RU2654404C1 - Method of subscapular muscle elongation with a tendon of the long head of biceps arm muscle in total shoulder joint endoprosthetics - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatology and orthopedics and may be applicable to elongation of the subscapular muscle with a tendon of the long head of the biceps arm muscle in total shoulder arthroplasty. Separate the tendon of the subscapular muscle from the attachment site by decortication. Tendon of the long head of the biceps arm muscle is cut off from the attachment site to the upper edge of the articular surface of the scapula. Perform tenodesis of the long head of the biceps arm muscle at the level of the small tubercle with preservation of function of the long head of the biceps arm muscle. Perform punctures on the tendon of the scapula muscle proximal to the associated bone plate. Through formed punctures, the tendon of the long head of the biceps arm muscle is drawn, forming a loop. End of the tendon stump of the long head of the biceps arm muscle is fixed to the place of tenodesis by transosseous sutures.

EFFECT: method allows to ensure front stability of shoulder joint, to prevent postoperative contracture of external rotation.

1 cl, 7 dwg

Description

The present invention relates to medicine, namely to reconstructive surgery in traumatology and orthopedics.

One of the important elements in restoring the function of external rotation during total joint replacement of the shoulder joint is to maintain the attachment of the subscapularis muscle, combined with its dosed extension.

There are several ways to extend the subscapularis muscle: lengthening the subscapularis muscle by stitching it end to end with the anterior section of the joint capsule, transverse Z-shaped plastic of the tendon of the subscapularis muscle, longitudinal Z-shaped plasticity of the tendon of the subscapularis muscle, extension of the subscapularis muscle due to osteotomy of the minor tubercle or through the use of additional tendon grafts.

However, these methods have the following disadvantages: 1) the complexity of the anatomical separation of the joint capsule and tendon of the subscapularis muscle; 2) the physiological length of the subscapularis muscle and the thickness of its tendon are not preserved and are not achieved; 3) not strong fixation with ligature seams.

As a prototype, a method was chosen to extend the subscapularis muscle during endoprosthetics of the shoulder joint, including deltopectoral access, release of the fake and subacromial spaces, mobilization of the tendon of the subscapularis to the base of the coracoid process, testing the amplitude of the external rotation of the shoulder, standard endoprosthetics, extension of the subscapularis. Nicholson GP, Twigg S., Blatz B., Sturonas-Brown B., Wilson J. Subscapularis lengthening in shoulder arthroplasty // J. Shoulder Elbow Surg. 2010. Vol. 19. P. 427-433).

The method has the following disadvantages: 1) a restriction in use due to the impossibility of anatomical differences in the tendon of the subscapularis muscle and capsule of the joint, since with severe post-traumatic deformities and transferred arthritis, a single scar conglomerate of the capsule and tendon of the subscapularis muscle is formed; 2) the extension of the subscapularis muscle is achieved by no more than 1.5 cm, which, with a rough restriction of the external rotation, does not allow to restore the physiological amplitude of the external rotation of 80 ° -90 °; 3) the length of the subscapularis muscle is not completely preserved, because the tendon of the subscapularis muscle is cut off 5-8 mm from the place of attachment; 4) tenodesis of the long head of the biceps is not performed, which significantly reduces its function as a flexor and main arch support of the forearm; 5) fixation of the anterior and posterior flaps with ligature sutures limits the possibility of early effective rehabilitation due to the risk of teething.

The task of the invention is to improve the method.

EFFECT: restoration of the function and length of the subscapularis muscle, ensuring anterior stability of the shoulder joint, elimination of postoperative contracture of external rotation and the possibility of early rehabilitation.

The technical result is achieved due to the fact that in a method that includes deltopectoral access, release of the fake and subacromial spaces, mobilization of the tendon of the subscapularis muscle to the base of the coracoid process, testing of the amplitude of external rotation of the shoulder, installation of components of the endoprosthesis, extension of the subscapularis muscle, suturing of the wound, the tendon is separated the subscapularis muscle from the attachment site by means of decortication, the tendon of the long head of the biceps of the shoulder is cut off from the attachment site to the upper edge of the articular surface of the scapula, tenodesis of the tendon of the long head of the biceps of the shoulder muscle is performed at the level of the minor tubercle, punctures are made to the tendon of the subscapularis muscle, followed by stitching of the tendon of the long head of the biceps of the shoulder muscle, forming a loop, and the end of the stump of the tendon of the long head of the biceps is fixed shoulder muscles to the site of tenodesis with transosseous sutures.

A method for lengthening the subscapularis muscle with a tendon of the long head of the biceps of the shoulder during total shoulder replacement is illustrated by the drawings, where in FIG. 1 shows the naked shoulder joint with deltopectoral access after extensive mobilization and release; in FIG. 2 - separation of the tendon of the subscapularis muscle from the site of attachment by decortication with a narrow chisel; in FIG. 3 - cutting off the tendon of the long head of the biceps of the shoulder from the point of attachment to the upper edge of the articular surface of the scapula; in FIG. 4 - tenodesis of the tendon of the long head of the biceps of the shoulder at the level of the small tubercle; in FIG. 5 - installation of the components of the endoprosthesis; in FIG. 6 - a scalpel performing two punctures with sizes of 4-5 mm above and below proximal to the subscapular muscle of the bone plate connected with the tendon; in FIG. 7 - extension of the subscapularis muscle by the tendon of the long head of the biceps of the shoulder and fixation of the end of the stump to the site of tenodesis with transosseous sutures.

The method is as follows. Used deltopectoral access. Stupidly and acutely perform release of the fake and subacromial spaces, mobilize the subscapularis muscle to the base of the coracoid process. The amplitude of the external rotation is tested: if the amplitude is less than 20 °, extension of the subscapularis muscle is necessary. The tendon 2 of the subscapularis muscle 1 is separated from the attachment site by decortication 4 with a narrow chisel 5, then the stump is removed on the ligatures 7. The tendon of the long biceps muscle of the shoulder 3 is cut off with a scalpel 6 from the point of attachment to the articular surface of the scapula. Tenodesis 8 of the tendon of the long head 3 of the biceps of the shoulder 12 is performed at the level of the small tubercle while maintaining the physiological length of the biceps of the shoulder. The stump of the long head of the biceps is removed on the ligatures 9. The components of the endoprosthesis are installed 10. After that, on the tendon stump of the subscapular muscle proximal to the associated bone plate, two punctures are made with a size of 4-5 mm above and below 11 to conduct a stump of the tendon of the long head of the biceps 3 The long head 3 of the biceps muscle 12 is carried out externally inward through the upper puncture and from the inside out through the lower puncture, followed by fixation with transosseous sutures of the stump of the long bicep head to the place of Nodeza. Wound closure. The method allows to extend the subscapularis muscle by 2-2.5 cm, thereby avoiding the contracture of external rotation in the postoperative period.

Clinical example. B-th K-tiev R.V., 38 years old, was in the traumatology and orthopedic department of the FSBI “PFMITS” of the Ministry of Health of Russia with a diagnosis of an overgrown four-fragment fracture of the proximal left humerus according to Neer. From the anamnesis it is known that the patient received a traffic accident on 07/19/2016. He was treated with a conservative plaster cast. On the control x-ray revealed the wrong ratio and non-fracture, with which he was hospitalized in the trauma department of the PFMIC for surgical treatment. Preoperative radiography of the left shoulder joint in 2 projections and CT diagnostics of the left shoulder joint were performed. On August 24, 2016, an operation was performed - reverse shoulder replacement with an extension of the tendon of the subscapularis muscle by the tendon of the long head of the biceps of the shoulder muscle due to intraoperatively revealed irreversible damage to the rotator cuff and a four-fragment fracture of the proximal humerus with significant displacement of fragments. The position of the patient on the operating table in the pose of "beach chair". Through the deltopectoral access, the fake and subacromial spaces were bluntly and sharply released, mobilization was performed in front of the subscapularis muscle to the base of the coracoid process; external rotation test was less than 20 °. The subscapularis muscle was lengthened according to the proposed method - the tendon of the subscapularis muscle was separated from the attachment site by decortication, the tendon of the long head of the biceps of the shoulder was cut off with a scalpel from the point of attachment to the upper edge of the articular surface of the scapula, tenodesis was made of the tendon of the long head of the biceps of the shoulder at the level of the minor tubercle. After installation of the components of the endoprosthesis on the stump tendon stump of the subscapularis muscle, two punctures 4-5 mm above and below were formed with a scalpel, through which the tendon of the long head of the biceps of the shoulder was carried out from the outside inward through the upper puncture and from the inside out through the lower puncture, forming a loop , with subsequent fixation of the end of the stump of the tendon of the long head of the biceps of the shoulder with transosseous sutures to the site of tenodesis. Wound closure. Intraoperatively, the amplitude of the external rotation reached 50 °. The method allowed to extend the subscapularis muscle by 2.5 cm. The left upper limb was fixed after the operation with a soft bandage Deso. The left upper limb was immobilized for 6 weeks. A daily isometric gymnastics was prescribed for the muscles of the shoulder and hand from 1 day after the operation.

The postoperative period was uneventful. The patient was examined 3 months after surgery. Radiologically, the components of the endoprosthesis are stable. Postoperative scar without signs of inflammation. The range of motion in the left shoulder joint: flexion of 80 °, extension of 35 °, abduction of 100 °, reduction of 70 °, external rotation of 40 °, internal rotation of 80 °. The continuation of isometric gymnastics for the muscles of the shoulder and hand is recommended.

The patient was examined after 6 months. Radiologically, the components of the endoprosthesis are stable. Movements in the shoulder joint in full: flexion 170 °, extension 40 °, lead 140 °, cast 80 °, external rotation 50 °, internal rotation 90 °. The patient undergoes a rehabilitation course, uses the operated limb in domestic and industrial activities.

When implementing the method, the front stability of the shoulder joint, the function and length of the subscapularis muscle are restored, the postoperative contracture of the external rotation is eliminated. The maximum extension of the subscapularis muscle by 2.5 cm is achieved, which gives a complete restoration of the physiological amplitude of the external rotation. The function of the biceps muscle of the shoulder as a flexor and the main arch support of the forearm is fully preserved. The method allows to reliably lengthen and fix the subscapularis muscle, also provides sufficient tension of the subscapularis muscle. The method has no limitations in application, since it is always possible to use tendons of the long head of the biceps of the shoulder.

Claims (1)

A method for lengthening the subscapularis muscle with a tendon of the long head of the biceps of the shoulder during total shoulder replacement, including deltopectoral access, release of the fake and subacromial spaces, mobilization of the tendon of the subscapularis to the base of the coracoid process, testing the amplitude of the external rotation of the shoulder, installation of the extension of the endoprosthesis, wounds, characterized in that the tendon of the subscapularis muscle is separated from the attachment site by decort ikacia, the tendon of the long head of the biceps of the shoulder is cut off from the point of attachment to the upper edge of the articular surface of the scapula, tenodesis of the long head of the biceps of the shoulder at the level of the small tubercle is maintained while maintaining the function of the long head of the biceps of the shoulder muscle, perform punctures on the tendon of the subscapularis muscle proximal to the bone related to it plate, through the formed punctures conduct the tendon of the long head of the biceps of the shoulder, forming a loop, the end of the stump of the tendon of the long head of the biceps and fix the place tenodesis transosseous seams.

Images