed to improve clinical results of the treatment, some problems is spent and remain unresolved (Yasuda K, 1998).

The success of restoration PKS depends on biomechanical properties of autografts which are defined by biological and mechanical criteria. Biological criteria include sinovialnoe an environment, a postoperative bleeding, a postoperative synovitis and restoration of vessels. Mechanical include structural properties of a graft: rigidity, durability of the graft, a previous condition of a graft, an initial tension of a graft, a graft isometry, graft fastening to a bone. The autograft should combine rigidity that provides its fastness to destruction and the elasticity causing tolerance to variable power influences. The demands shown to durability of a graft, are high enough - on the average 800 - 1700 N (Malygin M. A from co-workers., 1999).

Biomechanical properties of autografts were iucheny on models of reconstruction PKS at animals. In these experimental researches mechanical and structural properties of a graft in 12 months after operation made 20-50 % of control value PKS. The Specific gravity of successful reconstruction PKS makes from 75 to 90 % (Ritchie J.R., Parker R.D., 1996).

Last decade the technique artroskopicheskoj plastics PKS from ligament of a whirlbone with drilling of the femoral channel outside-inside (Cooper D.E is widely applied. et. al., 1998). Aperture visualisation, advanced surgical toolkit concern its advantages and smaller travmatichnoeg. At the exact
Placing of a femoral aperture in back and proximal position the specific gravity of satisfactory forward stability raises to 88 % (Aglietti R et al., 1997). Despite a significant amount of the works devoted to the surgical technics and a bodily machinery of restoration PKS, there are many unresolved questions in studying of the remote results of application of a technique outside-inside at artroskopicheskoj reconstruction PKS.

Reconstruction PKS by means of an autograft from whirlbone ligament cannot repeat completely kinematics intact PKS. If the graft does not take places near to isometric points, there is its appreciable strain which can lead to rupture. Changes in position of the femoral channel influence an isometry, than updating of the tibial channel (Cooper D.E much more strongly. et al., 1998). Insufficient bracing leads to instability of a knee joint and further can become the reason of an early degenerate arthritis. If the graft is fixed at a full extension, it becomes too strongly tense at a flexion and holds down a knee. If the graft fastens at a strong flexion, the graft weakens also a knee it appears is insufficiently fixed at an extension (Friedrich N.F., O’Brien W.R., 1998).

According to Vak K (1999), at patients with chronic instability of a knee joint artroskopicheskaja plasty PKS by means of tendons of semitendinous and gentle muscles yields good long-term results.

From the extremity of the fiftieth years for reconstruction of forward crosswise ligament various kinds of synthetic materials (lavsan, gorsteks, polyester, a carbonaceous fiber, polietilentereftalan) are used. Earlier the steady tendency in application for replacement of forward crosswise ligament lavsanovoj a tape or a fascicle lavsanovyh the threads imitating structure of forward crosswise ligament (Millers A.G was observed.,

Harsrba V. B, 1988; Palgov V. A, Shrajner V. A, 1989; Kaplij A.N., 1991; Kaplan River A et al., 1992). However studying of the remote results has shown, that the prosthesis surrounded in a cavity of a joint sinovialnoj tkanyo, nanosecond sprouts connecting tkanyo, the nanosecond grows into an osteal tissue of channels (Mironova Z.S., Lokshina E.G., Tsejtlina L.A., 1972; Bodulin V.V., 1973; Strum G.M., Larson R.L., 1985). For 5-7 years the arthrosis at patients, as consequence of the big changes in a joint in reply to introduction of a synthetic material (Teljushsnko D.S., 1966 earlier develops; GurgsnidzsN.I., 1981; Jenkins D.H., 1985).

Now searches in creation iskustvennyh ligaments from modern mazerialov (Malypsha MA proceed., 1999). At sochetannyh damages of the kapsulyju-copular apparatus of a knee joint at patients with inveterate damages ("a chronic trauma”) when the reserve of local tissues is limited and in 30-70 % of cases meet the phenomena patsllo - femoralnogo an arthrosis, the autoplasty is not optimum way of operative treatment of damage of forward crosswise ligament of a knee joint, especially at sportsmen that causes necessity of application of a plastic material and greatest possible organosbersgajushchej surgical tactics (SHojlevD., 1986; Ohotsky from co-workers., 1996; DcHaven K.E., 1980; Gilquist J. et al., 1991).

In reconstructive surgery of forward crosswise ligament of a knee joint also are applied allotkani. Allotransplants can be used, if they are safe from transfer to the recipient of any disease of the donor; do not cause allergic reactions from an organism; keep the biomechanical and morphological properties (Volova L.T., 1997). To preservation of biological preparations apply sublimation (Carpenters I.A., 1987), formalin pairs (Povidajlo L.A., 1966), silikogsl, spirtovyj a solution in a combination to formalin (Murzin V. E, Chavtur A.G., 1973). Depression of antigenic properties allomateriala is reached by processing of an osteal tissue in 0,5 % formalin solution, and also low-frequency ultrasound (Volova L.T., 1997). Also preparation is used
Allotransplants a lyophilization method. This technique allows to keep biomatsrial within 5 years at a room temperature (Carpenters I.A., 1988).

However changes prochnostnyh characteristics allotkani are studied insufficiently, possible in the course of preparation, storage, demothballing and at stages of neogenesis carrying over of various diseases and development of immune reactions (Mironov S.P. from co-workers., 1999; Malygin M. A, 2001).

Complications

One of the most frequent complications of treatment of inferiority PKS are forward gonalgias which meet in 5-50 % of cases (Olero A.L., Hutcheson L., 1993; Sgaglionc N.A. et al., 1993; Aglietti P. et al., 1998). Reconstruction PKS with arthrotomy use is accompanied by forward pains in a knee in 30-76 % of cases (I. et al., 1988; Straub T. et al., 1988; O'Brien S.J. et al., 1991), at use artroskopicheskoj technicians in 5-24 % (Bach B.R., 1989; Sgaglionc N.A. et al., 1993). Shelboume K.D. (1993) otmstil, that ventral defect of ligament of a whirlbone contributes to occurrence patello-femoralnyh pains. According to Aglietti R (1992 54 % of patients after operation had patello - femoralnye symptoms, from them only at 15 % their nanosecond was before operation. According to Kartus J. (1999) forward gonalgia depends on restriction of volume of movement in a joint and losses of ventral sensitivity of a knee joint. At MrT-isslsdovanii 31 patients in 2 years after reconstruction PKS by means of an autograft from whirlbone ligament it is revealed, that only at 1 patient the donor area is completely restored. Rosenberg T.D. (1992) has shown by means of MRT, that century of donor area in 12-24 months after operation remains steady defect and appreciable formation of cicatrixes is observed.

Other complication after an autograft fence is the postoperative oligotrophy the four-head of a muscle of a hip who conducts to disturbance of balance with muscles of back group of a hip, leads
To disturbance of a bodily machinery of a joint also reduces mobility (Gerber S, Matter R, 1983). The Flexion contracture combined with delicacy by four head of a muscle, also leads to occurrence patello - femoralpyh symptoms as it is thus enlarged patello - femoralyjue pressure that leads patello-femoralnomu to an arthrosis (Sachs R.A. et al., 1990). For preventive maintenance of similar clinical symptoms Shelboume K.D. And Nitz R (1990) recommend intensive aftertreatment in the first days after operation and subject to criticism any immobilisation. Clinical observations show, that the intensive rehabilitational program allows to eliminate a flexion contracture and to reduce forward gonalgias (Wojtys E.M. ct al., 1990).

At walking and podnimanii feet maximum patello - fsmoraliys kompressirujushchie loads are peer to the size peer to half of mass of a body, and deep knee-bend to a flexion in KS under an angle 120 ° can be accompanied by load augmentation in 7 times from size peer to body weight (Hungerford D.S., Barry M, 1979; Kaufman K.R. ct al., 1991). In the postoperative period when peri patelljarnye tissues kontragprovany and the cartilage is most vulnerable, this load it can appear enough for occurrence of irreversible changes. On this basis it is possible to draw a conclusion, that appreciable strengthening chstyrehglavoj with use of exercises should be avoided a muscle until there is no full amplitude of movements, and okolosustavnye parapatelljarnye tissues will get normal elasticity (Wojtys E.M. et al., 1990).

At times reduction of amplitude of movements after operation stanoyovitsja a much bigger problem, than insufficiency PKS. It is known, that deficiency of an extension more than 10 ° or a flexion less than 130 °, nepriemyolemy for the patient. Reduction of volume of movements in a joint can be bound to use artrotomicheskogo access, artrofibrozom, an immobilisation of an extremity, the wrong program of aftertreatment.

Restriction of mobility after operation as a result of technical errors during an intervention are described in many works (Mohtadi N.G. et al., 1991; Hamer C.D. et al., 1992; Glasgow S.G. et al., 1993; Muncta T. et al., 1993; Freeman T.R., Souryal T.O., 1998). Enncking W.F., Horowitz M. (1972) have described advance of a contracture of a capsule and okolosustavnyh structures, and also fibrous changes in prsnadkolennikovyh sinovialnyh bags and back torsions and have noted cellular changes in a cartilage with the advent of sites of an arthrosis as a result of an immobilisation.

Paulos L.E. (1987) has described group of patients with the restriction of movements bound to a whirlbone and named this complication "infrapatellar contracture syndrom", Noyes F.R. (1993) has informed about anayologichnoj to group using the term "patella infera syndrom", specifying on a combination of a contracture with artrofibrozom okolonadkolennikovyh tissues. In both series of researches it is underlined a flexion contracture, insufficiency the four-head of a muscle and restriction of mobility of a whirlbone. Comparison of length of ligament of a whirlbone and height of its standing with an opposite side has shown, that on the operated party the ligament is a little bit shorter also a whirlbone settles down more low. Paulos L.E. (1991) informs, that the given syndrome is accompanied by narrowing of an articulate cleft patello-femoralyjugo joints and leads to advance patello-femoralnogo an arthrosis.

Indications to artroskopicheskim to manipulations at adhesive process variabelny also depend on many factors. At their application the augmentation of inflammatory changes after operation is possible. At rising of level of a pain, that in the subsequent can conduct to a contracture the four-head of a muscle and morbidity okolonadkolennikovyh tissues, they can give success. Brown H.R. And Indelicate Rivers A (1992) consider, that auditing artroskopija a knee joint is shown, if the flexion contracture under an angle 15 ° exists more than 6 weeks after operation.

Shelboume K.D., Nitz P. (1990) consider, that the surgical intervention is shown at a flexion contracture under an angle 10 ° between 6 and 12 weeks after operation if physiotherapeutic treatment does not give expected effect.

Muscular delicacy the four-head of a muscle of a hip after reconstruction PKS can be bound to an operational trauma, arthrotomy use, a fence of an autograft from whirlbone ligament, an immobilisation, not enough intensive aftertreatment (Lossc R.E., 1988; Snyder-Mackler L. et al., 1991; Glasgow S.G. et al., 1993). Noyes F.R. (1987) notes reduction of length of a circle and muscular delicacy in the first some days after reconstruction PKS, contrary to physiotherapy. After artroskopichsskph they it is less than interventions, than at artrotomicheskom access. Irrespective of character of an operative measure the patient suppresses activity chstyrehglavoj muscles. It can be bound to a painful syndrome, a hemorrhage and longly existing flexion contracture (Jensen K, Graf Century K, 1993).

For restoration of muscular function after reduction of a painful strain of a muscle the electrical stimulation (Sisk T.D is recommended. et al., 1987). Morrissey M.C. (1985) has informed on application after a recon gruktsii PKS elsktromiostimuljatsii, in 9 and 12 weeks after operation force of muscles in the basic and control group did not differ. Some authors note deficiency of working capacity the four-head of a muscle at use of a graft from whirlbone ligament (Barber F.A., Small N.C., 1991). So, on Shelboume K.D., Nitz R (1990) deficiency through jud after operation makes about 9 %, and according to Harder R.A. (1991) - 12 % deficiency for chstyrehglavoj muscles and 9 % for muscles of back group. Miiitravmatichesky access and the intensive program of aftertreatment, in their opinion, eliminate muscular delicacy.

Jackson D.W. And Schaefer K.K. (1990) have described so-called
"Cyclops" a-syndrome which consists in restriction of an extension after operation, in connection with formation and the subsequent organisation of an intraarticulate hematoma, and then formation of a cicatrical fibrous tissue with involving in autograft process (Sachs R.A. ct al., 1998). To tap it it is possible at MrT-issledovanni (Howell S.M. ct al., 1991).

Inexact carrying out tibialnogo the tunnel, its shift to front serves impindzhsment-syndrome development. It is shown by painful click at an anticnemion extension that can lead to extension restriction p to early destruction of an autograft. Painful click speaks impact of an autograft with bugorkami an intercondylar eminence (Mohtadi N.G. ct al., 1991; Christen V, Jakob R.P., 1992; Fu F. et al., 1993).

The comparative analysis of early postoperative disturbances after artroskopicheskoj with application of autografts from ligament of a whirlbone and tendons of "a goose pad” has shown plastics PKS, that less complications is observed at a graft from a thin and semitendinous muscle, in larger degree concerning pain estimations, than in characteristics of a range of movement. But in both groups acuteness of a pain was concerning low and differences between these two groups, apparently, have big клиніРіеского no value as use of grafts "bone-ligament-bone" is bound to the raised level of sports loads in 4 months after operation (l-'cllcr J.A. ct al., 2001). According to some authors studying of force of muscles of back group of a hip at a fence traispla§ggata from a thin and semitendinous muscle of nanosecond have taped for them deficiency (Lipscomb A.V. ct al., 1982; Sachs R.A. ct al., 1990), except data Mardcr R.A. (1991). In the latter case the author is convinced, that by one of the factors which have affected result, there was insufficiently intensive aftertreatment.

After reconstruction PKS with use of autografts from whirlbone ligament complications of the general character, such are possible also
As problems with healing of wounds, an exudate, an infection and a venous clottage, and also seldom meeting fractures of the osteal block, whirlbone fracture during time or after operation, rupture of ligament of a whirlbone after operation.

Aftertreatment

Very important role in formation of an end result of reconstruction PKS is played by aftertreatment as as a result of consecutive application of various rehabilitational actions results improve, treatment terms are reduced, reduction of frequency of relapses of instability of a knee joint is provided. Aftertreatment tactics is based on the account of a situation with influence of an immobilisation and an atrophy of muscles and should be early and effective (Puddu G. et at, 2002).

Till now the consent concerning an optimum rehabilitation course after plasty PKS except for the reference of early restoration of the movement, put forward Eriksson E (1976) is not reached more 25 years ago. Several years ago it was offered to treat patients after reconstruction PKS by means of exercises closed kinetic chains (ZKTS), instead of exercises open kinetic chains (OKTS) to protect graft PKS. But Beynnon B.D. (1997) dokatal, that differences in loads on PKS between exercises ZKTS and OKTS are minimum. According to Morrissey M. S (2000) at sravnii exercises OKTS and ZKTS for extensors of a knee at patients during the early period after reconstruction PKS when the area of bracing of graft PKS is the most weak, it is not taped differences in their influence on function of a knee joint.

According to Yack H.J. (1993) exercises on resistance OKTS, unlike ZKTS, lead to larger forward tibial shift. Exercises OKTS can be more dangerous to knee extensors for broken off or reconstructed PKS.

Smirnov M. L (2002) has carried out the analysis of programs of aftertreatment after artroskopicheskoj reconstruction PKS and has taped, that after
Stabilising operations on a knee joint functional disturbances (a painful syndrome, postoperative contractures, an oligotrophy of muscular stabilizers of a knee, disturbance of basic function, a lameness) which complicate high-grade restoration of function of the bottom extremity are observed. It can be bound to gravity of a trauma, great volume of operation, features of a structure of a knee joint, non-observance of principles of aftertreatment in the postoperative period. Absence of preoperative preparation leads to the complications influencing an end result of treatment. Hence, at the given pathology complex multipurpose treatment with use of the differentiated programs of aftertreatment taking into account principles of regenerative treatment is necessary.

Functional na§ruzok it is possible to consider level admissible at observance of two conditions: first, if it nanosecond puts harm restored at artroskopicheskoj operations to structures; and in - the second if loads do not cause morbidity and otchechnosti a knee joint (Trachuk A.P. from co-workers., 2000).

In the early postoperational period for the purpose of reduction of a reactive edema and a synovitis cryotherapy is shown. Applying of a bubble or a package with ice to area of the top torsion is performed in within the first days after operation and the next days 3-5 times a day after physical exercises.

The most important agent of restoration of function after artroskopicheskoj reconstruction PKS are the physiotherapy exercises. Isometric exercises for muscles of a hip and an anticnemion begin in the first days after operation and continue during all postoperative period. Duration of exercises and amplitude of movements should define and as to limit the patient depending on degree of expression of a painful syndrome and muscular fatigability. Special attention give to preventive maintenance of venous stagnation in the bottom extremity and
To achievement of a full extension of an anticnemion in a knee joint since the first day after operation.

Malygin M. A (2001) considers, that after artroskopicheskogo endoprotezirovanija PKS in the postoperative period it is necessary for patients to apply interferentsionnye currents and medical gymnastics for the purpose of cupping of a painful syndrome, preventive maintenance of an oligotrophy of muscles and restoration of functions of a knee joint. Walking by means of crutches with the dosed out load on a foot is authorised from 1st day after operation, the flexion and an extension within 30 ’ is authorised in the first 2 days. By 4-7 days patients can reach flexions of a knee joint to 90*. By 10-12 days after operation patients started to go with a full load on a foot.

According to Kroitaru I.I. (2001), at carrying out of rehabilitational treatment after artroskopicheskoj plastics PKS the basic attention is given to early activization of patients, strengthening of muscles of the operated extremity and restoration of movements in a knee joint.

For high-grade restoration of function of an extremity in a rehabilitational complex it is expedient to use physiotherapy methods (Abdulkina N.G. from co-workers., 2002). The last are referred on struggle against a painful syndrome, contractures of a knee joint, on preservation and puffiness putting off on circulation improvement in the bottom extremity.

Now in clinical practice widely use numerous methods of an electrical stimulation (ES) nervously-muscular structures. Application ES promotes rising of power of reduction of muscles, activity of nervously-muscular spindles, and also activates microcirculation and a metabolism in a muscular tissue. By data miograficheskih researches constant and impulsive magnetic fields (IMP) have stronger and long exciting an effect on muscular system, than other kinds ES (Ushakov A.A., 1996).

The program of aftertreatment of nanosecond is less important, than operation on reconstruction PKS (Puddu G. et al., 2002). The Great value at a choice of a technique of aftertreatment has a correct choice of the graft, adequate placing in the channel, quality of its fastening. The basic methods of aftertreatment: cryotherapy, a combination of exercises of Construction Department and ZKS, passive movements, an electrical stimulation of muscles, various hydrotherapeutic procedures.

In the first and second weeks of the postoperative period cryotherapy, isometric reduction by the four-head of a muscle of a hip by a certain technique, vytjagivanie a knee on a board (10 minutes each 2 hours to 90 ’ in the first week), gait working out, elsktromiostimuljatsija are spent. On the third and fourth weeks after operation exercises on a velosimulator and in water are added. Within the second, third and fourth months of the postoperative period exercises on balansirnoj to a board begin. Since fifth postoperative month the patient can run in a various regimen in the absence of a muscular oligotrophy. Homing to playing sports is possible only after control survey of the doctor, as a rule, in 6 months after operation.

Last years interest to an estimation of results of reconstruction PKS of a knee joint has increased. The considerable quantity of various estimated scales, such as system of estimation Lysholm, IKDC, Tegner, SARS, FORS (Semert N has been developed. et al., 1999).

System IKDC became most widely accepted and used system of an estimation of a knee joint. Researches Semert N. (1999) have shown, that the estimation system 1KDC is represented reliable system of an estimation of results of reconstruction PKS. High correlation of system of estimation IKDC with scale Lysholm, tests КТ-1000, test Lachman, the test of level of activity Tegner and functional tests is shown. Interest to functional tests, such as jumps on one foot as the test of jumps for one foot is surveyed as a simple agent of an estimation of functional activity has amplified. Functional tests

Are important! Addition of system of estimation IKDC (Puddu G. et al., 2002).

Thus, the analysis of literary data about features of clinic, diagnostics of posttraumatic instability of a knee joint, tactics of treatment and methods of aftertreatment of patients has shown following blanks: the algorithm of inspection of the patient as at a stage of statement of the diagnosis after a trauma, and in the remote terms after reconstruction PKS by an autograft from whirlbone ligament is insufficiently full developed, there is not enough izuchenny the major details, such as a locating and a condition of osteal channels, places of a fence of a graft, and also the condition is immediate the graft and fixatives in the remote terms after operation. There is opened a question on tactics of postoperative functional aftertreatment of the patient. Any of a considerable quantity of estimated tests does not reflect efficiency of treatment and aftertreatment as a whole, that testifies to absence of a common opinion about treatment and aftertreatment methods.

Frequency of relapses of instability of the knee joint, progressing development deforming gonartroza, loss of professional suitability of an active part of the population define an urgency of the selected theme.

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Scientific source GRANDFATHERS SERGEY JUREVICH. ANALYSIS of REMOTE RESULTS artroskop And CHESKY PLASTY of FORWARD CROSSWISE LIGAMENT of the KNEE JOINT the AUTOGRAFT FROM LIGAMENT of the WHIRLBONE With BRACING by TITANIC SCREWS. The dissertation on competition of a scientific degree of the candidate of medical sciences. Moscow - 2006. 2006

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