Authors
Kokorin V.V.1, 2, Krainyukov P.E.1, 3, Matveev S.A.2, Kuzmin D.B.2, Khimchenko Yu.V.1
1 Central Military Clinical Hospital. P.V. Mandryka of the Ministry of Defense of the Russian Federation, Moscow
2 FPirogov National Medical and Surgical Center, Moscow
3 Peoples Friendship University of Russia (RUDN University), Moscow
Abstract
The article presents the pathomorphological features of the clinic, the diagnosis and treatment of a patient with signs of enthesopathy of the bone-tendon-capsule (CSC) complex of the lateral ankle joint.
Enthesopathy is one of the forms of damage to paraarticular tissues that has not been studied to date, it can be characterized as a degenerative-dystrophic inflammatory process that occurs at the sites of attachment of tendons, ligaments, joint capsules and fascia to the bone (CSC-complex — enthesis), in the presence of common clinical, x-ray, ultrasound, magnetic resonance and other characteristic signs, and the absence of rheumatoid and similar factors in the blood plasma.
A feature of the clinical observation was the absence of characteristic complaints and prior stress illnesses in the patient. The tumor-like deformation of the lateral part of the ankle joint, accidentally discovered by the patient in everyday life, did not cause any concern, which is also not characteristic of this pathology. The patient was forced to consult a doctor with a feeling of discomfort in the ankle joint with dorsal flexion of the foot while walking in shoes.
Outpatient surgeon performed a standard amount of diagnostic research — general clinical, biochemical blood tests, x-ray — diagnosed with ankle bursitis and conducted a course of conservative treatment with non-steroidal anti-inflammatory drugs in combination with perifocal injections of a group of glucocorticosteroids (Diprospan) in the area of pathological changes. Despite the ongoing treatment, a lasting positive effect was not achieved. The patient was sent and hospitalized in a Central Military Clinical Hospital. P.V. Mandryka.
According to the developed protocol, a thorough analysis of complaints, medical history, clinical and manual examination was carried out, an expanded scope of studies was performed: general clinical, biochemical, microbiological, cytological, x-ray, ultrasound, magnetic resonance. Consulted by an oncologist — no signs of malignancy were detected. Based on the analysis and research results, the diagnosis was established — enthesitis of the bone-tendon-capsule (CSC) complex of the lateral part of the left ankle joint.
In the process of complex treatment of the patient, according to the developed standardized scheme, in the proliferation phase, the technology of perifocal implantation, platelet-enriched mass, in the region of the CSC-complex was used.
The applied technique made it possible to level out manifestations of enthesopathy of the lateral external ankle CSC-complex of the left ankle joint as soon as possible, to create conditions for the restoration of degeneratively altered tissues, among which were the distal end of the short tendon of the fibula head of the metatarsal bone, the long and short tendon of the fibula , astragalocalcanean tendon structures, capsule of the ankle joint.
As a result of the treatment, a persistent positive clinical effect was obtained in the form of leveling the feeling of discomfort in the ankle joint, restoring the physiological contours and the full range of movements in it, the physiological biomechanics of walking was normalized — the result was estimated to be good.
Keywords: enthesis, bone-tendon-capsule complex, immunomodulation, platelet-enriched mass, PRP.
References
1. Balabanova RM. Entezity: diagnostika i lechenie. Russkii meditsinskii zhurnal. 2012;20(11):538–540.
2. Zhigalo AV, Morozov VV, Pochtenko VV, Chevardina MA. Modern approach to classification of dupuytren disease. Voprosy rekonstruktivnoi i plasticheskoi khirurgii. 2018;21(2):50–61.
3. Zubkov MA, Andreichenko AE, Kretov EI, et al. Ultrahigh field magnetic resonance imaging: new frontiers and possibilities in human imaging. Uspekhi Fizicheskih Nauk. 2019;189(12):1293–1314. Doi: 10.3367/ufnr.2018.12.038505.
4. Kirsanov VA, Bordukov GG, Polovinko VV. Analiz effektivnosti plazmoterapii pri lechenii entezopatii verkhnei konechnosti. In: Tekhnologicheskie innovatsii v travmatologii, ortopedii i neirokhirurgii: integratsiya nauki i praktiki. Saratov: Amirit; 2019. P. 116–119.
5. Kirillova ER, Lapshina SA, Myasoutova LI, et al. Podkhody k ob"ektivizatsii porazheniya periartikulyarnykh tkanei. Prakticheskaya meditsina. 2008;(1):11–14.
6. Kunder EV. Reaktivnyi artrit. Mezhdunarodnye obzory: klinicheskaya praktika i zdorov'e. 2015;(6):46–63.
7. Trufanov GE, Pchelin IG, Pashnikova IS. Luchevaya diagnostika povrezhdenii golenostopnogo sustava i stopy. Rukovodstvo. 2nd ed. St. Petersburg; 2014. 368 p.
8. Khitrov D. Local injection therapy of damage of paraarticular tissue. Khirurgiya. Zhurnal im. N.I. Pirogova. 2017;(11):44–50. Doi: 10.17116/hirurgia20171144-50.
9. Shutov YuM, Shutova MZ, Novikov ND, et al. Optimum treatment of epicondilitis of brachium. Journal of Siberian Medical Sciences. 2015;(3):47.
10. Abate M, Carlo LD, Salini V, Schiavone C. Metabolic syndrome associated to non-inflammatory Achilles enthesopathy. Clin Rheumatol. 2014;33(10):1517–1522. Doi: 10.1007/s10067-014-2524-3.
11. Arend CF. Role of sonography and magnetic resonance imaging in detecting deltoideal acromialenthesopathy: an early finding in the diagnosis of spondyloarthritis and an under-recognized cause of posterior shoulder pain. J Ultrasound Med. 2014;33(4):557–561. Doi: 10.7863/ultra.33.4.557.
12. Benjamin M, McGonagle D. The enthesis organ concept and its relevance to the spondyloarthropathies. Adv Exp Med Biol. 2009;649:57–70. Doi: 10.1007/978-1-4419-0298-6_4.
13. Dennis MG, Kay-Geert AH, Ai LT. Differentiation between osteoarthritis and psoriatic arthritis: implications for pathogenesis and treatment in the biologic therapy era. Rheumatology (Oxford). 2015;54(1):29–38. Doi: 10.1093/rheumatology/keu328.
14. Gleb S, Itzhak R. Enthesis as a target organ in rheumatic diseases: an expanding frontier. Clin Rheumatol. 2017;36(10):2163–2165. Doi: 10.1007/s10067-017-3749-8.
15. Juneja SC, Defects in tendon, ligament, and enthesis in response to genetic alterations in key proteoglycans and glycoproteins: a review. Arthritis. 2013;2013:4812. Doi: 10.1155/2013/154812.
16. Wang X, Xie L, Crane J. Aberrant TGF-β activation in bone tendon insertion induces enthesopathy - like disease. J Clin Invest. 2018;128(2):846–860. Doi: 10.1172/JCI96186.
