RU2452417C1 - Method of surgical treatment of clavicle acromial end dislocations - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, in particular to traumatology and orthopedics. Two cuts of skin are made. Length of each cut does not exceed 3-4 cm. One cut is made in projection of coracoid process of scapula on deltoid-pectoral sulcus. After that intermuscularly coracoid process of scapula is exposed with access for manipulations, by means of which transplant of coraco-clavicular ligament is brought. Second cut is made on upper surface of acrimioclavicular joint and distal third of clavicle. Upper surface of clavicle is exposed layer-by-layer. After that, in clavicle by means of drill formed are canals for passing ligament transplant. After passing under coracoid process transplant is brought through soft tissues to canals in clavicle, brought out through canals, fixed in position of clavicle reposition with two titanium interferential screws. In case of necessity after performing revision of acromioclavicular joint, injured meniscus is excised.

EFFECT: method ensures reduction of trauma of soft tissues, reduction of risk of interferential complications and trophic disorders in zone of surgical aggression, reduction of rehabilitation terms.

4 cl, 1 ex, 10 dwg

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and is intended to restore acromioclavicular articulation surgically and restore biomechanics of the upper limb.

There is a method of prosthetics of the capsule-ligamentous apparatus for dislocation of the acromial end of the clavicle of the III degree in adolescent patients, in which two linear incisions are made: 3-6 cm long in the area of the acromial-clavicular joint, 1-2 cm long in the projection of the coracoid process of the scapula. Bone channels form parallel to the plane of the bone in the acromion from the outside to the inside. The prosthesis is formed by several nodes, which are tied under the clavicle, in the area of attachment of the capsule of the articulation of the clavicle, above the acromioclavicular articulation (Patent No. 2381012 RU. Publish 02.10.10).

A known method of replacing the clavicle-acromial ligament with dislocation of the acromial end of the clavicle, in which one channel is formed in the bones of the acromial process of the clavicle, through which a loop from the suture is drawn, the latter is thrown onto the acromial process, tying the free ends of the thread with a knot, fixing the loop thread inside the knot. After that, two channels in the acromion are made in the direction from top to bottom to the articular surface of the acromial process so that one of the ends of each of the channels faces the articular site. Then one of the threads is passed through one of the channels, and the other through the other channel from the bottom up and the dislocation is reduced by pulling the threads of the acromial end of the clavicle, matching the acromial articular surface, after which the threads are tied into a knot (Patent No. 2,339329 RU. Publ. 27.11. 2008).

A known method of prosthetics of the capsule-ligamentous apparatus during dislocation of the acromial end of the clavicle of the I-II degree, in which access to the acromial-clavicular joint is performed, channels are made in the clavicle and acromion, lavsan ribbons are passed through them, the ends of the tapes are connected and subsequently sutured to the operating room the wound. In this case, a linear skin incision is made along the upper surface of the acromion, joint and clavicle, and the fascial-cellular layers are shifted to the sides. The acromion and clavicle are drilled at the borders of the joint capsule in oblique directions with respect to the longitudinal axis of the clavicle, the lavsan tape or flat prosthesis is first placed around the clavicle, forming a knot, then it is inserted intraosseously and removed from the clavicle without reaching the joint capsule. After that, they are placed on the capsule and carried out intraosseously in the acromion, removed at the base, the ends are pulled and tied together. At the same time, an acromioclavicular connection is wrapped in a lavsan mesh, the edges of the mesh are sewn with lavsan threads to the tape prosthesis and soft tissues, from the free ends of the tape prosthesis form a second eternally located branch covering the mesh prosthesis from above. Then form a node on the outer surface of the acromion (patent No. 2312613 RU. Publ. 20.12.2007).

To perform open replacement of the ligamentous apparatus of the acromioclavicular joint, several surgical approaches are traditionally used. The most famous and most often used in practice is the so-called "epaulette" access. The skin incision line begins in the projection of the posterior surface of the acromial process, externally arches around the acromioclavicular joint and continues anteriorly from the clavicle along its lower edge to the border of the distal and middle third. Then, a massive skin-subcutaneous flap is formed, thrown back and inside, the distal third of the clavicle is secreted, separating part of the fibers of the deltoid muscle, the acromioclavicular joint, intermuscularly accessing the coracoid process of the scapula. This technique allows for optimal visualization of all necessary anatomical structures for the convenience and simplicity of the main stage of the operation (Boychev B. Operative orthopedics and traumatology. / B. Boychev, B. Konforti, K. Chokanov. - Sofia: Publishing House "Medicine and Physical Education", 1961 .-- 832 p.).

However, the described access has a fairly high degree of soft tissue trauma, the need for the formation of an extensive detachment of the skin-subcutaneous flap, which is associated with a high risk of complications, as well as trophic changes in the skin flap. Disinsection of the deltoid muscle is also a negative point due to the risk of damage to the axillary nerve when mobilizing more than 1 cm of muscle from the acromial process of the scapula. In addition, the deltoid muscle with the deltoid-thoracic fascia are the most important dynamic stabilizers of the acromioclavicular joint and their intraoperative damage requires an extension of the rehabilitation period.

Access to the acromioclavicular joint is also known, in which the skin incision line starts from the acromial process of the scapula, continues above the clavicle to the border of the distal and middle third, from where it passes to the deltoid-pectoral groove and continues to the level of the coracoid process (Revenko T.A. Atlas of operations for injuries of the musculoskeletal system./ Revenko T.A., Guryev V.N., Shesternya N.A. - M .: Medicine, 1987. - 272 p.).

A known method for the surgical treatment of chronic ruptures of the clavicular-acromial joint, in which, after cutting, clavicular clavicle, the lavsan ribbon is fixed to the coracoid process of the scapula, the acromion and the corresponding section of the clavicle are enveloped with the formation of a cross between the segments of the lavsan ribbon, next to which two narrow vertical channels are formed in the clavicle , they carry out ligatures, with their help, in the place of intersection, the lavsan tape is fixed by periosteal sutures, which allows to achieve the full range of movements in the ple the jaw joint, the disappearance of pain and prevent osteoarthritis (patent No. 2138217 RU. Publ. 09/27/1999).

However, the known method is quite traumatic and does not reduce the risk of infectious complications and trophic disorders, reduce the rehabilitation time of the upper limb.

The objective of the present invention is to reduce tissue trauma, significantly reduce the risk of infectious complications and trophic disorders in the area of surgical aggression, preservation of the deltoid muscle as the most important dynamic stabilizer of the joint.

This object is achieved by the fact that in the method of surgical treatment of dislocations of the acromial end of the clavicle, including making cuts of the skin and canals in the clavicle, two skin incisions are made, the length of each of which does not exceed 3-4 cm, while one of the cuts is made in the projection of the coracoid process scapula along the deltoid-thoracic groove, then the coracoid process of the scapula is secured intramuscularly with access for manipulations, by means of which the transplant of the clavicular-clavicular ligament is brought, in addition, the second incision is made t along the upper surface of the acromioclavicular joint and the distal third of the clavicle, then the upper surface of the clavicle is separated in layers and then the channels are formed in the clavicle with a drill to conduct a ligament graft, which, after being held under the coracoid process, is brought through the soft tissues to the channels in the clavicle, removed through them and fixed in the position of repositioning of the clavicle with two titanium interference screws.

It is advisable to revise the acromioclavicular joint in case of impossibility of closed removal of the dislocation in the acromioclavicular joint. This indicates damage to the cartilaginous meniscus, which, when revising the joint, is excised in this case.

A carbon tape is used as a transplant of the clavicular-clavicular ligament. Its use is due to the bioinertness of the material, its biological compatibility and subsequent biodegradation with the formation of a cicatricial regenerate, full in mechanical and biological indicators.

The present invention is illustrated by a detailed description, a clinical example and illustrative material, on which:

Figure 1 shows a first skin incision in the projection of the coracoid process;

Figure 2 illustrates the intramuscular secretion of the apex of the coracoid process;

Figure 3 shows the transplant of the clavicular-clavicular ligament;

Figure 4 illustrates a second skin incision in the region of the acromial end of the clavicle;

5-7 characterize the formation of channels and the passage through them of a graft;

Fig. 8 illustrates graft fixation in the clavicle canals;

Figure 9 shows the shoulder girdle after surgery;

Figure 10 - x-ray acromioclavicular joint after surgery.

The method is as follows.

A single skin incision is made 3-4 cm long in the projection of the coracoid process of the scapula, oriented along the deltoid-thoracic groove. The apex of the coracoid process is secured intramuscularly, a channel is formed underneath in the soft tissues into which the graft-clavicular ligament is transplanted. It is possible to use IMUSS carbon tape produced by SPC UVIKOM LLC as a transplant (reg. Ud. Ministry of Health of the Russian Federation No. 29/12010299 / 0629-00).

Next, a second skin incision is made in the area of the acromial end of the clavicle 4 cm long. The acromioclavicular joint and distal 3-4 cm of the upper surface of the clavicle are secreted in layers. At the points projection-corresponding to the attachment points of the beaks of the clavicular-clavicular ligament, drill channels are formed for the transplant of the clavicular-clavicular ligament, the latter is passed through the channels and fixed with two titanium interference screws in the position of the clavicle. After surgery, the correct biomechanical position of the shoulder girdle was achieved.

If the meniscus is damaged, after performing an audit of the acromioclavicular joint, it is excised.

The method of open replacement of the coraco-clavicular ligament using surgical access to it can be carried out using standard surgical instruments authorized for use.

Using this method, 20 patients with ruptures of the ligamentous apparatus of the acromioclavicular joint were treated. All patients underwent replacement of the coraco-clavicular ligament with a synthetic implant. The duration of surgery was from 40 to 60 minutes. In the postoperative period, complications in the form of infection, skin necrosis and trophic changes in the edges of the wounds were noted.

An example of the method.

Clinical example. Patient N. 29 years old. Diagnosis: ligament rupture of the left acromioclavicular joint Rockwood 3, dislocation of the acromial end of the left clavicle. He entered the trauma department on 01.25.2010. After preparation on January 27, 2010, the patient underwent surgery - open reduction of the dislocation of the clavicle, replacement of the clavicular-clavicular ligament. In the operating room, after processing the surgical field, in the patient’s position, the “beach chair” made one skin incision 3 cm long in the projection of the coracoid process of the scapula, which was oriented along the deltoid-thoracic groove (Figure 1). Intermuscularly, the apex of the coracoid process was isolated (Figure 2). Under it in the soft tissues formed a channel into which a graft-clavicular ligament transplant was introduced (Figure 3). As a transplant, carbon tape “IMUSS” manufactured by LLC SPC UVIKOM was used (reg. Unit of the Ministry of Health of the Russian Federation No. 29/12010299 / 0629-00).

A second skin incision was made in the region of the acromial end of the clavicle 4 cm long (Figure 4). The acromioclavicular joint and distal 4 cm of the upper surface of the clavicle were isolated in layers. At the set points, a drill with a diameter of 4.5 mm formed two vertical channels in the collarbone for conducting a ligament transplant (Figs. 5-7). A ligament graft was passed through the channels in the soft tissues and fixed with interference screws in the position of repositioning of the clavicle (Figs. 8-10). The wounds were sutured in layers leaving drainage for active aspiration. The duration of surgery was 40 minutes, blood loss was estimated at 50 ml. Drainage for active aspiration was removed after 24 hours. The wounds healed without signs of inflammation, the sutures were removed on the 10th day after the operation.

The proposed method for the open replacement of the coraco-clavicular ligament allows a complete open reconstruction of the coraco-clavicular ligament without additional difficulties and time costs.

In addition, the proposed method is gentle with respect to soft tissues, its application allows you to save the area of attachment of the deltoid muscle to the clavicle, while maintaining the function of the muscle as a dynamic joint stabilizer.

Achievement of such a result was made possible due to the technical ability established by the authors to perform open reconstruction of the clavicular-clavicular ligament using this access without using special tools and using surgical technique that is gentle on soft tissues.

The application of the claimed method improves the clinical effectiveness of treatment of injuries of the acromioclavicular joint and shortens the rehabilitation of the upper limb, improving the quality of life of the patient.

The proposed method is used in GMLPUZ "Chelyabinsk Regional Clinical Hospital" and at the Department of Traumatology, Orthopedics and Field Surgery GOU VPO, located in Chelyabinsk.

Claims (4)

1. A method for the surgical treatment of dislocations of the acromial end of the clavicle, including making cuts of the skin and canals in the clavicle, characterized in that two cuts of the skin are made, the length of each of which does not exceed 3-4 cm, while one of the cuts is made in the projection of the coracoid process of the scapula along the deltoid-thoracic groove, then the coracoid process of the scapula is secured intramuscularly with access for manipulations, by means of which the transplant of the clavicular-clavicular ligament is brought, in addition, a second incision is made along the upper surface the spines of the acromioclavicular joint and the distal third of the clavicle, then the upper surface of the clavicle is separated in layers and then the channels are formed in the clavicle with a drill to conduct a ligament graft, which, after being held under the coracoid process, is brought through the soft tissues to the channels in the clavicle, removed through them and fixed in position repositioning of the clavicle with two titanium interference screws. 2. The method according to claim 1, characterized in that according to the testimony perform an audit of the acromioclavicular joint. 3. The method according to claim 1, characterized in that a carbon tape is used as a ligament transplant. 4. The method according to claim 1, characterized in that the damaged cartilage meniscus is excised.

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