RU2417773C1 - Method for reconstructing tendon of quadriceps muscle of thigh - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to orthopaedics, traumatology in treating an injured tendon of a quadriceps muscle of thigh. The implant is a titanium nickelide mesh implant consisting of three quadrangular petals. Side petals extend from the central petal at an angle 40-50 degrees and spaced 1.0 cm from its distal end. The implant is placed by making a vertical midline incision to exposure the quadriceps muscle of thigh. Lateral, medial and straight heads of the quadriceps muscle of thigh are mobilised separately. Splits are formed in lateral and medial vastus muscles. The central petal of the implant is inserted in the tendon split and fixed with a titanium nickelide suture. In a upper pole of a patella, there is a notch bone bed created wherein a distal end of the central petal of the mesh implant which is fixed to the patella with transosseous loop-shaped titanium nickelide suture is placed. The side petals of the mesh implant are inserted in the splits of the lateral and medial vastus muscles and fixed with blanket titanium nickelide sutures, and anchored to tendinous formations at the patella with titanium nickelide suture.

EFFECT: implant shape allows distributing load uniformly on the entire complex created and provides connection of the lateral vastus muscles and patella that increases fixation reliability, considerably enhanced bonding strength.

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Description

The invention relates to medicine, in particular to methods of treating a musculoskeletal system, and can be used in surgical treatment of both fresh and chronic injuries of the quadriceps tendon.

Depending on the age of the patient and the age of the gap, various plastic methods are used.

There is a method of surgical treatment of chronic injuries of the quadriceps tendon, described by A.F. Krasnov, G.P. Kotelnikov, S.N. Izmalkov in the book. "Medical rehabilitation of patients with damage to the extensor apparatus of the knee joint", - Saratov, - 1994. - P.91-95.

This method consists in the following: the place of damage to the tendon is exposed, the quadriceps muscle is divided into separate portions. The tendon of the rectus muscle is secreted along with cicatricial regenerate and a corrugating suture is applied to them. Hands produce a long stretching of the rectus muscle for 15-20 minutes, with the goal of fatigue, which contributes to some restoration of its length. After that, the muscle is fixed by passing the thread of the corrugating seam through the transverse channel in the patella. The medial and lateral portions of the quadriceps are sutured as duplicates over the restored tendon of the rectus muscle. The wound is sutured in layers tightly.

However, this method has a number of significant disadvantages:

1. Only one rectus muscle is directly fixed to the patella, together with a cicatricial regenerate that lengthens its tendon, and the medial and lateral wide muscles, pulled towards each other and stitched as duplicates over the rectus muscle, retain connection with the patella only through the tendon of the straight head, which reduces the reliability of their fixation to the patella.

2. Fixation of the rectus muscle to the patella with a corrugating suture through the transverse transosseous canal is extremely unreliable under conditions of inevitable for chronic injuries of osteoporosis due to the high probability of thread penetration of the trabecular osteoporotic bone.

3. A method of lengthening the scar-modified rectus muscle due to its "fatigue" by 20 minutes stretching the arms during surgery seems

ineffective.

4. Since the authors believe that gross structural and functional disorders that develop over time in the damaged tendon-muscle complex make intraoperative comparison of the diverged ends of the quadriceps tendon impossible, their method only involves strengthening the scarring between the ends of the tendon and normalizing muscle tone , which cannot be considered optimal for restoring the function of the extensor apparatus of the joint.

Regarding fresh ruptures, there is, for example, a known technique for plasty of the quadriceps femoris tendon ruptures which is technically uncomplicated and suitable for treating fresh, most treatable ruptures (V.D. Chaklin. Fundamentals of operative orthopedics and traumatology. - M .: Medicine. - 1964 - S. 738). The method, in addition to the routine actions of accessing, detecting a gap and completing the closure of the wound, comprises reposition, constriction of the end-to-end tendon stumps and fixation of the formed joint. Two thick silk sutures are sutured through the thickness of the tendon at a distance of 2-3 cm from the ends, the ends of the sutures are cross-linked or U-shaped to the ends of the stumps and tied after being pulled together to close.

The method, despite its widespread prevalence, is not sufficient. The tendon, due to its longitudinal fibrillation, weakly retains the ligature, gets loose, and with significant mechanical stress, the gap recurs. To strengthen the connection of a torn tendon, especially an old one, several days after injury, reinforcing connecting elements of autoplastic or substitute biocompatible material are used.

The most technically closest method is lavsanoplasty according to Movshovich (Movshovich IA Surgical orthopedics: a guide for doctors. - M .: Medicine. - 1983. - S. 226-227), often used for degenerative changes in the tendon. The method consists in the following: make a longitudinal section along the inner edge of the tendon of the rectus femoris and patella. The tendon and partially the muscle are dissected in the frontal plane for 5 cm in order to sew the ends of the lavsan ribbon into this cleavage. A transverse channel is formed in the patella and a finely meshed lavsan tape 10 mm wide is passed through it. The ends of the tape are inserted into the split tendon of the rectus muscle and hemmed with lavsan sutures to the tendon.

Due to the low biocompatibility of the lavsan implant material, these methods are not very effective. According to the greatest similarity of the technical essence, lavsanoplasty according to Movshovich was selected as a prototype of the proposed method for plastics of a torn tendon of the quadriceps femoris.

The objective of the proposed technical solution is to restore the function of the extensor apparatus of the knee joint with injuries of the quadriceps tendon, increase the viability of the plastic of the damaged tendon of the quadriceps femoris muscle by strengthening it with a mesh implant made of titanium nickelide and making sutures with titanium nickelide thread.

The problem is achieved by the method of plastic surgery of the quadriceps femoris tendon. A longitudinal incision is performed to expose the quadriceps femoris. A split is formed by dissecting the tendon and partially the muscle. Sew one end of the implant into the cleavage formed. A bone bed is formed in the patella to fix the second end of the implant. The implant is fixed with its tension.

A mesh implant made of titanium nickelide, consisting of three quadrangular petals, is used as an implant. Side lobes extend from the central lobe at an angle of 40-50 degrees and are located at a distance of 1.0 cm from its distal end. To install the implant, a longitudinal midline incision is made to expose the quadriceps femoris. Separate mobilization of the lateral, medial and straight heads of the quadriceps femoris is carried out. Splits form in the lateral and medial wide muscles. The central lobe of the implant is inserted into the tendon cleavage of the straight head and fixed with a thread of titanium nickelide. In the upper pole of the patella, a bone bed is formed in the form of a groove in which the distal end of the central lobe of the mesh implant is placed, which is fixed to the patella with transosseous loop-like sutures, a thread from titanium nickelide. In the splits of the lateral and medial broad muscles, the lateral lobes of the mesh implant are inserted and fixed with twisting sutures, a thread of titanium nickelide and hem them to the tendon formations on the patella with a thread of titanium nickelide.

Novelty of invention

- A mesh implant made of titanium nickelide, consisting of three quadrangular petals, is used as an implant. Side lobes extend from the central lobe at an angle of 40-50 degrees and are located at a distance of 1.0 cm from its distal end. The strength properties of titanium nickelide correspond to the best modern biocompatible materials and are sufficient for normal tendon tensile stresses. The elastic properties of titanium nickelide and ligament tissue are similar. Therefore, under tensile loads, the deformation of the formed complex is consistent, not leading to overstrain at the boundaries of these components. The direction of the side lobes is selected based on the features of the anatomical zone.

- Make a longitudinal midline incision to expose the quadriceps femoris. Performing an incision in the middle provides better visualization of the stumps of a torn muscle and more convenient access to the lateral and medial heads of the quadriceps femoris.

- Spend a separate mobilization of the lateral, medial and straight heads of the quadriceps muscle, preparing them for the introduction of a three-leaf mesh implant. They are split. A central lobe of a three-leaf mesh titanium nickelide implant is inserted into the formed tendon cleavage of the straight head, and it is fixed with a titanium nickelide thread. The side lobes of the mesh implant are inserted into the formed splitting of the lateral and medial wide muscles, fix them with twisted sutures with a thread of titanium nickelide and hem them to the tendon formations of the patella. The three-sheeted shape of the mesh implant allows you to strengthen the tendon of the quadriceps femoris in three directions of the applied load along m.rectus femoris, m.vastus medialis, m.vastus lateralis.

- In the upper pole of the patella, a bone bed is formed in the form of a groove in which the distal end of the mesh implant is placed, which is fixed to the patella with tension, transosseous loop-like sutures, titanium nickelide thread. This provides less trauma to the patella, compared with the prototype, allowing you to firmly fix the distal end with a thread of titanium nickelide. In addition, the distal part of the implant is also sutured to the tendon formations of the patella with a thread of titanium nickelide.

The shape of the mesh implant allows you to strengthen the tendon of the quadriceps femoris in three directions. Titanium nickelide, from which the three-sheet mesh implant is made, and the titanium nickelide suture used, stimulate and accelerate regeneration due to the microporous structure of the implant surface and threads, which stimulates healing and reduces the treatment time and anatomical and physiological restoration of this area, reduces the risk of postoperative complications.

The shape of the implant allows you to evenly distribute the load on the entire created complex and provides a link between the medial and lateral wide muscles with the patella, which increases the reliability of their fixation, significantly increases the strength of the joints.

The invention is illustrated by the drawings shown in Fig.1-4.

Figure 1 shows the position of a three-leaf mesh implant after installation.

Figure 2 is a skiagram of the knee joint in direct projection with the implant placed.

Figure 3 shows the installation of the implant in the transverse fissures of the heads of the quadriceps femoris and the fixing sutures with a thread of titanium nickelide.

Figure 4 shows a three-leaf implant.

The proposed method is as follows.

The operation is performed in the patient’s position on the operating table lying on his back under combined anesthesia. The surgical field is treated three times with an alcohol solution of chlorhexidine bigluconate. The middle longitudinal section 1 along the anterior surface of the thigh to the patella reveals the distal sections of the quadriceps muscle, the diverged ends of the damaged tendon and the proximal pole of the patella. Cicatricial and fibrous tissue filling the diastasis is dissected, mobilized muscle bundles of the lateral heads. Then proceed to the separation and the formation of the Central zone of the torn tendon of the rectus femoris 2 Fig.3. In this case, they do not try to isolate only its own longitudinal bundles extending in the upper layer of the common tendon. Separate mobilization of the heads of the quadriceps femoris is carried out. A straight head 2 is cleaved. Then a lateral 3 and medial 4 wide muscle is cleaved. FIG. 3. In the formed end 2 of the tendon of the rectus muscle, the central lobe 5 of the mesh implant of titanium nickelide is inserted into the cleavage and stitched through the entire thickness with a twisted seam 6 using a thread of titanium nickelide. In the center of the upper pole of the patella 7, an osseous saw forms a bone bed in the form of a groove 8 according to the size of the distal end 9 of the mesh implant of FIG. 3. The distal end 9 of the mesh implant is immersed in the groove 8 and fixed with tension by cranially separate loop-like sutures 10 with a thread of titanium nickelide. Thus, a strong fixation of the rectus muscle to the patella is created. The lateral 3 and medial 4 wide muscles are pulled with seams - with the restraints to the sides and upwards, they are maximally mobilized, stretched, pulled down and the lateral 11 and medial 12 petals of the mesh implant are inserted into the splits, respectively, Fig.3. Sew 13 with twisted sutures and sutured with sutures 14 to tendon formations at the patella 7. The wound is sutured in layers. The location of the implant after installation is shown in FIG. 1 Insert two drains. An aseptic dressing is applied, gypsum immobilization is carried out. Figure 2 shows a skiagram of the knee joint, which shows the position of the mesh three-sheeted implant on the side.

A mesh implant of titanium nickelide is used, consisting of three petals 5, 11, 12 of a quadrangular shape. FIG. 4. The side lobes 11, 12 extend from the central lobe at an angle of 40-50 degrees and are located at a distance of 1.0 cm from its distal end 9.

Patient B., 54 years old, was admitted to the clinic of traumatology and orthopedics of MLPU GKB No. 1, case history No. 4223/314, 04/10/07 with a chronic rupture of the quadriceps muscle of the left thigh. Injured one year ago, got hit by a rope on the front of the thigh. It was unsuccessfully treated conservatively.

Operation 10.04.07 under anesthesia, direct access with a median longitudinal section along the front surface of the thigh to the patella, the place of rupture of the tendon of the rectus femoris muscle is exposed. Mobilization of the tendon of the quadriceps femoris with a defect of 3.5 cm from the scars. We perform splits by dissecting the straight head to a depth of 5 cm, the lateral and medial heads to a depth of 3 cm. In the upper pole of the patella, an oscillating saw forms a bone bed in the form of a groove up to 1 cm deep in size of the distal end of the mesh implant, into which it is immersed and cranially fixed in the bone bed with a suture made of titanium nickelide thread. The lateral and medial lobes of the implant are immersed in tendon formations of the lateral and medial broad muscles of the thigh. We fix them with a twisted seam thread from titanium nickelide. We hem the distal part of the implant to the tendon formation of the patella with a thread of titanium nickelide. The mesh implant is made of nickel-titanium wire with a diameter of 0.06 mm, the mesh size of the textile weave is 0.25 mm. The length of the petals depends on the characteristics of the anatomical zone, for this patient the length of the central petal is 5.5 cm, the side petals are 3 cm. The side petals extend from the central petal at an angle of 45 degrees. The side lobes are located 1 cm from the distal end of the central lobe. Layered closure of the surgical wound, drainage, limb is fixed with a plaster cast. 10 days after the operation, movements in the joint on the functional splint began. The postoperative period without complications, was discharged for outpatient treatment. On radiographs of the knee joint, a mesh implant in the hip extensor is determined.

In a patient with chronic damage to the tendon of the rectus femoris muscle and a significant defect in the extensor apparatus of the knee joint, the success of surgical treatment was due to the use of a three-petal mesh implant made of titanium nickelide, which restored the extensor function of the knee joint and limb supportability. 4 weeks after the removal of gypsum immobilization and a two-week course of physiotherapy exercises, the full range of movements of the knee joint was restored. There were no complications in the postoperative period. The duration of treatment was reduced by 2 weeks.

The shape of the mesh implant allows you to strengthen the tendon of the quadriceps femoris in three directions. Titanium nickelide, of which the three-leaf mesh implant is made, and the suture material made of titanium nickelide stimulate and accelerate regeneration, which leads to a reduction in treatment time and a reduction in the number of complications of the postoperative period.

Claims (1)

Method for plastic surgery of the quadriceps femoris tendon, including a longitudinal incision to expose the quadriceps femoris, splitting by cutting the tendon and partially rectus femoris, suturing one end of the implant into the formed cleft, fixing the second end of the implant with tension, characterized in that as the implant uses a mesh implant of titanium nickelide, consisting of three quadrangular petals, the side petals extend from the central petal at an angle of 40-50 ° at a distance of 1.0 cm from its distal end, the incision is made longitudinal median, mobilization of the heads of the lateral broad, medial wide and rectus femoris muscles is carried out, additional splits are formed in the lateral and medial broad muscles, the central lobe of the implant is inserted into the cleft of the head of the rectus muscle, and it is fixed a filament of titanium nickelide, in the upper pole of the patella, a bone bed is formed in the form of a groove, the distal end of the central lobe of the implant is placed in the groove, and it is fixed to the patella with transosseous loop-like joints with a titanium nickelide thread, lateral petals of the implant are inserted into the splits of the lateral and medial broad muscles, fix them with twisted seams with a titanium nickelide thread and hem them to the tendon formations on the patella with a titanium nickelide thread.

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