RU2800314C1 - Method of fixing the distal tendon of the biceps muscle of the shoulder to the tuberosity of the radius and a device for its implementation - Google Patents

Abstract

FIELD: traumatology; orthopedics.

SUBSTANCE: group of inventions is intended for fixing the distal tendon of the biceps brachii muscle to the tuberosity of the radius. The method includes isolating the distal tendon, suturing it, accessing the tuberosity of the radius. The tendon is stitched with two nylon threads, leaving 4 ends of the ligatures free. Access to the tuberosity of the radius is carried out through a 3–5 cm incision along the anterior surface of the forearm in the projection of the tuberosity of the radius. Using a direction determination device, a hole with a diameter of 3.2–4.3 mm is formed in the tuberosity of the radius. If the duration of the detachment of the distal tendon of the biceps muscle of the shoulder exceeds 3 weeks, the site of tendon attachment is milled until the appearance of "bloody dew". The threads of the stitched tendon are brought out to the back surface of the forearm. The distal tendon of the biceps is fixed by the threads with the help of a washer, in which two opposite sides are preliminarily cut off by at least half the width of the washer wall. Two ligatures are carried out in the center and two along the cut-off edges of this washer, fixing each pair of ligatures with knots on the wall of the washer. The device for determining the direction for forming a channel in the radius contains a rod connected at one end to a guide element with a through hole, a corrugated handle is fixed at the second end of the rod. The rod and the guide element are connected at an angle of 45–50°. The guide element is made in the form of a semi-annular stop with an inner diameter of 20 mm, and the outer end of the stop is connected to the guide bush for the drill, which includes a through hole with a diameter of 3.2 mm.

EFFECT: group of inventions improves the efficiency of treatment of distal tendon tear of the biceps brachii.

3 cl, 12 dwg, 2 ex

Description

SUBSTANCE: group of inventions refers to traumatology and orthopedics, and is intended for fixing the distal tendon of the biceps brachii muscle to the tuberosity of the radius.

The biceps brachii (biceps) is located in front of the shoulder. It is attached to the bones of the shoulder and forearm by tendons. Distally (in the area of the elbow joint), the biceps tendon is one, and it is attached to the tuberosity of the radius. There are two tendons in the area of the shoulder joint (the long and short heads of the biceps), and they are attached to the upper pole of the glenoid cavity of the scapula, and the coracoid process of the scapula.

Injuries to the distal biceps tendon are most often caused by sudden injury and tend to result in greater arm weakness than injuries to the proximal biceps tendons. The strength of pronation and supination of the forearm is reduced by 35-40%.

A torn distal biceps tendon does not grow to the bone on its own without surgical treatment, although the rest of the muscles of the upper limb are good at compensating for movements in the elbow joint. However, they cannot completely replace all the functions of the injured tendon, especially the movement of turning the forearm from palm down to palm up.

To restore the function of the upper limb, as a rule, surgical treatment for the reinsertion of a torn tendon is recommended.

So, from the prior art, a method for treating a detachment of the distal tendon of the biceps muscle of the shoulder (RF patent 2284782, publ. 20.01.07). In this method, one ligature of the tendon suture is passed through a channel drilled in the tuberosity of the radius, the second ligature is passed between the ulna and the radius, the ends of the ligatures are pulled and tied, which ensures reliable fixation of the tendon. The disadvantages of this method are the following points:

1. When fixing the tendon with an interrupted suture, a displacement occurs towards the interosseous space.

2. Danger of damage to the neurovascular bundle.

3. The complexity of the ligature in the interosseous space.

4. Weak fixation.

The prior art method of fixing the distal tendon of the biceps brachii muscle to the tuberosity of the radius (RF patent 2534517, publ. 10/27/14). A suture is applied to the distal tendon of the biceps in the sagittal plane, two parallel channels 2 mm in diameter are formed in the tuberosity of the radius, through which both ends of the ligatures are passed, pulled and tied on the posterior surface of the radius, opposite to the location of the tuberosity. The disadvantages of this method are:

1. Difficulty in performing 2 parallel canals in the radius.

2. Difficulty in conducting ligatures in the canals of the radius.

3. With bone weakness (osteoporosis), there is a high probability of destruction of the interosseous bridge.

From the prior art there is known a method for the treatment of detachment of the distal tendon of the biceps brachii (RF patent 2300338, publ. 10.06.07), we have chosen for the prototype. The method is carried out by accessing the tuberosity of the radius and fixing the tendon to it. What is new in the method is that the tendon is fixed by passing ligatures through a channel drilled in the tuberosity of the radius, and then the ligatures are removed through the holes in the bone graft, made in the form of an irregular triangle with rounded corners and two holes, and the plane of the graft adjacent to the radius is even, and its size is equal to the width of the radius. The disadvantages of this method are:

1. Difficulty in performing, associated with the harvesting of a bone graft in the ulna, and the formation of holes in it, which can lead to its destruction.

2. Increased traumatization of soft tissues.

In this case, there is a problem common to all known methods - the instability of the needle/drill when forming a hole in the tuberosity of the radius. The simplest technique used in such cases to prevent slipping of the tip of the pin or drill from the bone is the manual formation of a notch with an awl at a given point on the bone surface (moreover, the notch should be the deeper, the greater the expected instability of the stop), into which the pin or drill is then rested and drilling begins. This method captivates with its simplicity, but has a number of disadvantages, which include the following:

1) the complexity of the formation of the notch, especially if the drilling point is set at the level of the diaphysis of the tubular bone or the cortical plate of the metaphysis without signs of osteoporosis;

2) the danger of the awl slipping off the bone surface with damage to nearby soft tissues, the likelihood of which increases, firstly, if the given direction deviates from the perpendicular to the bone, and, secondly, when the point of contact with the bone is eccentric, on the edge or crest of the bone;

3) the low efficiency of this technique with the remaining probability of slipping of the end of the rotating needle or drill beyond the recess - due to the fact that its depth (usually no more than 2-3 mm) is not always sufficient.

So, in the prior art there are various approaches to ensure the precision accuracy of osteoperforation - using various devices used in the osteosynthesis of the femoral neck. These include devices - conductors A.V. Kaplan, V.B. Abduev and other authors. So, the Demyanov apparatus is known, described in the Osteosintez manual for doctors, edited by S.S. Tkachev (1987) and used for osteosynthesis of the femoral neck (Fig. 2, a, b). To use it, it is necessary to skeletonize the area of the outer surface of the proximal femur, install the device on it and pass a needle through its channel, and then a three-blade Smith-Petterson nail. With its efficiency and precision accuracy of performing osteoperforation, the prototype device has significant disadvantages:

1) the need to increase the volume of surgical intervention and skeletonization of a much longer area of the proximal femur than is necessary for osteosynthesis of the femoral neck;

2) the complexity of the application with not always justified large expenditures of time;

To solve such problems in the prior art, a device for determining the direction for forming a channel in the bone is known (Single guide for drills D 3.5 mm, steel, found from the Internet on 06/01/2022 a cutting element with a through hole, and a handle is fixed at the second end of the rod. The disadvantages of this guide are the impossibility of fixing it at an angle necessary to form a hole in the tuberosity of the radius and install it in the center of the diaphysis of the radius; which does not allow to clearly fix the distal tendon of the biceps brachii muscle in an anatomically optimal position.

Thus, there is a need for a method for fixing the distal tendon of the biceps brachii to the tuberosity of the radius and a device for its implementation, devoid of the above disadvantages.

The technical result of the proposed group of inventions is to increase the effectiveness of the treatment of detachment of the distal tendon of the biceps of the shoulder due to the low trauma of the intervention and optimally selected features of fixing the distal tendon of the biceps of the shoulder to the tuberosity of the radius, allowing to avoid postoperative complications that violate the integrity of the fixation.

To achieve this technical result in a method for fixing the distal tendon of the biceps muscle of the shoulder to the tuberosity of the radius, including the selection of the distal tendon through a skin incision along the anterior surface of the lower third of the shoulder, stitching the tendon, access to the tuberosity of the radius in the upper third of the forearm, it is proposed to flash the tendon with two nylon threads, leaving 4 ends of the ligatures free, while access to the tuberosity of the radius is carried out through the incision 3 -5 cm along the anterior surface of the forearm in the projection of the tuberosity of the radius, the damaged tendon is passed from the surgical wound of the shoulder to the wound of the forearm in the tendon canal, in the position of supination of the forearm, a hole with a diameter of 3-4.5 mm is formed using a direction determining device in the tuberosity of the radius, the threads of the sutured tendon are brought out to the dorsum of the forearm with the help of a guide, the distal tendon of the biceps is fixed sa behind the thread with the help of a washer, in which two opposite sides are preliminarily cut off by at least half the width of the washer wall and not more than up to 1 mm of the washer wall width, while two ligatures are carried out in the center and two along the cut-off edges of this washer, fixing each pair of ligatures with knots on the washer wall.

If the duration of the detachment of the distal tendon of the biceps brachii muscle is more than 3 weeks, after the formation of a hole in the tuberosity of the radius, the site of attachment of the tendon is milled to "bloody dew".

To fix the distal tendon of the biceps brachii muscle to the tuberosity of the radius, a device for determining the direction for forming a channel in the radius is proposed, containing a rod connected at one end to a guide element with a through hole, and a corrugated handle is fixed at the second end of the rod, characterized in that the rod and the guide element are connected at an angle of 45-50 degrees, the guide element is made in the form of a semi-circular stop with an inner diameter of 20 mm, moreover, the outer end of the stop is connected to the guide sleeve for the drill, which includes a through hole with a diameter of 3.2 mm.

In FIG. 1-2 are schematic representations of a directional device for forming a canal in the radius in different projections.

In FIG. 3-12 shows the main stages of surgical intervention according to the proposed method.

The device for determining the direction for forming a channel in the radius is a guide (Fig. 1-2), containing a rod (1) connected at one end to a guide element (2) with a through hole (6). A corrugated handle (3) is fixed at the second end of the rod (1). The rod (1) and the guide element (2) are connected at an angle of 45-50 degrees. The guide element (2) is made in the form of a semi-annular stop (4) with an inner diameter of 20 mm, and the outer end of the stop (4) is connected to the guide sleeve (5) for the drill, which includes a through hole (6) with a diameter of 3.2 mm.

The method is carried out as follows.

An incision of up to 2.5-3 cm along the anterior-inner surface of the shoulder in the lower third of the shoulder is the end of the damaged distal tendon of the biceps brachii (Fig. 3). The damaged tendon is brought out into the wound (Fig. 4). The tendon is stitched with two nylon threads No. 4, leaving 4 ends of the ligatures free (Fig. 5). An additional 3-5 cm incision is made along the anterior surface of the forearm in the upper third in the projection of the tuberosity of the radius (Fig. 6). The damaged tendon is passed from the operating wound of the shoulder to the wound of the forearm in the tendon canal (Fig. 7). In the position of pronation of the forearm using the proposed device form a hole in the tuberosity of the radius (Fig. 8-9). If the duration of the detachment of the distal tendon of the biceps brachii muscle is more than 3 weeks, after the formation of a hole in the tuberosity of the radius, the tendon attachment site (the area around the hole) is milled until “bloody dew” appears. What allow:

1. To improve the blood supply to the place of attachment of the tendon to the bone in case of an old tear of the tendon.

2. Increase the area of contact between the tendon and the bone.

3. Reduce the time of union.

In the previously made hole in the tuberosity of the radius with the help of a conductor, nylon threads are brought out to the back surface of the forearm (Fig. 10). The distal biceps tendon is fixed using a pre-prepared washer (7), in which two opposite sides are cut off by at least half of the washer wall width up to 1 mm of the washer wall width (7). Cutting off a smaller thickness can lead to the collection of ligature knots at one point and displacement of the tendon, the contact of the tendon with the tuberosity of the radius is broken, while the washer can turn perpendicular to the bone; cutting off a greater width of the wall of the washer can lead to damage to the washer itself (bend of the structure, breaks), as well as ligature knots in the future, and, accordingly, to the failure of the surgical intervention. In this case, two ligatures are carried out in the center and two along the cut-off edges of this washer (7), fixing each pair of ligatures with knots on the wall of the washer (7) (Fig. 11). In FIG. 12 is a view of the biceps tendon in the wound after repair.

The highly effective application of this group of inventions is illustrated by the examples below.

Example 1. Patient H, born in 1976 (46 years old), was admitted to the 1st Orthopedic and Traumatology Department of the Podolsk Regional Clinical Hospital on July 27, 22 with a diagnosis of subcutaneous rupture of the distal biceps tendon on the right. 08/01/22, the operation was performed - Primary suture of the distal biceps tendon on the right.

In the position of the patient on the back, after introducing the patient into anesthesia and treating the surgical field with a solution of skin antiseptic, in the unbent position of the right upper limb, a longitudinal linear incision of 3 cm was made along the anterior surface of the shoulder in the lower third above the alleged end of the damaged distal biceps tendon, the skin, subcutaneous fat, own fascia of the shoulder were dissected, the found end of the tendon was brought out into the wound, stitched according to Cuneo with kapron No. 4 with a double ligature thread, taken on a holder. Through the second incision of 3 cm along the anterior surface of the forearm in the position of supination in the tuberosity of the radius, using the proposed device for determining the direction to form a channel in the radius, a hole with a diameter of 3.2 mm was made in the anteroposterior direction with a drill.

At the exit point of the drill on the posterior surface of the forearm, an original conductor was inserted through an incision up to 2 cm.

The ends of the ligatures, previously taken on the holder, were brought into the wound on the anterior surface of the forearm, passed through the channel in the radius with the help of a conductor, and fixed with interrupted sutures to a titanium washer with truncated opposite edges so that they were located opposite each other, for a tight fit of the washer to the place of fixation. Two opposite sides of the washer were truncated earlier at half the width of the washer wall.

The strength of fixation was checked by palpation and passive movements in the elbow joint.

The upper limb was fixed in the position of supination of the forearm with the elbow joint bent at an angle of 90, for a period of 3 weeks. Full recovery of limb function and work capacity associated with physical labor occurred after a course of FTL, exercise therapy 5 weeks after the operation.

Example 2. Patient O, born in 1976 (46 years old), was admitted to the 1st Orthopedic and Traumatology Department of the Podolsk Regional Clinical Hospital on 22.06.22 with a diagnosis of Subcutaneous rupture of the distal biceps tendon on the left. Injury 06/01/22 household.

28.06.22, the operation was performed - delayed suture of the distal biceps tendon on the left according to the proposed method.

In the position of the patient on the back, after introducing the patient into anesthesia and treating the surgical field with a solution of skin antiseptic, in the extended position of the left upper limb, a longitudinal linear incision of up to 3 cm was made along the anterior surface of the shoulder in the lower third above the alleged end of the damaged distal tendon of the biceps, the skin, subcutaneous fat, own fascia of the shoulder were dissected, the found end of the tendon was brought out into the wound, stitched along Cuneo with capron No. 4 with a double ligature thread, taken on a holder.

Through the second incision up to 5 cm along the anterior surface of the forearm in the position of supination in the tuberosity of the radius, using the proposed device, a hole was made with a drill in the anteroposterior direction with a diameter of 3.2 mm, which was expanded to 4.3 mm. On the drill, using a cannulated cutter with a diameter of 8.0 mm, the site of attachment of the torn tendon was milled to "bloody dew".

At the exit point of the drill on the posterior surface of the forearm, an original conductor was inserted through an incision up to 2 cm.

The ends of the ligatures, previously taken on the holder, were brought into the wound on the anterior surface of the forearm, passed through the channel in the radius with the help of a conductor, and fixed with interrupted sutures to a titanium washer with truncated opposite edges so that they were located opposite each other, for the tight fit of the washer to the place of fixation. Two opposite sides of the washer were truncated earlier to 1 mm of washer wall width.

The strength of fixation was checked by palpation and passive movements in the elbow joint.

The upper limb was fixed in the position of supination of the forearm with the elbow joint bent at an angle of 90 degrees for a period of 3 weeks. Full recovery of limb function and work capacity associated with physical labor occurred after a course of FTL, exercise therapy 5 weeks after the operation.

The proposed group of inventions, namely the method of fixing the distal tendon of the biceps brachii muscle to the tuberosity of the radius and the device for its implementation, will reduce the cost of surgery due to adequate import substitution, the operation is easy to perform, available to any trauma surgeon, and will also reduce the time of rehabilitation of the patient and avoid intra- and postoperative complications.

Claims (3)

1. A method of fixing the distal tendon of the biceps brachii muscle to the tuberosity of the radius, which includes isolating the distal tendon through a skin incision along the anterior surface of the lower third of the shoulder, stitching the tendon, access to the tuberosity of the radius in the upper third of the forearm, characterized in that the tendon is stitched with two nylon threads, leaving 4 ends of the ligatures free, access to the tuberosity of the radius is carried out through an incision 3-5 cm along the anterior surface of the forearm in the projection of the tuberosity of the radius, the damaged tendon is passed from the surgical wound of the shoulder to the wound of the forearm in the tendon canal, in the position of supination of the forearm, a hole with a diameter of 3.2-4.3 mm is formed using a direction determination device in the tuberosity of the radius, the threads of the sutured tendon are brought to the back surface of the forearm using a guide, the distal tendon of the biceps is fixed sa behind the threads with the help of a washer, in which two opposite sides are first cut off at least half the width of the washer wall, while two ligatures are carried out in the center and two along the cut-off edges of this washer, fixing each pair of ligatures with knots on the washer wall. 2. The method of fixing the distal tendon of the biceps brachii according to claim 1, characterized in that if the separation of the distal tendon of the biceps brachii is exceeded for more than 3 weeks after the formation of a hole in the tuberosity of the radius, the insertion site of the tendon is milled until "bloody dew" appears. 3. A device for determining the direction for forming a channel in the radius for implementing the method according to claim 1, containing a rod connected at one end to a guide element with a through hole, and a corrugated handle is fixed at the second end of the rod, characterized in that the rod and the guide element are connected at an angle of 45-50 °, the guide element is made in the form of a semi-circular stop with an internal diameter of 20 mm, and the outer end of the stop is connected to the guide sleeve for drill, including a through hole with a diameter of 3.2 mm.

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