RU2721936C1 - Method for treating complex fractures of proximal humerus - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to traumatology, and can be used for reduction and fixation of fragments in complex fractures of fractures of proximal humerus. Method involves surgical deltopectoral access to the shoulder joint between the deltoid and pectoralis major muscles with skin and subcutaneous fat incision along the deltopectoral sulcus, suturing with single threads of tendons first of the subscapular muscle, then supraspinatus and infraspinatus muscles. Tract of tendon threads with remains of tubercles is dissolved in sides, and a bone allogenic graft is introduced into the marrowy canal, which is a fragment of fibular bone with length of 6–8 cm, including a head having a skewed surface, a neck and a part of the diaphysis, and provided through the entire surface with through channels filled with human-type collagen 1 sponge. Graft introduction into the marrowy canal is performed by diaphyseal part by orienting the skewed surface of the head on the glenoid cavity of scapula so that after reposition the angle between the diaphysis of the humerus and the head of humerus is 130°. Threads with which the tendon of the rotator cuff are sutured are passed through the holes of the osteosynthesis plate of the proximal humerus fractures. Thereafter, under control of fluoroscope, said plate is laid 0.5–1.0 cm distally from apex of greater tubercle posteriorly and parallel to crest of greater tubercle such that angle between plane of articular surface and longitudinal axis of plate corresponds to caput-collum-diaphyseal angle of humerus. Through the central opening in the plate, the head is inserted into the head of the humerus, and the wire is inserted through the ends of all threads drawn through the holes in the plate, while pressing the plate to the proximal humerus; the fragments are repositioned by pulling them on the transplant; thereafter, plate is locked by locked screws while threads ends are locked in plate holes.EFFECT: method provides strengthening a proximal humerus with reliable reposition by reliable fixation of fragments and using an allogenic graft impregnated with human collagen type 1.9 cl, 13 dwg, 2 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used in the surgical treatment of patients with complex fractures of the proximal humerus, accompanied by bone deficiency.

State of the art

Fractures of the proximal humerus account for about 5-7% of all fractures in adult patients and occupy the third place in frequency among fractures in elderly patients after fractures of the proximal femur and leafal radius. Fractures of the proximal humerus account for up to 75% of all fractures of the humerus in patients older than 60 years, while in women they occur 2-3 times more often than in men [Lomtatidze E.Sh., Lomtatidze V.E., Potseluyko S .AT. [and others.] Analysis of the functional results of internal osteosynthesis in fractures of the proximal humerus // Bulletin of Traumatology and Orthopedics. N.N. Priorova. - 2003. - No. 3. - S. 62-66.]. Fractures of this localization have a strong effect on limb function in the near and distant periods after injury. Epidemiological studies indicate a constant increase in the number of such fractures and a doubling of their number in patients over the age of 80 in the next 20 years [Palvanen M., Kannus P., Niemi S., Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006; 442: 87-92 .; Song J.Q., Deng X.F., Wang Y.M., Wang X.B., Li X., Yu B. Operative vs. nonoperative treatment for comminuted proximal humeral fractures in elderly patients: a current metaanalysis. Acta Orthop Traumatol Turc. 2015; 49 (4): 345-53.].

Currently, there are no unambiguous recommendations on the choice of tactics for the treatment of patients with fractures of the proximal humerus. This is due to the large number of possible treatment options: conservative and surgical, a large number of modifications of the surgical treatment method.

The most severe, multi-fragmented proximal humerus fractures usually develop in older people with poor bone quality. It is extremely difficult to reposition and retain fragments with traditional metal fixators during such fractures. Natural complications are fracture failure or abnormal fusion as a result of unsuccessful reposition, or secondary displacement [Jung S.W. et al. Factors that influence reduction loss in proximal humerus fracture surgery // Journal of orthopedic trauma. - 2015. - T. 29. - No. 6. - C. 276-282.]. A possible treatment option is anatomical arthroplasty of the shoulder joint. The functional outcome of such operations is rarely satisfactory, as To restore the function of the hand, fixation of the large and small tubercles is necessary, and they, with poor bone quality, are usually destroyed and cannot be fixed. Arthroplasty of the shoulder joint is possible with a reversible design, but a large number of complications with such arthroplasty in the acute period of trauma are noted in the publications. [Zumstein M.A. et al. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review // Journal of shoulder and elbow surgery. - 2011. - T. 20. - No. 1. - P. 146-157.]. [Anakwenze O.A. et al. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review // Journal of shoulder and elbow surgery. - 2014. - T. 23. - No. 4. - P. 73-80]. To fix multi-fragmented fractures of the proximal humerus, it is customary to use specialized metal plates with screws locking in them. However, with poor bone quality, complications such as eruption of screws, improper adhesion with varus deformation, migration of screws with unscrewing them from the plate develop [Launonen A.P. et al. Treatment of proximal humerus fractures in the elderly: a systematic review of 409 patients // Acta orthopedic. - 2015. - T. 86. - No. 3. - P. 280-285.] [Haasters F. et al. Complications of locked plating for proximal humeral fractures-are we getting any better? // Journal of shoulder and elbow surgery. - 2016. - T. 25. - No. 10. - P. .. 295-303 .; Biermann N. et al. Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies // Archives of orthopedic and trauma surgery. -2019. - P. 1-25.]. To prevent these complications, it is necessary to strengthen the bone destruction zone. For this purpose, the humeral head is augmented with methyl methacrylate cement. The disadvantage of this solution is the heating of the cement during the polymerization to significant temperatures. In addition, cement is toxic, which can lead to the development of bone cement implantation syndrome, and does not degrade in the body [Schliemann B. et al. Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures // Journal of shoulder and elbow surgery. - 2015. - T. 24. - No. 12. - P. 1968-1973; Hines C. B. Understanding Bone Cement Implantation Syndrome // AANA Journal. - 2018. - T. 86.-No. 6.].

Bone grafts used to strengthen the fracture area are known in the art. They are non-toxic and degrade over time. [Cha H. et al. Treatment of comminuted proximal humeral fractures using locking plate with strut allograft // Journal of shoulder and elbow surgery. - 2017. - T. 26. - No. 5. - C. 781-785. http://dx.doi.org/10.1016/i.ise.2016.09.09.0551. It is known to use a cryopreserved allogeneic transplant from the tubular part of the fibula, ulna or radius, which strengthens the fracture zone in complex fractures of the proximal humerus. [Hinds R.M. et al. Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation // Journal of shoulder and elbow surgery. - 2015. - T. 24. - No. 6. - C. 889-896.]. The disadvantages of such transplants include the cylindrical shape, which does not ensure the stability of its position in the fracture zone - the transplant can fall into the bone marrow canal of the humerus, which requires additional techniques and means of holding it until the fracture is fixed. Such transplants have almost no osteoconductive effect, as they consist of the tubular part of the bone. The graft also cannot be used as a carrier of biologically active substances. In addition, the grafts are stored frozen in special equipment, the graft is thawed before surgery, and if there is no need to use the graft, repeated freezing for its use is already excluded.

It is also known to use a combined bone allograft in the treatment of patients with traumatic bone defects, with non-fused fractures, false joints, fractures with delayed consolidation (RU 2524618). A combined allogeneic bone graft is a non-demineralized bone block obtained from the spongy bone of a donor and containing human type 1 collagen in the form of a sponge with a fine-mesh structure obtained by freeze-drying a bone block impregnated with a collagen solution throughout the volume of the bone block. However, this graft is not convenient for strengthening the fracture area during fractures of the proximal humerus, because in this zone, the spongy bone passes into a tubular one and for reinforcing this area, a material sufficiently strong in fracture and having a cylindrical shape is needed. The graft is convenient for filling defects in the cancellous bone and stimulating osteogenesis in case of violation of fracture consolidation, but is not suitable for strengthening the fracture in the diaphyseal and metaphyseal areas of the bone. In addition, the method of saturating the transplant with a collagen solution does not ensure its maximum collagen saturation - filling natural and formed cavities, as well as the uniform distribution of collagen throughout the volume of the transplant, which significantly improves the conditions for fixation and subsequent differentiation of mesenchymal cells.

With 3 and 4-fragment fractures of the proximal humerus, inaccurate reposition of fragments of the humerus (in particular the large tubercle), inaccurate reposition of the plate and its loose fit to the bone, as well as failure of fixation in the postoperative period, leads to the development of subacromial impingment and poor functional treatment outcomes. Achieving at the same time the correct position of the fragments, the correct positioning of the plate and its tight fit to the bone is a difficult surgical task.

Currently, there are many ways to fix fragments in fractures of the proximal humerus, but there is no specific algorithm of actions that would allow for a clear anatomical reposition for any type of fracture, including 3-and 4-fragment fractures.

Most often, knitting needles are used as joysticks to reposition fragments of the humeral head [Bucholz, Robert W .; Heckman, James D .; Court-Brown, Charles M .; Tornetta, Paul. "Rockwood And Green's Fractures In Adults, 7th Edition." Lippincott Williams & Wilkins. 2010.1072-1075.]. The disadvantage of this method is the difficulty in positioning the knitting needles due to the displacement of fragments of the humeral head under the acromial process of the scapula. The acromial process of the scapula often limits the amplitude of movement of the joysticks, this leads to the need to hold the needles several times, which in turn causes additional trauma to the bone and surrounding soft tissues. In addition, when carrying out intensive manipulations with fragments of the head of the humerus with the help of joysticks, they often tear out. This is especially evident in elderly patients with reduced bone density. Each pulling out of the knob leads to a loss of reposition and requires the re-establishment of the joystick. Loss of fixation of the joystick knitting needle in the bone (when it is torn out) leads to the formation of a bone cavity in the place of its installation. In addition, the frequent retransmission of the joysticks leads to additional trauma to the bone and surrounding soft tissues, an increase in the number of cavities in the bone, and a decrease in the total bone density of the humeral head (which is especially noticeable during osteosynthesis under conditions of osteoporosis or osteopenia). The creation of additional bone cavities after the joysticks makes the final fixation of the fracture using plates difficult, as it reduces the fixation capabilities of the screws.

Sewing tendons of the muscles of the rotator cuff of the shoulder (VMP) is recommended by many authors, both for reposition and for enhancing fixation of the fracture. However, recommendations on the tactics of these manipulations vary.

So Arkhipov S.V. and Kovalersky G.M. Sewing the tendons of the muscles of the rotational cuff of the shoulder is used to reposition a fragment of a large or small tubercle, after which temporary fixation of fragments of the head of the humerus with Kirschner spokes (2-3 needles), at the same time, the proximal shoulder to the diaphysis is made spoke. After temporary fixation is achieved, the plate is positioned, the final fracture fixation is made by the plate and provisional knitting needles are removed [Arkhipov S.V., Kovalersky G.M. Shoulder surgery. Moscow 2015 171-173.]. The authors also propose holding compression screws to achieve tight contact of the plate with the bone, and the authors use the holes in the plate to install wire loops in order to additionally fix small fragments.

The disadvantage of this method is the preliminary fixation of fragments with knitting needles (two to three knitting needles, sometimes more). Conducting provisional locking knitting pins further interferes with the positioning of the plate. Spent provisional knitting needles often pass through the area of maximum bone mass of the fragment. The plate has to be laid bypassing the knitting needles, this leads to the fact that the locked screws passing through the plate and fixing the fragments go through the zone of smaller oblique mass of the fragment. Re-conducting of the spokes leads to the loss of temporary reposition and to the displacement of fragments. Suturing to the plate of the tendons of only the infraspinatus and supraspinatus muscles (without obligatory suturing of the subscapularis muscle) creates an imbalance in the tightness of the plate to the bone.

The prior art for the fixation of fractures of the proximal humerus is known to use plates with suturing the tendons of the upper limbs for reposition of tubercle fragments. At the same time, tendons are stitched first, then the threads are threaded through the plate, the plate is repositioned and fixed to the bone [Nho S.J., Brophy R.H., Barker J.U., Cornell C.N., & Macgillivray J.D. Innovations in the management of displaced proximal humerus fractures. The Journal of the American Academy of Orthopedic Surgeons, 15 1 (2007), 12-26.].

However, flashing of the VMP tendons with threads only in the presence of a fracture at the fixation point creates an imbalance of forces when these threads are tensioned (that is, when the fragments are repositioned), which complicates the plate positioning process. This is also the result of the absence of a central spoke, which centers the plate and thereby tightly presses the (correctly positioned) plate to the bone. The main problem that the surgeon encounters when repositioning fragments and positioning the plate is the difficulty in achieving a correct and minimally traumatic reposition of fragments without interference in laying the plate.

It is known from the prior art to use stitching of the tendons of the VMP muscles and their suturing to the plate to increase the fixation strength. However, only tendons that are attached to broken fragments are sutured (tendons of the supraspinatus and infraspinatus muscle in case of fractures of the large tubercle, tendon of the subscapular muscle in fractures of the minor tubercle). For reposition, the authors use a large number of Kirchner spokes and clamps (in particular, Lowman's clamp) [Lynn A. Crosby, Robert J. Neviaser Proximal humerus fractures. Evaluation and management. Springer 2015. 99-105.]. However, the use of a large number of Kirschner spokes, as already mentioned, complicates the positioning of the plate and the passage of screws through it. The use of clamps for reposition causes additional trauma to the surrounding soft tissues, and has the risk of damage to the envelopes of the humerus of the arteries (in particular the posterior envelope) and the axillary nerve.

Closest to the claimed solution is a method of osteosynthesis in a fracture of the proximal humerus (Patent for invention No. 2673146), in which stitching of the tendons of the upper limb muscle is used to reposition fragments of the humerus, and a pin is used for fixation. The method according to the invention is as follows. An incision is made in the skin and subcutaneous adipose tissue 5-6 cm long between the anterior and middle bundles of the deltoid muscle from the anterolateral angle of the acromion to the projection of the axillary nerve. The deltoid muscle is bred. Sew with separate strands of the tendon of the supraspinatus, infraspinatus and subscapularis muscles with at least two stitches each, and the tendons of the supraspinatus and infraspinatus muscle are sutured at a distance of 1-1.5 cm from the places of their attachment to the large tubercle of the humerus, and the tendon of the subscapularis muscle - a distance of 1-1.5 cm from the place of its attachment to the small tubercle of the humerus. The fragments are repositioned by traction at the ends of the filaments drawn through the tendons, and first, the large tubercle is repositioned by traction in the lateral and distal directions behind the ends of the filaments, conducted through the tendons of the supraspinatus and infraspinatus muscles, then the humeral head is rotated by traction in the dorsal direction beyond the ends a thread drawn through the tendon of the subscapularis muscle. While retaining traction for the threads, a longitudinal incision is made of a length of 1-1.5 cm of the tendon of the supraspinatus muscle, through which an inlet for the pin is formed in the head of the humerus. After insertion of the pin, it is fixed with locking screws through the holes of the pin, with the proximal locking screws passing through the large and small tubercles of the humerus, and the distal locking screw through the diaphysis of the humerus. The threads held through the tendons of the threads are fixed to the screw caps, while the screws located in the region of the large tubercle of the humerus are fixed by the threads passed through the tendons of the supraspinatus and infraspinatus muscles, and the threads held through the small tubercle of the humerus are fixed through the tendon of the subscapularis muscle. The method allows to reduce the morbidity and duration of the intervention, to increase the reliability of the reposition, to prevent disturbance of the blood supply to the head of the humerus.

However, in order to flash all of these tendons, the surgeon needs to have a fairly wide surgical access. Surgical access through the deltoid muscle is limited from below by the anatomical course of the axillary nerve. Existing trans-deltoid access should take place no further than 5 cm below the acromion, otherwise there is a risk of damage to the axillary nerve trunk. The location of the axillary nerve is indicative and there are anatomical features that can lead to a higher location of the nerve. The wider the surgical access, the higher the risk of axillary nerve damage. Moreover, in the anterior sections, the axillary nerve is no longer presented in the form of a clear trunk, but in the form of many branches that innervate the anterior portion of the deltoid muscle. Producing a wide dilution of the deltoid muscle (5-6 cm from the acromion), surgeons cross all the small bundles of nerves that go to the front of the deltoid muscle. This leads to denervation and atrophy of the anterior portion of the deltoid muscle. The less the bundles of the deltoid muscle are bred, the more small branches of the axillary nerve will be preserved.

In addition, the proposed sequence of flashing tendons of the supraspinatus, infraspinatus, and subscapularis muscle with at least separate threads with two stitches each is less convenient, often leading to the use of additional devices for accessing the tendon of the supraspinatus muscle, since after fractures, the displacement of fragments is such that the tendon of the supraspinatus muscle often goes deep under the acromion and it is impossible to physically pull it out for flashing without special devices (knitting needles, elevators, etc.).

In addition, the method of reposition of bone fragments in the known solution is associated with a high risk of displacement during insertion of the implant, due to the fact that after the end of traction for the strands, the fragments return to their place under the influence of muscle force, and when the pin is inserted, there is no center of application of forces during traction. In this case, the installation of proximal locking screws implies the presence of bulky guides that interfere with the preservation of traction by the joysticks.

In addition, fixing the joystick threads to the screw caps also has its drawbacks. The screw caps for the locking pin are barrel-shaped. When the screws are inserted tightly to the bone, there is absolutely no room left for the thread to be thrown onto the screw head. This may cause the thread to slip off the screw head and loosen it. Shortening the screw to the bone to facilitate fixation of the thread around it can lead to subacromial impingement (collision of the screw head and the acromial process of the scapula). In addition, the attachment of threads from the supraspinatus and infraspinatus muscle to the screw fixing the large tubercle (the point of attachment of these muscles), and from the tendon of the subscapular muscle to the screw through the small tubercle, increases the tearing force applied to the screw.

In addition, this type of osteosynthesis can be used only in the early stages after an injury. After 5-7 days, the scars formed between the fragments will not allow for accurate reposition of the fragments using this technique, or require additional surgical access.

An additional injury to the joint is inflicted by an incision in the supraspinatus muscle (1-1.5 cm) to form a channel for insertion of a pin.

The technical problem to be solved is the development of a technically simple, anatomical, and low-traumatic method for osteosynthesis of complex multi-fragmented fractures of the proximal shoulder with a decrease in bone density using an allogeneic bone graft and plate, which provides strengthening of the humerus bone tissue, adequate reposition of fragments, their reliable fixation, and prevention of secondary displacement at any time after the injury.

Disclosure of the invention

The technical result to which the claimed invention is directed is to strengthen the proximal humerus with reliable reposition and fixation of fragments during surgical treatment of complex multi-fragmented fractures of the shoulder (heavy 3-4 fragment fractures of the proximal humerus), accompanied by bone deficiency, on any terms after injury, while minimizing the risk of complications caused by surgery.

The technical result is ensured by a complex of techniques, including the use of an allogeneic bone graft from a fragment of the fibula in combination with the technique of reposition and fixation in the process of surgical treatment of a fracture of the humerus. The transplant used has osteoconductive properties, can serve as a carrier of biologically active substances and does not require special storage conditions.

The technical result is achieved by implementing the method of osteosynthesis in case of fracture of the proximal humerus, including surgical access to the shoulder joint, suturing of the supraspinatus, infraspinatus and subscapularis muscle with separate threads, followed by reposition of the fragments by means of traction at the ends of the threads conducted through the tendons, after which osteosynthesis is performed with using an implant with fixing the ends of the threads to the implant and fixing the implant to the humerus with locking screws, while:

- additionally, a combined allogeneic bone graft is used, which is a fragment of the fibula of the donor 6-8 cm long, including a head, one of the surfaces of which is beveled, the neck and part of the diaphysis, provided along the entire surface with through channels made with a diameter of not more than 2 mm, located at a distance of 3-5 mm from each other, filled with collagen 1 type of person in the form of a sponge with a fine-meshed structure;

- to the shoulder joint provide deltopectoral access with a cut of the skin and subcutaneous fat between the deltoid and pectoralis major muscle;

- a plate with holes is used as a retainer for holding locking screws for osteosynthesis of the proximal humerus;

- flashing tendons is carried out first of the subscapularis muscle, then supraspinatus and infraspinatus;

- after suturing the tendons with tubercle fragments, they are bred to the sides and the graft is inserted into the medullary canal with the diaphyseal part, where it falls to the head, while the beveled surface of the fibular head is oriented to the articular cavity of the scapula so that the angle between the diaphysis of the humerus and the head of the humerus after reposition was approximately 130 °, and with the thrust behind the threads, the large and small tubercles were compared, the position of the fragments was monitored with a fluoroscope;

- after reposition, the ends of the threads are threaded through the holes provided for holding the threads in the plate, the plate is centered relative to the articular surface of the humerus, after which the central knitting needle is installed in the central hole, followed by reposition of the fragments by traction at the ends of the threads, holding the plate with the central knitting needle;

- the ends of the threads are fixed to the holes in the plate.

Suture of the tendons of the subscapular, supraspinatus and infraspinatus muscles is performed with non-absorbable sutures (Terilen 5, FiberWire 2, etc.) at a distance of 1 cm from the place of attachment of the tendon to the fixation point (large or small tubercle), as shown in FIG. 4, 5. In this case, each tendon is sutured with a cruciform suture with double intersection at a right angle of the suture line, parallel to the corresponding end side of the plate, with the ends of the threads leading out from the outside of the tendon.

The method uses a pre-bent plate for the proximal humerus.

Operational access is performed through standard delto-pectoral access. An incision is made in the skin and subcutaneous fat, starting from the coracoid process of the scapula to the 3/3 of the shoulder 15 cm long, find v.cephalica, and by moving it laterally, they access the deltoid and pectoralis major muscles to the shoulder joint.

For reposition, the ends of the threads coming from the tendons are passed through the holes in the plate corresponding to the direction of the tendon fibers: the threads coming from the subscapularis muscle are passed through the holes on the front edge of the plate, the threads from the supraspinatus muscle through the upper holes in the plate, the threads from infraspinatus muscle - through openings located on the posterior edge of the plate.

The plate is centered after threading through the holes in the plate under the electron-optical transducer, focusing on the articular surface of the humerus, after which the central spoke is inserted through the center of the plate and the center of the humeral head, while achieving the correct angle of inclination of the articular surface of the humerus head to the longitudinal axis of the plate (optimally 130 °).

Reposition of fragments by traction at the ends of the threads is carried out by tensioning the threads (all 3 threads at the same time), fixing the VMP, pressing the plate with your finger to the proximal humerus. In this case, the strands are first tensioned and only then, when the strands are stretched, the plate is pressed against the already repaired fragments of the humerus. This manipulation allows you to achieve a quick and high-quality reposition of fragments and to ensure a snug fit of the plate to the bone.

The plate is fixed to the proximal humerus with lockable screws. The threads are held and the plate is pressed firmly against the bone, and the holes are drilled along the guide of the holes most suitable for screwing in. Then fix the plate with screws. The first to use the holes located in the upper-anterior quadrant of the plate, as they are easy to install from the existing surgical access and allow you to fix the plate in isolation to the proximal bone. After passing the proximal screws, fix the plate to the diaphysis of the bone through the oval hole with a 3.5 mm cortical screw, positioning the front edge of the plate behind the tendon of the long head of the biceps muscle. Control the position of the fragments on the image intensifier tube.

The fixation of the ends of the threads to the holes in the plate is carried out by alternately tying the threads. The subscapular tendon is first fixed to the plate. In the position of the internal rotation of the shoulder, the threads are tied at 6 knots. Further, in the position of abduction and external rotation of the shoulder, the tendon of the supraspinatus muscle is also fixed with 6 nodes. The last step, in the position of the external rotation of the shoulder, the tendon of the infraspinatus muscle is fixed to the plate.

Since the length of the cortical screw, which initially fixes the diaphysis of the bone, is often large, it is subsequently replaced with shorter locking screws

Thus, when implementing the proposed method, the strengthening of the bone tissue of the humerus and reliable fixation of the fracture area are realized through the use of a graft, the head of which does not allow the graft to fall into the bone marrow channel of the humerus, holding it until the fracture is fixed, the neck and upper part of the diaphysis fibula (transplant) fill the defect of the cancellous bone of the shoulder head, reinforce the fracture area. The osteoconductive effect is realized by reducing the mass of cortical and spongy non-demineralized bones by drilling holes with a diameter of 2 mm at a distance of 3-4 mm from each other and due to the presence of sponges of type 1 allogeneic collagen in natural and formed by drilling. The sponge is hygroscopic, i.e. when the sponge is saturated with biologically active substances, the transplant can acquire osteoinductive properties.

In addition, this method of osteosynthesis is feasible at any time after the injury, does not require an additional cut of the tendon of the supraspinatus muscle, and is performed through an anatomically safe interval between the muscles (deltoid and pectoralis major), which excludes damage to the deltoid muscle (as the main force carrying out movement in the shoulder joint) .

Thus, in the claimed solution, in contrast to the prototype method, a bone allogeneic transplant of a certain shape is used, a deltopectoral access is performed, which is performed between the deltoid and pectoralis major muscles, which allows for wide surgical access to the shoulder joint without risk of postoperative neurological complications. Stitching the subscapular muscle tendon with the first stage and traction for this joystick allows you to “pull out” the tendon of the supraspinatus muscle from under the acromion and it is much easier to flash tendons without using metal tools. Reposition of fragments is carried out simultaneously with their fixation to the plate, thereby there is no risk of their displacement with the introduction of the implant. The presence of a central spoke creates a vector of application of all forces, which is directed to the plate. Due to the simultaneous traction of the joysticks and pressing the plate to the bone, a repositional moment is created, which contributes to the simultaneous reposition of all tendons and fragments. Fixation of fragments in the plate occurs without bulky guides, which facilitates maintaining the tension of the threads and maintaining reposition of fragments.

The fixation of the thread in the hole in the plate (compared with the prototype, where the fixation is carried out to the screw caps) is much more reliable, while there is no risk of loosening the fixation.

The sequential flashing of all the tendons of the VMP muscles, regardless of the presence of a bone fragment fracture at the attachment point, allows reposition of the fragments using non-absorbable filament joysticks. Reposition is achieved by setting the central knitting needle and the balance between the filament joysticks. The central knitting needle, as well as the obligatory flashing of all three tendons of the muscles of the VMP, allows you to correctly distribute the forces during reposition, while not shifting the plate (due to the imbalance of the threads). An imbalance of the threads can develop, firstly, when not superimposed for all three tendons. Secondly, even when applying threads for all three tendons, in the absence of a central spoke, traction behind the threads leads to the displacement of the plate up and back. Attempts to simultaneously hold the plate in the correct position and maintain a balance between the strands result either in straining of the strands (and possibly incorrect reposition of fragments) or in violation of the position of the plate (more up and back, which can lead to subacromial impingement syndrome). Pulling the tendon of the VMP muscles to the plate (when pulling the filament joysticks) allows you to put a bone fragment of a large tubercle under the plate, thereby ensuring its tight pressing after the final osteosynthesis and at the same time fixing it with a screw through the maximum bone mass of the fragment.

The developed original sequence of manipulations increases the effectiveness of surgical treatment of complex fractures of the proximal humerus, allows for fast, accurate and reliable reposition, as well as stable fixation in multi-fragmented fractures, including conditions of osteoporosis. The method provides reliable placement of an allogeneic bone graft in the bone canal, tight fixation of the plate to the proximal humerus, reinforced with a bone graft from the fibular head, which minimizes the risk of complications, for example, secondary displacement of fragments, head collapse, eruption of screws in the shoulder cavity the joint

Brief Description of the Drawings

The invention is illustrated by drawings, where in FIG. 1 shows a general view of the graft; FIG. 2 - shows a diagram of the installation of the transplant into the bone marrow canal with suturing the tendons of the rotating cuff of the shoulder; FIG. 3 shows the stitching scheme of the subscapularis muscle, in FIG. 4 is a fracture of the proximal humerus fixed by the plate after reposition of the fragments and tendons attached to the plate with a diagram of the threads passing through the plate, in FIG. Figure 5 shows the individual stages of reposition: A - alternately flashing tendons of the muscles of the upper limbs, positioning the plate, installing the central knitting needle, threading the threads through the corresponding holes in the plate; B, C - thread tension, reposition of fragments;

In FIG. 6-9 presents the results of a study of a particular patient according to example 1 with a multi-fragmented fracture of the proximal humerus with bone deficiency; in particular in FIG. 6 is a radiograph of the left shoulder joint (direct posterior projection), FIG. 7 - MSCT of the left shoulder joint, A - horizontal plane, B - frontal plane, C - sagittal plane; in FIG. 8 - radiograph of the left shoulder joint 8 months after surgery. The fracture is fused. There are no signs of collapse of the humeral head. The diaphyseal perforated part of the graft is still visible; in FIG. 9 - MSCT of the left shoulder joint. The transplant is being rebuilt - there is no border between the cancellous spongy bone and the spongy bone of the transplant, which indicates a pronounced osteoconductive effect of the transplant, A - horizontal plane, B - frontal plane, B - sagittal plane; in FIG. 10-13 show the results of a study of a particular patient according to example 2 with a multi-split fracture of the proximal humerus with bone deficiency, in particular, in FIG. 10 is a radiograph of the left shoulder joint (direct posterior projection); in FIG. 11 - MSCT of the left shoulder joint, A - horizontal plane, B - frontal plane, C - sagittal plane; in FIG. 12 - radiograph of the left shoulder joint 6 months after surgery. The fracture is fused. Small collapse of the humeral head. The diaphyseal perforated portion of the graft is still visible, in FIG. 13 - MSCT of the left shoulder joint. The graft is being rebuilt - the border between the cancellous spongy bone and the spongy bone of the transplant disappears, which indicates a pronounced osteoconductive effect of the graft.

The implementation of the invention

Below is a more detailed description of the proposed solution.

Before starting surgical treatment, a combined allogeneic bone graft is made. For the manufacture of a transplant, use the head, neck and part of the fibular diaphysis obtained during the posthumous donation in accordance with the law of the Russian Federation of December 22, 1992 No. 4180-1 “On transplantation of organs and (or) human tissues”. The fibula is obtained from the shin of a cadaver no later than 24 hours after death. A longitudinal outer incision along the lower leg exposes the entire fibula, remove it. The extracted material is frozen at a temperature of -40 ° C and quarantined until tests for vector-borne infections are obtained.

After confirming the absence of infections, a fragment is cut off from the frozen fibula, including the head of the fibula with the neck and part of the diaphysis in such a way that the total length is 6-8 cm. The periosteum, cartilage and soft tissue residues are removed with an electric band saw. Then, drill holes with a diameter of 2 mm form through holes on the entire surface of the bone at a distance of 3-5 mm from each other, thereby reducing the mass of the bone, and creating niches for filling with a type 1 collagen solution. The resulting bone block is immersed in a 3% hydrogen peroxide solution and under vacuum suction minus 2 atmospheres to remove fat and bone marrow residues. The hydrogen peroxide solution is changed every 20 minutes until the solution becomes light. The next step, the bone is washed 3-4 times in physiological saline and again immersed in a 3% hydrogen peroxide solution and left in a refrigerator at + 4 ° C on a medical shaker. After 12-20 hours, bone fragments are immersed for dehydration in 95% alcohol and left for a day at a temperature of + 4 ° on a medical shaker. After extraction from alcohol, for degreasing, the bone is poured with a mixture of 95% alcohol and ether in a ratio of 1: 1 per day. Then fill in with pure ether for a day. The last step is passively drying the product in a fume hood for 24 hours. The bone block is ready for saturation with a type 1 collagen solution.

To increase the osteoconductive potential and increase the hygroscopicity of the graft, the bone is saturated with a 5% collagen solution in a special centrifuge. The graft is placed in a sterile disposable container with rigid walls and a lid (for example, a plastic tube with a screw cap). The container is poured with a human type 1 collagen solution so that it completely covers the bone, the container is closed with a lid and placed in a centrifuge. Centrifugation is carried out with an acceleration of 100g for 30 minutes The amount of collagen in the test tube decreases during centrifugation (goes to the bone), so the collagen is periodically added so that it again covers the graft and the centrifugation session is repeated until the collagen volume ceases to decrease. This is regarded as complete saturation of the bone with collagen.

After saturation of the product with collagen, it is frozen at a temperature of -80 °, placed in a lyophilic chamber and lyophilized for 2.5-4 hours until the collagen completely dries. After lyophilization, the collagen solution, which is located in the bone graft in the formed channels, is transformed into a hygroscopic sponge with a pronounced osteoconductive effect and, due to its hygroscopicity, can be a carrier of biologically active substances. After thawing, the graft can be used in the treatment of complex fractures of the proximal humerus.

The following is a more detailed description of a method for the surgical treatment of complex multi-fragmented fractures of the proximal humerus accompanied by bone deficiency using an allogeneic bone graft.

If the patient has a three - four-fragment fracture of the proximal humerus against osteoporosis accompanied by bone deficiency, which is diagnosed with computed tomography of the shoulder joint, the proximal humerus is exposed by delto-pectoral access. The operation is performed under conduction anesthesia in the position of the patient on the back. The patient is laid eccentrically relative to the longitudinal axis of the operating table, shifting the injured shoulder closer to the center of the table. The patient's head is fixed with additional stops, the electron-optical converter is placed on the side of a healthy shoulder girdle. Delta-pectoral access is as follows. An incision is made in the skin and subcutaneous adipose tissue starting from the coracoid process of the scapula to the 3/3 of the shoulder 15 cm long, find v.cephalica, and deflecting it laterally access between the deltoid and pectoralis major muscles to the shoulder joint. After access to the humerus, they alternately identify: the pectoralis major muscle, the tendon of the long biceps muscle head coming out from under it, the short head of the biceps muscle. The tendon of the long head of the biceps muscle is traced to the level of the inter-tubercle groove and we identify the large and small tubercles of the humerus. From the small tubercle begins the tendon of the subscapularis muscle, which goes under the short head of the biceps muscle.

After identifying the damaged structures - the head of the shoulder, the large and small tubercles, the tendons of the subscapular, supraspinatus, infraspinatus and small round muscles are sequentially stitched with non-absorbable sutures (for example, Terylene 5, Fiber Wire 2). In particular, the tendon of the subscapularis muscle is found in the first stage and stitched. Suturing of the tendon of the subscapularis muscle is performed by threads at a distance of 1 cm from a small tubercle. Next, the threads are taken to the clip. The second stage is the flashing of the tendon of the supraspinatus muscle. For this, the acromial-coracoid ligament is identified, it is brought up, after which traction for the tendon of the subscapularis muscle is found, and the tendon of the supraspinatus muscle is found and removed from under the acromial process of the scapula. The tendon stitching pattern and thread type are the same for all tendons of the muscles of the rotator cuff of the shoulder. Moreover, the thinner and stronger the threads used, the smaller the nodes will be after fixing the tendons to the plate. The third stage identifies and sutures the tendon of the infraspinatus muscle. A muscle tendon is attached to the middle of the posterior edge of a large tubercle. To facilitate flashing of the tendon of the infraspinatus muscle, traction is used for the tendon of the supraspinatus muscle. The result is three filament joysticks (subscapular, supraspinatus and supraspinatus). These joysticks allow you to fully control the position of fragments and the head of the humerus without the risk of eruption, which often happens with spoke joysticks in conditions of reduced bone mass in the elderly. The indicated sequence of muscle flashing makes it possible to gradually achieve reduction of fragments of the humeral head. Manipulation with the first holding joystick allows you to achieve a partial reposition of the humeral head and facilitate access to the tendon of the supraspinatus muscle, which is located deep in the subacromial space. Stitching of the supraspinatus muscle tendon with the second stage and manipulation of this (second) joystick allows you to access and flash even more difficult to achieve (through the anterior deltopectoral surgical access) tendon of the external rotator (infraspinatus muscle).

Using the threads as reins, the tendons and the remnants of the tubercles attached to them are bred to the sides. The bone marrow canal of the humerus and the subchondral bone of the humeral head are opened for review. The rehydration transplant obtained in a bone jar is soaked for 15 minutes in physiological saline or saturated with biologically active substances, for example, an autologous platelet lysate, platelet-rich plasma, and bone morphogenetic protein. After that, the transplant is inserted into the bone marrow canal by the diaphyseal part, where it falls to the head. One of the surfaces of the head of the fibula is beveled. This surface is oriented to the articular cavity of the scapula, because the angle between the diaphysis of the humerus and the head of the humerus after reposition should be approximately 130 °. By pulling the strings, the remains of the tubercles and the head of the shoulder are pulled onto the head of the fibula “like a hood on the head”. The beveled surface of the head of the fibula allows you to orient the head of the humerus at an angle of about 130 ° without effort. Using filaments, large and small tubercles are compared. A fluoroscope controls the position of the fragments.

The next step is to sequentially thread the threads coming from the tendons of the VMP (rotatable cuff of the shoulder) through the corresponding holes in the plate for the proximal humerus. In this invention, the openings of the plates for the proximal humerus are used to suture all three tendons of the muscles of the rotator cuff of the shoulder, regardless of the presence of a fracture of the corresponding fragment of the humerus (in contrast to the recommendations of the plate manufacturer), because this allows you to achieve the correct balance of forces during reposition of fragments and improve the tightness of the plate to the bone, thereby increasing the strength of fracture fixation. With a satisfactory position of the fragments, the plate is positioned, positioning it behind the intermine furrow and 5-10 mm below the upper edge of the large tubercle, the threads are passed through special holes in the plate with angular stability for the proximal shoulder (DC or PHILOS). Tighten the threads, thereby correctly positioning the plate - 5 - 10 mm distal to the apex of a large tubercle and posterior to the crest of a large tubercle. Temporarily fix the plate to the head with the central Kirschner spoke. The presence of a graft allows you to do this, because a transplant head consisting of cancellous bone replaces a bone defect in the head of the humerus. The presence of a spoke allows you to press the plate centered while tensioning the threads, while the installation of this central spoke determines the reposition vector of the broken sections of the proximal humerus. Sewing in the tendons of the VMP muscles, which are attached to unbroken fragments, creates compensatory forces that prevent the bending of the spokes and one-sided (acentric) displacement of the plate, which also forms the correct vector of reposition of the broken fragments.

The position of the plate is checked for image intensifier tubes, being guided by the location of the central spokes.

After that, the tension of the threads fixing the VMP is produced, pressing the plate with the finger to the proximal part of the humerus. This manipulation allows you to achieve a quick and high-quality reposition of fragments and to ensure a snug fit of the plate to the bone.

The next step is to fix the plate to the proximal humerus with lockable screws. The plate is placed on the plate, which does not require an additional incision in the tendon of the supraspinatus muscle. Holding the threads and tightly pressing the plate to the bone, they drill through the guide of the holes most suitable for screwing in. Then fix the plate with screws. The holes in the upper-anterior quadrant of the plate should be used first, since they are easy to install from the existing surgical access and allow the plate to be fixed in isolation to the proximal part of the bone. 2-3 proximal screws are inserted through the plate into the head, which, thanks to the graft, are firmly fixed in the spongy bone of the graft and the remains of the subchondral bone of the humeral head. The next stage, the plate is attached to the diaphysis of the humerus through the oval hole of the plate with a 3.5 mm cortical screw, positioning the front edge of the plate behind the tendon of the long head of the biceps muscle. The plate on the diaphysis should be located posteriorly and parallel to the outer edge of the inter-tubercle groove. Control the position of the fragments on the image intensifier tube. Screwing in the diaphyseal screw allows you to achieve the correct reposition of the diaphysis relative to the proximal bone.

The next step is to tighten and fix the threads to the plate, remove the central spokes and install additional screws. In this case, the subscapularis muscle is fixed through the holes on the front edge of the plate, the supraspinatus muscle through the posterior-upper holes in the plate, the supraspinatus muscle through the holes located on the rear edge of the plate. Since the length of the cortical screw, which originally fixes the diaphysis of the bone, is often large, it is subsequently replaced by shorter blocking screws. The fixation of fragments by the plate is carried out according to the principles of absolute stability, which allows to achieve a strong fixation and begin early rehabilitation.

Clinical example 1. Patient M., 56 years old, turned to the SRI SP after falling on the street. Upon admission, a closed multi-fragmented fracture of the proximal metaepiphysis of the left humerus was diagnosed with displacement (see Fig. 6-9). On the 7th day, osteosynthesis of the proximal metaepiphysis of the left humerus was performed with a plate with angular stability with bone grafting using a combined allogeneic transplant from the head of the fibula. In the postoperative period, the arm was alternately immobilized with a kerchief bandage for 6 weeks, the patient was engaged in therapeutic exercises. During control radiography and MSCT, 8 months after the operation, it was revealed that there was no secondary displacement of the fragments, the fracture was growing together, and the graft was rebuilding.

Clinical example 2. Patient M., 76 years old, came to the SRI SP after falling on the street. Upon admission, a closed multi-fragmented fracture of the proximal metaepiphysis of the left humerus was diagnosed with displacement (see Fig. 10-13). On the 4th day, osteosynthesis of the proximal metaepiphysis of the left humerus was performed with a plate with angular stability with bone grafting by the claimed combined allogeneic transplant from the fibula head. In the postoperative period, the arm was alternately immobilized with a kerchief bandage for 6 weeks, the patient was engaged in therapeutic exercises. During control radiography and MSCT, 6 months after the operation, it was revealed that there was no secondary displacement of the fragments, the fracture was growing together, and the graft was rebuilding.

Claims (9)

1. A method of osteosynthesis in a fracture of the proximal humerus, including surgical deltopectoral access to the shoulder joint between the deltoid and pectoralis major muscle with a cut of the skin and subcutaneous fat along the deltopectoral groove; stitching with separate strands of tendons, first the subscapularis muscle, then the supraspinatus and infraspinatus muscles, after which the thrust behind the strands of the tendon with the remnants of the tubercles is pulled apart and a bone allogeneic transplant is introduced into the marrow canal, which is a fragment of the fibula 6-8 cm long, including the head having a beveled surface, a neck and a part of the diaphysis, and provided with through channels along the entire surface filled with a sponge from type 1 collagen of a person, while the transplant is introduced into the bone marrow canal by the diaphyseal part, orienting the beveled surface of the head to the articular cavity of the scapula, so that after reposition angle between the diaphysis of the humerus and the head of the humerus was 130 °; then the threads with which the tendons of the rotator cuff of the shoulder are sewn are passed through the holes of the plate for osteosynthesis of fractures of the proximal humerus, after which, under the control of the fluoroscope, this plate is laid 0.5-1.0 cm distal to the apex of the large tubercle posteriorly and parallel to the crest of the large tubercle, so that the angle between the plane of the articular surface and the longitudinal axis of the plate corresponded to the cervical-diaphyseal angle of the humerus, a needle is inserted through the central hole in the plate into the head of the humerus and pulls the ends of all the threads drawn through the holes in the plate, while pressing the plate against the proximal humerus, reposition of fragments, pulling them onto the graft; after which the plate is fixed with lockable screws, and the ends of the threads are fixed in the holes of the plate. 2. The method according to p. 1, characterized in that the through channels in the bone allogeneic transplant are made with a diameter of not more than 2 mm, are located at a distance of 3-5 mm from each other, while the channels are filled with collagen in the form of a sponge. 3. The method according to p. 1, characterized in that the flashing of the tendons of the subscapular, supraspinatus and infraspinatus muscles is carried out with non-absorbable sutures at a distance of 1 cm from the attachment point with three stitches. 4. The method according to p. 1, characterized in that they use a pre-bent plate for the proximal shoulder. 5. The method according to p. 1, characterized in that the deltopectoral access is carried out through an incision of the skin and subcutaneous fat, starting from the coracoid process of the scapula to the upper third of the shoulder 15 cm long, find v.cephalica and, removing it laterally, access between deltoid and pectoralis major muscles to the shoulder joint, followed by visualization of the tendon of the long head of the biceps of the shoulder, the small tubercle and the tendon of the subscapularis muscle starting from it. 6. The method according to p. 1, characterized in that the central spoke through the Central hole of the plate to center it is carried out at an angle of 130 ° to the longitudinal axis of the plate to the center of the articular surface of the humeral head to the subchondral layer. 7. The method according to claim 1, characterized in that for reposition of the fragments, traction beyond the ends of all 3 strands simultaneously begins at the moment when the plate is 1-1.5 cm from the bone, while after reposition of the fragments, pressing the plate to the bone finger carry it by sliding along the central spoke to the location in the correct position on the head of the humerus. 8. The method according to p. 1, characterized in that the plate is mounted on the bone and fixed to the proximal humerus with lockable screws, while holding the threads and tightly pressing the plate to the bone, drill holes for screwing in the upper the front square of the plate, after which the plate is fixed with screws to the proximal part of the bone, then the plate is fixed to the bone diaphysis through the oval hole with a 3.5 mm cortical screw, positioning the front edge of the plate behind the tendon of the long head of the biceps muscle. 9. The method according to p. 1, characterized in that the fixation of the ends of the threads to the holes in the plate is carried out by interrupted sutures.

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