RU2407473C1 - Method of surgical treatment of injuries of rotatory cuff components in case of shoulder neck fractures, fracture-dislocations, dislocations of shoulder - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to orthopedics and traumatology and can be used in surgical treatment of shoulder neck fractures, fractures-dislocations and dislocations of shoulder. In case of dislocations - in upper third of anterior-lateral zone of shoulder transversally transossally superficially synthetic thread is passed, both ends are vertically upwards brought into supra-acromiclavicular space behind and in front of, after centration of head in joint, threads are tied on gause bandage above acromion with fixation of shoulder head in congruent position. In case of fractures and fracture-dislocations - additionally before passing synthetic thread reposition of fracture is carried out, two holes are formed in direction of shoulder head to intramedullary canal and bent rod is introduced into holes, and after fixation of humerus head transossally with two threads in opposite direction in projection of greater and/or minor tubercle sutures are sawn, threads are pulled together by ends and tied above injured tubercles in position of reposition, injured elements of rotatory cuff of shoulder are restored by sewing in anatomically correct direction.

EFFECT: method ensures anatomical restoration of rotatory cuff of shoulder, reduction of trauma and risk of infectious post-operational complications development, reduction of surgery volume and treatment terms.

1 ex, 3 dwg

Description

The alleged invention relates to medicine, namely to orthopedics and traumatology, and can be used in the surgical treatment of injuries of the rotator cuff of the shoulder with fractures of the neck of the shoulder, dislocations and fractures of the shoulder of all types, in accordance with the universal classification of AO / ASIF M.E. .Muller. Guide to internal osteosynthesis. Methodology recommended by the AO group (Switzerland), Springer-Veriag, 2001, 650 pp.

One of the problems of modern traumatology - orthopedics is the further development of effective surgical methods for treating injuries of the rotational cuff of the shoulder, which often accompany fractures of the surgical neck of the shoulder, dislocation and fracture-dislocation. Therefore, the treatment of such patients can be considered important. Damage to this type is more common in older people. Short rotator muscles - supraspinatus, infraspinatus and small round - participate in the rotation and flexion of the arm in the shoulder joint. The tendons that attach these muscles to a large tubercle of the humerus experience great mechanical stress with aggravation of the upper limb. Beyond the load lead to transverse rupture of the tendons or their separation from the humerus. In both cases, such an injury is considered severe. The arm in the shoulder joint loses active mobility, the patient becomes disabled. Analyzing the data of foreign and domestic literature on the surgical treatment of injuries of the rotational cuff of the shoulder, it should be noted that the most common and effective methods for their treatment are open reduction, internal fixation in various ways. However, among the variety of methods described there are no sufficiently clear, differentiated indications for the use of each of them, as well as the analysis of long-term results of operated patients for each of the methods of operations. In young patients, damage to the rotational cuff of the shoulder is an absolute indication for surgical treatment. Without surgical treatment, this category of patients is more likely to develop shoulder contracture. At the same time, pain and impaired function of the shoulder joint and limb are disturbing. Improper treatment can also lead to later complications, severe atrophy of the shoulder girdle, which are accompanied by severe contractures, difficult to treat, post-traumatic deforming arthrosis of the shoulder joint. These complications can be avoided by using the earliest and most accurate anatomical restoration of the rotational cuff of the shoulder. In some cases, it is not possible to carry out a radical operation (for people who are weakened, as well as with serious concomitant diseases and for many other reasons), which negatively affects the results of treatment.

A known method of surgical treatment of tendon ruptures of rotator muscles of the shoulder: Lanshakov V.A., Gunter V.E., Halaman A.G., Kornev V.P., Maksimov A.K., Sisin Yu.A. Description of the invention to the patent of the Russian Federation. RU (11) 2202972 (13) C ² . Status: according to data as of August 10, 2007 - has terminated.

The method is as follows (according to the methodology of the operation). The shoulder joint is exposed by anterior approach (Chaklin) with the intersection of a portion of the deltoid muscle. Allocate and mobilize a package of tendons, refresh their damaged edges. Tendons are cut longitudinally from the mobilized edge in depth according to the size of the plate implant. An implant is introduced into the incision and the resulting reinforced bag is stitched with suture material 3 of superelastic titanium nickelide according to the method of Rozov-Vodyanov. The exit of the central sutures is located on the distal edge of the tendon pack, peripheral - through the middle of its thickness. In the head of the humerus at the base of a large tubercle, the osteotome performs a bone bed of round through holes in size of the formed package, retreating 1.5 cm down from the top of the large tubercle, obliquely, to the entrance hole of the bone bed. The distal ends of the removed sutures 3 are drawn through round holes from the bed to the outside, the reinforced bag is immersed in the bed and transosseously fixed to the shoulder head by tensioning and tying the distal ends of the removed sutures. The surgical wound is sutured in layers and drained. The limb is placed on a wedge-shaped pillow in the abduction position at an angle of 70 degrees and fixed with a Thomas bandage. In the postoperative period, pain blockades, physical and drug treatment, electrical stimulation of the muscles, swinging movements on the wedge-shaped pillow are performed (from the 3rd day after the operation). The wedge-shaped pillow is removed by the end of the 6th week after surgery.

The disadvantages of the method of surgical treatment of tendon ruptures of rotator muscles of the shoulder:

1) During the operation by this method, various technical difficulties are possible due to the untreated treatment methodology.

1) Treatment is accompanied by the development of inflammatory reactions.

2) Extensive preparation of soft tissues.

3) Costly method provision.

4) The likelihood of damage to blood vessels with subsequent bleeding.

5) The likelihood of nerve damage with subsequent neuritis.

The closest analogue is the method of surgical correction of chronic shoulder dislocations: Tolstykh A.L., Samoday V.G., Letnikov A.N., Voronezh State Medical Academy named after N.N. Burdenko, State Educational Institution “VOKB No. 1 of the City of Voronezh”, Technology for Open Directing of ZPV. To date, the technique is as follows: operations are performed under endotracheal anesthesia. The patient is in the "on the back" position. After processing the surgical field, a 7-8 cm incision is made in the projection of the lateral edge of the coracoid process (CO) along the fibers of the deltoid muscle. The front group of deltoid muscle fibers is possibly stratified. The apical part of the KO is distinguished, in which the canal is drilled and the thread for the screw d = 3.5-4.5 mm is cut. KO mobilize and cut 1.5 cm from its apex. After that they take the hooks inside and down. This opens the capsule of the joint, scars and the head of the shoulder. At the next stage, one of the assistants moderately rotates the humerus outside, secrete a small tubercle. The tendon of the subscapularis muscle is cut off from the bone. A joint capsule is partially opened along the upper contour of the head. There is the possibility of introducing wide elevators for the articular surface of the shoulder head, anatomical or surgical neck from its inside. The shoulder head is lifted by elevators and taken out. The articular cavity of the head is projected at the bottom of the wound. Remove scars that interfere with the reduction. After preparing the shoulder joint, the shoulder head is again lifted by the elevators, and the assistant brings the elbow joint to the body with its rotation first outside, then inside. Thus, the shoulder head is directed towards the prepared articular cavity of the scapula. The achieved position is fixed with 2 knitting needles, transarticularly passed through the head into the articular surface of the scapula to hold it in the abduction position up to ∠25 ° -30 °, which prevents its relaxation. The duration of fixation of the shoulder head to the articular surface of the scapula is reflected in the subsequent stiffness of the shoulder joint. Reducing the timing of fixation of the head of the humerus threatens with relaxation in the "usual" place in old cases. The choice of the optimal solution seems to be in bone autoplasty of the anteroposterior edge of the articular process of the scapula, especially with injuries such as Bankart. The bone graft is taken from the iliac crest according to the shape of the anteroposterior edge of the articular process of the scapula and fixed with 2 screws to the neck of the scapula. The edge of the bone graft protrudes above the articular surface of about 3-4 mm, combining arthrosis with an increase in the joint area of the humeral head and scapula. The duration of transarticular fixation of the shoulder head can be reduced in these cases to one day and involves early passive, and then active movements in the damaged joint. After fixing the head, the subscapularis muscle is sutured to the small tubercle with transossal lavsan sutures. Restoring the integrity of the shoulder rotators is the basis for successful rehabilitation of the patient. A fragment of the coracoid process is reinserted and fixed with a tightening screw or hemmed with a lavsan transossal suture, which is especially indicated for possible fragmentation of the apical part. Postoperative treatment is usual. The disadvantages of the method of surgical correction of chronic dislocations of the shoulder:

1) High invasiveness of surgery has a risk of developing infectious postoperative complications.

2) Possible damage to blood vessels, nerves of the shoulder, impaired function

limbs.

Tasks:

1. Anatomical restoration of the rotator cuff of the shoulder.

2. Reduce extensive soft tissue trauma.

3. Reduce the risk of developing infectious postoperative complications.

4. Avoid intraoperative damage to blood vessels, nerves.

5. To reduce the volume of surgical intervention for anatomical

restoration of the rotator cuff of the shoulder.

The essence of the invention is a method for the surgical treatment of injuries of the components of the rotator cuff of the shoulder during fractures and fractures, shoulder dislocations, including the elimination of dislocation, reposition of fractures, and / or displacement of the head and fixation of tendons, characterized in that in the upper third of the anterolateral zone of the shoulder is lower 1–3 centimeters of tubercles transversely transversally transversally, superficially, at a distance of 1.5–1.8 centimeters, a synthetic thread is carried out, both ends are brought up vertically up into the supraacromial space, I eat the lateral end - through the soft tissue under the acromion at the back, and the medial end - in front of the acromion, after openly centering the head in the joint, the threads are tied on a gauze pellet above the acromion with the shoulder head fixed in a congruent position with shoulder traction along the axis and transposed with two threads in in the opposite direction Z-shaped from above and below in the projection of the large and / or small tubercles, the seams, the ends of the threads are pulled together and tied over the damaged tubercles in the reposition position, restored by stitching spawned elements of the rotational cuff of the shoulder in the anatomically correct position.

The technical result of the method is:

1) Ensuring the reliability of treatment results.

2) The method is minimally invasive, inexpensive in execution, does not require traumatic surgical access, has a smaller area of damage to soft tissues.

3) Reduces the risk of developing infectious complications compared with osteosynthesis with a plate implant made of titanium nickelide and titanium thread, percutaneous osteosynthesis with knitting needles.

3) The synthetic thread fixing the head of the shoulder does not lead to a violation of the blood supply.

4) High-quality medical and social rehabilitation of the patient.

The method was tested on 42 patients for 10 years. Almost all operated patients were followed up to 6 months later. These observations allow us to conclude that the proposed method is sufficiently effective. The method is as follows. For a better understanding, the method is shown in figures 1 and 3, where 1 is a fracture-dislocation of the shoulder with separation of both tubercles; 2-3 - fragmentary fracture of the head of the left shoulder after the dislocation is repaired, with osteosynthesis of the neck of the shoulder, osteosynthesis of tubercles. The method is as follows: see - figure 1, 2, 3, where: 1 -components of the rotator cuff of the shoulder; 2 - fracture-dislocation of the head of the shoulder; 3 - a curved metal rod for osteosynthesis; 4 - synthetic thread; 5 - subacromial space; 6 - lateral end of the thread; 7 - medial end of the thread; 8 - acromion; 9 - gauze pelot; 10 - Z-shaped seams around the tubercles. Provide anterolateral access in the upper third of the shoulder to the humerus in the patient’s position on the back with a hand brought to the body and bent at the elbow joint at 90 degrees, and laid on a side table. Depending on the size of the shoulder, the average access size is up to 14 cm, formed in the direction of the fibers of the deltoid muscle by dissecting the layers of skin, subcutaneous tissue, superficial (own) fascia, and shoulder aponeurosis go to the deltoid muscle. In the course of the fibers of the deltoid muscle, with a soft preparation clamp, extend the muscle up to 3 cm, and then with two fingers of both hands disconnect the muscle along the entire length of the access to the sub-deltoid space. They enter the zone of fracture or fracture-dislocation of the shoulder 2. Prepare a place for insertion of the rod: prepare the bone from the periosteum, moving away from the fracture line of the surgical neck of the shoulder along the lateral surface of the humerus to the point of attachment of the deltoid muscle. A “triangle” is formed on the bone with the base - the fracture site, and the sides are: on the right - the medial edge, on the left - the lateral edge. Using a single-tooth retractor, traction is carried out along the axis of the shoulder with the elbow joint bent at 90 degrees, and the fracture is repositioned by rotational movements. Closer to the top of the "triangle" of the upper third of the anterior lateral zone of the shoulder, 2 holes are formed in the direction of the shoulder head at an acute angle to the bone to the medullary canal and a curved metal rod 3 is inserted into the holes with a diameter of 0.2-0.3 cm, congruently adjacent to the humerus. Next, in the upper third of the anterolateral zone of the shoulder at a level below the tubercles of 1-3 centimeters transversely transversally, superficially, at a distance of 1.5-1.8 centimeters, a synthetic thread 4 is carried out, both ends are brought up vertically upwards into the supraacromial space, with the lateral end 6 through soft tissue under the acromion 5 in the back, and the medial end in front of the 7 acromion 8, after openly centering the head in the joint, the threads are tied on a gauze pellet 9 above the acromion with fixation of the shoulder head in a congruent position with shoulder traction and along the axis, and trans-seam is stitched with two threads in the opposite direction Z-shaped 10 from above and from below in the projection 1 of the large and / or small tubercles, the seams are pulled together and tied over the damaged tubercles in the reposition position, damaged parts of the rotational cuff of the shoulder are restored by flashing in anatomically correct position. Sutures on the wound in layers, leaving drainage. Manipulation is carried out under R-control, immobilization in a Deso plaster cast for a month. The seam fixing the head of the shoulder is removed after a month. After the plaster cast is removed, the development of contracture with the help of physical therapy is prescribed until the limb function is restored (on average 2-3 weeks). For the purposes of preoperative examination of patients, as well as when studying long-term results of treatment, in addition to clinical methods, an X-ray method and computed tomography are used.

The method provides for some application limitations:

1) Inflammatory diseases in the area of operation.

2) In all cases, it is mandatory to immobilize with a plaster cast or similarly a soft bandage.

3) the presence of diseases in the stage of decompensation.

Example. Patient G., and. b. No. 671, was admitted to the clinic on 05/09/07 after a household injury - he fell from a height of 2 meters to his left upper limb. He was hospitalized for surgical treatment with a diagnosis of Closed fracture dislocation, 3-fragmented fracture of the head of the left shoulder, with fractures of the large and small tubercles with displacement. After a routine examination, 05/11/07. the patient underwent surgery: open reduction of dislocation of the shoulder, open reposition of fractures, curved metal rod metal osteosynthesis with a curved metal rod for fracturing the surgical neck of the left shoulder, centering the head of the shoulder with transosseal fixation through acromion, restoration of the rotational cuff of the shoulder, drainage. Under intravenous anesthesia, anterolateral access in the upper third of the left shoulder is up to 15 cm, in the position of: a patient lying on his back, with a hand brought to the body and bent to 90 degrees, and laid on a side table. Dissecting the skin in layers, subcutaneous tissue, superficial fascia, shoulder aponeurosis, provided access to the deltoid muscle. In the course of the fibers of the deltoid muscle, the muscle was widened by 3-4 cm with a soft preparation clamp, and then with two fingers of both hands they disunited the muscle along the entire length of the wound to the sub-deltoid space 5 and proximal to the acromion 8. We went into the fracture-dislocation of the shoulder 2. We prepared a place for introduction of the rod: the bone was prepared from the periosteum, moving away from the fracture line of the surgical neck of the shoulder along the lateral surface of the humerus down to the point of attachment of the deltoid muscle. An open reduction of the dislocation of the head of the shoulder was performed, then with the help of a single-tooth retractor, traction along the axis of the shoulder with an elbow bent at 90 degrees was carried out, with rotational movements they reached a reposition of a fracture of the neck of the shoulder. Distal from the fracture site of the surgical neck of the shoulder in the lower corner of the wound, 2 holes were formed in the humerus in the direction of the shoulder head at an acute angle to the bone to the medullary canal and a curved metal rod 0.2-0.3 cm was inserted into the holes, congruent to the humerus, a rod was inserted into the head of the shoulder under R-control. Next (Fig. 3) in the upper third of the anterolateral zone of the shoulder at a level below the tubercles of 1-3 centimeters transversely transversally, superficially at a distance of 1.5-1.8 centimeters, a synthetic thread 4 is carried out, both ends are vertically upwardly directed into the supraacromial space, and the lateral end 6 is through the soft tissue under the acromion at the back, and the medial end 7 is in front of the acromion. After open centering of the head in the joint, the threads are tied on a gauze pellet 9 above the acromion with fixation of the shoulder head in a congruent position with axial traction of the shoulder and transosseously stitched with two threads in the opposite direction Z-shaped 10 from above and below in the projection of large and / or small tubercles 1 The seams at the ends of the threads are pulled together and tied over the damaged tubercles in the position of reposition, restored by flashing the damaged elements of the rotational cuff of the shoulder in the anatomically correct position. Sutures were laid in layers on the wound, leaving subcutaneous rubber graduates. Aseptic dressing, immobilization in a Deso plaster cast for a month. Then, after removing the plaster cast, the removal of the suture that fixes the shoulder head is prescribed the development of contracture, physiotherapy exercises until the function is restored within 3 weeks. The treatment result is satisfactory. Limb function restored almost completely. The manipulation was carried out under R-control. Immobilization in a Deso plaster cast for 4 weeks. The removable seam fixing the shoulder head was removed after a month. After removing the bandage, Deso was prescribed the development of contracture using physiotherapy to restore function for 2-3 weeks. The treatment result is satisfactory. Limb function restored almost completely. In the near and distant follow-up period, unsatisfactory treatment results were not detected. The method is recommended for widespread use in the treatment of patients.

Claims (1)

A method for surgical treatment of injuries of the components of the rotator cuff of the shoulder with fractures of the neck of the shoulder, fractures, dislocations of the shoulder, characterized in that when dislocations in the upper third of the anterolateral zone of the shoulder at a level below the tubercles 1-3 cm transversely transversally superficially at a distance of up to 1.5 -1.8 cm, a synthetic thread is carried out, both ends vertically upward into the supra-acromial space, with the lateral end through the soft tissue under the acromion at the back and the medial end at the front of the acromion, after the open center of the head in the joint, the threads are tied on a gauze pellet above the acromion with fixation of the shoulder head in a congruent position with axial traction of the shoulder, and in case of fractures and fractures-dislocations, the fracture is repositioned additionally before the synthetic thread is performed, two holes are formed in the direction of the shoulder head to the bone of the cerebral canal and into the holes, a curved rod is inserted congruently adjacent to the humerus, and after fixing the head of the humerus in a congruent position, transosseously are stitched with two threads in ivopolozhnom direction of the Z-shaped top and bottom in the projection of large and / or small bumps seams, tightening the thread and tie the ends of the damaged tubercles in position reposition, restore damaged elements rotator cuff by stitching in the anatomically correct position.

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