RU2793881C1 - Method for reconstruction of the rotator cuff of the shoulder joint in case of massive irreparable injuries accompanied by arthropathy - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention can be used for surgical treatment of patients with massive irreparable damage to the rotator cuff of the shoulder joint. The retracted rotator cuff of the shoulder joint is replaced with a combined graft of the autotendon of the long peroneal muscle and propylene mesh, at least 6 mm thick, formed in 4–5 layers, which is fixed in a state of tension to the tendon part of the supraspinatus and infraspinatus muscles on one side and the greater tubercle of the humerus — with another. With severe osteoporosis, the presence of cysts and other factors that impoverish the quality of bone tissue, the graft from the lateral side is additionally fixed to the head of the shoulder with screws.

EFFECT: method ensures restoration of shoulder function, reduction of pain syndrome due to replacement of the rotator cuff of the shoulder joint with a combined graft from the autotendon of the long peroneal muscle and propylene mesh.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for surgical treatment of patients with massive irreparable damage to the rotator cuff of the shoulder joint (TMJ), including those accompanied by paresis of the axillary nerve (with the "terrible triad"), if the function is preserved suprascapular nerve.

One of the main functions of the rotator cuff (TMC) is to ensure the coaxial location of the head of the shoulder and the glenoid cavity of the scapula during any movements of his hand. If the transverse size of the TMJ injury is more than 5 cm, and two or more tendons are involved in the rupture, then it is referred to as massive, respectively. Such ruptures, in case of chronic injuries, are characterized by retraction of the damaged tendons of the 2nd or 3rd degree according to the classification of D. Patte, 1990 [1], in which their edges are at the level of the central part of the humeral head or at the level of the glenoid cavity of the scapula , and secondary instability usually develops with anterior superior subluxation of the humeral head. It is known that the formation of massive full-thickness ruptures of the SMJ occurs gradually and leads to chronic pain syndrome, complete loss of the compressive function of the shoulder rotators and the development of "pseudo-paralysis" of the upper limb (PPVC) in 20% of patients.

At present, the following methods have been the most developed in the treatment of patients with massive irreparable damage to the rotator cuff of the shoulder joint of the TMJ:

Arthroscopic anchor suture (AAS)

This technique is often inapplicable due to degenerative changes in muscle and tendon tissues that develop against the background of aseptic inflammation, retraction and “sticking” of the edges of damaged UPJ tendons with nearby anatomical structures, therefore, in the special scientific literature, the authors use the term “irreparable” rupture in relation to such injuries. VMPS [2].

Reverse arthroplasty

To date, the main indication for performing reverse shoulder arthroplasty (REPS) is the final - 4th and 5th stages of shoulder joint arthropathy (APS) according to K. Hamada's classification, with complete replacement of the shoulder joint with an endoprosthesis. [3]. The high cost of the implant. Traumatic operation.

InSpace or balloon plastic

It is used and gives good results with massive ruptures of the SMJ and fatty infiltration of 3-4 degrees according to Goutallier [4]. However, it is only a depreciation factor, it does not restore the continuity and function of the SMPS. The high cost of the implant.

Capsule reconstruction (collagen dermal matrix: GraftJacket, Wright, Medical, Arlington, etc.), autotransplantation, xenotransplantation It is a method of reconstruction of the upper part of the capsule of the shoulder joint. It restores the vertical stability of the shoulder joint, the centering of the head of the humerus in relation to the glenoid cavity of the scapula and improves the biomechanics of the shoulder as a whole [5]. The operation uses tissue. The high cost of the implant.

Tendon-muscle transfers

Has good results up to 80%. Gives “bringing down” of the head of the shoulder in case of its anterior-superior subluxation by moving the point of fixation of the tendon part of the muscles to the head of the shoulder [6]. However, it is only a retaining, bringing down the head of the shoulder, a factor that does not restore the continuity and function of the SMPS. Technically difficult to perform, provides for additional access, more invasive than the proposed method. In addition, it is most preferred in young, middle-aged patients with good muscle tone.

The first four methods in terms of consumables are expensive, not applicable in the case of axillary nerve paresis, for example, in the so-called "terrible triad of the shoulder joint". The method of tendon-muscle transfers is technically more complicated, more traumatic, limited in use in the elderly. It does not replace the lost (reduced) tissue of the rotator cuff and is also inappropriate for paresis of the axillary nerve.

A known method of restoring the upper capsule of the shoulder joint [7]. including access to the shoulder joint, formation of a bed in the humerus and placement of the graft with its fixation to the upper part of the glenoid.

However, such attachment of the graft only allows restoring the layer between the humeral head and the acromion, being a spacer, displacing the humeral head downwards. The cuff itself is not restored.

A known method of surgical treatment of chronic rupture of the tendon and supraspinatus muscle [8], taken as a prototype. The acromial process is dissected in a Z-shape, the torn tendon is sutured, and a transverse fold of the shoulder joint capsule is formed. The fascia of the supraspinatus muscle is dissected and a terylene mesh in the form of a tennis racket is sutured to the posterior surface of the supraspinatus muscle. The narrow part of the mesh is thrown over the joint space of the shoulder joint, overlapping the level of the suture of the tendon of the supraspinatus muscle and the fold of the joint capsule in the position of shoulder abduction. The mesh is sutured to the joint capsule. Channels are formed in the humerus and a terylene tape is passed through them and a mesh is sewn with it, capturing the fibers of the supraspinatus muscle, the tape is pulled and tied. The acromial process is restored, the wound is sutured, and a drain splint is applied.

However, the method involves only strengthening the anterolateral and upper part of the shoulder joint with the restoration of the function of the supraspinatus muscle of the shoulder with a slight contraction of the damaged muscle. In the case of retraction of the damaged tendons of the 3rd degree according to the classification of D. Patte (1990), in which their edges are at the level of the glenoid cavity of the scapula, the mesh graft alone will not fill the volume between the humeral head and the acromion, acting as a spacer that lowers the humeral head from upper subluxation. Therefore, the method cannot be used to restore the function of the rotator cuff of the shoulder joint with massive irreparable damage to the CMJ accompanied by APS of 1-3 degrees, manifested by a decrease in the distance between the head of the humerus and the acromion from 6 to 0 mm, including the "terrible triad of the shoulder joint" .

EFFECT: restoration of shoulder function in case of massive irreparable damage to the TMJ and reduction of pain syndrome in case of shoulder joint arthropathy (APS), as well as restoration of shoulder joint function in case of the "terrible triad of the shoulder joint". The proposed surgical method is a "prosthetic combined TMJ tendoplasty". The essence of the operation is to replace the contracted (retracted) rotator cuff of the shoulder joint with a combined graft of the autotendon of the long peroneal muscle and propylene mesh, at least 6 mm thick, formed in several (4-5) layers and fixed in a state of tension to the tendon part of the supraspinatus and infraspinatus muscles on one side and a large tubercle of the humerus on the other.

Augmentation of the tendon tissue with propylene mesh (combined graft) increases the strength characteristics of the graft for tearing and eruption. Due to the appearance of a “layer (graft thickness of at least 6 mm) between the acromion and the head of the shoulder, bringing the head down from its upper subluxation, that is, the spacer effect of the graft, the pain syndrome is stopped - the impingement syndrome (impact) disappears. The created conditions make it possible to restore the functions of the TMJ even with the “terrible triad of the shoulder joint. In addition, the use of a propylene mesh in the formed graft significantly reduces the cost of the operation.

The method is carried out as follows.

On FIG. 1-9 show the steps of the operation.

Fig. 1 - Formation of a combined graft.

Fig. 2 - Mounting unit Ossel.

Fig. 3 - Stitching the cuff.

Fig. 4 - Fixation of the graft.

Fig. 5 - Medial fixation.

Fig. 6 - Lateral fixation of the graft.

Fig. 7 - Fixing an additional row with screws.

Fig. 8 - X-ray - screw in the head of the shoulder with lateral fixation of the graft.

Fig. 9 - Sutured wound on the shoulder.

An anteroexternal access is made from the acromial process, its anteroexternal edge along the muscle fibers of the deltoid muscle 5-6 cm, modeling resection of the lower part of the acromion by 1/3 of its thickness. Next, the contracted tendon part of the supraspinatus and infraspinatus muscles is bluntly and sharply isolated and stitched with 4 non-absorbable threads (Fig. 3) at a distance of 0.7 cm, in each node of which one of the two threads is carried out as a lasso or an Ossel fastening knot (Fig. 2).

The autotendon of the long peroneal muscle is taken from a 2 cm access with a stripper, and the muscle fibers are removed. The tendon is cut into 4-5 equal parts of 5-6 cm in length, or folded 5-6 times, placed on a 5 * 11 cm propylene mesh; less than 6 mm in thickness (Fig. 1), is sutured proximally to the TMJ with the free ends of 4 non-absorbable sutures (Fig. 4, 5).

Then, with a chisel or an oscillating saw, a receiving bed is formed on the head of the shoulder in the area of the b/tubercle, threads are inserted transosseously into the receiving bed of the medial epimetaphysis of the shoulder, the graft is fixed with transosseous interrupted sutures to the head of the shoulder (Fig. 6). In the case of severe osteoporosis, the presence of cysts and other factors that impoverish the quality of bone tissue, the possible failure of transosseous fixation, when the transosseous suture is unreliable, a second fixing row is formed (Fig. 7,8). At this stage, the free ends of the ligatures are not cut off. Lateral to the receiving bed, 1 cm, in the epimetaphysis, 2 spongy screws 40 * 6.5 mm with toothed washers are inserted, for which the free ends of the threads of the lateral row are held in tension, the screws are twisted, pressing the threads and the free edge of the graft with washers.

After fixation of the graft, the wound is sutured in layers with the restoration of the attachment of the deltoid muscle in the area of cut-off from the acromion (Fig. 9). The shoulder is fixed in the outlet splint for 2 weeks at an angle of 90 degrees, then 2 weeks at an angle of 60 degrees, and 2 weeks at 30 degrees. 2 weeks - scarf bandage. The total fixation period is 2 months.

The advantages of the proposed method are:

- low invasiveness (this technique can be attributed to mini-open),

- the presence of autotissue at the base of the graft, which determines the possibility of integration with the tissues of the anatomical formations of the damaged joint,

- creation of volume (spacer effect) that prevents the development of impingement of the shoulder joint (collision of the head of the shoulder and glenoid), patients notice the disappearance of pain, including night pain, already on the 5-8th day,

- has high strength and resistance to eruption by ligatures,

- restoration of the function of the shoulder joint.

In addition, in comparison with other conventional methods for the treatment of massive irreparable damage to the upper urinary tract, the proposed method is the least expensive, and therefore can be widely implemented and used in health facilities operating in the structure of compulsory medical insurance.

Clinical example 1.

Patient W., born in 1974 applied to the Polevsk Central City Hospital on June 29, 2022 with complaints of pain in the right shoulder joint. Lack of active and passive movements in the right shoulder joint. Numbness of the fingers of the right hand, weakness in the right hand.

Injury from 02/06/2022. He was treated conservatively at the place of residence without effect.

Examined by a traumatologist, a neurologist, performed: x-ray of the right shoulder joint, EMG of the right upper limb.

Diagnosed with chronic irreparable damage to the urinary tract, chronic subluxation of the right shoulder, mixed contracture of the right shoulder joint, post-traumatic rough brachial plexopathy on the right (“terrible triad of the shoulder”), hospitalized.

On June 30, 2022, an operation was performed according to the proposed method - “prosthetic combined TMJ tendoplasty” on the right.

Progress of the operation: an autotendon was harvested, a graft 6 mm thick was formed (4 parts of the tendon 5 cm long, wrapped with a propylene mesh). Shoulder access. When revising the joint, a large amount of scar tissue was found in its cavity. The shoulder is dislocated downward and anteriorly, after the removal of scars, due to the lack of anatomical stabilizers, it is not held in the correct position. SMPS (supraspinatus and infraspinatus muscles) are retracted to the level of the upper edge of the glenoid, soldered to the surrounding tissues. VMPS mobilized from scars, stitched.

The formed graft is fixed medially to the SMPS and laterally to the bone bed in the projection of the large tubercle of the head of the shoulder in tension and abduction of the shoulder up to 45 degrees. The arm is fixed in the abduction position with an orthosis. On the 5th day after the operation, the patient noted the disappearance of pain.

At 2 months the patient began rehabilitation. In the right shoulder joint, partial disappearance of numbness of the hand, restoration of the strength of the hand, forearm, increase in the volume of active and passive movements in the right shoulder joint. Continues rehabilitation. On radiographs of the shoulder joint, the dislocation was eliminated. Satisfied with the immediate result, tangible positive dynamics.

Clinical example 2.

Patient N., born in 1952 turned to the Polevsk Central City Hospital on 08/02/2022 with complaints of pain in the right shoulder joint, mainly at night - intense, not relieved by taking analgesics, as a result - sleep disturbance. Weakness, limitation of active and passive movements in the right shoulder joint.

Injury in January 2022. He was treated conservatively at the place of residence by a neurologist for "shoulder-shoulder periarthritis" without effect.

On July 21, 2022, he performed an MRI of the right shoulder joint, turned to a traumatologist.

With a diagnosis of chronic irreparable damage to the TMJ, mixed contracture of the right shoulder joint. Rotary arthropathy of the right shoulder joint, hospitalized.

On August 10, 2022, an operation was performed according to the proposed method on the right.

Progress of the operation: an autotendon was harvested, a graft 6 mm thick was formed (5 parts of the tendon 6 cm long, wrapped with a propylene mesh). Shoulder access. During revision of the joint: osteophytes of the acromion, b/tubercle of the head of the shoulder, scar tissue in the joint cavity, detachment of the SMPS (supraspinatus and infraspinatus muscles) from the b/tubercle, retraction to the level of the upper edge of the glenoid, the tendons are soldered to the surrounding tissues. Severe osteoporosis. VMPS mobilized from scars, stitched. The formed graft is fixed medially to the SMPS and laterally to the bone bed in the projection of the large tubercle of the head of the shoulder in tension and abduction of the shoulder up to 45 degrees. The graft was additionally fixed to the head of the shoulder with screws. The arm is fixed in the abduction position with an orthosis. On FIG. 11 - Sewing of the graft.

Already on the 8th day after the operation, the patient notes the disappearance of pain in the right shoulder joint, the normalization of sleep. Currently undergoing rehabilitation. I am very pleased with the result.

Clinical example 3.

Patient K., born in 1959 turned to the Polevsk Central City Hospital with complaints of pain in the right shoulder joint, aggravated after physical exertion, not relieved by taking analgesics, night pains. Weakness, limitation of active and passive movements in the right shoulder joint. 08/06/2022 performed an MRI of the right shoulder of the joint, turned to a traumatologist.

With a diagnosis of chronic irreparable damage to the TMJ mixed contracture of the right shoulder joint. Rotary arthropathy of the right shoulder joint, hospitalized.

09/09/2022 Operation - according to the proposed method on the right.

On FIG. 10 - MRI before surgery: retraction of the supraspinatus muscle.

On FIG. 11 - Formation of the graft (the thickness of the graft is 8 mm.

On FIG. 12 - Formation of the receiving bed on the head of the shoulder, transosseous ligatures.

On FIG. 13 - Transosseous suture of the graft.

On FIG. 14 A, B, C, D - Functional images of the patient 1.5 months after surgery.

Progress of the operation: an autotendon was harvested, a graft 8 mm thick was formed. Shoulder access. During revision of the joint: osteophytes of the acromion, b/tubercle of the head of the shoulder, scar tissue in the joint cavity, detachment of the SMPS (supraspinatus and infraspinatus muscles) from the b/tubercle, retraction to the level of the upper edge of the glenoid, the tendons are soldered to the surrounding tissues. The bone quality of the proximal humerus is good. VMPS mobilized from scars, stitched. The formed graft is fixed medially to the SMPS and laterally to the bone bed (transosseous suture) in the projection of the large tubercle of the humeral head in tension and abduction of the shoulder up to 45 degrees. The arm is fixed in the abduction position with an orthosis.

On the 6th day after the operation, the patient noted the disappearance of pain in the right shoulder joint, normalization of sleep. Currently undergoing rehabilitation. At 1.5 months Abduction and adduction of the shoulder - up to 90 degrees, painless. Satisfied with the result.

Thus, the proposed method allows you to restore the function of the shoulder in case of massive irreparable damage to the TMJ and reduce pain in case of arthropathy of the shoulder joint (APS), as well as restore the function of the shoulder joint in the "terrible triad of the shoulder joint".

Used Books

1. Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res. 1990; 254:81-86.

2. Randelli, P. History of rotator cuff surgery / P. Randelli, D. Cucchi, V. Ragone, P. Cabitza // Knee Surg. Sports Traumatol. Arthrosc. - 2015. - Vol.23. - P. 344362 Maillot C, Martellotto A., Demezon H., Harly E., Le Huec J.C. Clin J Sport Med. Multiple Treatment Comparisons for Large and Massive Rotator Cuff Tears: A Network Meta-analysis. 2019 Nov 15. doi: 10.1097/JSM.0000000000000786.

3. Savarese E and Rocco Romeo. New Solution for Massive, Irreparable Rotator Cuff Tears: The Subacromial "Biodegradable Spacer". Arthroscopy Techniques. 2012; 1(1): e69-e74.

4. Mihata, T. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears / T. Mihata, T.Q. Lee, C. Watanabe [et al.] // Arthroscopy. - 2013. - Vol. 29, No. 3. - P. 459-464.

5. Gerber, C. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report / C. Gerber, T.S. Vinh, R. Hertel, C.W. Hess // Clin. Orthop.Relat. Res. - 1988. - N 232. - P. 51-61.

6. Dokolin S.Yu. Surgical treatment of patients with arthropathy of the shoulder joint due to massive ruptures of the rotator cuff 14.01.15 - Traumatology and Orthopedics Dissertation for the degree of Doctor of Medical Sciences, St. Petersburg - 2020 https://vak.minobrnauki.gov.ru/advert/100050872.

7. Patent RU 2150246, Method of surgical treatment of chronic supraspinatus tendon rupture / Voskresensky E.V., Aleinikov A.V., Appl. 06/10/1997, Published. 06/10/2000, bul. 16.

Claims (2)

1. A method for reconstructing the rotator cuff of the shoulder joint in case of massive irreparable damage accompanied by arthropathy, including access to the shoulder joint, the use of a mesh as a fixing material, characterized in that a combined graft of the autotendon of the long peroneal muscle and propylene mesh is used as the fixing material, transplant formed from 4-5 layers of autotendon, not less than 6 mm thick, wrapped with propylene mesh and stitched around the perimeter with a seam, the graft is fixed in a state of tension to the tendon part of the supraspinatus and infraspinatus muscles from the medial side and laterally to the greater tubercle of the humerus. 2. The method according to p. 1, characterized in that in case of osteoporosis, the graft from the lateral side is additionally fixed to the head of the shoulder with screws.

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