RU2723218C1 - Method of treating fresh ruptures of the thigh quadriceps muscle tendon - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, particularly to traumatology, and can be used in treating fresh tendon ruptures of a thigh quadriceps muscle. Tendon is accessed; the tendon stumps are aligned; a suture is sutured with the needle and suture. Four sutures are made of four longitudinal tendons 15 arranged along the tendon cross-section in the thickness of the tendon on the stump joint line, as well as eight embracing loops 1, 2, 3, 4, 5, 6, 7, 8, for each stump arranged in rows of four female hinges symmetrically on both sides of the longitudinal axis of the stump, two locking hinges 9, 10, for each stump, connecting between each other enclosing loops on each side of the stump longitudinal axis, and two units 16, for each stump arranged symmetrically, located on both sides of the longitudinal axis of the stump and line joints of tendons. Each knot on the stump is formed in the area of location of the embracing loops by joining ends of thread 11 and 12, 13 and 14, loops of which are located on the opposite stump, and forms additional locking loops 17, 18, located on both sides of longitudinal axis of stump. Threads equipped with two needles at ends are used. After the suture is applied, the wound is treated and sutured together.EFFECT: method provides strong connection of stumps of a torn tendon of thigh quadriceps muscle without disturbing its nutrition and function, due to use of a seam with optimum ratio of strength characteristics and number of threads and loops of forming seam, which provides the required strength, with less disruption of tendon.3 cl, 11 dwg, 1 ex

Description

The field of technology.

The invention relates to medicine, in particular to traumatology, can be used in the treatment of tendon ruptures of the quadriceps femoris.

The level of technology.

The quadriceps femoris is a massive and powerful muscle-tendon complex that includes the rectus lateralis wide, intermediate broad, medial broad muscle. Each muscle has its own origin, but in the knee, all the muscles pass into the common tendon (tendon of the rectus muscle), which covers the patella and attaches to the tibial tuberosity. The quadriceps femoris muscle creates significant effort that is transmitted to the tendon. When treating fresh tendon ruptures of the quadriceps femoris muscle, it is required to provide a reliable, durable joint to the ends of the tendon.

The prior art method for fastening the tendon of the quadriceps femoris muscle with fresh injuries (source [1]: patent RU 2144802). The method is carried out by transosseous fixation of the tendon to the patella. The tendon is fixed with three loop-shaped U-shaped sutures, which are brought to the front surface of the patella through two inclined channels so that the threads of each after binding lie on the tendon bundles attached to the patella. The sutures are reinforced with a synthetic fiber blocking screed, which, in the form of a wide loop-like suture, is passed through the torn tendon along the front surface of the patella and fixed under its ligament, which reduces the duration of immobilization due to the strength of the suture.

In this method [1] the seam uses a six-stitch seam, contains six longitudinal threads and not blocked nodes. Under load, the forces generated by the quadriceps femoris muscle lead to stretching of the nodes and threads, as a result of which diastasis may appear between the connected ends of the tendon. The applied seam requires an increase in mechanical strength and resistance to polycyclic loads.

A known method of applying a tendon suture (source [2]: AF Krasnov, VM Arshin, VV Arshin. Traumatology. Handbook. Rostov-on-Don, publishing house "Phoenix". - 1998. - 608 p. S. 252-254), which consists in holding the thread with two straight needles at the ends in the transverse direction through the tendon, departing from the edge of the damaged end, piercing the tendon obliquely with one and the other needle with crossing the thread in the thickness of the tendon, removing the ends of the thread through the end part of the tendon, holding the threads in the same way at the other end of the tendon and tying the ends of the threads with the formation of intra-trunk sutures

The seam [2] contains two longitudinal veins (filaments) and nodes located at the junction of the ends of the tendon. The seam is weak for the tendon of the quadriceps femoris, requires increased mechanical strength and resistance to polycyclic loads.

Known suture tendons (source [3]: Traumatology and orthopedics. / Under the editorship of GS Yumashev. 3rd edition. M: Medicine, 1990, S. 109-110). The suture begins, stepping back from the edge, passing the thread through the tendon in the transverse direction. Then, from additional injections, both ends of the thread are parallel to the tendon fibers to the edge. After a similar holding of another thread through the second segment of the tendon, the threads are tied.

The seam [3] does not provide strength at high loads, which leads to eruption, rupture of the seam.

A known method of closed recovery of the tendon of the quadriceps femoris muscle (source [4]: patent application RU 93017951). A transverse puncture of soft tissues through the thickness of the tendon of the rectus muscle is made 5–6 cm proximal to the gap area with a cutting needle and suture material is used (lavsan thread, tape). Next, the suture material is carried out sequentially through the puncture points of the skin and soft tissues in a zigzag manner through the thickness of the tendon with the formation of at least two intersections and its ends are brought out through micro incisions to the skin at the level of the tendon rupture line. The second thread (tape) is immersed transdermally around the patella. The ends of the suture are removed along the edges of the base of the patella through the distal part of the tendon rupture and then to the skin through micro-incisions in the exit areas of the ends of the thread. With a single-tooth crochet, the patella is grabbed percutaneously at the apex and pulled up as far as possible to the tear line of the proximal part of the tendon. Tighten and tie the ends of the suture material threads. Knots are immersed under the skin, catgut sutures are applied to microcuts. Additionally, impose nodal immersion sutures along the edges of the quadriceps tendon through the thickness of the tendon of the inner and outer wide muscles and through the thickness of the lateral (medial and lateral) support ligaments of the patella. A gypsum splint is applied for 6 weeks.

The suture [4] does not provide mechanical strength at high loads, which leads to the appearance of diastasis in the stitched tendon.

Tailhefer. Bulletin set memoires de la societe de chirurgie. 1925;51: 959-963), шов по Kessler (Источник[6]: The "grasping" technique for tendon repair. Kessler I. Hand. 1973 Oct; 5(3):253-5), шов по Savage (Источник [7]: In vitro studies of a new method of flexor tendon repair. Savage R.: J Hand Surg Br. 1985 Jun; 10(2):135-41.), шов по Krakow (Источник[8]: A new stitch for ligament-tendon fixation. Brief note. Krackow KA, Thomas SC, Jones LC. a. J Bone Joint Surg Am. 1986 Jun; 68(5):764-6. Источник [9]: Ligament-tendon fixation: analysis of a new stitch and com-parison with standard techniques. Krackow KA, Thomas SC, Jones LC. Orthopedics. 1988; 11:909-17). В классическом исполнении они являются двух- или четырехжильными швами, содержат по 2 или 4 продольных нити, с одной или двумя парами узлов, погруженными между культями поврежденного сухожилия. Способ выполнения сухожильного шва с блокирующими петлями по Krackow (источник [10]: Середа А.П. Лечение свежих разрывов ахиллова сухожилия. Виды сухожильных швов. Рисунок 50. Способ выполнения обвивного сухожильного шва с блокирующими петлями по Krackow. Рисунок 51. Вариации обвивных сухожильных швов с блокирующими петлями по Krackow. Интернет - сайт Клиники травматологии и ортопедии Первого МГМУ им. И.М. Сеченова, режим доступа http://travmaorto.ru/270.html), может быть выполнен одной нитью или представлять собой два шва, расположенных один выше, вокруг или поверх другого под определенным углом. Также может отличаться количество ярусов («мономеров») петель - от двух и больше. Классический шов по Krakow (фиг. 1) состоит из 3-4 пар блокирующих петель, равномерно распределяющих нагрузку на область разрыва сухожилия за счет взаимно симметричного расположения петель и нитей. После прошивания проксимальной и дистальной культи поврежденного сухожилия формируется два узла, расположенных между культями сухожилия на лини стыка. Модификация шва Krakow-Giftbox (фиг. 2) отличается тем, что после прошивания культей сухожилия нити проводятся на противоположную сторону через волокна сухожилия, где на расстоянии от зоны разрыва формируются узлы. Таким образом, шов Krakow-Giftbox является четырехжильным с узлами, расположенными вдали от зоны разрыва.Known tendon sutures for the type of end-to-end used for fresh tendon rupture of the quadriceps femoris. For example, a seam according to Cuneo (Source [5]: Surun cas de suture secondaire des tendons flechisseurs ducinquieme doigt.

Tailhefer. Bulletin set memoires de la societe de chirurgie. 1925; 51: 959-963), Kessler stitch (Source [6]: The "grasping" technique for tendon repair. Kessler I. Hand. 1973 Oct; 5 (3): 253-5), Savage stitch (Source] [7]: In vitro studies of a new method of flexor tendon repair. Savage R .: J Hand Surg Br. 1985 Jun; 10 (2): 135-41.), Krakow stitch (Source [8]: A new stitch for ligament-tendon fixation. Brief note. Krackow KA, Thomas SC, Jones LC. a. J Bone Joint Surg Am. 1986 Jun; 68 (5): 764-6. Source [9]: Ligament-tendon fixation: analysis of a new stitch and com-parison with standard techniques. Krackow KA, Thomas SC, Jones LC. Orthopedics. 1988; 11: 909-17). In the classic version, they are two- or four-vein sutures, contain 2 or 4 longitudinal threads, with one or two pairs of nodes, immersed between the stumps of the damaged tendon. Krackow tendon suture with blocking loops (source [10]: Sereda AP, Treatment of fresh Achilles tendon ruptures. Types of tendon sutures. Figure 50. Krackow twist tendon suture with blocking loops; Fig. 51. Enclosure tendon variations seams with locking loops according to Krackow. Internet site of the Clinic for Traumatology and Orthopedics of the First Moscow State Medical University named after IM Sechenov, access mode http://travmaorto.ru/270.html), can be performed with one thread or can be two seams, located one above, around or on top of the other at a certain angle. The number of tiers ("monomers") of the loops may also differ - from two or more. The classic Krakow suture (Fig. 1) consists of 3-4 pairs of locking loops that evenly distribute the load on the tendon rupture area due to the mutually symmetrical arrangement of the loops and threads. After flashing the proximal and distal stump of the damaged tendon, two nodes are formed located between the stumps of the tendon at the junction line. The modification of the Krakow-Giftbox suture (Fig. 2) is characterized in that after stitching the tendon stitches, the threads are drawn to the opposite side through the tendon fibers, where nodes are formed at a distance from the rupture zone. Thus, the Krakow-Giftbox seam is four-core with nodes located away from the gap zone.

The disadvantages of the analogue [8; 9; 10] are insufficient tensile and tensile strength for those efforts that arise in the tendon of the quadriceps femoris. At the same time, the use of three or four pairs of loops on each side of the torn tendon forces the extensive section of the tendon to be devascularized, which disrupts the nutrition of cells and leads to tissue degradation. Over time and the load on the loops increases, the strands stretch, squeezing the tendon bundles covered by them, loosening the loop, therefore, the more loops are used in the seam, the greater the loss of tension during loading and the greater the likelihood of diastasis between the stumps of the tendon. Due to the presence of longitudinal elements of the suture, the tendon loses its flexibility and elasticity. The out-of-position nodes prevent gliding of the tendon in the thickness of the tissues. Despite the fact that the tendon of the quadriceps femoris muscle, like all extrasynovial tendons, is not so demanding for slipping, leaving a node on the surface of the tendon is undesirable.

Thus, the technical problem is to ensure a strong connection of the ends of the damaged tendon without disturbing its nutrition and function.

The essence of the technical solution.

The task to which the technical solution is directed is to ensure a firm connection of the torn tendon of the quadriceps femoris muscle by increasing the strength of the suture and its resistance to polycyclic loads, reducing trauma to the tendon as a result of suturing.

The technical result consists in providing a solid connection between the stumps of a torn tendon of the quadriceps femoris muscle, a suture with an optimal ratio of strength characteristics and the number of threads and loops forming the suture. The suture providing the necessary strength, with less disruption of the vital activity of the tendon, allows to join the stump of the damaged tendon and hold them in the desired position, improving operating conditions and providing conditions for tissue regeneration.

The technical result is achieved by the fact that in the method of treating fresh tendon ruptures of the quadriceps femoris muscle, they access the tendon, combine tendon stumps, and a suture is applied with a thread and a needle. It is characterized in that a seam is formed of four independent filaments, comprising: eight longitudinal veins located along the tendon cross section in the thickness of the tendon at the junction line of the stumps; eight covering loops, for each stump, arranged in rows of four covering loops symmetrically on two sides of the longitudinal axis of the stump; two blocking loops, for each stump, connecting the covering loops located on each side of the longitudinal axis of the stump, and two nodes for each stump, made symmetrically, located on both sides of the longitudinal axis of the stump and the junction line of the tendons. Each node on the stump is formed in the area of the location of the covering loops by connecting the ends of the thread, the loops of which are located on the opposite stump, and forms additional blocking loops located on both sides of the longitudinal axis of the stump. Use threads equipped with two needles at the ends, after suturing, the wound is treated and sutured in layers.

The method provides a strong connection of the stumps of a torn tendon of the quadriceps femoris.

The method is illustrated by the description, examples of practical use and illustrations, which depict:

FIG. 1 - seam according to Krakow;

FIG. 2 - seam Krakow-Giftbox;

FIG. 3 - shows the first four covering loops of the suture: a continuous line indicates the threads located outside the tendon, a dashed line indicates the threads located inside the tendon;

FIG. 4 - view of the seam after flashing both stumps;

FIG. 5 is a cross-sectional view of a seam along a tear line;

FIG. 6 is a view of the seam after holding the threads on opposite stumps before joining the stumps;

FIG. 7 - photo of the seam, to the junction of the stumps;

FIG. 8 is a view of the seam after tensioning the seam and the junction of the stumps;

FIG. 9 is a photograph of the seam, after tensioning the seam and the junction of the stumps;

FIG. 10 is a view of the seam after the formation and blocking of nodes;

FIG. 11 is a photograph of the seam after the formation and blocking of nodes.

In figures 1 to 11, the numbers indicate:

1 - the first female loop;

2 - second female loop;

3 - the third female loop;

4 - fourth female loop;

5 - fifth female loop;

6 - sixth female loop;

7 - the seventh female loop;

8 - the eighth female loop;

9 - the first blocking loop;

10 - second blocking loop;

11 - the first end of the first thread;

12 - the second end of the first thread;

13 - the first end of the second thread;

14 - the second end of the second thread;

15 - veins of a seam;

16 - node;

17 - the first additional locking loop;

18 - second additional locking loop.

The implementation of the method.

Under anesthesia, through an incision of the soft tissues, access to the tendon of the quadriceps femoris muscle at the site of rupture, expose the stumps of the torn tendon. A thread equipped with two needles is sutured. A four-vein suture is applied to each stump, the ends of the longitudinal threads forming the veins of 15 suture are fixed on the opposite stump. In total, the seam contains eight longitudinal veins 15 (Fig. 5), evenly spaced across the cross section of the tendon in the thickness of the tendon at the junction line of the stumps. To form a suture on each stump, the tendon stump is divided into two halves, located on both sides of the longitudinal axis of the stump. The seam is formed of four independent threads. The seam begin on one half of the stump (Fig. 3). The first thread, a longitudinal injection of a needle with a thread from the side of the gap with a needle out at a distance of 5 to 7 mm from the edge of the stump. Further along the seam line at a distance of 2-3 mm from the needle puncture, the next needle puncture is carried out, directed from top to bottom perpendicular to the length and diameter of the tendon stump. The thread is partially stretched leaving a loop. A needle with a thread is drawn into the loop formed, embracing the extreme bundle of tendon, forming the first female loop 1. The first female loop 1 is pulled and locked. Further, departing from the first female loop 1, a similar second female loop 2 is formed, the extreme bundle of tendon is covered with a thread, the needle is pierced from the bottom up, conducting the thread from the outside to the inside. The second female loop 2 is tightened and locked. They retreat towards the midline of the stump, stretch the thread and form the first blocking loop 9, sticking the needle up and down. Cover the middle bundle of the tendon and inject the needle from the bottom up, form the third covering loop 3. The third covering loop 3 is tightened and blocked. Follow in the opposite direction to the tendon rupture line, along the seam line at a distance of 2-3 mm, needle is injected from top to bottom, leaving part of the thread, cover the middle tendon bundle and inject the needle from the bottom up, form the fourth covering loop 4. The fourth covering loop 4 tighten and block. At a distance of 5 to 7 mm from the edge of the stump, the needle is injected from above toward the tendon rupture and the thread is brought into the gap. Thus, two ends of the first thread 11 and 12 are formed in the gap. The female loops 1, 2, 3, 4 are formed back symmetrically with an equal pitch between the threads. It is important to orient the threads at a right angle and at an equal distance from each other. Suture elements, suture threads located in the loops, form a shape should have a shape close to squares with a side equal to 1/6 of the tendon width. Then, on the principle of mirror symmetry, the second thread with needles is stitched on the other side of the stump, four more covering loops 5, 6, 7, 8, the second blocking loop 13 are formed and the two ends of the second thread 13, 14 are brought into the tendon rupture. In the tendon rupture there are four ends 11, 12, 13, 14 from two threads with needles. Similarly, the opposite stump is stitched (Fig. 4), totaling eight covering loops, two blocking loops and breaking the four ends of the threads with needles into the gap. The needle puncture points on the opposite stumps are located differently: on one side the puncture points are located closer to the center of the cross section of the tendon portion involved in the suture; on the other hand, the injection points are located closer to the periphery. Needles with threads of one stump are carried out on the opposite stump (Fig. 6; 7) according to their puncture points so that all eight threads become parallel. The puncture points correspond to the angles inside the first pairs of blocking loops 9, 10. The threads drawn from the same stump and emerging on the opposite stump, it is convenient to manipulate and apply efforts to tighten the junction line of the stumps. Combine tendon stumps. For the ends of the threads 11, 12, 13, 14 both sides of the seam are pulled up and the stumps are brought together (Fig. 8; 9). On the surface of the tendon, connecting the ends of the threads (11 and 12; 13 and 14) form nodes 16 (Fig. 10; 11) which control the degree of tension of the suture elements. The connected ends of the threads (11 and 12; 13 and 14) form additional blocking loops 17 and 18. After the formation of nodes 16 they are immersed deep into the tendon. The threads are pulled and together with the needle removed remotely from the gap zone. Threads are cut, removing needles and unclaimed remains of threads. As a result, the resulting seam contains: eight longitudinal veins 15 (Fig. 5), evenly spaced across the cross section of the tendon in the thickness of the tendon at the junction line of the stumps; eight covering loops 1, 2, 3, 4, 5, 6, 7, 8, for each stump, arranged in rows of four loops symmetrically on both sides of the longitudinal axis of the stump; two locking loops 9 and 10, for each stump, connecting the surrounding loops (2 and 3; 6 and 7) located on each side of the longitudinal axis of the stump; two nodes made on each stump, symmetrically located on both sides of the longitudinal axis of the stump and the junction line of the tendons; two additional blocking loops connecting the surrounding loops located on each side of the longitudinal axis of the stump. After suturing, the wound is treated and sutured in layers. The seam is eight-strand, with threads symmetrically located relative to the cross section of the tendon. An increase in the number of veins (threads passing intrasternally through the cross section of the tendon) contributes to a more even load distribution, since symmetrically drawn strands hold equal portions of the tendon in volume, avoiding the formation of weaknesses. The seam contains threads drawn through the blocking loops on the opposite side, which after the formation of the node form additional pairs of blocking loops, reducing the load on the nodes themselves, redistributing it to adjacent surrounding loops. Removing nodes from the break line increases the strength of the seam. The completed suture is less extended, which positively affects the viability of the tendon and its regenerative potential. Nodes 16 plunged deep into the tendon fibers.

Clinical example.

A patient with a fresh tendon rupture of the quadriceps femoris muscle (Fig. 7; 9; 11), the injury was received 1 day before the operation. The patient under anesthesia, through an incision of the soft tissues, had access to the tendon of the quadriceps femoris at the rupture site, the stump of the torn tendon was exposed. Woven polyfilament yarns with two atraumatic needles 2/0 (USP) seam. A four-stitch seam was made for each stump (Fig. 7). The ends of the threads stitching one stump are fixed by nodes 16 on the opposite stump (Fig. 11). Four strands were used to form the seam elements on each of the stumps. The suture began on the left half of the proximal stump. With the first thread, we performed a longitudinal injection of the needle with the thread from the rupture side with the needle punctured at a distance of 7 mm from the edge of the proximal stump. Then, at a distance of 2-3 mm from the needle puncture, the next needle puncture was made, directed from top to bottom perpendicular to the surface of the proximal tendon stump. The thread was extended leaving a small loop. A needle with a thread was drawn into a small loop formed, embracing the leftmost tendon bundle with a thread, the first female loop 1 was formed. The first female loop 1 was pulled up and thereby blocked. Further, departing from the first female loop 1, a similar second female loop 2 was formed, embracing the leftmost tendon bundle with a thread, the needle was pierced from the bottom up. The second female loop 2 was pulled up and locked. Stepping back towards the midline of the stump, they stretched the thread and formed the first blocking loop 9, sticking the needle up and down. They covered the middle bundle of the proximal stump and injected the needle from the bottom up, forming the third female loop 3. The third female loop 3 was pulled up and blocked. At a distance of 3 mm, the needle was injected from top to bottom, leaving part of the filament, covering the middle bundle of the proximal stump and pricked the needle from the bottom up, forming the fourth female loop 4. The fourth female loop 4 was pulled up and locked. At a distance of 7 mm from the edge of the proximal stump, a longitudinal injection of the needle was performed from above towards the tendon rupture and the end of the thread was brought into the gap. In the gap formed two ends of the first thread. Suture threads were placed in loops so that the shape of the loops was close to square with a square side equal to 1/6 of the tendon width. Further, in a similar mirror-like manner, the second right side of the proximal stump was stitched with a second thread with needles. Four more covering loops 5, 6, 7, 8, a second blocking loop 13 were formed and the ends of the second thread 13, 14 were brought into the tendon rupture. Similarly, a distal stump was stitched using the third and fourth thread. The ends of the filaments forming a suture on the distal tendon stump were brought out longitudinally to the proximal stump of the tendon. The ends of the filaments forming a suture on the proximal tendon stump brought out the longitudinally distal stump of the tendon. Manipulating the threads and applying effort pulled together the junction line of the stumps, aligning the tendon stump (Fig. 9). The ends of the threads were tied on the surface of the restored tendon, at a distance from the junction line, forming nodes 16 and additional blocking loops 17 and 18. The nodes 16 were immersed deep into the tendon. The threads were cut by removing the needles. The resulting seam contains eight longitudinal veins 15, evenly spaced across the cross section of the tendon in the thickness of the tendon at the junction line of the stumps, eight covering loops 1, 2, 3, 4, 5, 6, 7, 8, four blocking loops evenly located on the tendon. After suturing, the wound was washed, treated with an antiseptic, sewn in layers, and a bandage was applied. The suture showed high tensile strength, diastasis at the junction of the tendon stumps was not found in the postoperative period.

Claims (3)

1. A method of treating fresh tendon ruptures of the quadriceps femoris muscle, in which access to the tendon is made, tendon stumps are combined, a suture is inserted with a thread and a needle, characterized in that a suture is formed from four independent filaments containing eight longitudinal veins located along the tendon cross section in thicker than the tendon at the junction line of the stumps, eight covering loops, for each stump, arranged in rows of four covering loops symmetrically on both sides of the longitudinal axis of the stump, two blocking loops, for each stump, connecting the surrounding loops located on each side of the longitudinal the axis of the stump, and two nodes, for each stump, made symmetrically, located on both sides of the longitudinal axis of the stump and the junction line of the tendons, each node on the stump is formed in the location of the surrounding loops by connecting the ends of the thread, the loops of which are located on the opposite stump, and forms additional blocking loops located on both sides of the longitudinal axis of the stump, use threads equipped with two needles at the ends, after suturing, the wound is treated and sutured in layers. 2. The method according to p. 1, characterized in that the woven multifilament yarn with two atraumatic needles 2/0. 3. The method according to p. 1, characterized in that the threads in the seam loops form a shape close to a square with a side equal to 1/6 of the tendon width.

Images