RU2429793C1 - Method of surgical management of massive old ruptures of rotatory cuff tendons - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: it involves an extended transacromial approach to a defect zone of a rotator cuff. Replacing tendons are separated from those preserved; ends of the separated tendons are transferred to the defect zone and packed with a holding platform made of a biocompatible material. This created package involves a portion of tendons of a teres minor muscle and a subscapular muscle by transversal and longitudinal excision. The holding platform is a trapezoid flap of a titanium nickelide wire. The transferred ends of the tendons are lined and fixed to the wire by a blanket suture along the perimetre of each contact spot. An end of the created package is buried in a slot-like bed formed in a head of humerus towards a surface normal. It is fixed by a retention suture through a bone and by a fastening bracket to a bone. An osteotomised acromial process is restored by reposition of a single fragment to be fixed by titanium nickelide fastening elements to accelerate osteointegration. ^ EFFECT: higher reliability of tendon fixation, reduced injury rate, reduced time of reconvalescence. ^ 1 ex, 2 cl, 4 dwg

Description

The invention relates to medical orthopedic technology.

The shoulder joint provides maximum mobility and a variety of functional capabilities of the upper limb. Any damage to the supporting, stabilizing or motor elements of the joint leads to noticeable damage to human performance, and in extreme cases to disability. The task of restoring the tendon fragment of the articular apparatus is exacerbated by the impressive, from an engineering point of view, mechanical strength of the tendons - poorly extensible, relatively thin in cross section of fibrous formations. Rotary shoulder tendons are able to withstand tensile strength up to 300 kg, which surpasses the most advanced artificial materials in specific strength. With such initial data, the restoration of tendons torn or torn from their attachment to the bones, in their former strength, is a difficult surgical task. Difficulty increases to the practical impossibility of recovery for “old” breaks, when the delay in treatment exceeds 2 months. During this period, the torn tendon degrades, irreversibly shrinks in length and becomes inoperable. In such cases, the resulting damage to the upper sector of the rotator cuff is compensated by less functionally strained tendons of the lower complex. Surgery of such complicated pathologies is functionally isolated: rupture of more than two tendons at the same time is conditionally referred to as “massive”. The main difficulty of such operations is the attachment of the transposed tendon to the bone in a new location (insertion) with sufficient strength. The maximum secrecy of the connecting seams is also prescribed to prevent irritation of surrounding tissues, ensuring normal blood supply and tissue repair. Various treatment methods have been developed, according to the set of surgical actions, adapted to the severity of the damage, the timing of the delay in treatment, and the age of the victims.

A known method of surgical treatment of massive chronic tendon rupture of the rotator cuff [Cofield R.H. Subscapsular musche transposition for repair of chronic rotator cuff tears. Surg. Gynecol. Obstef. 1982. 154 (5). P.667-672]. It includes the mobilization, separation, stitching and transposition of the tendon of the subscapularis muscle upward, laterally, by stitching it with transosseous sutures to the large tubercle of the humeral head. The local torn tendon is sutured to the transposed one to increase the strength of the complex formed.

The disadvantages of the method, in addition to the inevitable trauma of the donor site of the cuff, the following:

1. The impossibility of joint suturing of two or more torn tendons.

2. Low adaptive ability of stitched tendons and viability of the entire operation.

A modification of the previous analogue is known [Puavolainen P. Teres minor transfer. Jn: Burkhead Wzjn., Ed Rotator cuff Disorders, Baltimore, M. D.: Williams and Wilkins, 1966; p.342-348], which consists in separating and transposing the tendon-bone block of the small round muscle, moving the support points outward and fixing the bone fragment of the block with a screw. Bone-to-bone integration is believed to be more successful, stronger, and more durable than tendon-to-bone integration. The obvious disadvantages of this method are associated with additional trauma to the bone tissue (on the donor site and the screw fixation site), a long - up to 1.5 years - rehabilitation period and the need for reoperation to remove the screw, the possibility of resorption of the bone block and subsequent violation of joint stability.

Known adopted for the prototype method of surgical treatment of massive chronic rupture of the tendons of the rotator cuff [Mura N., O'Driscoll and all Biomechanical effect of a patch graft for large rotator cuff tears: a cadaver stady. Clin Orthop Relat Res, 2003: 415: 131-138], modified relative to the above analogues in terms of fixing the formed package to the head of the humerus.

The ends of the preserved tendons transplanted to the place of the defect are attached to the head of the humerus using a biological or synthetic implant made in the form of a trapezoidal perforated plate (platform). To the wide base of the trapezium, the repaired ends of the tendons are attached. The narrow end of the implant is sutured to the head of the humerus at the base of the large tubercle. Indirect, through the plate, the attachment of the tendon is considered more reliable than direct. Low biocompatibility of biological and polymeric materials leads to a decrease in the quality of insertion and the viability of the entire recovery operation.

The technical result of the invention is to improve the quality of insertion, the viability of the operation.

The specified technical result is achieved by the fact that in the method of surgical treatment of massive chronic rupture of tendons of the rotator cuff of the shoulder, including access to the defect zone of the rotator cuff, separating replacement tendons from the preserved ones, transposition of the ends of the separated tendons into the defect zone and grouping them into a package together with the fastener a platform made of biocompatible material, the placement and fixation of the formed package to the head of the humerus, carry out an extended trans acromial access, formed package portion tendons involve small round and chuck muscles by their transverse and longitudinal cut, as the mounting platform is used trapezoidal flap titanium-nickel alloy mesh. To fix the formed package in the head of the humerus, a slit-like bed is made, oriented in the direction normal to the surface, into which the end of the formed package is immersed and fixed with suture material and braces. The osteotomized acromial process is restored by reposition of the separated fragment and fixing it with fasteners made of titanium nickelide to ensure accelerated osseointegration.

It is preferable to use titanium nickelide as a suture and fastening material of bone staples.

The dominant feature that ensures the attainability of the technical result is the packaging of the movable tendons together with a mesh platform of nickel-titanium wire. The mesh plays the role of a strength basis and improves the quality of insertion due to the properties of the material, mesh structure and rational arrangement (in a row) of the ends of the tendons. The distribution of the suture fixation points of the tendon ends along the perimeter of the contact spots reduces the mechanical stress on the fabric, which is prone due to its breakaway to suture thread penetration. In the bone bed there is a differentiated integration of the tendon tissue with the mesh and the mesh with bone tissue. Thus, due to the universal and high biocompatibility of titanium nickelide, the network plays the role of an intermediate link and the matrix of tendon integration with bone. High mechanical strength of titanium nickelide determines the necessary component of insertion - the strength and reliability of fixation. The use of titanium nickelide as a material of the suture thread and osseous fastening staples is subject to similar conditioning.

The relative simplicity of surgical manipulations during insertion by the proposed method allows transacromial access, i.e. to maintain the integrity of the acromioclavicular ligament and deltoid muscle, suffering with regular access, and thereby prevent postoperative conflict of the sliding apparatus of the subacromial joint. The fastest repair of the resected acromial process is facilitated by its fixation with titanium nickelide fasteners. The choice of transposable tendons is due to the desire to balance the efforts of the rotator apparatus and the mobility of the shoulder joint.

Improving the quality of insertion leads to an earlier restoration of the function of the shoulder joint and rehabilitation of the patient.

The used complex of the proposed method is original in world practice according to the achieved technical result and its connection with the properties of individual features, which should indicate that the proposal meets the criterion of "inventive step".

The illustrations show:

Figure 1 - Scheme of displacement replacement tendons:

1 - the head of the humerus, 2 - the bone bed, 3 - the movable ends of the tendons

Figure 2 - Bone bed and oriented formed a package of tendons on the platform: 4 - formed package, 5 - threads for transosseous stitching.

Figure 3 - Scheme of fixation of the formed package: 6 - mesh platform, 7 - mounting bracket.

Figure 4 - External view of the patient after convalescence.

The attainability of the technical result is confirmed by specific examples of the clinical application of the method in the clinic of traumatology and orthopedics GIDUV.

Example

Patient K., 55 years old, was admitted to the clinic of traumatology and orthopedics of the Novokuznetsk GIDUV on 02/05/2008 (case history No. 1357/89) with a diagnosis of chronic (more than 3 months) massive rupture of the tendons of the shoulder rotators, gas in the fake space, incongruency joint space, usuration at the base of a large tubercle.

The patient underwent an operation of the proposed method, carried out as follows.

Under conduction anesthesia, transacromial enhanced access exposes the subacromial joint. There was a narrowing of the subacromial space, ligament compaction, exposure of the surface of a large tubercle, a bone niche with dimensions of 1.5 × 1 cm - traces of transosseous rupture near the anatomical neck. The ends of torn tendons are submerged beyond visual accessibility.

For plastics of the indicated defect, the ends of the tendons 3 of the small round and half of the subscapularis are mobilized, cut off, transposed upward (Fig. 1), laid in a row on the mounting platform 6 (Fig. 3), hemmed along the perimeter of the contact spots to the platform mesh and, for strength and seals, stitched through the thickness of the formed packet 4 (figure 2) with a nickel-titanium thread.

In the head of the humerus 1 at the base of a large tubercle, a slit-like bone bed 2 (FIGS. 2, 3) is made through the volume of the bone niche, corresponding in size (25 × 5 × 10 mm) to the distal end of the formed packet. The end of the package is freely immersed in it, fixed with transosseous sutures and a fastening osseous bracket 7 (Fig. 3). A fragment of the osteotomized acromion is repaired and fixed with fixing pins and brackets made of titanium nickelide. The wound is drained, sutured in layers. The limb is fixed by a discharge wedge-shaped pillow.

After 6 months of a smooth postoperative period, the pins and staples were removed from the acromion. Radiologically established the consistency of the radial joint; after 1 year - restoration of functions in the range of movements (figure 4). The results obtained and expert assessment indicate an increase in the quality of insertion, strength reliability and safety of range of motion in the joint. A concomitant positive factor is also a reduction in the risk and complexity of the operation, preservation of the hospitalization terms for the patient's convalescence.

According to the degree of readiness of the technical composition and sophistication of the operation methodology, the proposed method meets the patentability criterion of "industrial applicability".

Claims (2)

1. A method of surgical treatment of massive chronic tendon rupture of the rotator cuff, including access to the defect zone of the rotator cuff, separating replacement tendons from the preserved ones, transposing the ends of the separated tendons into the defect zone and forming them into a bag together with a mounting platform made of biocompatible material, placement and fixation of the formed package on the head of the humerus, characterized in that they provide extended transacromial access to the area of a defect, a part of the tendons of the small round and subscapular muscles is involved in the formed package by their transverse and longitudinal cutoffs, a trapezoidal flap of a nickel-titanium mesh is used as a fixing platform, the transposed ends of the tendons are placed in a row and fixed to the mesh with twisted seams around the perimeter of each contact spot, the end of the formed packet is immersed in a slit-like bed made in the head of the humerus in the direction normal to the surface, fixed with a suture thread and osseous fasteners oh bracket osteotomised acromion process is reduced by repositioning a separate piece and fixing the fixing of TiNi elements to provide an accelerated osseointegration. 2. The method according to claim 1, characterized in that titanium nickelide is used as the fixing suture material and fixing brackets.

Images