RU2614096C1 - Method for acromioclavicular joint ligament lavsan plastics in case of rupture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin incision is perfromed in the acromioclavicular joint projection. The acromion and the clavicle are mobilized, four channels are drilled, including two in the acromion and two in the clavicle at the same distance from the articular surface, dorsally and ventrally. A double lavsan thread is passed through the channels. The thread is first passed from the top to the bottom in the ventral canal in the acromion, then from the bottom to the top in the ventral channel of the clavicle, then the thread is passed from the top to the bottom in the dorsal channel of the clavicle, and finally from the bottom to the top in the dorsal channel of the acromion. Joint anatomic integrity is provided by finger pressure, thread ends are tied with a double knot without removing the finger pressure.

EFFECT: method can reduce the frequency of relapses, reduce the number of postoperative complications, shorten the rehabilitation period.

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Description

The invention relates to medicine, namely to traumatology, and can be used to restore acromioclavicular articulation when it is dislocated with a rupture of the ligamentous apparatus, both with "fresh" and old.

The main causes of damage to the acromioclavicular joint are often falls on the outstretched arm and on the shoulder joint. In cases where the damage is limited to rupture of the clavicle-acromial ligaments, an incomplete dislocation or subluxation of the acromial end of the clavicle is observed. If powerful clavicular-coracoid ligaments (trapezoidal and conical) are torn, a complete supra-acromial dislocation of the clavicle occurs. Retraction of the trapezius muscle shifts the clavicle up and posterior to the scapula, and the entire upper limb in the vertical position of the patient due to gravity is shifted down. According to different authors, dislocations of the acromial end of the clavicle are from 1 to 17.2% among other dislocations and occupy third place, giving way to dislocations of the shoulder and forearm.

According to modern literature, more than 300 surgical methods are known for treating dislocations of the acromial end of the clavicle with metal fixators and suture ligaments. (Vinogradova T.D. Kulevich A.Yu. Treatment of traumatic dislocations of the acromial end of the clavicle // Military Medical Journal, 1982. - No. 8. - P. 25-28)

In 1861, E. Soore first stitched the collarbone and acromial end of the scapula with silver wire. (Titarenko S.V., Abdrakhmanov R.F., Potapov A.N., Fursa N.A., Grishchenko O.B. Surgical treatment of dislocations of the acromial end of the clavicle in the conditions of the Taganrog Municipal Clinical Hospital, Moscow State Pedagogical Institute // Abstract of the IX Congress of Traumatologists - Orthopedists. - Saratov, 2010. - S. 55-56.) A submersible transossal wire seam is known. Due to the frequent eruption of bone, wire breakage, it is used only as an additional fixing element (Vinogradova TD, Kulevich A.Yu. Treatment of dislocations of the acromial end of the clavicle. Military-medical journal. - 1982. - No. 8. - P. 25 -28).

The most widespread of modern techniques has been splinting with Kirschner spokes drawn through the articular surfaces of the acromial end of the clavicle and the acromial process of the scapula. Knitting with needles is possible both with exposure of the joint and in a closed way. Despite the apparent simplicity of the technique, its negative aspects were also noted: the migration of spokes, the development of contractures. To prevent these complications, more powerful clamps were proposed - pins of small diameter. Similar methods of treating dislocations of the acromial end of the clavicle were proposed independently by A.D. Lee (1961) (Lee A.D. On a new surgical method for the treatment of dislocation of the acromial end of the clavicle // Orthopedics, traumatology and prosthetics. - 1961. - No. 9. - P. 81-86.), B.L. Goldman (1965) (Goldman BL The surgical treatment of dislocations of the acromial end of the clavicle: Proceedings of the Jubilee Scientific Conference dedicated to the 30th anniversary of the Department of Traumatology and Orthopedics of the Novokuznetsk GI-Duva. - Kemerovo, 1965. - P. 280-284). In wide circles of domestic traumatologists, this design acquired the name Li-Goldman's nail. At the same time, G.E. developed in 2002 became the most famous in the world. Fade and J.E. Scullion, the so-called hook-shaped plate (Fade G.E., Scullion J.E. Hook plate fixation for lateral clavicular malunion // AO Dialogue, 2002. - Vol. 15, No. 1. - P. 14-18). The design is a plate having a hook-shaped end, which is inserted under the acromion along the rear surface, after which the plate is fixed to the clavicle with 6-8 screws with a diameter of 3.5 mm.

Thus, the most reliable method of submersible stabilization of the ACS at the current stage of development of traumatology remains splinting of the latter with metal clips. Moreover, the most reliable of these clamps are a biomechanically sound design in the form of a hook, the end of which is brought under the acromion.

However, a rather traumatic approach is used to immerse the hook-shaped plate, and fixation of a relatively small bone diameter, which is the clavicle, with 6-8 screws, is possibly biomechanically excessive, which can lead to iatrogenic fracture of the clavicle along the screw channel.

The most promising type of surgical intervention is the restoration of the ligamentous apparatus of the acromioclavicular joint using various methods of plastic surgery to keep the collarbone in the correct position (Nikitin G.D. Alloplasty in the treatment of injuries of muscles, tendons and ligaments. - St. Petersburg, 1994. - C . 53).

There are techniques for ligament plastic surgery aimed both at restoring exclusively the acromioclavicular ligament or clavicular-clavicular ligament, and both ligaments.

The essence of the method consists in the formation of channels in the clavicle and scapula, through which synthetic materials that replace damaged ligaments are passed. As synthetic materials are proposed: kapron threads, lavsan threads, nylon, polypropylene threads, nylon.

The method of Bennel was used as a prototype (Yu.P. Kolesnikov, A.I. Sviridov, G.M. Dubrovin. Dislocations and fractures of the clavicle. Voronezh. 1992, p. 61). This method involves the creation of a new artificial clavicular-clavicular ligament. The position of the patient on the back. A roller is placed under the blade. The arcuate anterior external incision gives access to the clavicular-acromial joint. The remnants of the joint capsule or cicatricial adhesions in the clavicle and acromial process of the scapula are removed, they are sufficiently mobilized. Using an electric drill, three holes are made: one in the acromial process, slightly departing from its end, the other two in the outer section of the clavicle. Through these holes, a thick silk thread or dacron tape is drawn in the following sequence: from top to bottom through the hole in the acromial process, then from bottom to top through the first hole in the clavicle. Next, the end of the thread is threaded into the Deschan needle, a fingernail process is felt with a finger, under which the Deschan needle is carried out from inside to outside, the thread is removed from the needle and carried upward through the second hole in the clavicle. After that, the outer end of the clavicle is adjusted and held with finger pressure. Both ends of the thread are thoroughly tightened and tightly tied with a double knot, over which soft fabrics are sewn. The limb is fixed in the designated position with a plaster cast for 2 weeks. Two weeks later, LFK, massage. Disability is restored 1.5-2 months after surgical treatment.

The disadvantages of the method include:

1. The restoration of the ratio of the acromioclavicular joint is performed by one thread or tape with a mass of kinks (up to 6), which leads to overstrain of the thread or tape when tying knots, as a result of which in the postoperative period there is persistent pain syndrome, impaired movement in the joint.

2. Long operational access due to holes in the collarbone at a considerable distance from the acromion.

3. Long term rehabilitation.

The objective of the invention is to develop a more efficient and reliable method of lavsanoplasty in case of rupture of the acromioclavicular joint by overlapping both the vertical and horizontal U-shaped continuous suture with double lavsan thread, so as to ensure the anatomical integrity of the acromioclavicular joint.

The task is achieved by the method of lavsanoplasty of the ligaments of the acromioclavicular joint when they are broken, including access to the acromioclavicular joint, removal of the remains of the joint capsule or cicatricial adhesions in the clavicle and acromial process of the scapula, mobilization of the acromion and clavicle. The method includes fixing by holding the thread through the channels formed in the clavicle and acromion of the scapula, tightening and tying the ends of the thread.

A skin incision is performed in the projection of the acromioclavicular joint, mobilize the acromion and clavicle up to 2 cm, drill four channels 0.3 cm in diameter, two in the acromion, two in the clavicle at the same distance from the articular surface dorsally and ventrally. A double Dacron thread USP 6 is passed through the channels. The thread starts from top to bottom along the ventral canal in the acromion, then the thread is carried out from the bottom up to the ventral canal of the clavicle, then the thread is passed from top to bottom along the dorsal canal of the clavicle, and the thread is finished from bottom to top. dorsal canal of acromion. By means of finger pressure, the anatomical integrity is attached to the joint, the ends of the thread are connected with a double knot, without removing the finger pressure.

The novelty of the invention:

A skin incision is performed in the projection of the acromioclavicular joint, mobilizing the acromion and clavicle up to 2 cm.

Four canals are performed with a diameter of 0.3 cm, two in the acromion, two in the clavicle at the same distance from the articular surface dorsally and ventrally.

The sequence of passing the thread through the channels, allowing you to simultaneously simultaneously vertical and horizontal U-shaped continuous seam double dacron thread.

Thus, the anatomical integrity of the acromioclavicular joint is completely restored without violating the integrity of the articular surfaces of the acromioclavicular joint.

The set of essential features of the invention, due to the continuous connection with a double dacron thread of the acromioclavicular joint without violating the integrity of the articular surfaces of the acromioclavicular joint, allows to obtain a new technical result:

to simplify the method, by reducing the mechanical effect on the tissue;

enables early activation of patients, due to the durable, anatomically substantiated connection of tissues without disturbing biomechanical functions;

significantly reduce pain in the postoperative period due to less traumatic surgical access;

carry out early activation of patients, rapid improvement in the quality of life of patients due to the absence of extensive plaster casts.

The claimed method allows to reduce the recurrence rate, to reduce the number of postoperative complications, to shorten the rehabilitation period, i.e. increase the effectiveness of treatment.

The invention is illustrated in the schematic drawings in FIG. 1 - FIG. 3

In FIG. 1 is a schematic representation of the canals in the clavicle and in the acromion.

In FIG. 2 diagram of conducting mylar threads through the acromion and collarbone in the frontal plane.

In FIG. 3 is a schematic representation of the threads after completion of the plastic.

In FIG. 1 - FIG. 3 shows: 1 - collarbone, 2 - acromion, 3 - channels in the clavicle, 4 - channels in the acromion, 5 - double dacron thread, 6 - formed knot when tying the ends of the dacron thread.

The method is as follows.

A skin incision is performed in the projection of the acromioclavicular joint, dissection of the subcutaneous fat, opening access to the acromioclavicular joint. They remove the remnants of the joint capsule or cicatricial adhesions in the clavicle and acromial process of the scapula, mobilize the acromion up to 2 cm, the clavicle up to 2 cm. Using an electric drill, make four holes with a drill 0.3 cm in diameter: two in the acromion, two in clavicle at one distance from the articular surface, dorsally and ventrally. A double Dacron USP 6 is continuously passed through these channels using a medical wire. The thread starts from top to bottom along the ventral canal in the acromion, then the thread is carried out from the bottom up to the ventral canal of the clavicle, then the thread is passed from top to down along the dorsal canal of the clavicle holding the thread from the bottom up to the dorsal canal of the acromion. Finger pressure gives the anatomical integrity to the joint. Both ends of the thread are tied with a double knot, without removing finger pressure. The wound is washed with a 3% solution of H ₂ O ₂ , sutured subcutaneous fascia, skin.

Example:

Patient F., 33 years old, was admitted on 01.20.15 with a diagnosis of a chronic rupture of the acromioclavicular joint on the right. Personal injury on 12/28/14. Conducted conservative treatment, kerchief immobilization, NSAIDs, analgesic therapy - without effect. Sent to a hospital.

The skin and visible mucous membranes of normal color, clean. Peripheral lymph nodes are not palpable. In the lungs, vesicular breathing, no wheezing. NPV = 16 per min.

Cor-tones are clear, rhythmic. ChS = 78 in min; HELL = 130/80 mm Hg

The abdomen is soft, painless on palpation. Liver on the edge of the costal arch. There are no symptoms of peritoneal irritation. The chair is regular. Urination is free, painless.

St.loc: in the area of the acromioclavicular joint on the right, deformation of the soft tissues, a positive symptom of the key, pain on pressing the collarbone on the right are noted. The forced position of the right upper limb (on the scarf), the movement in the right shoulder joint is not in full, painful.

General blood test: Er - 4.2 × 10 ¹² / l; Hb - 131 g / l; ESR - 7 mm / h; L - 5.0 × 10 ⁹ / l; T - 230.0 × 10 ⁹ / L.

Coagulogram: PTI-100%; fibrinogen A - 3.4 g / l.

O / b - 63 g / l; creatinine - 76 mmol / l; urea 3.3 mmol / l; sugar - 4.9.

General urine analysis: beats. weight - 1014, protein - neg, L - 0-2 in s / z .;

ECG - sinus rhythm, heart rate = 85 per min, vertical EOS, increased electroactivity of the left ventricle of the myocardium.

On the 2nd day after hospitalization, the patient underwent surgical treatment - lavsanoplasty of the acromioclavicular joint on the right.

Under general anesthesia (intravenous) access in the projection of the acromioclavicular joint, the acromioclavicular joint is highlighted on the right. The periosteum, elements of the damaged ligament, meniscus were separated in a sharp and blunt way, the acromion and clavicle were mobilized by 1.5 cm. Four channels were made using an electric drill, two in the acromion, two in the clavicle at a distance of 1 cm from the joint dorsally and ventrally . A double dacron thread USP 6 was continuously passed through these channels using a medical wire. The thread was drawn starting from the top-down along the ventral canal in the acromion, then drawn from the bottom-up along the ventral canal of the clavicle, then passed from top to down along the dorsal canal of the clavicle, and finished with the thread bottom-up on the dorsal canal of the acromion. Finger pressure gave the articulation anatomical integrity. Both ends of the thread are tied with a double knot, without removing finger pressure. The wound was washed with a 3% solution of H ₂ O ₂ . Hemostasis is dry. Layered suturing. Rubber graduate. Aseptic dressing. On a limb a kerchief bandage.

P / o diagnosis: chronic rupture of the acromioclavicular joint on the right.

The duration of the operation is 35 minutes.

Sutures were removed on the 8th day, wound healing by primary intention.

Discharged from the hospital after 8 days. I started working after 21 days from the date of surgical treatment.

During the follow-up examination after 3 months, there is no data for a relapse, there is no pain syndrome, and movements in the limbs are in full. During the follow-up examination after 6 months, there is no data for a relapse, there is no pain syndrome, and movements in the limb in full. During the follow-up examination after a year, there is no data for relapse, pain does not indicate movement in the limb in full.

The claimed method allows to reduce the time of surgery to 30-40 minutes, early activation of patients from 1 day after surgical treatment, to reduce the frequency of relapses (according to this method, about 8 surgical interventions were not observed relapses), to reduce the frequency of complications (there were no complications patients), shorten rehabilitation periods (disability periods of 21 days), i.e. increase the effectiveness of treatment.

Claims (1)

The method of lavsanoplasty of the ligaments of the acromioclavicular articulation when they are broken, including access to the acromioclavicular articulation, removing the remnants of the joint capsule or cicatricial adhesions in the clavicle and acromial process of the scapula, mobilizing the acromion and clavicle, fixing by passing the thread through the channels formed in the clavicle and acromion of the scapula, tightening and tying of the ends of the thread, characterized in that they perform a skin incision in the projection of the acromioclavicular joint, mobilize the acromion and clavicles up to 2 cm, four channels with a diameter of 0.3 cm are drilled, two in the acromion, two in the collarbone at the same distance from the articular surface, dorsally and ventrally, through the channels a double dacron thread USP 6 is carried out, the thread starts from top to bottom along the ventral canal in the acromion, then the thread is drawn upward and downward along the ventral canal of the clavicle, then the thread is carried out upward-downward along the dorsal canal of the clavicle, the thread is completed upward and downward along the dorsal canal of the acromion, the anatomical joint is attached by finger pressure stinity, the ends of the thread are connected by a double knot, without removing finger pressure.

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