RU2755833C1 - Method for plastics of the ligamentous apparatus of the acromioclavicular joint in traumatic injury - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to traumatology, and can be used to restore the acromioclavicular joint in case of its dislocation with rupture of the ligamentous apparatus in case of traumatic injury. Access to the acromioclavicular joint by incision of the skin in the projection of the acromioclavicular joint, mobilization of the acromion and clavicle, form two parallel canals in the clavicle and acromion of the scapula, pass through the channels of connecting flexible elements made of non-absorbable suture material - threads, tied to the ends are pulled and the wound is sutured in layers. The formation of channels is carried out in parallel planes vertically located along the axis of the clavicle. Wherein the formation of the canal in the clavicle and the acromion of the scapula is carried out, starting from the surface of the cortical layer with an exit not higher than the middle of the articular surfaces with the formation of pairwise mating exit holes in the articular surfaces, and fixation is carried out with two threads, which are carried out with the help of a conductor. In this case, the first thread is wound from the side of the scapula, passed through the mating outlet openings in the acromion of the scapula and the clavicle and brought out the clavicle. After the first thread leaves the clavicle, before its introduction into the second canal, a second thread is placed under the resulting loop. Then the first thread is passed into the second channel, passed through the mating outlet openings in the clavicle and the scapula acromion, and the scapula acromion is brought out. Then the articular end of the clavicle is immersed in the anatomically correct position and the free ends of the first thread are tied over the bone of the scapula, and the free ends of the second thread are tied to the ends of the first thread.EFFECT: invention provides a decrease in trauma, an increase in the reliability of fixing the clavicle in the correct position in relation to the acromion of the scapula, and also creates the possibility of recreating the upper portion of the acromioclavicular ligaments by performing canals and holding the thread connecting the clavicle and the acromion of the scapula above the zone of location of the subclavian neurovascular bundle and using an additional thread located above the acromioclavicular joint in a taut state.1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology, and can be used to restore the acromioclavicular joint in case of its dislocation with rupture of the ligamentous apparatus, both with "fresh" and with old ones.

There is a known method of plastic ligaments, including access to the acromioclavicular joint by incision of the skin in the projection of the acromioclavicular joint, mobilization of the acromion and the clavicle, the formation of parallel channels in the clavicle and acromion of the scapula, conducting flexible connecting elements through the channels, connecting the ends by tying and layer-by-layer suturing of the wound (see the description of the invention to the patent of the Russian Federation No. 2124871 "Method of surgical treatment of dislocation of the acromial end of the clavicle", IPC A61B 17/56, publ. 20.01.1999).

The known method can be applied both for fresh and old, mainly partial dislocations of the acromial end of the clavicle with rupture of the acromioclavicular ligament.

In the known method, one "bicortical" canal is made in the clavicle and one "bicortical" canal in the acromion so that the upper opening in the clavicle and the lower opening in the acromion are in line with the axis of the end of the clavicle after its reduction.

The canals are formed vertically to the surface of the clavicle bone and acromion, while a flexible connecting element made of a tendon is passed through the canal in the clavicle from bottom to top, and from the upper opening in the clavicle, to the lower opening in the acromion with an exit to the outside.

The disadvantage of this method is high trauma, both when drilling vertically located channels to the thickness of the bone, and when conducting a flexible connecting element from bottom to top, since the risk of injury to large neurovascular formations of the upper limb located near the holes in the clavicle is not excluded.

The known method of plastic ligament, including access to the acromioclavicular joint by incision of the skin in the projection of the acromioclavicular joint, mobilization of the acromion and clavicle, the formation of channels in the clavicle and acromion of the scapula, conducting through the channels of flexible connecting elements made of non-absorbable suture material - thread, connection of its ends of the thread by tying and layer-by-layer suturing of the wound (see the description of the invention to the patent of the Russian Federation No. 2159592 "Method of surgical treatment of dislocation of the acromial end of the clavicle", IPC A61B 17/00, publ. 27.11.2000).

In the known method, bicortical canals are formed vertically to the surface of the clavicle bone and acromion to the thickness of the bone: one canal in the clavicle and two canals in the acromion. A non-absorbable suture material in the form of a thread is used as a connecting element.

One end in the form of a loop of a doubled thread is brought out from the bottom up through the hole in the clavicle to its outer surface and fixed in the acromial part of the clavicle, each of the opposite (free) ends of the thread is brought out through one of the channels to the outer surface of the acromion, tied with a knot, and then passed under the threads on the outer surface of the clavicle and tied with a knot.

The disadvantage of this method is high trauma, both when performing vertically located channels to the thickness of the bone, and when passing the thread from bottom to top, since the risk of injury to large neurovascular formations of the upper limb located near the holes below the clavicle is not excluded.

The closest in technical essence and the achieved result to the proposed method, taken as a prototype, is a method of plastic ligaments, including access to the acromioclavicular joint by incision of the skin in the projection of the acromioclavicular joint, mobilization of the acromion and clavicle, the formation of two parallel located channel in the clavicle and acromion of the scapula, passing through the channels of connecting flexible elements made of non-absorbable suture material - suture, tying with tension of its ends and layer-by-layer stitching of the wound (see the description of the invention to the patent of the Russian Federation No. 2614096 "Method of lavsanoplasty of the acromioclavicular joint ligaments in their break ", IPC A61B 17/00, publ. 03/22/2017).

In the known method, two "bicortical" canals are formed in the acromion, two bicortical canals in the clavicle at the same distance from the articular surface (dorsally and ventrally). A double lavsan thread is passed through the canals, and the thread is passed from top to bottom along the ventral canal in the acromion, then the thread is passed from bottom to top along the ventral canal of the clavicle, then the thread is passed from top to bottom along the dorsal canal of the clavicle, and the thread is finished from bottom to top along the dorsal the acromion channel. By means of finger pressure, the joint is given anatomical integrity. The ends of the thread are tied in a double knot without relieving finger pressure.

The disadvantage of this method is significant trauma, both when performing vertically located channels to the thickness of the bone, and when passing the thread from bottom to top, since a high risk of injury to large neurovascular formations of the upper limb located near the holes in the clavicle is not excluded. In addition, this method does not provide for the reconstruction of the important upper portion of the acromioclavicular ligaments. In addition, if the knot is not pulled out after the thread is passed in a very complex route of the canals, excessive mobility of the acromial end of the clavicle by the "key" type is not excluded.

The technical problem and the result of the proposed invention is to reduce the trauma of the method due to the execution of the channels and the thread connecting the clavicle and the acromion of the scapula above the zone of the location of the subclavian neurovascular bundle, increasing the reliability of fixing the clavicle in the correct position in relation to the acromion of the scapula, as well as the possibility of recreating an important upper portions of the acromioclavicular ligaments due to the use of an additional thread located above the acromioclavicular joint in a taut state.

The technical result is achieved by the fact that the method of plastics of the ligamentous apparatus of the acromioclavicular joint in traumatic injury includes performing access to the acromioclavicular joint by cutting the skin in the projection of the acromioclavicular joint, mobilizing the acromion and clavicle, forming two parallel channels in the clavicle and acromion scapula, passing through the channels of connecting flexible elements made of non-absorbable suture material - threads, tying with the tension of its ends and layer-by-layer suturing of the wound, while the formation of the channels is carried out in parallel planes vertically located along the axis of the clavicle, and the formation of the channel in the clavicle and acromion of the scapula is performed, starting from the surface of the cortical layer with an exit no higher than the middle of the articular surfaces with the formation of pairwise conjugated exit holes in the articular surfaces, and the fixation is carried out with two threads, which are carried out with the help of a conductor, and the first thread is wound from the side of the scapula, passed through the mating outlet openings in the acromion of the scapula and the clavicle and brought out of the clavicle, after the first thread leaves the clavicle, before its introduction into the second canal, under the resulting loop is laid with a second thread, then the first thread is passed into the second canal, passed through the mating outlet openings in the clavicle and acromion of the scapula, and the acromion of the scapula is brought out, then the articular end of the clavicle is immersed in the anatomically correct position and the free ends of the first thread are tied over the bone of the scapula, and the free ends of the second thread are tied to the ends of the first thread.

In the sources of patent and scientific and technical information, no technical solutions with a similar set of essential features have been identified.

The essence of the proposed method is illustrated by drawings, where:

in fig. 1 - shows the parallel execution of the channels in the articulated ends of the acromial end of the clavicle and scapula, top view;

in fig. 2 - shows the location of the first thread in the canals of the articulated ends of the acromial end of the clavicle and scapula before repositioning the dislocated end of the clavicle;

in fig. 3 - shows the location of the additional thread under the first thread;

in fig. 4 - shows the final position of the acromioclavicular joint and its reconstructed due to the threads of the damaged ligaments during trauma;

in fig. 5 - shows a longitudinal section of the execution of channels 1 and 3 in the vertical plane in the clavicle 5 and the acromion of the scapula 6, side view.

The method of plastics of the ligamentous apparatus of the acromioclavicular joint in traumatic injury includes performing access to the acromioclavicular joint by incising the skin in the projection of the acromioclavicular joint with preliminary clarifying X-ray diagnostics. The access is performed under general anesthesia, making a linear or slightly Z-shaped to the upper surface of the acromioclavicular joint, dissecting the skin and underlying soft tissues to the bone, starting from the distal third of the clavicle to the base of the acromial process of the scapula.

Then the soft tissues are bred with hooks, after which a thin (2-4 mm) drill in the articulated ends of the clavicle 5 and the acromion of the scapula 6 form single-cortical canals: two channels 1 and 2 in the clavicle 5 and two channels 3 and 4 in the acromion of the scapula 6. Channels 1, 3 and 2, 4 are formed in vertical parallel planes located along the axis of the clavicle. The formation of each channel 1 and 2 or 3 and 4 in the clavicle 5 or the acromion of the scapula 6, respectively, is carried out, starting from the surface of the cortical layer of the clavicle 5 and the acromion of the scapula 6 with an exit no higher than the middle of the articulated surfaces with the formation of pairwise conjugated exit holes in the articulated surfaces (outlet openings are not shown in the drawing). Since both bones are soft enough, the exit of the canals above the middle of the articular surface may result in the bone above the canal breaking during drilling and especially when the thread is pulled when tying the knots.

The fixation is carried out with two threads 7 and 8 of non-absorbable suture material, which is carried out through the channels using a guide wire (the guide wire is not shown in the drawing). A lavsan thread or tape is used as a non-absorbable suture material. The first thread 7 is wound from the side of the scapula 6 through channel 3, passed through one pair of mating outlet openings formed in the acromion of the scapula 6 and the clavicle 5, and brought out of the clavicle 5 through channel 1. After the first thread 7 exits through channel 1 to the outside of the clavicle 5, before introducing it into channel 2, a second thread 8 is placed under the resulting loop, bending around the first thread 7. Then the first thread 7 is drawn into channel 2 of the clavicle 5, passed through the second pair of mating outlet holes formed in the clavicle 5 and the acromion of the scapula 6, and withdrawn outward through channel 4 in the acromion of the scapula 6. Then the articular end of the clavicle 5 is immersed in the anatomically correct position with the elimination of the dislocation (with a finger or an instrument) and, without cutting off the free ends of the first thread 7, they are tied with tension over the bone of the scapula 6, and the free ends of the second the threads are tied with tension to the free ends of the first thread 7 on the acromial process of the scapula 6. This connection of threads 7 and 8 allows you to restore the important upper portion of the ligaments a cromioclavicular joint and provide additional tension in the intracanal loop of the first suture 7, and, consequently, provide a better (reliable) fixation of the joint. Then the wound is sutured in layers.

Execution of the channels by the proposed method, namely in vertical parallel planes located along the axis of the clavicle 5, starting the formation of the channel from the surface of the cortical layer with an exit no higher than the middle of the articular surfaces with the formation of pairwise mating exit holes in the articulated surfaces, eliminates the need for threads 7 and 8 under the lower surface of the clavicle 5 and the acromion of the scapula 6, which significantly reduces trauma, since it eliminates the risk of damage to the subclavian neurovascular bundle.

Example

Patient D., 48 years old, was admitted to the center with a diagnosis of subcutaneous rupture of the acromioclavicular joint on the right, stage 3 according to Tosi's classification. After clarifying X-ray diagnostics, the patient under general anesthesia performed an intervention according to the proposed method: a 6-7 cm incision at the distal end of the clavicle and acromion, the upper surface of both bones was mobilized. Single-cortical canals were formed at an angle with an exit no higher than the middle of the articular surfaces of the bones, into which one thread was drawn from the side of the acromion with preliminary laying of the second thread under the loop of the first one above the acromial end of the clavicle. After the dislocated end of the clavicle was repositioned, the free ends of the first thread were tied together in a taut state over the acromion. The ends of the second suture were tied to the free ends of the first suture to recreate the upper portion of the acromioclavicular ligament. The wound was sutured in layers.

On the control X-ray, the position of the articular end of the clavicle is adequate, the patient was discharged from the department. During the follow-up period up to six months, complete restoration of the functionality of the right upper limb was noted.

Claims (1)

The method of plastics of the ligamentous apparatus of the acromioclavicular joint in traumatic injury, including access to the acromioclavicular joint by cutting the skin in the projection of the acromioclavicular joint, mobilizing the acromion and the clavicle, forming two parallel channels in the clavicle and acromion of the scapula, passing through the channels connecting flexible elements made of non-absorbable suture material - threads, tying with tension of its ends and layer-by-layer suturing of the wound, characterized in that the formation of channels is carried out in parallel planes vertically located along the axis of the clavicle, and the formation of a channel in the clavicle and acromion of the scapula is performed starting from the surface a cortical layer with an exit no higher than the middle of the articular surfaces with the formation of pairwise conjugated exit holes in the articular surfaces, and the fixation is carried out with two threads, which are carried out with the help of a conductor, and the first thread is wound from the side of the scapula, passed through the mating outlet openings in the acromion of the scapula and the clavicle and brought out of the clavicle, after the first thread leaves the clavicle, before its introduction into the second canal, under the resulting loop is laid with a second thread, then the first thread is passed into the second canal, passed through the mating outlet openings in the clavicle and acromion of the scapula, and the acromion of the scapula is brought out, then the articular end of the clavicle is immersed in the anatomically correct position and the free ends of the first thread are tied over the bone of the scapula, and the free ends of the second thread are tied to the ends of the first thread.

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