RU2729734C1 - Savushkin method of surgical repair of extensor tendons by tendon suture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and can be used as tendon suture for tendons, sliding of which does not occur in tendon canal. Fracture reduction and osteosynthesis, "refreshing" of ends of the injured tendon are performed. Transverse sheath is made at the end of the tendon. Needle is pricked in vertical direction from top to bottom, from the edge of tendon 4–6 mm, with the needle passing through the centre of the tendon or from the proximal or distal ends of the tendon. Needle is pricked in on the second end of tendon 4–6 mm from its edge in a direction from below upwards, passing in the centre of the tendon and coming out on its opposite side. Further, the first end of the tendon is pricked in from the first prick in, 1–2 mm distal from the tendon rupture point in the horizontal direction, with the suture passing in the centre of the tendon. Then, the second end of the tendon is pricked in the horizontal direction on the thread exit thread of the same name, needle prick is performed 1–2 mm distally from the point of rupture, and the suture is delivered through the middle of the tendon. Sutures are tightened with free tension of tendon till contact of tendon ends and surgical knot is performed. Passage of the thread through the centre of the tendon forms an overlap of the thread inside the tendon in mutually perpendicular directions with the possibility of reducing a weakening of the tendon with a suture.

EFFECT: method enables reducing the length of the operation and accelerating the healing, as well as simplifying the technique of the tendon suturing ensured by the declared techniques.

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Description

The technical field to which the invention relates

The invention relates to medicine, namely to traumatology and orthopedics, in particular, to the method of I.S. Savushkin. surgical repair of the extensor tendons with a tendon suture and can be used as a tendon suture for other tendons that do not slide in the tendon canal.

State of the art

There is a method of surgical treatment of subcutaneous ruptures of the tendon of the long head of the biceps brachii muscle with insufficient length, which consists in dissecting the soft tissues in the upper and middle third of the shoulder, removing the torn tendon into the wound, dissecting it in the frontal plane for 3-4 cm, introducing it into this "Splitting" of a fine-meshed lavsan tape 10 mm wide, drilling two holes in the intertubercular groove at an angle of 90 ° and fixing one end of the tape to the muscle, and the other end transosoally in the intertubercular groove of the humerus (see Movshovich I.A., Operative Orthopedics: A guide for physicians. M, 1994, p. 118, p. 319-320).

The disadvantage of this method is high trauma, since two large-diameter holes are made in the humerus, which leads to bending of the tendon and disruption of its blood supply, in addition, a foreign body (tape) of significant size remains in the zone of fixation of the tendon.

There is a known method for restoring the Achilles tendon in case of ruptures by fixing the proximal ends, while the proximal section of the tendon is stitched above the damaged zone with two U-shaped loop-shaped sutures, is lowered, displaced anteriorly into the depth of the wound and fixed through the transverse canal to the heel bone, and bundles of split fibers at the ends the tendons are carefully adapted and connected with single thin sutures (see US Pat. RU No. 2201160 IPC А61В 17/56, publ. 03/27/2003, bull. No. 9).

The disadvantage of this method is the long operation time.

There is a method of surgical treatment of subcutaneous ruptures of the tendon of the long head of the biceps brachii muscle with insufficient length, including access to the middle third of the humerus, making holes in the intertubercular groove and fixing the tendon, while the tendon is stitched all over with a tendon suture, holes are drilled in the intertubercular groove under an angle of 45 °, forming them in the form of a cone, the threads of the tendon suture are passed through the holes, the tension of the threads restores muscle tone and the threads are tied, forming a blocking knot (see US Pat. RU No. 2318462 IPC AVI 17/56, publ. 03/10/2008 , bulletin No. 7).

The disadvantage of this method is trauma, since holes are drilled in the intertubercular sulcus at an angle of 45 °, forming them in the form of a cone, which disrupts its blood supply.

There is a method for restoring a defect in the extensor tendons of the fingers of the hand, including linear cuts in the projection of the ulnar flexor of the hand and in the area of the dorsum of the lower third of the forearm, as well as stitching together the muscle-tendon parts of the extensor tendons of the 1st finger and the muscle-tendon part of the long muscle tendon, abducting the 1st finger, holding the tendon of the ulnar flexor of the hand from the ulnar side of the forearm to its dorsum and stitching it to the previously sewn tendons of the 1st finger by forming a loop with maximum extension and abduction of 1 finger, as well as stitching together the distal muscle-tendon parts of the extensors of 2-5 fingers of the hand, while additionally plastic restoration of the tendons of the extensors of 2-5 fingers of the hand is carried out by replacing their defect with an autotendon of the long palmar muscle at maximum extension of the hand and plastic is performed of the defect of the ulnar extensor of the hand also in the position of its maximum extension bathing with an autotendon of the plantar muscle of the leg (see. pat. RU No. 2357691 IPC A61B 17/56, publ. June 10, 2009, bul. No. 16).

The disadvantage of this method is the complexity of the operation, trauma and long-term treatment.

A known method of surgical treatment of a fresh subcutaneous rupture of the Achilles tendon, including the imposition of a percutaneous suture on the proximal fragment of the tendon and fixation of the thread, while the suture thread is consistently applied to the proximal end of the tendon, a Cuneo suture is applied to the distal end, a cruciate suture is applied to the distal end, and the heel canal is formed, a through canal is formed fixed to the ends of the thread, freely passing through the canal of the calcaneus (see US Pat. RU No. 2393804 IPC A61B 17/56, publ. 10.07.2010, bull. No. 19).

The disadvantage of this method is the long-term postoperative healing of the tendon.

There is a known method of reinforcing the Achilles tendon, including holding an autotendon in its thickness, while for reinforcement a portion of the longitudinally split tendon of the long peroneal muscle is used on the distal base, which is U-shaped along the Achilles tendon through a through channel formed in the thickness of its proximal end at a distance of 3 -5 cm from the seam of the Achilles tendon; fix the Achilles tendon and a portion of the tendon of the long peroneal muscle with sutures proximally at the entrance and exit of the through canal and distally, retreating from the Achilles tendon suture by 3-5 cm (see US Pat. RU No. 2 616767 IPC A61B 17/00, publ . 18.04.2017, bulletin No. 11).

However, this method has disadvantages: the complexity of the operation, trauma and long term of treatment.

The closest in technical essence and the achieved positive effect and adopted by the author as a prototype is the surgical approach for intra- and periarticular fractures of the distal radius, including an incision of soft tissues: skin, subcutaneous tissue, own fascia, while the incision starts from the apex of the styloid process of the radial bones, which lead in the proximal direction to the dorsal portion of the cortical plate of the radial bone, after which it is rotated at an angle of 45 degrees and an incision is made proximally 5-7 cm long towards the head of the radial bone, then bluntly penetrate into the interval between the radial artery and the brachioradial tendon muscles in such a way that they expose the place of attachment of the square pronator muscle and the brachioradialis muscle to the lateral edge of the radius, then the tendon part of the square pronator muscle is cut off from the lateral edge of the radius in an acute way and subperiosteal dissection is performed in the medial direction in this way Om that a single full-layer skin - subcutaneous - fascial - muscle flap containing the median nerve, the square pronator muscle and the tendons of the flexor muscles of the hand and fingers in their intact synovial sheaths are retracted medially, fracture reposition and osteosithesis are performed, after osteosynthesis of the fracture in its correct position the tendon part of the square pronator muscle is refixed to the lateral edge of the radius with the seizure of the tendon of the brachioradialis muscle with separate non-absorbable interrupted sutures with an interval of 5 mm each, their own fascia of the forearm and skin are sutured with individual interrupted sutures (see. pat. RU No. 2668478 IPC A61B 17/56, publ. 01.10.2018, bul. No. 28).

However, this method has drawbacks: the complexity of the operation, trauma, and the execution of the tendon suture with separate non-absorbable interrupted sutures with an interval of 5 mm each does not provide fast healing, which contributes to the possibility of cutting the tendon with a thread and the failure of the tendon suture.

Disclosure of invention

The objective of the present invention is to develop a method for surgical restoration of extensor tendons with a tendon suture, which simplifies the method, shortens the operation time and accelerates healing.

The technical result, which can be achieved with the help of the present invention, comes down to simplifying the method, shortening the operation time and accelerating healing.

The technical result is achieved using a method of surgical restoration of the extensor tendons with a tendon suture, including performing fracture reposition and osteosynthesis, while the tendon suture is performed after "refreshing" the ends of the damaged tendon, and the cut at the end of the tendon is carried out in the transverse direction for contact between the ends of the tendon, while at the beginning of the tendon suture, the needle is inserted in a vertical direction from top to bottom, retreating from the edge of the tendon 4-6 mm with the passage of the needle through the center of the tendon, or from the proximal or from the distal ends of the tendon, then followed by the injection of the needle at the second end of the tendon, retreating from its edge 4-6 mm, in the direction from bottom to top, passing through the center of the tendon and exiting on the opposite side, making an injection at the first end of the tendon, departing from the first injection 1-2 mm distal to the tendon rupture site in the horizontal direction with the thread passing through the center tendon exercise an injection at the second end of the tendon in the horizontal direction on the side of the thread exit of the same name, while the needle is inserted 1-2 mm distal from the break, and the thread is passed through the middle of the tendon, then the thread is pulled with free tension of the tendon until the contact of the tendon ends and a surgical knot is performed, while the passage of the thread through the center of the tendon forms an overlap of the thread inside the tendon in mutually perpendicular directions with the possibility of reducing the eruption of the tendon by the thread.

Thus, the stated technical result is achieved using the method of surgical restoration of the extensor tendons with a tendon suture, while the tendon suture is performed after the wound toilet and "refreshing" the ends of the damaged tendon, and the cut at the end of the tendon must pass in the transverse direction in order to achieve better contact between the ends of the tendon. The stages of performing the method of surgical restoration of the extensor tendons with a tendon suture are as follows:

- at the first stage of the suture of the tendon, the injection is carried out in a vertical direction from top to bottom, departing from the edge of the tendon 4-6 mm with the passage of the needle strictly through the center of the tendon. The beginning can be carried out both from the proximal and from the distal ends of the tendon. The choice of needle and thread is carried out in accordance with the diameter of the tendon on which the suture will be applied;

- at the second stage, the needle is injected at the second end of the tendon, departing from its edge a similar distance, 4-6 mm in the direction from bottom to top, strictly passing through the center of the tendon and exiting on the opposite side of it;

- at the third stage, the injection is carried out at the first end of the tendon, departing from the first injection 1-2 mm distal to the place of tendon rupture in the horizontal direction with the passage of the thread strictly in the center of the tendon;

- at the fourth stage, the injection is carried out at the second end of the tendon in the horizontal direction on the same side of the thread exit after the third stage of the tendon, while the injection is also carried out 1-2 mm distal from the rupture site, and the thread passes strictly through the middle of the tendon;

- at the fifth stage, the thread is tightened and the surgical knot is performed. Tightening of the thread is carried out with free tension of the tendon until the contact of the tendon ends. The passage of the thread through the center of the tendon and the formation of the overlap of the thread inside the tendon in mutually perpendicular directions creates conditions for reducing the teething of the tendon by the thread, since excessive tightening of the thread leads to the formation of excessive compression on the tendon, shortening it and the formation of a coarse knot significantly exceeding the size of the tendon, which is negative affects its further sliding.

Fixation of the tendon by any means is undesirable, as this can lead to a decrease in the contact of the tendon ends and the failure of the tendon suture. If necessary, the surgeon can supplement the tendon suture with individual adaptive interrupted sutures.

The strength characteristics of the seam allow early development of the injured limb. The proposed method of surgical restoration of the extensor tendons with a tendon suture is intended for suturing the extensor tendons, as well as other tendons, which do not slide in the tendon canal. A feature of the method is its simplicity and speed of execution, which is a key factor in case of simultaneous damage to a large number of tendons and during replantation of a limb and allows to reduce the time of surgery.

The essence of the method for performing surgical repair of the extensor tendons with a tendon suture is as follows.

The method of surgical restoration of extensor tendons with a tendon suture includes performing fracture reposition and osteosynthesis, while the tendon suture is performed after "refreshing" the ends of the damaged tendon, and the cut at the end of the tendon is carried out in the transverse direction for contact between the ends of the tendon, while at the beginning the tendon suture is carried out injecting the needle in a vertical direction from top to bottom, retreating from the edge of the tendon 4-6 mm with the passage of the needle through the center of the tendon, or from the proximal or from the distal ends of the tendon, then followed by the injection of the needle at the second end of the tendon, departing from its edge 4- 6 mm, in the direction from bottom to top, passing through the center of the tendon and exiting on the opposite side of it, performing an injection at the first end of the tendon, departing from the first injection 1-2 mm distal to the tendon rupture site in the horizontal direction with the thread passing through the center of the tendon, performing an injection on the second end of the tendon horizontally direction on the side of the thread exit of the same name, while the needle is inserted 1-2 mm distal from the break, and the thread is passed through the middle of the tendon, then the thread is pulled with free tension of the tendon until the contact of the tendon ends and a surgical unit is performed, while the passage of the thread through the center of the tendon forms an overlap of the thread inside the tendon in mutually perpendicular directions with the possibility of reducing the eruption of the tendon by the thread.

Brief description of drawings and other materials

FIG. 1 shows a method of surgical restoration of the extensor tendons with a tendon suture, the implementation of the injection in the vertical direction from top to bottom, general view.

FIG. 2, the same, the implementation of the injection of the needle at the second end of the tendon, departing from its edge a distance, 4-6 mm in the direction from bottom to top, strictly passing through the center of the tendon and exiting on the opposite side of it;

FIG. 3, the same, the implementation of the injection of the needle at the first end of the tendon, departing from the first injection 1-2 mm distal to the place of tendon rupture in the horizontal direction with the passage of the thread strictly in the center of the tendon;

FIG. 4, the same, the injection is carried out at the second end of the tendon in the horizontal direction on the same side of the thread exit after the third stage of the tendon;

FIG. 5, the same, thread tightening is performed and a surgical knot is performed.

Implementation of the invention

Examples of a specific implementation of the method for surgical restoration of extensor tendons with a tendon suture.

Example 1. A method of surgical restoration of extensor tendons with a tendon suture is as follows.

For a better understanding of the method of surgical repair of the extensor tendons with a tendon suture, the suture is schematically shown in FIG. 1, 2, 3, 4, 5 where:

- tendon 1 - first end, tendon 2 - second end, suture 3, tightening 4 sutures 3, surgical knot 5, while the method of surgical restoration of tendons 1, 2 extensors with a tendon suture includes performing fracture reposition and osteosynthesis, while the tendon suture is performed after "refreshing" the ends of the damaged tendon 1, 2, and the cut at the end of the tendon 1, 2 is carried out in the transverse direction for contact between the first and second ends of the tendon 1, 2, while at the beginning of the tendon suture, a needle is inserted (not shown in Fig. ) in a vertical direction from top to bottom, retreating from the edge of the tendon 4-6 mm with the passage of the needle through the center of the tendon 2, or from the proximal or from the distal ends of the tendon 2, then followed by the injection of the needle at the second end of the tendon 1, retreating from its edge similarly 4-6 mm, in the direction from bottom to top, passing strictly along the center of tendon 1 and exiting on the opposite side of it, then by injection at the first end tendon 1, deviating from the first injection, 1-2 mm distal to the place of rupture of tendon 1 in the horizontal direction with the passage of the thread 3 strictly in the center of the tendon 1, making the injection at the second end of the tendon 2 in the horizontal direction on the side of the thread 3 of the same name, while the needle is inserted 1-2 mm distal from the rupture site, and thread 3 is passed strictly through the middle of tendon 2, then thread 3 is tightened with free tension of tendon 2 until the contact of tendon 1, 2 ends and surgical knot 5 is performed, while thread 3 passes through the center of the tendon 1, 2 forms an overlap of the thread 3 inside the tendon 1, 2 in mutually perpendicular directions with the possibility of reducing the eruption of the tendon with the thread 3.

The proposed method of surgical restoration of the extensor tendons with a tendon suture was tested on 10 patients - the experimental group and 10 patients - the control group in which the method of surgical restoration of the extensor tendons was carried out in a conventional way (see Movshovich I.A., Operative Orthopedics: A Guide for Physicians. M, 1994 , p. 118, p. 319-320).

Nosology: open fracture of the distal metaepiphysis of the left radial bone, chopped wound of the left forearm with damage to the extensor tendons of 1-5 fingers; laceration of the left forearm in the lower third with damage to the tendons of the short and long radial extensors of the wrist, short and long extensors of 1 finger, own extensor of 2 fingers; laceration of the left leg with damage to the tendons of the anterior tibial muscle, extensor longus of 1 finger, long extensor digits. In the control group, 7 patients aged from 28 to 46 years had weak characteristics of the tendon suture, namely, thread eruption, which did not allow early development of the injured limb. In the experimental group: the postoperative scars are even, without eruption of threads, which made it possible to perform early development of the injured limb.

Examples of specific clinical implementation on patients of the method of surgical restoration of extensor tendons with a tendon suture.

Example 2. Patient M., 56 years old, as a result of careless handling with an ax, received an open fracture of the distal metaepiphysis of the left radial bone, a chopped wound of the left forearm with damage to the extensor tendons of 1-5 digits, short and long radial extensors of the wrist, superficial branch of the radial nerve, dorsal carpal branches of the radial artery. On an emergency basis, the osteosynthesis of the radius with screws, the suture of the artery, nerve, and all 9 tendons was performed using the proposed method. they were damaged outside the tendon canals. Plaster immobilization was applied. Passive development started from 4 days after the operation, active movements are carried out 3 weeks after the operation. In the long term, complete restoration of function.

Example 3. Patient K., 19 years old, as a result of damage to the disk of a grinding machine ("Bulgarian") received a lacerated wound in the left forearm in the lower third with damage to the tendons of the short and long radial extensors of the wrist, short and long extensors of 1 finger, own extensor of 2 fingers, and also partial damage to the extensor tendon of the fingers. On an urgent basis, the primary surgical treatment of the wound, the suture of all damaged tendons was performed. Plaster immobilization. Passive development started from 4 days after the operation, active movements are carried out 2 weeks after the operation. In the long term, complete restoration of function.

Example 4. Patient L., 38 years old, as a result of careless handling with a circular saw, received a lacerated wound of the left leg with damage to the tendons of the anterior tibial muscle, long extensor of 1 finger, long extensor of fingers. The primary surgical treatment of the wound was performed. The torn edges of the wound and tendons were excised - the tendons were sutured. Plaster immobilization. Plaster immobilization. Passive development started from 4 days after the operation, active movements are carried out 3 weeks after the operation. In the long term, complete restoration of function.

The postoperative period in all patients in examples 2, 3, 4 was uneventful. Healing of the tendons occurred by primary suturing with a tendon suture. The patients were examined after 1 and 3 months. Healing is noted by primary suturing with a tendon suture. Recovery.

The proposed invention has the following advantages in comparison with the prototype and other known technical solutions:

- simplification of the method of surgical restoration of the extensor tendons with a tendon suture;

- the possibility of suturing the extensor tendons, as well as other tendons, the sliding of which does not occur in the tendon canal;

- reducing the time of the surgical intervention;

- acceleration of healing.

Claims (1)

A method of surgical restoration of extensor tendons with a tendon suture, including performing fracture reposition and osteosynthesis, while the tendon suture is performed after "refreshing" the ends of the damaged tendon, and the cut at the end of the tendon is carried out in the transverse direction for contact between the ends of the tendon, characterized in that at the beginning of the tendon the suture is inserted into the needle in a vertical direction from top to bottom, departing from the edge of the tendon 4-6 mm, with the passage of the needle through the center of the tendon or from the proximal or from the distal ends of the tendon, then followed by the injection of the needle at the second end of the tendon, departing from its edge 4-6 mm, in the direction from bottom to top, passing through the center of the tendon and exiting on the opposite side of it, performing an injection at the first end of the tendon, departing from the first injection 1-2 mm distal to the tendon rupture site in the horizontal direction, with the thread passing through the center of the tendon by injecting the second end of the tendon in the horizontal direction on the side of the thread exit of the same name, while the needle is inserted 1-2 mm distal from the break, and the thread is passed through the middle of the tendon, then the thread is pulled with free tension of the tendon until the contact of the tendon ends and a surgical unit is performed, while the passage of the thread through the center of the tendon forms an overlap of the thread inside the tendon in mutually perpendicular directions with the possibility of reducing the eruption of the tendon by the thread.

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