RU2489111C1 - Method of arthroscopic tenomyoplasty of front part of shoulder joint capsule for treatment of its recurring instability - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopedics and can be applied for treatment of patients with recurring instability of shoulder joint in presence of risk factors of development of shoulder joint instability recurrences. Intra-joint tenotomy of long head of biceps muscle of arm is performed. Tendon of long head of biceps muscle of arm is passed under greater pectoral muscle, and then in front and above tendon of subscapular muscle, with its downward displacement. Tendon of long head of biceps muscle of arm is fixed by means of interferential screw in preliminarily formed canal on front surface of joint process of scapula.

EFFECT: method ensures elimination of shoulder joint instability, reduction of operation trauma and risk of development of postoperative complications.

1 ex, 7 dwg

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used to treat patients with recurring instability of the shoulder joint.

The progress of arthroscopic technologies in recent years has made it possible to widely introduce into the everyday practice of orthopedists the technique of suture fixation of a damaged capsule in the treatment of recurrent instability of the shoulder joint [2, 3, 4, 5, 6, 7, 9]. The low-invasiveness of the method, the possibility of performing the operation under local (conduction) anesthesia, and a short period of hospitalization are attractive circumstances for both the surgeon and the patient [11, 15]. However, an analysis of the long-term results of performing such operations reveals risk factors for postoperative relapses of instability, such as massive damage to the bone structures of the joint (impression bone-cartilage defect of the shoulder head more than 1.5 cm and bone deficiency of the anterior edge of the articular process of the scapula more than 25% of its total area ), degenerative changes ("poor quality"), hyperelasticity, sprains of the capsule, high initial level of physical activity of the patient (engaging in "contact" types sports), which in 5-20% of patients lead to repeated dislocation after surgery [8, 17, 18, 19].

The closest analogue of the proposed method is the technique of arthroscopic stabilization of the shoulder joint using a fragment of the coracoid process and the short head of the biceps of the shoulder, proposed by R. Boileau [1]. However, this method has a significant drawback - greater trauma due to the formation of a bone wound and the possibility of damage to the brachial plexus elements during osteotomy of the coracoid process or mobilization of a fragment of the short head of the biceps of the shoulder. Our method is not related to the need for osteotomy and, with an adequate stabilizing effect, simultaneously allows us to solve the problem of injuries and degenerative changes in the cartilaginous lip of the articular cavity of the scapula at the site of attachment of the tendon of the long head of the biceps of the shoulder muscle that accompanies almost all cases of recurring instability of the shoulder [10, 17, 18].

The technical result of the proposed invention is

- improving the outcome of surgical treatment of patients with recurring instability of the shoulder joint in the presence of risk factors for its recurrence in the postoperative period;

- elimination of instability of the shoulder joint by forming an additional muscular-tendon barrier;

- reducing the invasiveness of the operation.

The result of the invention is achieved due to the fact that the tenotomy of the long head of the biceps of the shoulder is performed intraarticularly, carried out under the pectoralis major muscle, and then along the front surface and above the tendon of the subscapularis muscle, moving it downward, followed by fixation of the longus of the biceps of the shoulder muscle with an interference screw in a preformed channel on the front surface of the articular process of the scapula.

The experience of arthroscopic diagnosis of morphological changes within the joint with recurrent instability showed that the most frequent combination of soft tissue lesions (55%) was an injury to the anterior capsule of the joint (ALPSA variant) and various injuries of the cartilaginous lip of the articular cavity of the scapula at the site of attachment of the tendon of the long head of the biceps of the shoulder ( variants of SLAP II-IV) [10, 19]. This circumstance made it possible to discuss for such patients a tenotomy of the intraarticular part of the tendon of the long head of the biceps of the shoulder with subsequent tenodesis in the interval of the supraspinatus and subscapularis to the subarticular tubercle of the scapula arthroscopically, in addition to the suture of the damaged ligament of the capsule using anchor fixators, in the presence of one or more of the listed risk factors for relapses [11, 12]. The main idea of this stage of the operation was the possibility of creating conditions for the subscapular muscle to move down without its surgical trauma and the formation of an additional muscle-tendon barrier, including the tendon of the biceps of the shoulder and the subscapularis, in the way of dislocation of the head of the shoulder in the "high risk of recurrence" positions with abduction and external rotation of the upper limb (Fig.6).

The lack of information in the patent and scientific literature on the technique of lowering the subscapular muscle without surgical trauma and strengthening the head of the shoulder with an additional muscular tendon barrier (tendon of the long head of the biceps of the shoulder and the subscapularis muscle) by performing tenotomy of the intraarticular part of the long head of the biceps of the shoulder with its subsequent tenodesis in the interval of the supraspinatus and subscapularis muscle to the subarticular tubercle of the scapula arthroscopically, in addition to the suture of the damaged the language of the capsule using anchor clips indicates that the claimed technical solution meets the criterion of "novelty." This solution does not follow explicitly from the prior art and the effect achieved by the claimed solution is revealed as a result of a targeted search by the inventors themselves, which indicates that the technical solution meets the criterion of "inventive step". Compliance with the criterion of "industrial applicability" is determined by the possibility of using the proposed method in healthcare, namely, the effectiveness of arthroscopic tenomyoplasty of the anterior section of the capsule of the shoulder joint for the treatment of its recurrent instability, as shown in the description. This makes it possible to move on to the widespread introduction of the claimed invention in clinical practice, for which the applicant seeks patent protection of a new development.

Indications for performing the proposed operation are all types of instability of the shoulder joint, aggravated by the presence of risk factors for recurrence of instability. The figures depict:

Figure 1 - the position of the patient on his side; stitching the marked end of the tendon of the long head of the biceps of the shoulder in the subpectoral section.

Figure 2 is a schematic representation of the marked end of the tendon of the long head of the biceps of the shoulder in the subpectoral section.

Figure 3 - formed bone channel in the neck of the scapula.

Figure 4 - in the formed channel in the neck of the scapula immersed stitched end of the tendon of the long head of the biceps of the shoulder.

Figure 5 - arrangement of the tendon of the long head of the biceps of the shoulder in the formed channel of the neck of the scapula.

6 is a diagram explaining the mechanism of formation of an additional muscle-tendon obstruction (tendon of the long head of the biceps of the shoulder and subscapularis muscle) in the path of dislocation of the head of the shoulder.

7 is a cosmetic result of the operation.

The method is as follows.

Arthroscopy of the shoulder joint is carried out in the patient’s position on the side (Figure 1) with the extremity stretching along the axis from standard accesses (posterior - diagnostic, and two front cannulated instruments for the interval between supraspinatus and subscapularis). After the diagnostic phase of the operation and confirmation of damage to the ligaments of the anterior capsule of the joint and the SLAP zone, the damaged and lower joint arterio-brachial ligaments of the capsule are mobilized and refixed to two anchors with a double thread using an arthroscopic technique. Then, with the free ligature of a contrasting color, the intraarticular part of the long head of the biceps of the shoulder muscle is flashed through the anterior-upper port at a distance of 1-2 cm from the point of attachment to the articular articular tubercle of the articular process of the scapula and using its ablator perform its tenotomy above the superimposed ligatures. An unstable fragment of the articular lip is removed using a synovial resection of the shaver system.

Further, by direct access 5 cm long, made in the projection of the lower edge of the pectoralis major muscle, the tendon of the long head of the biceps of the shoulder muscle is secreted in layers and its marked end is brought out into the wound. (Figure 1, Figure 2). Using the transplant meter, the thickness of the tendon part of the long head of the biceps of the shoulder muscle is determined and its proximal section is sutured for 3 cm with a twisted seam.

Using the ablator, the synovial membrane and part of the joint capsule are removed in the interval between the supraspinatus and the subscapularis muscle, and the optic neck is used to release the neck of the scapula from the synovial membrane to the periosteum along the upper edge of the subscapularis muscle to form a channel in the neck of the scapula. Next, a stitched free end of the tendon of the biceps of the shoulder under the pectoralis major muscle is carried out in the anterior-lower port, placing it on the front surface of the subscapularis muscle, having previously removed the cannula from it.

Then the optics are placed in the anteroposterior portal and, using the femoral guide for reconstruction of the cruciate ligaments with a 7 mm offset, guide the knitting needle through the neck of the scapula along the upper edge of the subscapularis muscle from front to back, taking into account the topography of the suprascapular nerve and form a channel using a cannulated drill, corresponding in diameter to the thickness of the tendon of the long head of the biceps of the shoulder (Figure 3). Using a spoke-conductor in the channel, the stitched end of the tendon of the long head of the biceps of the shoulder is immersed and fixed with an interference screw (Fig. 4, Fig. 5, Fig. 6). Control the range of motion, stability of the joint, wash the joint and complete the operation (Fig.7).

Clinical example.

The operations of the proposed method were performed in three patients aged 34 to 56 years with a positive result. As an example, we present the clinical observation of patient M., 35 years old. Diagnosis: Chronic recurrent instability of the right shoulder joint. The injury was received on April 20, 2009 during sports (wrestling) - front-lower dislocation of the right shoulder. The dislocation was settled in the emergency room at the place of residence. Subsequently, dislocations occur up to 3-5 times a year with a slight load, shoulder abduction, in a dream. The last dislocation on 01.01.2011 occurred when putting on a jacket. 02/04/2011, the operation was performed according to the proposed method - arthroscopic "tonic" tenomyoplasty of the anterior capsule of the right shoulder joint. The postoperative period was uneventful, the immobilization of the shoulder joint was 4 weeks. The range of motion in the shoulder joint is restored. Relapses of shoulder dislocations in the long-term follow-up were not noted.

Claims (1)

A method for arthroscopic tenomyoplasty of the anterior portion of the capsule of the shoulder joint for the treatment of its recurrent instability, including moving the tendon of the biceps of the shoulder and its fixation to the articular process of the scapula, characterized in that tenotomy of the long head of the biceps of the shoulder is performed intraarticularly, carried out under the pectoralis major muscle, and then in front of and above the tendon of the subscapularis muscle, moving it downward, with subsequent fixation by the interference screw of the tendon of the long head of the biceps of the shoulder muscle in dvaritelno channel formed on the front surface of the articular process of the blade.

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