RU2150246C1 - Surgical method for treating inveterate rupture of musculus supraspinatus tendon - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves dissecting the acromial process in making Z-shaped cut. Transverse humeral articulation capsule fold is formed. Musculus supraspinatus fascia is dissected. Terylene gauze shaped as tennis racket is sutured to the posterior surface of the musculus supraspinatus. The narrow portion of the gauze is thrown over the articulation fissure overlapping in this way the musculus supraspinatus tendon suture level and articulation capsule fissure in the drawn-back forearm position. The gauze is sutured to the articulation capsule. Forearm bone canals are formed. Terylene ribbon is brought through them. The gauze is sewn with the ribbon so that musculus supraspinatus fibers are caught. The ribbon is tightened and tied. The acromion is repaired and the wound is sutured. Drawing-back splint is set. EFFECT: strengthened antreroexterior and superior part of the humeral articulation; centered humerus head when drawn back. 17 dwg

Description

 The present invention relates to medicine, namely to traumatology and orthopedics, and is intended for the rapid restoration of chronic ruptures of the supraspinatus muscle.

 A well-known method for the operative repair of a tendon rupture of the supraspinatus muscle (in the book by Watson-Jones R. “Fractures of bones and joint damage” .- M .: Medicine, 1972, p. 273), when the entire front section through the deltoid muscle is exposed in the form of a triangle the thickness of the tendon; the joint capsule and articular surface of the head of the shoulder becomes visible. At the apex of the triangle is the contracted tendon of the supraspinatus muscle, at the base there is a large tubercle where the tendon was torn off. The shoulder is pulled back to the approach of the torn fibers; a mattress is applied seams with chrome-plated catgut or silk or even from a fascia. A bone needle is used for the seam, as the seams are passed through a large tubercle, cutting through the bone. Then a deflecting splint or plaster abduction dressing is applied to prevent early damage in the area of stitches. The dressing should remain at least 2 to 3 months. "

 However, the known method has several significant disadvantages.

 1. Operational access involves the transverse intersection of the deltoid muscle, which violates its subsequent contractile capabilities.

 2. The sutures on the tendon have low mechanical strength.

 3. With significant retraction of the supraspinatus muscle, it is difficult to compare the torn ends of the tendon of the supraspinatus muscle.

4. The method involves prolonged immobilization (2 to 3 months) of the shoulder joint in the shoulder abduction position at an angle of 90 ^o .

A known method of surgical treatment of rupture of the tendon of the supraspinatus muscle (A. Zh. Abdrakhmanov, N. B. Orlovsky "Surgical treatment of injuries of the supraspinatus muscle and short rotators of the shoulder." - In the book: "Abstracts of the V Congress of Orthopedic Traumatologists of the Republic of the Soviet Baltic", 1986, part II, pp. 5–8), when “an anterior arcuate skin incision is made over the acromion and along the anterior edge of the deltoid muscle. The latter is partially separated from the acromion and the acromial end of the clavicle. The subacromial bag, joint capsule are exposed. In the absence of a visible defect in the capsule, the tendon of the supraspinatus muscle is mobilized in the form of a trapezoidal flap, which, together with part of the capsule, is turned upwards. The apex of a large tubercle is knocked down with a chisel. After excision of the scar-changed edge, the tendon of the supraspinatus muscle with U-shaped silk sutures fix the trans transversally in bone bed at the outer shoulder abduction rotation. The wound is sutured in layers and a plaster cast is applied for 6 to 7 weeks when the shoulder is retracted to 70 - 80 ^o . The full restoration of shoulder function is 6 to 7 months. "

However, the above known method has several disadvantages:
1. Surgical access without an osteotomy of the acromial process does not allow a sufficiently complete revision of the upper outer part of the joint capsule and tendon of the supraspinatus muscle.

 2. A long period of immobilization of the shoulder joint after surgery (6 - 8 weeks), which leads to stiffness in it.

 3. Long periods (6 - 7 months) of restoration of the full range of movements in the shoulder joint after surgery.

 For the prototype of the proposed solutions selected "Method of treatment of rupture of the supraspinatus muscle of the shoulder" N 912152, A 61 B 17/00, 1982, author S.V. Gulnazarova, which consists in the fact that "... through the anacromial anteroposterior access with cutting off part of the acromial process of the scapula penetrate the shoulder joint. The deltoid muscle together with the cut off part of the acromial process of the scapula is removed posteriorly and downward. The abdominal muscle is found in the supraspinal fossa and transverse channel: In the region of the head of the shoulder, at the base of the large tubercle, two channels with a diameter of 4–5 mm and a length of 25–30 mm with a distance between them of 15 mm are made along the bone axis. a large tubercle to its apex, through the channels in the head of the shoulder and the channel in the supraspinatus muscle, a canned allotomy is made, the ends of which are lapped in the position of the shoulder to a right angle. transossally to the acromial process of the scapula.The cut off end of the acromial process is thinned to the osteoperiostal part, to which the deltoid muscle is attached, and hemmed on its own hundred. The wound is sutured in layers.

However, in the above known method, there are a number of significant disadvantages that reduce its value:
1. The use of canned allotendin does not provide fully set goals, because:
a) not strong enough;
b) require a lot of time for restructuring;
c) for a long time fused with the walls of the bone canals and canal in the supraspinatus muscle.

 2. Tendon allograft, conducted through the "transverse channel in the abdomen of the supraspinatus muscle", can easily stretch and even cut through, weakening the tension of the restored tendon of the supraspinatus muscle and not preventing the subluxation of the shoulder head up.

 3. "Suspension of the" head of the shoulder "to eliminate subluxation of the shoulder" by trassossally fixing the free end of the allograft to the acromial process of the scapula prevents the possibility of active tension carried out through the channels of the tendons while contracting the supraspinatus muscle, which discredits the method.

 4. Tendon allografts are not fixed to the joint capsule, which, when tensioned, facilitates slipping of the tendons in front and behind the shoulder head, drastically reducing the pressure on its upper pole. All this significantly weakens the actions that prevent a subluxation of the shoulder head upward when the shoulder is abducted.

 5. The usually extended capsule of the joint is not sutured also to prevent subluxation of the humeral head when the shoulder is moved to the side.

6. The very name "Method for the treatment of rupture of the supraspinatus muscle of the shoulder" is misleading, because:
a) the method proposes the restoration of not muscle, but tendon of the supraspinatus muscle;
b) recovery concerns the tendon of the supraspinatus muscle of the scapula, and not the supraspinatus muscle of the shoulder.

The objective of the invention is:
1) restoration of the function of the supraspinatus muscle of the scapula;
2) strengthening the anterior and upper part of the shoulder joint to prevent subluxation of the shoulder head up and out and to ensure "centering" of the shoulder head when it is abducted.

 The problem is solved due to the fact that in the method, including access to the shoulder joint with dissection of the acromial process, the formation of channels in the humerus and the passage of the fixing material through them, carry out a "Z" -shaped section of the acromial process, stitch the torn tendon, form the transverse fold of the capsule shoulder joint, the fascia of the supraspinatus muscle is dissected and a terylene mesh in the form of a tennis racket is hemmed to its posterior surface, a narrow part of the mesh is thrown through the joint gap of the shoulder of the joint, overlapping the level of the tendon suture of the supraspinatus muscle and the fold of the joint capsule, in the shoulder abduction position, the mesh is sutured to the joint capsule, a terylene tape is drawn through the formed channels in the humerus and the mesh is sewn with it to capture the fibers of the supraspinatus muscle, the tape is pulled and tied, restoring integrity acromial process, layer by layer suture the wound, impose a discharge splint.

The implementation of the proposed method is presented in FIG. 1 - 17:
FIG. 1 - a projection of a skin incision;
FIG. 2 - stage of the operation - the skin flap is folded back, muscles are exposed;
FIG. 3 - stage of the operation - dissected periosteum over the scapular spine and collarbone;
FIG. 4 - operation stage — the trapezius and deltoid muscles are subperiosteally, the deltoid muscle is dissected along the vertical part of the skin incision;
FIG. 5 - stage of the operation - the acromial process is osteotomized, folded up and anteriorly, the place of rupture of the tendon of the supraspinatus muscle is exposed;
FIG. 6 is a diagram of an osteotomy of the acromial process (front view);
FIG. 7 is a diagram of an osteotomy of an acromial process (side view);
FIG. 8 - stage of the operation - "T" -shaped fascia of the supraspinatus muscle, "collecting" sutures on the capsule of the shoulder joint, tendon sutures on the tendon of the supraspinatus muscle;
FIG. 9 is a diagram of the application of loop-shaped tendon sutures;
FIG. 10 - a terylene mesh is sewn along the posterior surface of the supraspinatus muscle, under the fascia, longitudinal channels are drilled in the humerus, a terylene tape is drawn;
FIG. 11 - terylene mesh;
FIG. 12 - stage of the operation - the terylene tape is sewn simultaneously through the mesh and supraspinatus muscle, stretched and tied;
FIG. 13 - stage of the operation - sewn "T" -shaped section of the fascia;
FIG. 14 - stage of the operation - the acromial process is laid in place and fixed with a terylene tape;
FIG. 15, 16 - schemes of osteosynthesis of the acromial process with a terylene tape;
FIG. 17 - The wound is sewn in layers, skin sutures are applied.

VALUE OF POSITIONS
pos. 1 - projection of the main skin incision;
pos. 1a is a vertical part of an additional skin incision;
pos. 2 - scapular awn;
pos. 3 - acromial process of the scapula;
pos. 4 - acromioclavicular joint;
pos. 5 - clavicle;
pos. 6 - skin flap;
pos. 7 - trapezius muscle;
pos. 8 - deltoid muscle;
pos. 9 - supraspinatus muscle;
pos. 10 - the first cross section of the acromial process;
pos. 11 is a longitudinal section of the acromial process;
pos. 12 is a second cross section of an acromial process;
pos. 13 - capsules of the shoulder joint;
pos. 14 - the ends of the torn tendon of the supraspinatus muscle;
pos. 15 - loop-shaped tendon sutures;
pos. 16 - fold of the capsule of the shoulder joint with interrupted sutures;
pos. 17 - flap terylene mesh;
pos. 18 - dissected fascia of the supraspinatus muscle;
pos. 19 - a wide part of the terylene mesh;
pos. 20 - a narrow part of the terylene mesh;
pos. 21 - seams that fix the terylene mesh;
pos. 22 - humerus;
pos. 23 - longitudinal channels in the humerus;
pos. 24 - terylene tape;
pos. 25 - stitches terylene tape;
pos. 27 - node terylene tape;
pos. 28 - holes in the acromial process of the scapula;
pos. 29 - terylene tape and its node.

 The method is as follows.

 The patient is laid on the side opposite to that on the side of which there is damage to the supraspinatus muscle. Make the main skin incision (Fig. 1) along the scapular awn (Fig. 1, pos. 2) from its base to the end of the acromial process (Fig. 1, pos. 3), turning it anteriorly, through the projection of the acromioclavicular joint ( Fig. 1, pos. 4) and continuing strictly along the outer end of the clavicle (Fig. 1, pos. 5) by 1/3 of its length, from the level of the acromioclavicular joint; an additional incision is made downward (Fig. 1, pos. 1a), perpendicular to the main one, 5 cm long. In the course of the main skin incision, the periosteum is cut to the bone on the scapular spine (Fig. 2, pos. 2) from the clavicle (Fig. 2, pos. . 5). A skin flap (Fig. 2, pos. 6) is folded up. The subperiosteal is separated from the scapular awn and part of the clavicle, the trapezius muscle (Fig. 3, 4, pos. 7) and unscrew up. The posterior surface of the supraspinatus muscle is exposed (Fig. 4, item 9).

 Produce a "Z" -shaped (Fig. 5, 6, 7) osteotomy of the acromial process of the scapula so that the first transverse (Fig. 6, 7, pos. 10) section to half the thickness is produced at the level of a third of the length of the scapular spine from back to front, the longitudinal (Fig. 7, pos. 11) section is parallel to the flat part of the process, the second transverse (Fig. 6, pos. 12) section is closer to the end of the acromial process, from front to back to half the thickness.

 The dissected acromial process (Fig. 5, pos. 3), without violating the acromioclavicular joint (Fig. 5, pos. 4), is turned anteriorly and upward, exposing the upper and back of the capsule (Fig. 5, pos. 13) of the shoulder joint, as well as the ends of a torn tendon (Fig. 5, pos. 14) of the supraspinatus muscle (Fig. 5, pos. 9).

Both ends of the torn tendon (Fig. 9, pos. 14) of the supraspinatus muscle are sutured with loop-shaped tendon sutures (Fig. 9, pos. 15). Take the shoulder to 80 - 90 ^o from the torso and tie looped sutures, pulling the ends of the torn tendon to full contact. A transverse fold (Fig. 8, pos. 16) of the capsule of the shoulder joint is made above the site of the suture of the tendon of the supraspinatus muscle and sutured with 4–5 interrupted sutures. A rag in the form of a tennis racket (Fig. 11, pos. 17) is cut out from a medium-mesh, knotless terylene mesh, a “T” -shaped (Fig. 8, 10, pos. 18) fascia of the supraspinatus muscle is cut and the mesh is sewn along the posterior surface of the supraspinatus muscle its wide part (Fig. 10, 11, pos. 19), and the narrow (Fig. 10, 11, pos. 20) are thrown through the joint gap of the shoulder joint, the level of the suture of the supraspinatus muscle and the fold of the capsule are thrown and hemmed (Fig. 10 , 12, item 21) to the joint capsule in a moderate tension position. In this case, the shoulder remains in the position of abduction from the body at an angle of 80 - 90 ^o .

 Drill in the humerus (Fig. 10, pos. 22) of 2-longitudinal channels (Fig. 10, pos. 23) with a diameter of 4 - 5.0 mm. A terylene tape (Fig. 10, pos. 24) is longitudinally drawn into the channels and the hemmed mesh is stitched with a tape so that each individual stitch (Figs. 12, 13, pos. 25) passes through the supraspinatus muscle and mesh and captures the thickness of the supraspinatus muscle. After moderate tension, both ends of the tape are tied (Fig. 12, item 26). The truncated "T" -shaped fascia (Fig. 13, item 27) of the supraspinatus muscle is sutured.

Restore the integrity of the acromial process. To do this, it is installed in place, 2 holes are drilled with an awl from back to front (Fig. 15, item 28), a terylene tape is threaded (Fig. 15, 16, item 29) and tied. The peeled subperiosteal trapezius and deltoid muscles are returned to their place and their periosteal parts are sutured above the clavicle and scapular spine, respectively. Sutures are layered on the wound (Fig. 17). A standard take-away functional tire is imposed with shoulder abduction at an angle of 90 ^° and at an angle of 30-40 ^° to the frontal plane.

 From the 10th day, passive movements on the functional bus begin. Immobilization is stopped after 6 weeks from the time of surgery.

Clinical example
Bth St. Mich. Iv., 57 years old (i.p. N 123130), a driver by profession, entered the Nizhny Novgorod Research Institute of Traumatology and Orthopedics regarding rupture of the supraspinatus muscle on the left, separation of the large tubercle of the left humerus.

 From the anamnesis it was revealed that 3 months before admission during a car accident he received a closed dislocation of his left shoulder, which was put under emergency anesthesia in a district hospital. Immobilization was carried out for 3 weeks. Upon removal of the bandage, active flexion and especially abduction of the upper limb in the shoulder joint was sharply limited. Conservative treatment did not have results. He was sent to NIITO.

On admission, marked atrophy of the muscles of the left forearm was noted. Active movements in the left shoulder joint are sharply limited: abduction to an angle of 20 ^o , flexion to an angle of 20 ^o , extension to an angle of 15 ^o . Rotational movements are absent.

 Under anesthesia, an operation was performed: plastic of the tendon of the supraspinatus muscle on the left. A skin incision was made along the left scapular awn from its inner part outward, anteriorly above the acromioclavicular joint and further along the axis of the clavicle 22 cm long with an additional incision 5-7 cm long from the level of the acromioclavicular joint downwards along the shoulder axis.

The attachment site of the trapezius muscle to the scapular spine and clavicle is separated, and the supraspinatus muscle is found. The fibers of the deltoid muscle are spread, it is noted that the capsule of the shoulder joint is torn, the tendon of the supraspinatus muscle is atrophied and torn transversely. An osteotomy of the acromial process was made in the form of a “Z” -shaped section. On the surface of the supraspinatus muscle beneath its own fascia, a slender, nodular terylene mesh, shaped like a tennis racket, is sewn onto the muscle fibers. The severed joint capsule and tendon remnants of the supraspinatus muscle were sutured. The hand is passively withdrawn to an angle of 70 ^o and the narrow end of the nylon mesh is hemmed over the sutured capsule.

Drilled 2 longitudinal channels in the humerus slightly below the large tubercle. A terylene tape was drawn through the channels, which is then sewn through the stitched mesh with stitches to capture the fibers of the supraspinatus muscle and tied in a stretched state near the proximal part of the supraspinatus muscle. Two holes were drilled in the acromial process, it is juxtaposed with dissected planes and connected by a thick nylon thread. The wound is sutured in layers tightly. Iodine. Aseptic sticker. A retractable functional bus is placed in the retraction position at an angle of 85 ^o . The postoperative course is smooth. After 12 days, the abduction splint was replaced by the abduction thoraco-brachial plaster cast, and the patient was discharged for outpatient treatment.

 The dressing was removed 6 weeks after surgery.

 Appointed exercise therapy, FTL.

 Examined 1 year 2 months after surgery.

 Moderate atrophy of the muscles of the left shoulder girdle is noted.

Volume of passive movements in the left shoulder joint:
bending - 170 ^o , extension - 55 ^o , abduction - 170 ^o , rotation with an amplitude of 80 ^o .

Volume of active movements:
bending - 160 ^o , extension - 40 ^o , abduction - 160 ^o , rotation with an amplitude of 50 ^o .

With the active abduction of the left shoulder, the abduction level of 85 - 90 ^{o the} upper limb runs smoothly without undue effort.

 No complaints. He works according to his previous specialty - a driver. Satisfied with the operation.

The proposed method for surgical treatment of chronic rupture of the tendon of the supraspinatus muscle allows to improve treatment results due to the fact that:
1. Terylene knot-free mesh, hemmed subfasually to the posterior surface of the supraspinatus muscle, has a number of undeniable advantages, since when the supraspinatus muscle contracts, the mesh stretches by pulling on the terylene ribbons:
a) the mesh is stretched by pulling terylene tapes;
b) the mesh does not allow cutting through the muscle tissue of the supraspinatus muscle with the terylene tape in the places of the stitches passing through it and the muscle;
c) the net insures the stitches placed on the tendon of the supraspinatus muscle and the joint capsule.

 2. The terylene tape drawn through the bone canals, passing further simultaneously through the mesh and abdomen of the supraspinatus muscle, contributes to the fact that when the muscle contracts, the tape does not move out in front and outside of the shoulder head, and therefore, it is more fully stretched, thereby holding the shoulder head from the subluxation up and out.

3. Transverse sutures on the capsule of the shoulder joint, imposed with the limbs allotted up to 80 - 90 ^o , and their “collecting” character contribute to the additional holding of the head from the subluxation up and out when the limb is abducted.

 4. Overlapping the level of the suture of the tendon and the sutured capsule of the shoulder joint with one of the ends of the terylene mesh and suturing it to the more external parts of the joint capsule also helps to restore normal active shoulder abduction.

 Thus, as a result of the implementation of the proposed technical solution, a fastening system is created that allows you to actively "center" the shoulder head in relation to the articular surface of the scapula, to prevent subluxation of it up and out when the straightened limb is moved to the side due to the fact that the contracting supraspinous muscle pulls a mesh sewn to it and fully pulls the ribbons. In this case, muscle fibers are not cut, as with many other fixation methods previously proposed, and additional seams on the joint capsule and overlapping of the suture of the supraspinatus muscle and capsules additionally by the nylon mesh contribute to the solution of the main problem - restoration of the function of the supraspinatus muscle and upper limb.

Claims (1)

 A method of surgical treatment of chronic rupture of the tendon of the supraspinatus muscle by accessing the shoulder joint with dissection of the acromial process, forming channels in the humerus, passing through them the fixing material with the subsequent restoration of the acromial process, suturing the wound and applying the abduction splint, characterized in that the Z-shaped dissection of the acromial process, the torn tendon is sutured, the transverse fold of the capsule of the shoulder joint is formed, the fascia of the supraspinatus muscle and a terylene net in the form of a tennis racket is brought to the posterior surface of the supraspinatus muscle, the narrow part of the net is thrown through the joint space of the shoulder joint, overlapping the level of the tendon suture of the supraspinatus muscle and the fold of the joint capsule in the shoulder abduction position, the mesh is sewn to the joint capsule through the formed channels in the humerus spend the terylene tape and sew it with a mesh with the capture of the fibers of the supraspinatus muscle, the tape is pulled and tied.

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