RU140725U1 - TOOL FOR SURGICAL MINIMALLY INVASIVE TREATMENT OF DRY CHANNEL STENOSES AND PERIPHERAL TUNNEL SYNDROME OF THE SHOULDER AND BRUSH - Google Patents

Abstract

A tool for minimally invasive surgical treatment of tendon canal stenosis and peripheral tunnel syndromes of the forearm and hand, having a cutting element, characterized in that it includes handles, one of which is palmar, stationary, in its continuation equipped with a tube bent in an arc downward relative to the working field , the end of the tube - the nose of the tool - is beveled, narrowed and stale, and there is a longitudinal section behind it at a distance of 0.7-0.9 cm, at the beginning of which is fixed with the possibility of immersion in the section of the tube a knife-hook, having a cutting edge on the inside, while the knife-hook is connected by a rigid wire, which makes reciprocating movements with the movable handle when closing the jaws of the tool.

Description

The proposed utility model relates to medicine, namely to orthopedics and traumatology, and can be used when performing endoscopic surgical interventions on the hand and forearm (Nott, De Kerven’s disease, carpal tunnel syndrome) in a minimally invasive way. Among the stenosis of tendon canals (SSC) and peripheral tunnel syndromes (PTS) of the forearm and hand, Nott, De Kerven, and carpal tunnel syndrome are of most interest. The pathology of the first dorsal canal of the extensors of the fingers of the hand (I bone-fibrous canal) and its contents (tendons of the short extensor of the first finger of the hand and the long muscle that extends the thumb) were described by F. De Quervain in 1895 and bears his name - De Kerven’s disease ( stenosing ligamentitis I of the bone-fibrous canal). This disease occurs in 80-85% of cases from all stenotic extensor ligamentitis of the fingers [Ashkenazi A.I. Hand surgery M., 1990, pp. 294-298]. It is 7-8 times more often than other localizations of channel syndromes and 10 times more often in women, mainly at the age of 45-55 [Volkova AM Hand Surgery, Yekaterinburg, 1993, pp. 56-58].

The complications and failures of surgical treatment can be explained by many structural options for the 1st bone-fibrous canal. By Ta K.T. et al. [Ta K. T., Eidelman D., Thomson J.G. Patient satisfaction and outcomes of surgery for de Quervain's tenosynovitis // J. Hand Surg [Am]. 1999 Sep. 24 (5). P.1071-7], recurrence of De Quervin tenosynovitis is observed in 5%, damage to the sensitive branch of the radial nerve in 2%, soreness of the postoperative scar in 2% of cases. Mellor S.J., Ferris B.D. Complications of a simple procedure: de Quervain's disease revisited // Int J ClinPract. 2000 Mar. 54 (2). P.76-7. note that 13.6% required reoperation due to inadequate decompression, 18% of patients had unsatisfactory cosmetic results, 27% had damage to the surface branch of the radial nerve, 9% of patients had wound infection, and 4.5% developed reflected sympathetic dystrophy. He also notes poor wound healing and frequent damage to the superficial branch of the radial nerve when using a longitudinal incision.

The first description of stenosis of the bone-fibrous canal of the flexor tendons of the fingers dates back to 1850, when Notta published the article “A study on the peculiar disease of the shells of the tendons of the hand, characterized by the development of nodularity of the tendon canal of the flexors of the fingers and the obstacle to their movement”. Nelaton (1855) called this disease a springy finger. Along with this, there are other names: “snapping finger”, “knotted tendonitis”, “snapping finger”. The most modern name is stenosing ligamentitis annular ligaments [G.M. Alberton, W.A. High, A.Y. Shin, A.T. Bishop. Extensor triggering in de Quervain'sstenosing tenosynovitis.//The Journal of Hand Surger y - November 1999 (Vol.24, Issue 6, Pages 1311-1314]. The tendon of the long flexor of the I finger, surrounded throughout the synovial vagina, passes into the bone the fibrous canal, and is attached to the nail phalanx. At the level of the first metacarpophalangeal joint, the joint capsule is closely connected with the tenar muscles. On the palmar surface of the joint bag, the tendons of the short abducent muscle and the short flexor of the first finger include two sesamoid bones, between which the long tendon passes finger flexor and [Hand surgery, 2 volume, A. M. Volkova, 1993, pp. 123-129].

Among the peripheral tunnel syndromes (PTS), carpal tunnel syndrome (SZK, or compression-ischemic median nerve neuropathy) occupies a significant place. In terms of frequency of occurrence, it ranks first, accounting for 45% of all PTS [Agasarov LG, “On the diagnosis of tunnel hand syndromes”. Text. / L.G. Agasarov, E.A. Chuzavkova, A.A. Maryanovsky // The attending physician. - 1999. - No. 1, pp. 52-55], [L. Agasarov, “Tunnel Syndromes: Clinical and Pathogenetic Characterization, Diagnosis and Treatment”. Text. / L.G. Agasarov, E.A. Chuzavkova // Ros. honey. Journal. - 1999a. Number 3. pg. 48-53]. The cause of SCS in 78% of cases is an incorrectly healed fracture of the radial bone in a typical place, fractures and dislocations of the wrist bones, that is, in the vast majority of cases, SCC is post-traumatic [Hand Surgery, Volkova AM, vol. 2, p. 88, 1993 ]. The palm of the allocation of SZK into an independent nosological unit is traditionally given to Western colleagues. So, M.J. McArdle in 1950, first pointed out the connection of the syndrome with compression of the median nerve by the hypertrophic transverse ligament of the palm in the carpal tunnel. He also described the therapeutic tactics of dissecting this ligament for decompression of the nerve and noted its effectiveness, which was later confirmed by other M. Kremeretal doctors. (1953), R. Tanzer (1959), etc. [R. Luchetti, P. Amadio (Eds.), Carpal Tunnel Syndrome, Springer-Verlag Berlin Heidelberg 2007, History of Carpal Tunnel Syndrome, P.C. Amadio].

Despite a significant number of treatments for these pathologies, the results do not always satisfy either the patient or the doctor, because the consequence of surgical treatment is prolonged disability, a decrease in the quality of life due to relapses, incomplete and prolonged medical and social rehabilitation.

The only analogue of the proposed model is a scalpel, with the help of which an open method of treating stenosing ligamentitis of the fingers of the hand (Nott, De Kerven disease) is carried out, which consists in performing intravenous anesthesia, skin access 3-4 cm to the pathological focus - the ring-shaped ligament, dissection of the annular ligament using scalpels, suturing, wound drainage [Hand Surgery, Volume 2, AM Volkova, 1993, pp. 120-129]. With this approach, when using a scalpel, the following disadvantages are noted: the possibility of significant trauma, consisting in cutting the skin over a considerable length to ensure sufficient visualization; the possibility of prolonged postoperative wound healing and marginal necrosis of the skin; a long period of postoperative rehabilitation of the patient.

Tasks: reducing the period of surgical intervention, reducing injuries, improving and simplifying the work of the surgeon, reducing the time of medical and social rehabilitation of the patient.

The essence of the method of minimally invasive surgical treatment of tendon canal stenosis and peripheral tunnel syndromes of the forearm and hand is that the proposed tool includes handles, one of which is palmar, immovable, in its continuation equipped with a tube bent in an arc downward relative to the working field, the end of the tube beveled, narrowed and zauvalent, and there is a longitudinal section behind it at a distance of 0.7-0.9 cm, at the beginning of which it is fixed with the possibility of immersion in the cut of the tube knife-hook, from the inside s hand having a cutting edge, the knife hook connected wire engages integrally with the movable handle reciprocates when closing jaws of the instrument.

Technical result: the proposed tool allows to reduce the treatment period by 60% -70%, practically eliminate postoperative complications, create convenience for the surgeon and the time of surgery, provide a significant reduction in trauma during surgery, since this method allows you to use this model with minimally invasive surgery , and the curvature of the instrument creates the convenience of manipulation during surgery, which greatly facilitates the surgical reception of the surgeon. The immersion of the hook knife in the cut of the tube ensures that injuries to nearby tissues are avoided during the revision of the operating field, and the smooth and narrowed nose of the instrument with the hook knife lowered serves as a probe for the detection and dissection of additional tendon canals during their stenosis. The accepted sizes of the knife-hook, jaws, tubules, the curvature of the working end of the tool are justified by scientific research and confirmed in practice by testing it.

For a better understanding, the proposed tool is shown in the figure (Fig.), Where 1 is a general view of the tool with the work node A; 2 - a palmar handle with a jaw, motionless; 3 - movable handle with a jaw; 4 - a tube, is a continuation of the palmar handle; 5 - knife hook; 6 - a rigid wire passing in a tube is connected to a hook knife; 7 - a slot in the tube for dipping a knife-hook; 8 - tool nose; 9 - hook lock; a - node A of the tool in working condition with open branches; b - node A of the tool inoperative with closed branches and an immersed knife-hook; c - node A, top view.

The tool is used as follows (with Nott's disease): the patient is placed on the operating table, the upper limb is taken to 90 degrees and laid on the table. The surgical field is treated three times with an antiseptic, a tourniquet is applied to the lower third of the forearm, closer to the wrist joint. The fingers of the brush are moved to the position of hyperextension. Having departed 1.5-2 cm from the I metacarpophalangeal joint, on the palmar surface, two skin accesses up to 0.5-0.7 cm long are formed with a scalpel. An endoscopic conductor tube is introduced into the access in the direction of the annular ligament. Fiber optics are introduced into the conductor, air is injected through the openings of the conductor of the tube to 0.5-0.7 mm Hg. using a pneumatic pump to exfoliate soft tissues of the hand. Then, instrument (1) is carefully inserted through the contrapertric approach, a tube (4) with a sharp, weathered tip-nose (8) is passed under the annular ligament or transverse wrist ligament, branches (2, 3) are bred and with a hook knife (5) on the latch (9) connected to the wire (6) and located in the slot (7) of the end of the tube (4) is pulled over and cut it. The instruments are removed and a needle with a diameter of at least 0.3 cm is introduced to a depth of 1 cm of subcutaneous fatty tissue and air is passively insufflated through it. The tourniquet is removed and immediately after that an aseptic dressing is applied for a day. After that, the doctor examines the condition of the skin of the tenar region in order to detect subcutaneous hematoma, the presence of finger sensitivity. In 3% of cases, subcutaneous hematomas were recorded, they were drained and the aseptic dressing was replaced with a tight one. In such cases, the elevated position of the operated limb is recommended. The next day, the postoperative field is examined again, the presence of a hematoma, as a rule, is not determined. Assign activation of the fingers. In other cases, active development of the brush was carried out on the next day after surgery.

In case of De Kerven’s disease, a tourniquet is applied to the middle third of the forearm, and a scalpel is accessed 2 cm distal to the “anatomical snuff box” and 3.5-4.0 cm proximal to the styloid process of the radius, manipulations are performed in the projection of the first bone-fibrous ring. When the hook knife (5) is lowered, the nose of the instrument (8) is smooth and serves as a probe, which finds additional channels, often occurring in the pathology of 1 bone-fibrous channel of the forearm. In case of detection of these, the hook (5) is easily lifted by reducing the jaws of the tool (2, 3) and the channel is dissected. At the same time, injured additional tendons are released, passing in the additional canal, next to the first bone-fibrous canal. The postoperative period is carried out identically. The average stay of bed days is mainly 1 day, sometimes 2-3 days.

In case of carpal tunnel syndrome, the middle third of the forearm is also fixed with a tourniquet. Upper access is formed in the middle of the proximal fold of the forearm. Enter the working tool (1) under the carpal ligament. Then draw it across the carpal ligament to the desired exit point of the instrument. This point is projected onto the skin of the hand, it is 1 cm distal to the bisector of the angle formed by a straight line running along the 3 interdigital space and a straight line running along the maximum allotted first finger of the brush. The nose of the instrument (8) is subcutaneously placed under the distal edge of the carpal ligament, placed in a working position with a knife-hook (5) upwards and brought under the edge of the carpal ligament. By opening the tool branches (2, 3) and removing the “hook” under the carpal ligament, carefully pulling the tool “onto itself”, the latter is cut.

The proposed tool has been tested for five years on over 100 patients. The results of operations fully confirmed the noted result in the application.

Example 1. Patient Ostapenko LI, born in 1951 Medical history No. 29328. Received in General Clinical Hospital No. 3 on May 31, 2004 with a diagnosis of Carpal Canal Syndrome of the Left Hand. Pain syndrome". On the same day, an endoscopic ligamentotomy of the left hand retinaculum flexorum was performed using the proposed utility model. The patient was laid on the operating table, the upper limb was taken to 90 degrees and placed on the table. They treated the surgical field three times with an antiseptic, fixed the lower third of the forearm with a tourniquet, closer to the left wrist joint. The fingers of the hand were taken to the position of hyperextension. Having retreated 1.5-2 cm from the I metacarpophalangeal joint, on the palmar surface, two skin accesses up to 0.5-0.7 cm long were formed with a scalpel. An endoscopic conductor tube was introduced into the access in the direction of the annular ligament. Light-fiber optics were introduced into the conductor, air was injected through the openings of the conductor of the tube to 0.5-0.7 mm Hg. using a pneumatic pump to exfoliate soft tissues of the hand. Then, the instrument (1) was carefully inserted through the contrapertric access, a tube (4) with a sharp, weathered end-nose (8) was inserted under the transverse wrist ligament, the tool branches (2, 3) were parted and with the help of a hook knife (5) on the lock ( 9) connected to the wire (6) and located in the slot (7) of the end of the tube (4), pulling it “onto itself”, cut it. The instruments were brought out and a needle with a diameter of at least 0.3 cm was inserted to a depth of 1 cm of subcutaneous fatty tissue and air was passively insufflated through it. The operation was successful. The patient was discharged on April 2, 2004 with moderate, unstressed swelling of the left hand. The pain syndrome is completely stopped. Healing by first intention. Sutures were removed on the 11th day after surgery. Long-term relapses due to this pathology were not detected.

Example 2. Patient Volchenko V.P., born in 1937 Medical history No. 30603. He entered the General Clinical Hospital No. 3 on 06/15/2006 with the diagnosis: “Post-traumatic syndrome of the carpal tunnel of the left hand. Slightly consolidating scaphoid fracture with displacement. " 06/15/206 performed endoscopic ligamentotomy retinaculum flexorum of the left hand according to the technology described above. The operation was successful. Swelling of the hand is moderate. The pain syndrome is completely stopped. The wound healed by primary intention. Sutures were removed on the 12th day after surgery. The consolidation of the scaphoid fracture occurred 5 weeks after the operation. No relapse was detected.

Claims (1)

A tool for minimally invasive surgical treatment of tendon canal stenosis and peripheral tunnel syndromes of the forearm and hand, having a cutting element, characterized in that it includes handles, one of which is palmar, stationary, in its continuation equipped with a tube bent in an arc downward relative to the working field , the end of the tube - the nose of the tool - is beveled, narrowed and stale, and there is a longitudinal section behind it at a distance of 0.7-0.9 cm, at the beginning of which is fixed with the possibility of immersion in the section of the tube a knife-hook, having a cutting edge on the inside, while the knife-hook is connected by a rigid wire, which makes reciprocating movements with the movable handle when closing the jaws of the tool.

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