RU2663384C2 - Method of reinsertion of distal biceps brachii tendon with its disinsertion - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics when disinsertion of the distal biceps brachii tendon. Ligatures of the stitched tendon are drawn through two parallel channels drilled on the central surface of the bicipital tuberosity with diameter of 3.2 mm, symmetrically about the tip of the tuberosity and at a distance of 8 mm between the centers. In this case, the radius bone in the neck region is fixed at a distance of 14.1±0.3 mm from the center of tuberosity by a guide with distal and proximal positioners for the radius bone. Ligatures are stretched and fixed by a knot on the back surface of the radius bone.

EFFECT: method prevents damage to the anatomical formations of the forearm.

1 cl, 1 ex, 5 dwg

Description

The invention relates to medicine, in particular traumatology and orthopedics, and can be used for detachments of the distal tendon of the biceps of the shoulder, for anatomical fixation of it to the tuberosity of the radius, with a sufficient length of the tendon.

Known methods for fixing the distal tendon of the biceps of the shoulder with a sufficient length of fixation to the radius (Movshovich IA Surgical orthopedics: a Guide for doctors. M., 1994, S. 118-120), to the coronoid process of the ulna or to the tendon of the humerus muscles (Kaplan A.V. Damage to bones and joints. - M., 1979, p. 206-207).

When fixing the distal biceps tendon by known methods, as a rule, a wide S-shaped access is used in the anterior region of the elbow joint, passing in close proximity to the neurovascular formations of this region. Injury and technical complexity of access entails a high frequency of damage to anatomically important formations, such as the radial, muscular-cutaneous, median nerve and brachial artery with its branches, which in turn leads to the development of neurotrophic changes and significantly increases the rehabilitation time of patients.

A known method of fixing the distal tendon of the biceps of the shoulder to the tubercle of the radial bone, including the allocation of the distal tendon through a skin incision along the front surface of the lower third of the shoulder, applying a tendon suture, access to the tuberosity of the radius along the posterior surface of the upper third of the forearm. A suture is placed on the distal tendon of the bicep in the sagittal plane, two parallel channels with a diameter of 2 mm are formed in the tuberosity of the radius, through which both ends of the ligatures are drawn, stretched and tied on the back surface of the radius, opposite to the location of the tuberosity (description of patent RU 2534517, IPC A61B 17/56 (2006.01), published 11/27/2014, prototype).

The technical result of the application of the known method is reliable anatomically and biomechanically substantiated fixation of the distal tendon of the biceps of the shoulder to the tuberosity of the radial bone, which allows resorting to early functional treatment, reducing the recovery time of the full range of motion in the elbow joint and the average recovery time to 5-6 weeks.

In the known method, the formation of an oval groove in the tuberosity of the radius increases the invasiveness and duration of the intervention during the operation. The formation of channels in a recess equal to half the radius of the radius makes the strength of the latter in the region of fixation of the ligatures vulnerable due to the possibility of cracking.

The objective of the invention is to improve the results of surgical treatment of patients with traumatic injuries of the distal tendon of the biceps of the shoulder, reducing the period of rehabilitation of patients.

The technical result is a reduction in the invasiveness of surgical treatment by reducing the invasiveness of the operation and the risk of damage to anatomically important formations.

The technical result is achieved by the fact that in the method of reinsertion of the distal tendon of the biceps of the shoulder during its detachments, in which the ligatures of the stitched tendon are carried out through two parallel channels drilled on the central surface of the tuberosity of the radius, they are pulled and fixed with a knot on the back surface of the radius, the channels are made with a diameter 3.2 mm symmetrically with respect to the apex of the tuberosity and at a distance of 8 mm between the centers, while the radius in the neck region is fixed with a positioner at a distance of 14.1 ± 0.3 m tuberosity of the center.

In FIG. 1 shows a layout of guides for knitting needles in the implementation of the method; in FIG. 2 is a diagram of conducting mylar threads through Kirchner spokes left in the channels formed in the tuberosity of the radius; in FIG. 3 is a diagram of the completion of an operation; in FIG. 4 - the location of the guides for the spokes relative to the brachial artery, muscular-cutaneous nerve and the intermediate vein of the elbow when implementing the method; in FIG. 5 - distance from guides for knitting needles positioned on the tuberosity of the radius

1, 2 - guides for knitting needles;

3 - proximal positioner for the radius;

4 - through holes on the tuberosity of the radius;

a is the longitudinal size of the tuberosity of the radius;

b is the distance between the inner edges of the drilled holes;

C is the distance from the neck of the radius to the center of tuberosity;

d is the distance between the centers of the through holes;

5 - filaments in the distal tendon of the biceps of the shoulder, stitched with a suture according to Kuneo;

6 - Kirschner spokes;

7 - nodal fixation of threads on the dorsum of the radius;

8 - brachial artery;

9 - musculocutaneous nerve;

10 - an intermediate vein of the elbow;

11 - a deep branch of the radial nerve;

12 - the distance from the guides for the spokes to the deep branches of the radial nerve.

The method is carried out using a guide for reinsertion of the distal tendon of the biceps of the shoulder at its detachments, the description of which is given in the description of the patent of the Russian Federation for utility model No. 174880, IPC АВВ 17/17.

In the patient's position on the back, the limb is bent at the elbow joint to 90 degrees. Two linear skin incisions are made: the first - along the front-medial surface of the lower third of the shoulder up to 4 cm long; the second - along the dorsal surface of the upper third of the forearm 1.0 cm distal to the projection of the brachioradial joint, up to 5 cm long. Using a blunt and sharp method, the tendon sheath of the distal biceps tendon is opened, the central end of the torn tendon is released, mobilized, freed from scars, stitched over a seam of the Kuneo type with lavsan thread 5. Ligatures are clamped, the wound is covered with a sterile napkin. From the second section, the fascia is revealed in a blunt and sharp way, the dorsal surface of the upper third of the radius is visualized.

The forearm is bent to an angle of 90 degrees, in the position of extreme supination. With this position of the forearm, the tuberosity of the radial bone unfolds in the most palmar direction. From the first section along the tendon sheath of the distal tendon of the biceps of the shoulder in the distal direction, the proximal positioner 3 at a distance of 14.1 ± 0.3 mm from the center of tuberosity of the radius of the radius is placed under finger control in the distal direction. A positioner (not shown) with guides for the needles 1,2 is installed on the positioner 3. The distance from the stop of the proximal positioner 3 for the radius to the guide for the needles 1,2 is calculated so that when the positioner 3 is placed on the neck of the radius, the guide for the needles 1,2 are located directly on the tuberosity of the radius, symmetrically to the center of the radius and at a distance of d 8 mm between the centers of their axes.

Taking into account the reaming on guide spokes with a drill, the diameter of which is 3.2 mm, the distance b between the inner edges of the resulting holes is 4.8 mm, which is sufficient to maintain pressure by the ligature and prevents the penetration of the bone bridge, provides reliable fixation. The distances from the outer edges of the obtained holes to the edge of the tuberosity are the same on both sides, i.e. the holes are located evenly in the center of the tuberosity of the radius. Then along the guides for the needles 1,2 in the distal direction spend two Kirschner knitting needles 4 with a diameter of 1.0 mm Having gone through both cortical walls in the tuberosity of the radius of the radial bone, the spokes exit exactly at the center of the distal positioner for the radius (not shown). Then, two guides for the drill (not shown) are installed in the distal positioner for the radial bone, along which, in the proximal direction, by the cannulated drill, two through channels 7 are formed on the spokes 4 in the radius of the radius of the radius.

Then, in the reverse order, the distal and proximal parts of the guide with the positioners are dismantled, and using Kirschner spokes 4 left in the formed channels 7 in the distal direction, make lavsan threads 5, which are sewn with a suture along the Küneo distal tendon of the biceps of the shoulder. By tensioning the lavsan ligatures 5 on the back surface of the forearm, the tendon is pulled to the tuberosity of the radius to full contact. Lavsan filaments 5, conducted through channels 7 in the tuberosity of the radius, are fixed by a node 7 on the back surface of the radius.

After the tendon is pulled up and fixed, the fixation strength is checked by passive extension of the limb in the elbow joint. Produce layered wound closure. Aseptic dressing. The limb is immobilized with a Deso plaster cast for 5-6 weeks in the position of forearm flexion to 90 degrees and forearm supination.

A study of the anatomical data of 80 corpses of people of different sex and age was conducted, during which it was found that the implementation of the channels with a diameter of 3.2 mm is symmetrical about the apex of the tuberosity and at a distance of 8 mm between the centers and fixation of the radius in the neck at a distance of 14.1 ± 0, 3 mm from the center of tuberosity is safe from the point of view of the risk of damage to the brachial artery, muscular-cutaneous nerve and the deep branch of the radial nerve (Fig. 4, Fig. 5).

The method was tested when operating 4 patients with subcutaneous abruptions of the distal tendon of the biceps of the shoulder muscle.

Clinical example.

Patient K., 46 years old, was admitted to the traumatology and orthopedic department of BUZ VO VGKB No. 2 named after K.V. Fedyaevsky March 28, 2015 with a diagnosis of subcutaneous rupture of the distal tendon of the biceps of the left shoulder. On April 01, 2015, the patient underwent a reinsertion operation of the distal tendon of the biceps of the shoulder according to the proposed method. 3 position of the patient on the back. The upper left is bent at the elbow joint to 90 degrees. Two linear skin incisions are made: on the front-medial surface of the lower third of the shoulder and on the back surface of the upper third of the forearm. The central end of the tendon is dull and sharp. The tendon is stitched throughout with a suture of the Kuneo type with mylar thread. From the second section, the dorsal surface of the upper third of the radius is visualized. In the position of the extreme supination of the forearm, a proximal positioner for the radius is installed under the finger control on the neck of the radial bone. By the positioner for the radius, the proximal and distal parts of the guide are installed, close together and are fixed. Then, along the guides for the spokes, through two cortical walls are two Kirschner spokes with a diameter of 1.0 mm. On the guides for the drill by a cannulated drill in the direction of the spokes, two through channels are formed in the area of the tuberosity of the radius. The distal and proximal parts of the guide with positioners are dismantled. On the knitting needles are made dacron threads through the formed channels, and the distal tendon of the biceps of the shoulder is pulled up to the tuberosity of the radius in full contact. Lavsan filaments are fixed by a knot on the dorsum of the radius. The fixation strength is checked by passive extension of the limb in the elbow joint. Both wounds are sutured in layers. The limb is immobilized with a Deso plaster cast for 5-6 weeks in the position of forearm flexion to 90 degrees and supination. At the end of the period of gypsum immobilization, a rehabilitation course is carried out. After 2 weeks of rehabilitation, a complete restoration of the range of motion in the elbow joint and restoration of the strength of the biceps of the left shoulder are noted. The patient is able to work.

The proposed method of reinsertion of the damaged distal tendon of the biceps of the shoulder is less traumatic, reduces the time of surgical intervention, reduces the likelihood of damage to the neurovascular formations of the anterior ulnar region, the formation of heterotopic ossification, provides strong fixation of the tendon, eliminates cosmetic defect, shortens the rehabilitation time and helps to fully restore limb function in term of 7-8 weeks., the most rapid recovery of disability.

Claims (1)

The method of reinsertion of the distal tendon of the biceps of the shoulder during its detachments, in which the ligature of the stitched tendon is carried out through two parallel channels drilled on the central surface of the tuberosity of the radius, stretched and fixed by a knot on the back surface of the radius, characterized in that the channels are made with a diameter of 3.2 mm symmetrically with respect to the apex of the tuberosity and at a distance of 8 mm between the centers, while the radius in the neck region is fixed at a distance of 14.1 ± 0.3 mm from the center of tuberosity with a guide with distal and proximal positioners for the radius

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