RU2463982C1 - Method of treating fractures of head and neck of humerus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, to endoprosthetics of humerus. Operation is performed on back in pose of "beachgoer" with lifted to 30° head end and to 20° foot end, with cushion between shoulder blades. Skin, subcutaneous cellular tissue are dissected by longitudinal cut from acromial process downward, in projection of fissure between deltoid and greater pectoral muscles up to 10 cm long, deltoid muscle is split bluntly. Capsule is dissected by longitudinal linear 5-6 cm long cut. Head of humerus or its fragments are exposed, removed, edges of proximal part of bone diaphysis are aligned. Bone-marrow canal of humerus is elaborated to required size. Fitting leg and fitting plastic head are installed. Fitting endoprosthesis is fixed, and after volume and freedom of movements are checked, is removed. Shoulder leg is installed on cement, head is pressed on leg neck, joint is fixed. Rotary cuff is restored, capsule and soft tissues are sutured.

EFFECT: method ensures approach of proximal bone end to access, reduces possibility of injuring lateral subcutaneous vein, tendon of long head of biceps brachii, musculocutaneous nerve.

3 cl, 1 ex, 4 dwg

Description

Fractures of the proximal humerus (head and neck) are quite common and account for up to 4-12% of fractures of all localizations and 45% of fractures of the humerus (1, 3, 10). More than 70% of patients are elderly patients suffering from osteoporosis. In this age group, the frequency of fractures of the head and neck of the humerus increases to 12.8-19.8% (9, 10). The results of the treatment of severe fractures of the surgical neck and head of the humerus leave much to be desired. Thus, unsatisfactory outcomes in the treatment of fractures of the head and neck of the humerus, even with the use of modern methods of osteosynthesis, amount to 17-50% (2, 4, 7, 8). Despite the variety of applied methods for the treatment of fractures of the humerus, a high percentage of complications and unsatisfactory outcomes of elbow joint contracture remains (8-85%), and persistent disability (up to 30%) (5, 10, 11).

Thus, the search for alternative ways of treating fractures of the head and neck of the humerus is relevant and justified.

The invention relates to medicine, namely traumatology and orthopedics, and consists in the development of a new method for the treatment of severe fractures of the proximal humerus - the head and neck of the humerus. A known method of treating severe fractures of the head and neck of the humerus (Arzumanov S.V., Apaguni A.E. Tactics for treating fractures of the proximal segment of the humerus // International Pirogov Scientific and Practical Conference "Osteosynthesis and Endoprosthetics", May 15-16, 2008, Moscow , p. 9). The method consists in performing immersion osteosynthesis with adapted T-shaped plates with angular stability of the screws. With good anatomical and functional results, the authors state that satisfactory results were obtained in 27.3% of patients and good results in only 72.7%. In addition, the disadvantage of immersion osteosynthesis is the need for repeated operations associated with the removal of metal.

Materials and methods. We observed 45 patients with follow-up periods of up to 5 years who underwent shoulder joint replacement for fractures of the head and neck of the humerus. Men 27, women 18. The age of patients from 29 to 73 years.

Preoperative examination included standard radiography in 2 projections, CT of the shoulder joints, and, if necessary, electroneuromyography. Clinical, laboratory and instrumental research was carried out in a standard volume for operations of this level and degree of complexity.

For the operation of endoprosthetics in all cases, a domestic endoprosthesis of ESI firm (Russia) was used (Fig. 1).

Endoprosthesis belongs to the category of unipolar. It consists of a shoulder component 1-4 sizes, 132 mm long and a diameter of 6.5, respectively; 8.5; 10.5; 12.5 mm. The shoulder component is made of high-nitrogen anticorrosive steel FeCrNi standard ISO 5832-9. Material VT-6 (Ti-6Al-4V). If necessary, the shoulder component of the joint is made individually based on the topographic and anatomical features of the pathology in a particular patient. Typically, the need for individual humeral legs occurs with complex, combined fractures of the head and proximal end of the diaphysis of the humerus. Heads of an endoprosthesis of a shoulder joint of 3 standard sizes: respectively 23-16; 23-20 and 23-24 mm, and are available in 2 versions: mono - and bipolar (figure 2).

In the proximal part of the leg of the endoprosthesis there are conical expansion and 3 longitudinal ribs, with the help of which a fairly rigid proximal fixation of the leg of the endoprosthesis is carried out. In the same part of the leg there are 3 technological holes for fixing to them the elements of the joint capsule. To perform the operation, special tools are issued.

 Operation technique. The optimal position of the patient on the operating table is lying on his back in the pose of a “beach man” with the head end raised to 30 ° and the leg end up to 20 °, with a roller between the shoulder blades (Fig. 3.1). A longitudinal section from the acromial process downward, in the projection of the groove between the deltoid and pectoralis muscle up to 10 cm long, the skin, subcutaneous tissue are dissected, the deltoid muscle is stupidly stratified, the capsule of the joint is exposed (Fig.3.2) The capsule is dissected by a 5-6 cm long linear section ( Fig.3.3). The head of the humerus or its fragments and fragments, which are removed (Figure 3.4), are dull and sharp. The edges of the proximal part of the diaphysis of the humerus are aligned (Fig.3.5). In acute injury (up to 2 weeks), fragments of the head of the humerus stand out quite freely. In case of chronic injuries to the head and surgical neck of the humerus, false joints of the neck, as well as arthrosis, aseptic necrosis of the head, isolation and removal of it is extremely difficult, traumatic and usually accompanied by bleeding. This is due to the fact that the joint capsule, its surrounding soft tissues are scarred, tightly fused with bone fragments. With the allocation of the head and its fragments, a partial removal of the joint capsule occurs. In case of nontraumatic deformities of the humeral head, oblique osteotomy is performed (along the anatomical neck of the humerus). Using special raspaters opened and developed to the required size of the bone marrow canal of the humerus (Fig.3.6). In the bone marrow canal, a fitting leg was installed, on which a plastic fitting head was put on (Fig. 3.7). The fitting endoprosthesis was adjusted, the volume and freedom of movement were checked, after which it was removed. A shoulder leg was installed on bone cement, a head of the required size and type was pressed onto the neck of the leg. The joint was adjusted (Fig.3.8).

PVC drainage was applied to the neck of the endoprosthesis, the rotational cuff of the shoulder was restored, the capsule of the joint was sutured, and soft tissues were restored in layers. Active drainage was removed at the first ligation after 1 day.

In the postoperative period, the shoulder joint was immobilized for 7 days with a soft bandage with a wedge-shaped pillow in the armpit in order to divert the arm by 30 °. During this period, movement was allowed only in the elbow joint, wrist and fingers. From the 2nd week, exercise therapy, massage, and physiotherapy were prescribed. After 30 days - hydromassage, swimming in the pool.

The criterion of the effectiveness of surgical intervention was considered the cessation of pain and restoration of range of motion in the joint up to 30-40% of the norm by the outcome of 3-4 months.

The results of the treatment. The treatment results were studied in 41 patients in the period from 1 year to 4 years after surgery for shoulder joint replacement. 25 men, 16 women, aged 29 to 73 years old, including 13 patients with 3 or more fragmented fractures of the head and surgical neck of the humerus; with 2 fragmented fractures of the head and surgical neck of the humerus in the elderly - 28 patients. Postoperative results were evaluated using the Swanson shoulder score (A.B. Swanson shoulder score, 1989). The test allows you to assess the severity of pain, the amplitude of movements in the shoulder joint, the activity of everyday life. The maximum number of points (30) on this scale corresponds to the normal condition of the shoulder joint. Good and excellent results (more than 20 points) were obtained in 36 patients (87.8%); satisfactory results (15-19 points) - in 5 patients (12.2%).

Clinical example 1. Patient B., 34 years old, was admitted to the orthopedic department of the Saratov Design Bureau on 12.12.2007 with complaints of pain and lack of function in the left shoulder joint. 2 months I received a severe polytrauma ago, was operated on for a severe head injury and trauma to the abdominal organs. The left arm was fixed with a plaster cast. The diagnosis was established: Fragmented-comminuted fracture-dislocation of the head of the left shoulder joint with a significant displacement of fragments (figure 4.1).

12/14/2007 endoprosthetics of the left shoulder joint was performed with cement endoprosthesis of ESI firm (Fig. 4.2). The postoperative period was uneventful. Rehabilitation was carried out according to the usual scheme. When viewed after 1 year, the Swanson score for the shoulder was 22 points. Joint function is satisfactory (Fig. 4.3). When analyzing radiographs during the same period, the position of the components of the endoprosthesis is correct, there are no signs of instability. The patient is fully socially adapted, pleased with the results of the operation.

 Thus, shoulder joint replacement for fractures of the head and neck of the humerus is a high-tech surgical tool that allows you to get a good and long-term clinical and anatomical result in a short time. Endoprosthetics of the shoulder joint can be considered an alternative and effective method of treating severe pathology of the shoulder joint in comparison with various types of osteosynthesis and other methods of surgical manual.

Literature

1. Arzumanov S.V., Apaguni A.E. Tactics of treatment of fracture of the proximal segment of the humerus // in the materials of the international Pirogov scientific-practical conference “Osteosynthesis and endoprosthetics”, May 15-16, 2008, Moscow, p. 9.

2. Gulnazarova S.V., Mamaev V.I. Single-cavity endoprosthetics in the treatment of nonunion of the proximal humerus // Abstracts of the IX Congress of Orthopedic Traumatologists of Russia, Saratov, 2010, S.360-361.

3. K.S. Egorov, V.A. Neverov, A.A. Khromov, S.N. Chernyaev, A.D. Scheglov, I.N. Kravchenko, A.L. Shebarshov. The choice of fixation method for fractures of the proximal humerus // In the materials scientific. Conference "Modern Technologies in Traumatology and Orthopedics". - St. Petersburg, VMedA, 2010, p. 28.

4. Erofeev S.A., Lifanov A.V., Erofeev A.T., Heger M.E. On the treatment of fractures of the surgical neck of the humerus against osteoporosis // Abstracts of the IX Congress of Orthopedic Traumatologists of Russia, Saratov, 2010, S.814-815.

5. V.V. Klyuchevsky, Hassan Ben El Hafi. Treatment of near- and intraarticular fractures of the distal humerus // Traumatology and Orthopedics of Russia 2010, No. 3, S.96-102.

6. Kolomiets A.A. The first experience of arthroplasty of the shoulder and elbow joints // Abstracts of the IX Congress of Orthopedic Traumatologists of Russia, Saratov, 2010, P.420.

7. S.I. Makarova. Surgical treatment of three- and four-fragmented fractures of the proximal humerus // In the materials scientific. Conference "Modern Technologies in Traumatology and Orthopedics". - St. Petersburg, VMedA, 2010, p.27.

8. A.A. Mamedov, V.M. Prokhorenko, O.V. Falameeva, M.A. Gardening. Treatment of fractures of the surgical neck of the humerus in elderly patients with osteoporosis // In the materials scientific. Conference "Modern Technologies in Traumatology and Orthopedics". - St. Petersburg, VMedA, 2010, p.29.

9. Pankov I.O., Emelin A.L. Stable-functional osteosynthesis in the treatment of fractures of the proximal end of the humerus // Materials XIV Ros. nat. Congress "Man and his health." - St. Petersburg, 2006, S.50.

10. Chorny S.I., Prokhorenko V.M., Fomenko S.M. Endoprosthetics of the shoulder joint // Abstracts of the IX Congress of Orthopedic Traumatologists of Russia. Saratov, 2010, S.549-550.

11. V.M. Shapovalov, V.V. Khominets, S.V. Mikhailov, D.A. Shakun, F.I. Turakulov. Features of surgical tactics in the treatment of patients with fractures of the proximal humerus // In the materials scientific. Conference "Modern Technologies in Traumatology and Orthopedics". - St. Petersburg, VMedA, 2010, p.26.

Claims (3)

1. A method of treating fractures of the head and neck of the humerus, including the replacement of the affected shoulder joint with an endoprosthesis and characterized in that the operation is performed on the back in the pose of a “beach man” with the head end raised to 30 ° and the leg end up to 20 °, with a roller between the shoulder blades; a longitudinal section from the acromial process downward, in the projection of the groove between the deltoid and pectoralis muscle up to 10 cm long, cut the skin, subcutaneous tissue, stupidly deltoid muscle, expose the joint capsule, cut the capsule with a longitudinal linear section 5-6 cm long; secrete the head of the humerus or its fragments and fragments that are removed, the edges of the proximal part of the diaphysis of the humerus are aligned. 2. The method according to claim 1, characterized in that the bone marrow canal of the humerus is opened and developed to the required size with the rasers, a fitting leg is mounted on it, on which a plastic fitting head is put on, the fitting endoprosthesis is adjusted, the volume and freedom of movement are checked, after why is he leaving; a shoulder leg is installed on bone cement, a head of the required size and type is pressed onto the neck of the legs; the joint is repaired. 3. The method according to claim 1, characterized in that the neck of the endoprosthesis is drained, the rotational cuff of the shoulder is restored, the capsule of the joint is sutured, the soft tissues are restored in layers.

Images