RU2830418C1 - Method for surgical treatment of elbow joint contracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, and is intended for surgical treatment of elbow joint arthrofibrosis after fractures and chronic injury in elbow joint. Surgical treatment of elbow contracture involves using a posterior approach to the elbow joint, which is complemented by an approach to a fossa of the olecranon of humerus through a distal tendon of the triceps muscle. Triceps muscle of shoulder is released along its distal tendon part. "window" connecting the coronal fossa and the fossa of the olecranon of humerus is formed. Ossificates located in the posterior and medial parts of the elbow joint are resected. Medial collateral ligament of the elbow joint is released, wherein the excision of the scar tissue is limited by the posterior and transverse bundles of the medial collateral ligament of the elbow, preserving its anterior bundle. If observing ossificates in the anterior and/or lateral portions of the elbow joint, their resection is performed using an approach formed by separating the proximal portion of the posterior group of forearm muscles.

EFFECT: method enables resection of ossificates from the lateral and medial sides and reduces the likelihood of recurrent arthrofibrosis of the elbow joint and the formation of a heterotopic bone in the fossa of the olecranon and coronary fossa of the humerus due to a sufficient surgical approach, which enables to visualize the posterior portions of the elbow joint and perform extensive excision of the scar tissue, ossificates and heterotopic bone both in the anterior and posterior, as well as in the medial and lateral portions of the joint.

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Description

Field of technology

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the surgical treatment of post-traumatic and idiopathic contracture of the elbow joint.

State of the art

There are many methods of surgical treatment of elbow joint contracture, which has different etiologies, but is characterized by common pathogenetic mechanisms.

The main pathogenetic mechanisms of the formation of elbow joint contracture after injuries to the elbow joint area are: imbalance between pro- and anti-inflammatory cellular factors and structures, resulting in the formation of excess coarse fibrous connective tissue intra- and paraarticularly, which has less elasticity and a larger volume, preventing the normal range of motion of the elbow joint.

A method of surgical treatment of posttraumatic contracture of the elbow joint by arthroscopic intervention after application of a pin apparatus of external fixation is known (RU 2394516, C1). The method involves passing a pin through the epicondyle of the humerus, fixing it in a half-ring of the external fixation apparatus. Then a second pin is passed through the olecranon and fixed in another half-ring of the external fixation apparatus. Both half-rings are hinged to each other at the level of the elbow joint, in which one-stage distraction is created, then arthroscopy with cold-plasma ablation of pathologically altered tissues is performed. After that, movements in the elbow joint are passively developed with additional ablation of intra-articular obstacles and after bringing the movements to the maximum possible, the external fixation apparatus is dismantled.

The disadvantages of the method are the impossibility of performing arthroscopic release of the medial collateral ligament, which significantly contributes to an increase in the range of motion mainly due to flexion, as well as limited visualization through minimally invasive approaches, which narrows the possibilities of resection of ossifications, which does not allow the effective use of the arthroscopic arthrolysis method in the category of patients with moderate and severe forms of elbow joint contracture.

A method of surgical treatment of elbow joint contracture is known, which involves the formation of an opening between the coronoid fossa and the fossa of the olecranon process of the humerus. The method was proposed by Kashiwagi in 1978 (Kashiwagi D. Intraarticular changes of the osteoarthritic elbow, especially about the fossa olecrani. J Jpn Orthop Assoc. 1978; 52:1367-1382), and was first described in the English-language literature in 1990 by Stanley D., Winson I.G. (Stanley D., Winson I.G. A surgical approach to the elbow. J Bone Joint Surg Br. 1990; 72:728-729). With the patient in the supine position, under a tourniquet, through the posterior approach, with longitudinal dissection of the triceps tendon, the olecranon fossa of the humerus is exposed. Using a 2 mm drill, the olecranon fossa is fenestrated around the circumference, and then an osteotome is used to form an opening connecting the olecranon fossa and the coronoid fossa, which allows for resection of ossifications and prevention of collisions in the area of the coronoid and olecranon processes of the ulna with the humerus.

This method has limitations due to the localization of ossifications, and also does not allow for the full release of cicatricial paraarticular tissues, which narrows the possibilities of the method in terms of restoring range of motion.

As a prototype, we chose the method of surgical treatment of elbow joint contracture proposed by D.S. Ruch, J. Shen, G.D. Chloros, E. Krings, A. Papadonikolakis (D.S. Ruch et al. Release of the medial collateral ligament to improve flexion in post-traumatic elbow stiffness. J Bone Joint Surg. 2008; 90-B:614-18).

With the patient in the supine position, under a tourniquet, the method is implemented through a medial approach to the elbow joint, including the isolation of the ulnar nerve and its transposition if necessary. Excision of the medial collateral ligament begins with its posterior bundle, in the area of attachment to the olecranon in the distal direction. The fibers of the transverse bundle are also excised with subsequent control of the range of motion. If insufficient flexion is achieved, the posterior part of the anterior bundle is released by dissecting the flexors and the round pronator. Drainage of the postoperative wound is not performed; the wound is sutured layer by layer.

However, with this technique it is not possible to achieve a significant increase in the range of motion due to the extension component, and the increase in flexion may be limited by cicatricial changes and heterotopic ossifications in the coronoid fossa of the elbow joint, which does not allow the proposed technique to be effectively used in these cases.

Disclosure of the essence of the invention

The technical problem that this solution is aimed at solving is achieving the maximum range of motion in patients with elbow joint contracture, including moderate and severe forms, through flexion and extension, minimizing surgical trauma, and reducing the likelihood of relapse in the long term.

The technical result of the claimed method is as follows:

- improvement of the method, the possibility of its use in a wider category of patients with contracture caused by changes in both the anterior and posterior parts of the elbow joint;

- maintaining valgus stability of the elbow joint by preserving the anterior bundle of the medial collateral ligament of the elbow joint;

- the possibility of resection of ossifications from the lateral and medial sides thanks to the posterior approach;

- expansion of the release of the medial and transverse bundle of the medial collateral ligament by additional release of the distal triceps tendon;

- decompression in the area of the olecranon fossa and coronoid fossa due to the formation of a window in the bone plate of the distal humerus allows for the resection of heterotopic ossifications and scar tissue and the removal of the mechanical block when interacting with the olecranon and coronoid process of the ulna.

In addition, the proposed method allows to reduce the likelihood of recurrence of arthrofibrosis of the elbow joint and the formation of heterotopic bone in the area of the olecranon fossa and the coronoid fossa of the humerus.

The above results are achieved due to sufficient surgical access, allowing clear visualization of the posterior sections of the elbow joint and performing extensive excision of cicatricial tissues, ossifications and heterotopic bone in both the anterior and posterior, as well as in the medial and lateral sections of the joint. Formation of a window using active drainage in the postoperative period is aimed at removing bone in the area of the septum between the fossae of the distal humerus and minimizing hematoma in the area of the surgical intervention, which is a substrate for the development of profibrotic changes and the formation of heterotopic bone tissue.

When using this method, the patient can move on to active and passive movements in the elbow joint on the next day after surgery, starting with passive movements with a gradual increase in the range of motion and the inclusion of active movements. The ability to begin early development of movements in the elbow joint is extremely important for patients, otherwise the elbow joint is subject to progressive arthrofibrosis.

The elbow joint release technique we offer eliminates the need for additional implants and specialized surgical instruments. The posterior approach to the elbow joint allows adequate isolation of anatomical structures, visualization of the ulnar nerve with its subsequent isolation and constant visual control. Expansion of the access in the medial and lateral directions allows excision of fibrotic tissues located paraarticularly.

The proposed approach allows for simultaneous extensive release of paraarticular soft tissues, distal triceps tendon and resection of ossifications. Radical resection of ossifications allows for elimination of the bone block as the primary cause of contracture and makes it possible to limit the area of release of the medial collateral ligament, thereby restoring movements in the elbow joint and maintaining its valgus stability.

Thus, the proposed method ensures a reduction in the trauma of surgical intervention as a result of using a single posterior approach, the possibility of its use in a wider category of patients with contracture caused by changes in both the anterior and posterior sections of the elbow joint, and reduces the likelihood of recurrence of arthrofibrosis of the elbow joint and the formation of heterotopic bone in the area of the olecranon fossa and coronoid fossa of the humerus.

The essence of the invention is as follows.

In surgical treatment of elbow joint contracture, the posterior approach to the elbow joint is used to perform the intervention, which is supplemented by access to the fossa of the olecranon process of the humerus through the distal tendon of the triceps brachii. The triceps brachii is released along its distal tendon part. A "window" is formed connecting the coronoid fossa and the fossa of the olecranon process of the humerus. Ossifications located in the posterior and medial parts of the elbow joint are resected. The medial collateral ligament of the elbow joint is released, in which excision of cicatricial tissues is limited to the posterior and transverse bundles of the medial collateral ligament of the elbow joint, preserving its anterior bundle.

If there are ossifications in the anterior and/or lateral parts of the elbow joint, their resection is performed using an approach formed by spreading the proximal part of the posterior group of forearm muscles.

Brief description of the figures

The method is illustrated by the following figures:

Fig. 1 shows the formation of holes along the edge of the fossa of the olecranon process of the humerus.

Fig. 2 shows the area of excision of the medial collateral ligament.

Fig. 3 shows an X-ray of arthrofibrosis of the elbow joint with its contracture before surgery.

Fig. 4 shows an X-ray of the elbow joint after surgical treatment using the proposed method with the formation of an opening between the coronoid fossa and the fossa of the olecranon process of the humerus.

Fig. 5 shows the excision of the posterior and transverse bundles of the medial collateral ligament.

The method is carried out as follows.

With the patient in the lateral position, after the onset of anesthesia, the amplitude of passive movements in the elbow joint is assessed with photo fixation. A posterior approach to the elbow joint is performed under a pneumatic tourniquet: a skin incision in the projection of the lower third of the shoulder to the upper third of the ulna, the length of the approach can be increased in case of insufficient visualization. By spreading and dissecting the subcutaneous fat, the medial, lateral and posterior sections of the joint are exposed. The ulnar nerve is isolated, crossing the Osborne ligament and cicatricial tissues along its course, neurolysis of the ulnar nerve is performed, it is mobilized and abducted on an elastic holder. Ossificates of the medial section of the joint are visualized and resected.

Access to the fossa of the olecranon process of the humerus is created by longitudinally dissecting the distal part of the triceps tendon in its projection over a length of 3-4 cm to achieve the necessary visualization.

For the purpose of release, that is, mobilization of the joint, excision and dissection of soft, cicatricial tissues and resection of ossifications are performed.

Resection of ossifications and scar tissue is performed, releasing the posterior portion of the elbow joint capsule. Using a 2.5 mm drill, multiple holes are formed around the circumference of the olecranon fossa of the humerus with the maximum possible diameter (Fig. 1). A grooved chisel is used to connect the drilled holes, forming a through hole between the olecranon fossa and the coronoid fossa of the humerus.

The range of motion is monitored. If a collision between the olecranon apex and the distal humerus is detected, resection of the protruding ossificates is performed. Using the Buyalsky scapula, through access through the distal tendon of the triceps brachii, its release is performed along the tendinous portion. The release is performed by mobilization from the surrounding tissues.

In the case of the presence of ossifications in the lateral and/or anterior parts of the joint, revision is performed through an additional lateral approach by spreading the proximal part of the posterior group of muscles of the forearm with subsequent resection of the mentioned ossifications (located in the lateral and/or anterior parts of the joint).

The next stage is visualization of the posterior and transverse bundles of the medial collateral ligament. They are excised with scar-altered tissues (Fig. 2), preserving the anterior bundle of the medial collateral ligament, which allows for mobilization of the elbow joint.

Performing a release of the medial collateral ligament significantly increases the ability to increase the range of motion in the elbow joint due to the flexion component. The range of motion and stability of the elbow joint are assessed. An active drain is installed in the formed opening, and the postoperative wound is sutured layer by layer.

The stages of the operation are as follows.

Posterior approach to the elbow joint

Neurolysis, mobilization and abduction of the ulnar nerve on an elastic holder.

Access to the fossa of the olecranon process of the humerus through the tendon of the triceps brachii. Resection of ossifications located around the fossa and the apex of the olecranon process. Release of the posterior parts of the elbow joint.

Forming holes in a circle corresponding to the edge of the fossa of the olecranon process of the humerus with a 2.5 mm drill. Using a grooved chisel, forming a through hole along the course of the drilled holes.

Release of the distal part of the triceps brachii muscle over a distance of 9-11 centimeters, corresponding to its tendon part.

In case of localization of ossifications in the lateral and/or anterior parts of the joint, their visualization and release of the anterior and/or lateral parts of the joint are performed through the lateral approach.

Release of the medial sections of the joint, isolation of the posterior and transverse bundles of the medial collateral ligament. Excision of the posterior and transverse bundles of the medial collateral ligament.

Installation of active drainage

As evidence of the possibility of implementing the stated purpose and achieving the specified technical result, we provide a clinical example of the implementation of the proposed method.

Clinical example 1

Patient P., 39 years old, with a diagnosis of: Post-traumatic arthrofibrosis, mixed contracture of the left elbow joint.

Complaints: limited mobility in the left elbow joint.

History: six months before the visit, he was injured while playing sports. The patient is actively involved in powerlifting. The limited range of motion has been bothering him for a long time.

Examination reveals significant contracture of the left elbow joint. X-rays of the elbow joint show signs of arthrosis and the presence of heterotopic ossifications (Fig. 3).

After the surgical intervention performed according to the proposed method with fenestration of the window in the distal humerus, with release of the triceps tendon, posterior and transverse bundles of the medial collateral ligament, resection of ossifications in accordance with the proposed method. Ossifications were detected in the anterior and lateral sections of the elbow joint, their resection was performed using an additional approach formed by blunt and sharp separation of the proximal part of the posterior group of forearm muscles. The operated limb is fixed in a sling bandage. From the 2nd day after the surgery, the development of movements in the elbow joint began under the supervision of a rehabilitation specialist.

Discharged for outpatient treatment on the 3rd day after the operation.

On control radiographs 14 weeks after the operation, correct joint relationships are noted, and the formed window in the distal humerus is visualized (Fig. 4).

The patient noted a significant increase in the range of motion in the elbow joint, had no complaints after the surgery, and was satisfied with the clinical result.

Clinical example 2

Patient S., 48 years old, with the diagnosis: fracture of the humeral condyles consolidated under conditions of osteosynthesis with plates. Post-traumatic arthrofibrosis, contracture of the left elbow joint.

Complaints: discomfort, limited mobility in the left elbow joint.

History: trauma as a result of a fall 1 year before the visit; 7 days after the trauma, open reposition and osteosynthesis of the humeral condyles with plates were performed. The patient was then treated as an outpatient, underwent rehabilitation, but subsequently began to notice a decrease in the range of motion in the elbow joint. Conservative treatment was ineffective.

Examination reveals flexion-extension contracture of the elbow joint, radiographs show a fracture of both condyles of the humerus consolidated under conditions of metal osteosynthesis with a plate. Post-traumatic arthrosis of the left elbow joint.

A surgical intervention was performed (removal of metal fixators. Open arthrolysis of the left elbow joint) according to the proposed technique with release of the posterior and transverse bundles of the medial collateral ligament (Fig. 5), formation of a window in the distal humerus, release of the distal triceps tendon and resection of ossifications in accordance with the proposed method. Ossifications were identified in the anterior elbow joint, their resection was performed using an additional approach formed by blunt and sharp separation of the proximal part of the posterior group of forearm muscles. The operated limb is fixed with a sling bandage with subsequent early development of movements in the elbow joint under the supervision of a rehabilitation specialist.

Discharged for outpatient treatment on the 3rd day after the operation.

Control radiographs taken 12 weeks after the operation showed satisfactory joint relationships.

The patient noted an increase in the range of motion in the area of the left elbow joint due to an increase in the amplitude of flexion and extension; the patient did not present any complaints after the surgical intervention, no neurological symptoms were noted, and he was satisfied with the clinical result.

Clinical example 3

Patient G., 32 years old, with a diagnosis of: fracture of the humeral condyles consolidated under conditions of osteosynthesis with plates. Post-traumatic arthrofibrosis, contracture of the left elbow joint.

Complaints: discomfort, limited mobility in the left elbow joint.

History: trauma as a result of a fall 10 months prior to the visit as a result of a fall from a height of 4 m; 8 days after the injury, open reposition and osteosynthesis of the humeral condyles with plates were performed. The patient then received outpatient treatment, underwent rehabilitation, but subsequently began to notice a decrease in the range of motion in the elbow joint. Conservative treatment was ineffective. Surgical treatment was performed 3 months after the operation - removal of metal fixators (pins and wire) from the olecranon process of the ulna.

Examination reveals flexion-extension contracture of the elbow joint, radiographs show a fracture of both condyles of the humerus consolidated under conditions of metal osteosynthesis with a plate. Post-traumatic arthrosis of the left elbow joint.

The patient underwent surgery - "Removal of metal fixators. Open arthrolysis of the left elbow joint." CT revealed ossifications mainly in the lateral parts of the elbow joint, their resection was performed using an approach formed by blunt and sharp separation of the proximal part of the posterior group of forearm muscles. Intraoperatively, an increase in the range of motion in the left elbow joint was determined. The operated limb is fixed with a sling bandage with subsequent early development of movements in the elbow joint under the supervision of a rehabilitation specialist.

Discharged for outpatient treatment on the 3rd day after the operation.

The patient noted an increase in the range of motion in the area of the left elbow joint due to an increase in the amplitude of flexion and extension; the patient did not have any complaints after the surgery, no neurological symptoms were noted, and he was satisfied with the clinical result.

Claims (2)

1. A method for surgical treatment of elbow joint contracture, including release of the medial collateral ligament of the elbow joint, characterized in that the intervention is performed using a posterior approach to the elbow joint, which is supplemented by access to the fossa of the olecranon process of the humerus through the distal tendon of the triceps brachii; the triceps brachii is released along its distal tendon portion; a "window" is formed connecting the coronoid fossa and the fossa of the olecranon process of the humerus, ossifications located in the posterior and medial parts of the elbow joint are resected; then the medial collateral ligament of the elbow joint is released, during which excision of cicatricial tissues is limited to the posterior and transverse bundles of the medial collateral ligament of the elbow joint, preserving its anterior bundle. 2. The method according to item 1, characterized in that, in the presence of ossifications in the anterior and/or lateral sections of the elbow joint, their resection is carried out using an access formed by spreading the proximal part of the posterior group of muscles of the forearm.