RU2543630C1 - Device for transosteal suture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: device represents a ligature guide differing by the fact that it consists of a cerclage wire 1mm in diameter, 18-35 mm long; the wire has a 0.5-0.8 mm flattening 2-5 mm long in the middle; the wire is also curved so that it forms legs or a double working portion and a top representing an open loop with the greatest cross dimension of less than 3mm; the working portion of the device is uniformly curved over a length of 1/3-1/2 of its length from the top of the device at 1/4-1/3 of a circle 2.5-4 cm in diameter; a top tip is curved a little more than this uniform curvature and reflected over the length of 3-5mm at an angle of 15-20 degrees; a handle of the device is two loops of the cerclage wire lying in the same plane 0.5-1.0 cm in diameter.

EFFECT: more effective treatment of orthopaedic-traumatological patients suffering the transosteal suturing operation.

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Description

The invention relates to medicine, namely to medical devices used in traumatology and orthopedics.

In surgical traumatology and orthopedics, a transossal suture is widely used, during which a channel is formed in the bone for ligature through it.

Analogs

The intraosseous canal is usually drilled with a drill, and a ligature is passed through it using a surgical needle or Deschan ligature needle, which serve as a conductor of the thread. Since the intraosseous canals usually have a curved shape, and the drills used to drill them are straight, from two points opposite each other and at an acute angle (40-55 degrees) to the bone surface, two interosseous canals are connected to each other, the diameter of which is usually significantly (many times) exceeds the diameter of the ligature conductor.

Criticism of analogues

The use of a surgical needle or Deschan ligature needle as a conductor for a transossal suture, as a rule, is associated with technical difficulties and disadvantages, which include the following:

- to bring the surgical needle in line with the formed intraosseous canals, it is slightly bent (increase its curvature) or straightened, which is associated with the risk of breaking the needle or abalone and the associated problems of finding and extracting a needle fragment from bone or soft tissues;

- the risk of needle breakage is higher, the smaller its diameter, and when using a needle of a larger diameter, the need to expand the intraosseous channels increases, which is due not only to a direct correlation of their diameters, but also to an increase in the rigidity of the needle with a limitation on the ability to bring its curvature in accordance with the curvature of the formed intraosseous channels

- the pointed tip of the surgical needle is inconvenient in that it sticks into the walls of the intraosseous canals, and the needle is blocked at the slightest discrepancy between its curvature and the curvature of the canals;

- the presence of a fixed bend of a surgical and especially ligature needle sets strict requirements for the precision accuracy of drilling intraosseous canals for transosseous ligature passing through them, which is why it is necessary to expand the channels;

- forced expansion of the intraosseous canals is accompanied by a decrease in the bone bridge between the two bone holes, a significant weakening of its strength, an increase in the bone wound, the risk of iatrogenic fracture of this bridge and the bone itself with inconsistency of the transosseous suture and a decrease in bone quality. The use of a straight needle or a needle of lesser curvature also does not solve the problem of transossal ligature, because, firstly, it is not always technically feasible (for example, with the longitudinal and not transverse direction of the channel to the bone length) and, secondly, requires more free space on the other side of the bone. The latter circumstance dictates the need for wider access, an increase in the length of the skeletonization of this bone and the invasiveness of surgical intervention. Otherwise, the needle can stick into soft tissues, which, in addition to the difficulty of extracting it, is fraught with damage to important anatomical structures, such as the neurovascular bundle on the other side of the bone.

Prototype

As the closest analogue and prototype of the proposed device, Deschan's ligature needle, described in M.P. Brown “General principles of the technology of surgical operations” (Rostov n / A .: Publishing house "Phoenix", 1999. - 544 p. - S.73-75). The Deschan needle (Fig. 1, a) is a tool with which a surgical thread (ligature) is inserted under or through the anatomical structure on which the surgery is performed. It is designed to bring the ligature under the blood vessels, ducts or bone fragments. The working part of this needle (Fig. 1, b) resembles a curved surgical needle of an oval section with a closed eye at the end. In this case, the bending of the working part can be either to the right or to the left. Thread the thread into the eye of the instrument using a conventional surgical needle, the diameter of which is smaller than the eye of the Deschan needle. During the ligature, the working part of the Deschan needle is brought out under anatomical structures, the risk of damage of which is minimized due to the rounded end of the needle.

Prototype criticism

Along with the possibility of transossal ligatures, the prototype device has significant disadvantages:

- the diameter of the working part of the tool is 4-5 mm, which is many times greater than the diameter of the suture material, usually not exceeding 1 mm;

- the curvature of Deschan’s needle makes a bend from 1/2 to 5/8 of the circumference of its working part, which does not match either the direct course of the intraosseous canal or the curvature of two interosseous canals communicating with each other, which are usually carried out at an angle of 40-55 degrees to the surface bones;

- the rigidity of the instrument does not allow to change the shape of its working part and adapt to the direction of intraosseous canals communicating with each other;

- a forced increase in the diameter of the intraosseous canals is irrational from the point of view of bone mechanics (the ratio of the diameters of the suture material and intraosseous canals is usually not less than 1: 6) and traumatic from the point of view of its biology. So, the expansion of the intraosseous canals is accompanied by a decrease in the bone bridge between the two bone holes, a decrease in the quality of the bone, a significant weakening of its strength, an increase in the bone wound, the risk of iatrogenic fracture of this bridge and the bone itself with transosseous suture failure;

- the size of the closed eye of Deschan’s needle is rigidly set, and when using a ligature or needle, with which this ligature is drawn through it, equal to it or a larger diameter, they are jammed in the eye;

- since the bending of the working part of the Deschan needle can be either to the right or to the left, it is necessary to have both of its variants - in order to correspond to the specific anatomical and topographic conditions for each operation.

The purpose of the invention is to increase the effectiveness of the treatment of orthopedic and traumatic patients who undergo transossal suture surgery.

SUMMARY OF THE INVENTION

The goal is realized using the device (Fig. 2, a, b), which is a ligature conductor and consisting of a cerclage wire, whose diameter is 1 mm, its length is 18-35 cm, and in the middle it is flattened to 2-5 cm to 0.5-0.8 mm and bent to form legs or a double working part (1) and apex (3), which is an open loop, the largest transverse dimension of which is less than 3 mm, while the working part of the device itself is 1/3 -1/2 of its length from the top of the device is evenly bent by 1 / 4-1 / 3 of the circle (4), having boiling diameter of 2.5-4 cm, and the top of the tip (3) is bent slightly more than this uniform curvature and is bent over at an angle of 3-5 mm 15-20 degrees; the handle of the device are two loops of ends of the cerclage wire located in the same plane, with a diameter of 0.5-1.0 cm.

The material for the manufacture of the device is a cerclage wire for osteosynthesis, distinguished, firstly, by its plasticity - the ability to repeatedly deform without losing its strength, and, secondly, by inertness (areactivity) with respect to the patient’s tissues, i.e. Do not cause metallosis. A device is made as follows. The squelch wire, with a diameter of 1 mm and a length of 18-35 cm, is flattened in the middle with a hammer on the anvil to 0.5-0.8 mm for 2-5 cm (in proportion to this flattening of the wire, its width increases to 1.3-2 , 0 mm). Then, in the middle of this flattening section, this wire is bent in half with the formation of legs or a double working part (1), at one end of which - at the top (3), an open loop is formed with the Kocher clamp, the largest transverse dimension of which is less than 3 mm. In order for the device to be conveniently manipulated, form its handle in the form of two loops at the ends of the cerclage wire (2) having a diameter of 0.5-1.0 cm and located in the same plane (Fig. 2, a). After that, both legs (1) are closed, and the working part of the device for 1 / 3-1 / 2 of its length, starting from the top (3), is evenly bent by 1 / 4-1 / 3 of a circle (4) having a diameter of 2 5-4 cm (Fig.2, b). The tip of the apex (3) or its attacking end is bent slightly more than this uniform curvature of the working part of the device (4), namely, for 3-5 mm at an angle of 15-20 degrees. The purpose of this simulation of the tip of the tip is to make it easier to get into the second intraosseous canal and pass through one intraosseous canal and to exclude the already small probability of uncontrolled deformation of the device and violation of the exit of the end of the conductor beyond the bone surface.

Apply this device as follows. At a distance of 2.5-4.0 cm from each other at an angle of 40-50 degrees to the bone surface, two interosseous canals communicating with each other form. For precision accuracy in drilling intraosseous canals on the bone surface, two points are marked with an awl, which are successively abutted by the tip of the drill before giving it rotation - in order to avoid its slipping and deviation from the intended places of formation of the canals. In this case, the first channel is drilled to a depth of 2.0-3.5 cm (Fig. 3, a), and the second - until the sensation of failure in the first channel (Fig. 3, b). Then through both interosseous canals communicating with each other, a prefabricated device for a transossal suture is passed. When carrying out the device through both intraosseous canals, as a rule, there are no technical problems with the exit of its apex through the second hole above the bone surface. This is due to the fact that the device, being in channels whose diameter is not much (no more than 2 times - for example, with a channel diameter of 3-4 mm, the diameter of the working part of the device is about 2.5 mm) exceeds the diameter of the working part the device, in the narrow space of these canals, retains the advantage of its ductility (adapting to the curvature of the formed intraosseous canals) - with the exception of the negative side of this ductility, namely, uncontrolled deformation. From the latter circumstance, the device is guaranteed due to the fact that soft pressure along the axis of the device moves its working part further along the intraosseous canals, the walls of which do not allow the device to deform more than is necessary to adapt to the curvature of the channels and move along them. When the top of the device exits through the second hole above the bone surface, using a conventional surgical needle, a ligature is passed through its loop (Fig. 3, c) and, capturing one end of it, the working part of the device is removed in the opposite direction, and both ends of the ligature are connected (Fig.3, g) and apply a transossal seam. The fact that the loop of the device is open and plastic excludes the possibility of jamming of a surgical needle of any size with a ligature on it.

In addition to the transverse holding of the ligature in the tubular bone (Fig. 3, a, b, c, d), the device is similarly used for longitudinal holding (Fig. 4, a, b, c, d) in the tubular and flat bones.

Device application example

As an example of the use of the device for transossal suture, we give the following observation.

Patient M., born in 1973, was admitted to the traumatology department No. 2 of the Republican Orthopedic Traumatology Center on 10/28/13 with a diagnosis of a chronic rupture of the right pectoralis major muscle of type I (separation of the tendon of the muscle from the attachment point on the humerus).

From the anamnesis: more than a year ago, the patient received an indirect sports injury to the right shoulder girdle while performing a “half-strength” on the horizontal bar: when pulling and throwing the bent right arm above the crossbar with transferring the whole body weight to the overly strained right pectoralis major muscle, the latter broke with a bang , pain, hematoma formation and dysfunction of the right upper limb.

When examining the upper shoulder girdle, a retraction of the outer part of the right pectoralis major muscle, which has gathered in a muscle lump and in a reduced state, is shifted slightly more medially than the nipple, is noted. The retraction increases with muscle contraction in the process of bringing the shoulder to the body, turning the arm inwards, lowering and pulling it anteriorly and inwardly. The muscular roller, 11 × 11 cm in size, is palpately moderately painful, as is the area where it is not attached below the large tubercle of the humerus. The strength of bringing the shoulder to the body, turning the arm inwards, lowering and pulling it anteriorly and inward is significantly weakened in comparison with the contralateral side.

Due to the presence of a functional and cosmetic defect in the right upper shoulder girdle, as well as high physical demands of the patient, indications are given for surgical treatment.

10/31/13, the operation was performed: Transossal suture of the tendon of the pectoralis major muscle to the place of its attachment to the humerus. In the patient’s position on the back with a roller under the region of the right shoulder joint, a somewhat arcuate skin incision was made along the front surface just below the area of the right shoulder joint, 9-10 cm long. Subcutaneous tissue and fascia were dissected, and along the muscle fibers of the anterior portion of the deltoid muscle, the incision was deepened outward from the tendon of the biceps of the shoulder to the humerus below its large tubercle. At the same time, below the large tubercle of the humerus, at the place of the absent attachment of the tendon of the pectoralis major muscle, its clavicular portion was found, and the place of attachment of the sternal costal and abdominal portions was not detected and their retraction was noted with tension of the pectoral muscle. On the bone site where the flat tendon of the pectoralis major muscle was to be fixed, with a 3 mm drill, two communicating intraosseous canals were longitudinally drilled counter-angularly (about 45 degrees) to the bone surface at a distance of 3.5-4 cm from each other. At the same time, two points were marked on the surface of the bone with an awl, through which the channels were drilled: the first channel was drilled to a depth of 2.5-3 cm, and the second - until the sensation of failure in the first channel. Then through both intraosseous canals interconnected, without any technical difficulties, a prefabricated device for a transosseous suture was inserted.

This device was made of cerclage wire with a diameter of 1 mm and a length of 30 cm. In the middle, the wire was flattened with a hammer on the anvil to 0.7 mm for 4-5 cm, and in this flattening area it was bent in half to form legs or a double working part . At the top of the working part, a Kocher clamp formed an open loop, the largest transverse dimension of which was 2.5 mm. The device handle was formed in the form of two loops located in the same plane at the ends of the cerclage wire. The working part of the device for half its length from the top was evenly bent by 1/3 of a circle having a diameter of 3-3.5 cm, and the tip of the tip was bent a little more, namely, over 3 mm at an angle of 20 degrees. A device prefabricated in this way was sterilized along with other surgical instruments.

When the top of the device exited through the second hole above the bone surface, through its loop using a conventional surgical needle, a triple Dacron suture thread No. 4 was drawn and, capturing its end, the device was removed from the intraosseous canals in the opposite direction. Each of the two ends of the triple strands is fixed by a knot when exiting the channel with the formation of six ends of the strands. In a sharp and blunt way, the lateral part of the pectoral muscle collected in a lump was selected, straightened and mobilized, namely all three of its portions, each of which was stitched with U-shaped sutures. Then, through a bluntly formed channel under the anterior portion of the deltoid muscle, the tendon of the pectoral muscle is tied to previously formed transossal sutures in permissible tension. Passive movements in the shoulder joint are preserved. The tendon suture is wealthy. Nodal sutures were laid on the wound in layers, leaving drainage from glove rubber. An aseptic wound sticker and a gypsum turner on the Turner were applied.

The postoperative period was uneventful: the wound healed first, the sutures were removed on the ninth day, and the patient was discharged in a plaster cast (imposed for a month) for outpatient treatment with detailed recommendations. At the control examination, there was a lack of muscle retraction and a significant improvement in the function of the upper shoulder girdle (the prescribed rehabilitation treatment continues). The result of the treatment is regarded as good.

Features of the invention, distinctive from the prototype

Design features (distinguishing features of the prototype) device for transossal suture are:

- the material for the manufacture is cerclage wire;

- the diameter of the cerclage wire for the manufacture of the device is 1 mm, the length is 18-35 cm, and in the middle it is flattened to 0.5-0.8 mm for 2-5 cm;

- the top of the working part of the device is an open loop, the largest transverse dimension of which is less than 3 mm;

- the working part of the device for 1 / 3-1 / 2 of its length, starting from the top of the device, is evenly bent by 1 / 4-1 / 3 of a circle having a diameter of 2.5-4 cm;

- the tip of the top of the device is bent slightly more uniformly curved of the working part of the device and bent over 3-5 mm at an angle of 15-20 degrees;

- the handle of the device are two loops of ends of a cerclage wire located in the same plane, with a diameter of 0.5-1.0 cm;

- for precision accuracy in drilling the intraosseous canals on the bone surface, two points are outlined with an awl, which they successively abut with the tip of the drill before giving it rotation - to avoid its slipping and deviation from the intended channel formation site;

- the first channel is drilled to a depth of 2.0-3.5 cm, and the second - until the sensation of failure in the first channel.

The technical result (advantages over the prototype) of the device for transossal seam:

- the plasticity of the material of the device allows it to repeatedly deform without losing its strength;

- due to the plasticity of the device, it is possible to vary the shape and bend of its working part with bringing into correspondence with intraosseous canals of any curvature interconnected;

- the precision accuracy of the transossal suture, due to the fact that, being in the intraosseous canals, the diameter of which is not much greater than the diameter of the working part of the device (for example, when the diameter of the channels is 3-4 mm, the diameter of the working part of the device is about 2.5 mm), the latter in a narrow space retains the advantage of its plasticity, adapting to the curvature of the formed intraosseous canals, - without realizing its negative side, i.e. not controlled deformation. The device is guaranteed from uncontrolled deformation that soft pressure along its axis promotes the advancement of its working part further along the channels whose walls do not allow the device to deform more than is necessary to adapt to the channel curvature;

- higher efficiency of the transossal suture, caused by a much greater correspondence between the diameters of the drill and the thread, which is due to the lack of the need to expand the intraosseous canals for the possibility of passing through them the working part of the device;

- the absence of the need to expand the intraosseous canals minimizes the likelihood of reducing both the quality of the bone and the mechanical strength of the bone bridge between the two osseous openings, which is especially important in conditions of osteoporosis, and eliminates the risk of transosseous suture failure;

- atraumatic due to the lack of need for excessive drilling of intraosseous canals;

- the openness and ductility of the loop of the top of the working part of the device eliminates the possibility of jamming in it of a surgical needle of any size with a ligature mounted on it;

- the possibility of not only transverse, but also longitudinal ligatures in tubular and flat bones;

- the inertness (areactivity) of the device material eliminates the likelihood of metallosis in the patient - even in the case of a hypothetical and extremely unlikely leaving in the tissues of the patient device or its fragment;

- the best handling properties of the device are due to the handle formed in the form of two loops at the ends of the cerclage wire - with the possibility of holding the device into the intraosseous canals in one or the other direction;

- the cost-effectiveness and ease of manufacture of the device with no need to search for material (cerclage wire available in any orthopedic and traumatology department) and any arbitrarily long use without visible wear.

Thus, the proposed device can significantly improve the quality of surgical interventions using a transossal suture, widely used in surgical traumatology and orthopedics.

Information sources

1. A short course of surgical surgery with topographic anatomy // Guide edited by V.N. Shevkunenko and A.N. Maksimenkova. - L .: Medgiz. - 1951. - 796 p.

2. Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy. - Kursk; Moscow: CJSC Litera, 1996. - 720 p.

3. Huseynov A.G. Device for transossal ligature. Patent for invention No. 2332942 dated 09/10/2008.

4. Brown M.P. General principles of surgical technology // Guide for surgeons. - Rostov N / A: Phoenix Publishing House, 1999. - 544 p. - S. - 73-75. - prototype device.

Claims (1)

Device for a transossal seam in the form of a ligature conductor containing a handle and a working part, characterized in that it is made of cerclage wire, 1 mm in diameter, 18-35 cm long, with a flattening in the middle of up to 0.5-0.8 mm, made over 2-5 cm, moreover, the wire is bent with the formation of legs or a double working part and the top in the form of an open loop, the largest transverse dimension of which is less than 3 mm, while the working part is uniformly bent over 1 / 3-1 / 2 of its length from the top of the device on 1 / 4-1 / 3 of the circle, diameter 2.5-4 cm, the tip of the tip is bent more uniformly bent and bent for 3-5 mm at an angle of 15-20 degrees, and the handle is made in the form of two ends of a wire located in the same plane of the loop with a diameter of 0.5-1.0 cm.

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