М.А. Садовой, И.В. Зедгенидзе, И.А. Пахомов Повреждение

ÎÐÈÃÈÍÀËÜÍÛÅ ÑÒÀÒÜÈ
ÏÎÂÐÅÆÄÅÍÈÅ ÑÓÑÒÀÂÍÎÃÎ ÕÐßÙÀ
ÏÐÈ ÏÐÎÍÀÖÈÎÍÍÎ-ÀÁÄÓÊÖÈÎÍÍÎÌ ÌÅÕÀÍÈÇÌÅ
ÒÐÀÂÌÛ ÃÎËÅÍÎÑÒÎÏÍÎÃÎ ÑÓÑÒÀÂÀ
ÓÄÊ 616.728.4-001 : 616.72-018.3
Ì.À. Ñàäîâîé, È.Â. Çåäãåíèäçå, È.À. Ïàõîìîâ
ÔÃÓ «Íîâîñèáèðñêèé ÍÈÈÒÎ Ðîñìåäòåõíîëîãèé»,
äèðåêòîð – ä.ì.í. ïðîôåññîð Ì.À. Ñàäîâîé
ã. Íîâîñèáèðñê
Ïðîâåäåíî àðòðîñêîïè÷åñêîå èññëåäîâàíèå ãîëåíîñòîïíîãî ñóñòàâà ó 34 áîëüíûõ ñ âíóòðèñóñòàâíûìè ïåðåëîìàìè â îáëàñòè ëîäûæêè ñ èñïîëüçîâàíèåì àðòðîñêîïà ôèðìû «Ðè÷àðä Âóëô» äèàìåòðîì 4 ìì è óãëîì îáçîðà 30°.
 ðåçóëüòàòå èññëåäîâàíèÿ îáíàðóæåíî, ÷òî ïðîíàöèîííî-àáäóêöèîííûé ìåõàíèçì òðàâìû ãîëåíîñòîïíîãî ñóñòàâà âûçûâàåò ïîâðåæäåíèå ñóñòàâíûõ ïîâåðõíîñòåé. Ïðè
ýòîì çíà÷èòåëüíî ñòðàäàåò ãèàëèíîâûé õðÿù. Òèïè÷íàÿ
ëîêàëèçàöèÿ òðàâìû ñóñòàâíîãî õðÿùà – ñðåäíÿÿ èëè ïåðåäíÿÿ òðåòè âíóòðåííåãî êðàÿ áëîêà òàðàííîé êîñòè. Êðîìå òîãî, òðàâìà ìîæåò ðàñïðîñòðàíÿòüñÿ íà âíåøíþþ ñóñòàâíóþ ïîâåðõíîñòü áëîêà òàðàííîé êîñòè.  50% ñëó÷àåâ
ïîâðåæäàåòñÿ ñóñòàâíîé õðÿù ïåðåäíåãî êðàÿ áîëüøåáåðöîâîé êîñòè. ×àùå âñåãî âñòðå÷àåòñÿ ñî÷åòàíèå ïîâðåæäåíèé ñóñòàâíîãî õðÿùà âíóòðåííåãî êðàÿ áëîêà òàðàííîé
êîñòè è âíåøíåé ÷àñòè ïåðåäíåé áîëüøåáåðöîâîé êîñòè.
Ó 80% áîëüíûõ ïîâðåæäåíèÿ õðÿùà ñóñòàâíûõ ïîâåðõíîñòåé ãîëåíîñòîïíîãî ñóñòàâà èìåþò ôîðìó äåôåêòà ñ
ñóáõîíäðàëüíûì îáíàæåíèåì êîñòè. Ðàçìåð ïîâðåæäåííîé
÷àñòè ìîæåò âàðüèðîâàòüñÿ îò 4õ4 äî 30õ20 ìì.
Ïîëó÷åííûå ðåçóëüòàòû ãîâîðÿò î òîì, ÷òî íàðÿäó ñ
ïîâðåæäåíèåì êîñòíûõ è ñâÿçî÷íûõ ñòðóêòóð ãîëåíîñòîïíîãî ñóñòàâà ïðè ïðîíàöèîííî-àáäóêöèîííîì ìåõàíèçìå
òðàâìû ñóùåñòâåííî ñòðàäàåò ñóñòàâíîé õðÿù.
Ââåäåíèå
Òðàíñõîíäðàëüíûå ïîâðåæäåíèÿ ïðè ìåõàíè÷åñêîé òðàâìå ãîëåíîñòîïíîãî ñóñòàâà â ðÿäå
ñëó÷àåâ ïðèâîäÿò ê ðàçâèòèþ ðàçëè÷íûõ îñëîæíåíèé â îòäàëåííîì ïåðèîäå.
Îäíèì èç ñîâðåìåííûõ ìåòîäîâ èññëåäîâàíèÿ, ïîçâîëÿþùèì îñóùåñòâèòü âèçóàëüíûé
êîíòðîëü ñîñòîÿíèÿ ñóñòàâíîãî õðÿùà ãîëåíîñòîïíîãî ñóñòàâà, ÿâëÿåòñÿ àðòðîñêîïèÿ (2, 3, 6).
 íàñòîÿùåå âðåìÿ äàííîå èññëåäîâàíèå ïðèìåíÿåòñÿ êàê ñ äèàãíîñòè÷åñêîé, òàê ñ è ëå÷åáíîé
öåëÿìè (4, 5).
Ýêñïåðèìåíòàëüíûå èññëåäîâàíèÿ ïîçâîëèëè îïèñàòü ìåõàíèçìû òðàíñõîíäðàëüíûõ ïåðåëîìîâ òàðàííîé êîñòè, ïðè êîòîðûõ âñå ïîâðåæäåíèÿ ñâÿçûâàëè ñ èíâåðñèîííûì ìåõàíèçìîì
òðàâìû (1). Àíàëèç êëèíè÷åñêèõ íàáëþäåíèé
ïîêàçàë, ÷òî 43% òðàâì ëîêàëèçîâàëèñü â íàðóæ-
ÒÐÀÂÌÀÒÎËÎÃÈß
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ÎÐÒÎÏÅÄÈß
Arthroscopic research of ankle joint in 34 patients with
intraarticular fractures in ankle area has been made. The
fractures were caused by pronation-abduction mechanism of
trauma. The arthroscope of «Richard Wolf» firm with the
diameter 4 mm and viewing angle 30° was used.
In the result of the researches it has been revealed that
pronation-abduction mechanism of ankle injury causes trauma
of articular surfaces. At that hyaline cartilage significantly
suffers. Typical localization of articular cartilage injury is medial
or anterior third of internal edge of ankle bone block. Apart
from that the injury may spread on external articular surface
of ankle bone block. In 50 % articular cartilage of anterior edge
of shin-bone is injured. Most often the combination of injuries
of articular cartilage of internal edge of ankle bone block and
external part of anterior shin-bone.
In 80% injuries of the cartilage of articular surfaces of ankle
joint has a form of defect with subchondral bone exposure. The
dimensions of affected part may vary from 4õ4 up to 30õ20 mm.
Obtained results testify that along with the injury of bone
and ligamentous structures of ankle joint at pronationabduction mechanism of trauma, articular cartilage is
significantly affected. The size and character of articular
cartilage injury vary depending on the severity of trauma.
íîé ÷àñòè áëîêà òàðàííîé êîñòè, à îêîëî 57% –
âî âíóòðåííåé, êàê ïðàâèëî, çàäíåé òðåòè.
Ýòè äàííûå ïîäòâåðæäåíû àðòðîñêîïè÷åñêèìè èññëåäîâàíèÿìè ãîëåíîñòîïíûõ ñóñòàâîâ
áîëüíûõ, ïîëó÷èâøèõ òðàâìó âñëåäñòâèå íàñèëüñòâåííîé èíâåðñèè ñòîïû. Áîëåå òîãî, áûëè âûÿâëåíû ïîâðåæäåíèÿ ñóñòàâíîé ïîâåðõíîñòè ïåðåäíåãî êðàÿ áîëüøåáåðöîâîé êîñòè. Âñå èññëåäîâàíèÿ ïðîâîäèëèñü â ñðîêè îò 3 ìåñÿöåâ äî 3
ëåò ïîñëå òðàâìû ãîëåíîñòîïíîãî ñóñòàâà (5, 6).
Àíàëèç îòå÷åñòâåííûõ è èíîñòðàííûõ ëèòåðàòóðíûõ èñòî÷íèêîâ, ïîñâÿùåííûõ àðòðîñêîïèè ãîëåíîñòîïíîãî ñóñòàâà ó áîëüíûõ â ðàííåì
ïåðèîäå ïîñëå òðàâìû, ñâèäåòåëüñòâóåò î çíà÷èòåëüíîì ïðîáåëå â ýòîì âîïðîñå, ÷òî ïîáóäèëî íàñ ê ïðîâåäåíèþ äàííîãî èññëåäîâàíèÿ.
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ÎÐÈÃÈÍÀËÜÍÛÅ ÑÒÀÒÜÈ
Âûâîäû
 ðåçóëüòàòå èññëåäîâàíèé áûëî óñòàíîâëåíî, ÷òî ïðè ïðîíàöèîííî-àáäóêöèîííîì ïîâðåæäåíèè ãîëåíîñòîïíîãî ñóñòàâà ïðîèñõîäèò òðàâìèðîâàíèå ñóñòàâíûõ ïîâåðõíîñòåé, ïðè ýòîì
ñóùåñòâåííî ñòðàäàåò ãèàëèíîâûé õðÿù. Òèïè÷íîé ëîêàëèçàöèåé ïîâðåæäåíèé ñóñòàâíîãî õðÿùà ÿâëÿåòñÿ ñðåäíÿÿ èëè ïåðåäíÿÿ òðåòü âíóòðåííåãî êðàÿ áëîêà òàðàííîé êîñòè. Êðîìå ýòîãî, ïîâðåæäåíèå ìîæåò ðàñïðîñòðàíÿòüñÿ íà
íàðóæíóþ ñóñòàâíóþ ïîâåðõíîñòü áëîêà òàðàííîé êîñòè.  50% ñëó÷àåâ òðàâìèðóåòñÿ ñóñòàâíîé õðÿù ïåðåäíåãî êðàÿ áîëüøåáåðöîâîé êîñòè. Íàèáîëåå ÷àñòî âñòðå÷àåòñÿ ñî÷åòàíèå ïîâðåæäåíèé ñóñòàâíîãî õðÿùà âíóòðåííåãî êðàÿ
áëîêà òàðàííîé êîñòè è íàðóæíîãî îòäåëà ïåðåäíåãî êðàÿ áîëüøåáåðöîâîé.
Ó 80% áîëüíûõ ïîâðåæäåíèå õðÿùà ñóñòàâíûõ ïîâåðõíîñòåé ãîëåíîñòîïíîãî ñóñòàâà èìååò âèä äåôåêòà ñ îáíàæåíèåì ñóáõîíäðàëüíîé
êîñòè. Ðàçìåðû ïîâðåæäåííîãî ó÷àñòêà âàðüèðóþò îò 4õ4 äî 30õ20 ìì.
Ïîëó÷åííûå ðåçóëüòàòû ãîâîðÿò î òîì, ÷òî
íàðÿäó ñ ïîâðåæäåíèåì êîñòíûõ è ñâÿçî÷íûõ
ñòðóêòóð ãîëåíîñòîïíîãî ñóñòàâà ïðè ïðîíàöèîííî-àáäóêöèîííîì ìåõàíèçìå òðàâìû ñóùåñòâåííî ñòðàäàåò ñóñòàâíîé õðÿù.
ÒÐÀÂÌÀÒÎËÎÃÈß
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ÎÐÒÎÏÅÄÈß
Çàêëþ÷åíèå
Òàêèì îáðàçîì, èçíà÷àëüíî òÿæåëîå ïîâðåæäåíèå ñóñòàâíîãî õðÿùà âî âðåìÿ òðàâìû çíà÷èòåëüíî óõóäøàåò áëèæàéøèå è îòäàëåííûå ðåçóëüòàòû, è ýòîò ôàêò íåîáõîäèìî ó÷èòûâàòü ïðè
ïîñòðîåíèè ïëàíà ëå÷åíèÿ ïàöèåíòîâ ñ òðàâìîé
ãîëåíîñòîïíîãî ñóñòàâà.
Ëèòåðàòóðà
1. Berndt, A.L. Transchondral fractures (Osteochondritis
dissecans) of the talus / A.L. Berndt, M. Harty // J. Bone
Joint Surg. – 1959. – Vol. 41-A, N 6. – P. 988–1020.
2. Bobic, V. Arthroscopy in the management of sports
injuries / V. Bobic // J. Bone Joint Surg. – 1997. –
Vol. 79-B. – P. 107.
3. Buckwalter, J.A. Joint injury, repair and remodeling:
roles in post-traumatic osteoarthritis / J.A. Buckwalter,
T.D. Brown // Clin. Orthop. – 2004. – P. 7–16.
4. Chuckpaiwong, B. Microfracture for osteochondral
lesion of the ankle: outcome analysis and outcome
predictors of 105 case / B. Chuckpaiwong, E.M. Berkson
// Arthroscopy. – 2008. – Vol. 24, N 1. – P. 106–112.
5. Lundeen, R.O. Ankle arthroscopy in the adolescent
patient / R.O. Lundeen // Foot Surg. – 1990. – Vol.
29, N 5. – P. 510–515.
6. Van Dijk, C.N. Arthroscopy for problems after ankle
fracture / C.N. Van Dijk, R.A.W. Verhagen, J.L. Tol //
J. Bone Joint Surg. – 1997. – Vol. 79-B, N 2. – P. 280–
284.
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