RU2750844C1 - Method for holding the isometric position of the tendon of the long head of the shoulder biceps when performing its arthroscopic tenodesis - Google Patents

Abstract

FIELD: medicine; traumatology; orthopedics.

SUBSTANCE: invention relates to the field of medicine, namely to traumatology and orthopedics, it can be used for surgical treatment of the tendon pathology of the long head of the shoulder biceps. At the first stage, the tendon is temporarily fixed with a spinal needle or spoke through all the tissues of the shoulder joint, after which it is cut off. Then the interbugular ligament is dissected, the stump of the biceps tendon is found, which is fixed with the needle or spoke, and is re-fixed with the second spinal needle or spoke through to the humeral bone. The first needle or spoke is removed. After fixing the stump with an interference screw, the second needle or spoke is removed.

EFFECT: method increases the efficiency of treatment of patients with tendon pathology of the long head of the biceps, and also reduces the risk of damage to the regional neurovascular bundles, relapses of pathology, as well as the risk of fracture of the humeral bone by maintaining the biomechanical ratio by firmly fixing and holding the isometric position of the tendon of the long head of the biceps when performing its tenodesis.

1 cl, 1 ex, 7 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, can be used for the surgical treatment of pathology of the tendon of the long head of the biceps.

Lesions of the long biceps tendon are common causes of shoulder pain, which significantly impairs the patient's quality of life. The issue of choosing the optimal tactics for treating pathology is especially important in relation to young active able-bodied patients, whose contingent is increasing, including due to an increase in injury rates. Alternative effective methods of conservative treatment of pathology can hardly be indicated.

The main known options for surgical treatment of pathology of the tendon of the long head of the biceps are: 1) tenotomy - cutting off the tendon from the point of attachment to the supra-articular tubercle of the articular process of the scapula and 2) tenodesis - fixing the dissected tendon in one or another anatomical region. The fixation of the dissected tendon of the humerus in comparison with simple tenotomy is characterized by clinically significant advantages: preservation of the length and tension of the tendon of the long head of the biceps, prevention of muscle atrophy, creation of conditions for stabilization of the humeral head (Elser F., Braun S., Dewing S.V., Giphart JE, Millett PJ Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon // Arthroscopy. 2011. Vol. 27, N 4. Pp. 581-592. DOI: 10.1016 / j.arthro.2010.10 .014) and maintaining the functionality of the elbow joint in the context of flexion and supination strength, reducing the risk of spastic pain, minimal trauma to the skin (Patel KV, Bravman J., Vidal A., Chrisman A., McCarty E. Biceps Tenotomy Versus Tenodesis // Clin Sports Med. 2016. Vol. 35, No. 1. Pp. 93-111. DOI: 10.1016 / j.csm.2015.08.008).

When performing tenodesis, open and arthroscopic approaches are widely used. In open tenodesis, fixation can be achieved through a standard surgical approach using an interference screw (Mellano CR, Frank RM, Shin JJ [et al.]. Subpectoral biceps tenodesis with PEEK interference screw: A biomechanical analysis of humeral fracture risk // Arthroscopy. 2018 . Vol.34. Pp.806-813. DOI: 10.1016 / j.arthro.2017.09.012), bicortical or single-cortical buttons, suture anchor or suture with surrounding soft tissues (insertion of the biceps tendon into the rotator cuff suture or fixing suture to the tendon pectoralis major muscle). Open techniques have a number of disadvantages: the risk of neurovascular complications (impaired muscle innervation and loss of sensation as a result of adhesions around the nerves) and an unsatisfactory cosmetic result (scarring). The arthroscopic technique for performing tenodesis of the biceps consists in performing the operation under the control of endovideosurgical equipment through punctures of the skin. In some cases, surgeons use a combination of approaches, part of the operation is performed closed and part of the operation through an open access, performing the stage of preparing the tendon for fixation, bringing it to the skin through a small additional incision. Significant disadvantages of this technique of combining arthroscopy with the stage of cutaneous suturing and preparation of the tendon for fixation are the increased risk of infectious complications (Abraham VT, Tan V.N., Kumar VP Systematic Review of Biceps Tenodesis: Arthroscopic Versus Open // Arthroscopy. 2016. Vol. 32. Pp. 365-371. DOI: 10.1016 / j.arthro.2015.07.028) and defective preservation of isometric tension.

The completely closed arthroscopic technique of performing the operation is relatively difficult to master and requires good manual skills of the surgeon, but it has undeniable advantages: a decrease in the risk of neurovascular damage due to the stratographic arrangement of neurovascular bundles, minimization of the level of surgical impact on the joint as a whole, a better cosmetic effect of the operation and a reduction in terms of time. restoration of the usual physical activity.

The closest in technical essence and adopted as a prototype is "Method of fixing the tendon of the long head of the biceps brachii" (RF Patent No. 2479271, IPC А61В 17/56. Publ. 20.04.2013, Bul 11). The known method provides for fixing the tendon of the long head of the biceps brachii muscle using arthroscopic technique, which consists in fixing the tendon in the intraosseous canal formed in the humerus and additional fixation of the tendon by the imposition of two sutures to the tissues of the tendon sheath in the area of the intertubular groove of the humerus. In the known method, at the first stage of performing arthroscopic surgery inside the cavity of the shoulder joint, the site of attachment of the tendon to the articular process of the scapula is examined and cut off. Immediately after cutting off the tendon from the place of its anatomical attachment, the muscle tissue contracts and the tendon part is displaced towards the muscle abdomen. At the second stage of the operation, the arthroscope is removed from the joint cavity and placed in the subacromilous and subdeltoid spaces above the region of the intertubercular ligament and opened it. In the opened intertubular groove, a tendon stump of the long head of the biceps brachii is found. In the middle third of the intertubercular sulcus, a hole is placed into which the stump is immersed. The stump is fixed in the hole with an interference screw. An additional two sutures are placed between the tendon and the tissues of the tendon sheath in the region of the intertubercular groove of the humerus.

The disadvantage of the prototype is the loss of isometric tension of the tendon of the long head of the biceps at the first stage of the operation, when immediately after cutting off the tendon from the place of its anatomical attachment, the muscle tissue contracts and the tendon part is displaced towards the muscle abdomen. As a consequence, at the second stage of the operation, when the arthroscope is removed from the joint cavity and placed in the subacromilous and subdeltoid spaces to fix the tendon to the humerus with an interference screw in the middle third of the intertubercular sulcus, it is almost impossible to restore the biomechanical ratio of the length and tension of the tendon, due to the absence of any or anatomical landmarks. This disadvantage is due to the lack of intermediate, temporary fixation of the tendon during the operation, which will prevent arbitrary displacement of the tendon. The second disadvantage of the prototype is its complexity, due to the need to impose additional sutures between the tendon tissue of the long head of the biceps brachii muscle and the tissues of the tendon sheath in the area of the intertubercular groove of the humerus. When performing this procedure, the duration of the operation increases, the risks of surgical complications increase.

The technical result when using the proposed invention is to increase the efficiency of treatment of patients with pathology of the tendon of the long head of the biceps brachii due to firm fixation and retention of the isometric position of the tendon of the long head of the biceps when performing its tenodesis, maintaining the biomechanical ratio, reducing the risk of damage to regional neurovascular bundles and relapses pathology, reduced risk of humerus fracture, increased patient satisfaction.

The technical result is achieved by the fact that in the method of maintaining the isometric position of the tendon of the long head of the biceps brachii muscle when performing its arthroscopic tenodesis, including examination of the tendon attachment point to the articular process of the scapula, cutting it off and fixing the tendon with an interference screw in the intraosseous canal formed in the humerus, before by cutting off the tendon from the articular process of the scapula and before its final fixation to the humerus with an interferential screw, sequential temporary fixation of the tendon is performed with spinal needles or Kirschner wires.

At the first stage of the operation, inside the cavity of the shoulder joint, the place of attachment of the tendon to the articular process of the scapula is examined and the tendon is temporarily fixed with a spinal needle or knitting needle through all tissues of the shoulder joint, after which it is cut off. This technique prevents the tendon part from being involuntarily displaced towards the muscular abdomen due to fiber contraction. At the second stage of the operation, the arthroscope is removed from the joint cavity and placed in the subacromilous and subdeltoid spaces above the intertubercular ligament region. The search for this anatomical area is greatly facilitated by the previously installed needle or wire, since an anatomical landmark appears in the tissues of the subacromial and subdeltoid spaces of the shoulder joint. The intertubercular ligament is opened. In the opened inter-tubercular groove, a stump of the biceps brachii tendon is found, fixed with a needle or knitting needle. With the second spinal needle or knitting needle, in the projection of the lower third of the intertubercular groove, the tendon stump is fixed repeatedly through to the humerus. The first needle or knitting needle is removed. In the middle third of the intertubular groove, a hole is placed into which the tendon stump is immersed. The stump is fixed in the hole with an interference screw. Remove the second needle or needle. A final examination of the area of operation is made and the strength of the tendon fixation is tested.

The use of pins greatly facilitates the search for anatomical landmarks in the subacromial, subdeltoid spaces and the region of the intertubercular ligament. This method of temporary fixation preserves the anatomical balance of tension, isometry of the tendon, allows for optimal visualization inside the joint without using an open access, minimizes the level of surgical intervention and tissue trauma in the area of intervention, and significantly reduces the risk of surgical error.

The proposed method is implemented as follows.

The patient is placed on the operating table in the "beach chair" position (the arm is placed in the position of 30 ° abduction, 30 ° flexion and 10-20 ° external rotation in the shoulder joint). At the first stage of the operation, an arthroscope with a 30 ° lens is placed into the posterior approach to examine the intra-articular section of the tendon of the long head of the biceps brachii. In the presence of a pathology of the tendon and indications for tenodesis, temporary fixation of the tendon is performed with a spinal needle or knitting needle at the level of its confluence with the mucous tuberous groove through all tissues of the shoulder joint, by passing the needle through the tendon through and through. The tendon is cut off from the articular lip in the area of attachment to the supra-articular tubercle of the scapula. The fixation needle avoids contraction of the tendon after it has been cut off. Next, the stump of the tendon and the upper part of the articular lip are treated with an electrocautery. At the second stage of the operation, the arthroscope is removed from the joint cavity and placed in the subacromilous and subdeltoid spaces above the intertubercular ligament region. Bursectomy or acromioplasty is performed if indicated. An additional skin puncture is applied (anterolateral approach) and the arthroscope chamber is transferred into it. The use of an anterolateral approach makes it possible to visualize well not only the fixation needle or wire in the projection of the bicipital sulcus, but also n. musculocutaneus in its atypical location. Next, a third working approach is applied slightly below the fixation needle and the transverse ligament is dissected from the fixation needle to the upper edge of the pectoralis major muscle with an electrocautery. The second needle or Kirschner wire is used to fix the tendon to the humerus through and through in the lower third of the bicipital sulcus above the tendon of the pectoralis major muscle. After fixation of the tendon with a second needle or wire, the first fixation needle or wire is removed. The stump of the biceps is removed from the opened groove into the subdeltoid space, the bed of the groove is treated with an electrocautery to remove the remnants of the inflamed synovial membrane of the sheath of the biceps brachii tendon. After that, in the middle third of the bicypital sulcus, a blind hole with a diameter corresponding to two diameters of the biceps (usually 7-8 mm) and a depth of 25 mm is applied along the guidewire. It should be borne in mind that over-machining of the bicipital sulcus can lead to weakening of the bone and displacement of the screw, with a loss of fixation strength. The canal cavity and the edges of the hole are processed to remove bone chips and sharp edges. In the last stage, the biceps tendon, in one layer or folded in half, is immersed in the canal of the humerus. An interference screw is inserted through the guidewire into the canal, which achieves the final fixation of the tendon. After checking the reliability of the fixation, the second fixation needle or wire is removed.

The inventive method for the surgical treatment of pathology of the tendon of the long head of the biceps provides a technological medical result in increasing the effectiveness of treatment, while being universal, easy to use and available to a wide range of surgeons.

The inventive method of surgical treatment is illustrated by figures, which schematically show the stages of the intervention:

Fig. 1. General front view of the shoulder joint. The tendon of the long head of the biceps brachii (SDH) is fixed inside the joint with a needle or knitting needle through the skin and the intertubercular ligament through and through.

1. SDGB. 2. The head of the humerus. 3. Glenoid. 4. Lesser tubercle of the humerus and the tendon of the subscapularis muscle. 5. Intertubular ligament.

Fig. 2. View into the arthroscope chamber of the shoulder joint from the posterior approach. SDGB is fixed inside the joint with a needle or wire through the skin and the intertubercular ligament through and through.

1. SDGB. 2. The head of the humerus. 3. Glenoid 4. Subscapularis tendon.

Fig. 3. View of the shoulder joint through the arthroscope chamber from the posterior port. SDGB was cut off with arthroscopic scissors or electrocautery.

1. SDGB. 2. Head of the humerus 3. Glenoid 6. Arthroscopic scissors or electrocautery. 7. Locking knitting needle or needle.

Fig. 4. View into the arthroscope chamber from the anterolateral approach to the subacromilous and subdeltoid spaces of the shoulder joint. SDHP was fixed with a second spinal needle or wire at the level of the pectoralis major muscle tendon. The intertubercular ligament was opened.

1. SDGB. 2. The head of the humerus. 7. Fixation needle or wire 8. Dissected intertubercular ligament. 9. Acromio - coracoid ligament. 10. Second fixing needle or knitting needle. 11. Tendon of the pectoralis major muscle

Fig. 5. View into the arthroscope chamber from the anterolateral approach to the subacromilous and subdeltoid spaces of the shoulder joint. The first needle or knitting needle has been removed. The stump of the SDGB is removed from the intertubercular sulcus. A drill guide is installed in the middle third of the intertubular groove. A canal was drilled 8 mm, 25 mm deep in the humerus.

1. stump of SDGB. 2. The head of the humerus. 1. Drill guide 9. Acromio-coracoid ligament. 10. Second fixing needle or knitting needle. 11. Tendon of the pectoralis major muscle. 12. Drill with a diameter of 8 mm on a guide 13. Canal in the humerus.

Fig. 6. View into the arthroscope chamber from the anterolateral approach to the subacromilous and subdeltoid spaces of the shoulder joint. The SDGB stump is inserted into a canal superimposed in the intertubercular groove of the humerus. The conductor for the screw is immersed in the channel. The screw is inserted into the channel via a guide wire.

1. Stump of SDGB 2. 2. Head of the humerus. 10. Second fixing needle or knitting needle. 3. Canal 8X25 mm in the humerus 4. Intertubercular groove 5. Second fixing needle or wire. 11. Tendon of the pectoralis major muscle. 13. Canal in the humerus 14. Fixing interference screw 8 mm.

Fig. 7. View into the arthroscope chamber from the anterolateral approach to the subacromilous and subdeltoid spaces of the shoulder joint. The lead for the screw has been removed. The second fixation needle or knitting needle has been removed. Final inspection of the fixed SDGB.

1. Stump of SDGB 2. Head of the humerus. 8. Dissected intertubular ligament. 13. Channel in the humerus. 14. Fixing interference screw 8 mm.

The proposed method is supported by a clinical example.

Clinical example

Patient A., 32 years old, doctor. History of shoulder injury from falling on a rink.

Diagnosis: Chronic post-traumatic instability of the tendon of the long head of the biceps muscle of the right shoulder, tendonitis. Old injury of the intertubercular ligament.

After examination and preliminary preparation, surgical treatment was performed.

General anesthesia. The patient is positioned in the "beach chair" position (the arm is placed in the position of 30 ° abduction, 30 ° flexion and 10-20 ° external rotation in the shoulder joint). At the first stage of the operation, an arthroscope with a 30 ° lens is inserted into the posterior port. The intra-articular section of the biceps tendon was examined. The signs of chronic inflammation of the tendon were revealed. The tendon was tested under load; pathological mobility in the intertubercular sulcus was revealed, which is a consequence of damage to the intertubercular ligament. A decision was made to perform suprapectoral tenodesis of the tendon of the long head of the biceps with an interference screw. The tendon was temporarily fixed with a wire at the level of its confluence with the mucous tuberous groove through all the tissues of the shoulder joint and through the tendon. The tendon is cut off from the articular lip in the area of attachment to the supra-articular tubercle of the scapula. No fiber contraction occurred. The stump of the tendon and the upper part of the articular lip were treated with an electrocautery. At the second stage of the operation, an additional skin puncture was imposed (anterolateral approach). The arthroscope is removed from the joint cavity and is located through this access in the subacromilous and subdeltoid spaces, above the intertubercular ligament. Bursectomy was performed. The fixation wire was well visualized in the projection of the intertubular groove, and a reliable anatomical landmark was obtained. Next, a third working approach was imposed below the fixing pin, and the entire intertubercular ligament was dissected from the pin to the upper edge of the pectoralis major muscle with an electrocautery. The second wire was used to fix the tendon to the humerus through and through in the lower third of the intertubular groove above the tendon of the pectoralis major muscle. After fixing the tendon with the second wire, the first wire was removed. The stump of the tendon of the long head of the biceps brachii was brought out of the opened groove into the subdeltoid space; the groove was treated with an electrocautery to remove the remnants of the inflamed synovial membrane of the sheath of the biceps brachii tendon. After that, a blind hole with a diameter corresponding to two diameters of the tendon - 8 mm and a depth of 25 mm was imposed on the guidewire in the middle third of the intertubercular sulcus. The cavity of the canal and the edges of the hole were processed, bone chips and sharp edges were removed. The stump of the biceps tendon, in one layer, is immersed in the canal of the humerus. An interference screw was inserted through the guidewire into the canal, which achieved the final fixation of the tendon. After checking the reliability of fixation, examination of the area of intervention, the second fixing pin was removed.

Mobility of the right upper limb immediately after surgery is limited by a Dezo bandage for 4 weeks. After 7 days, the stitches were removed. After 4 weeks, a rehabilitation program was started. The follow-up examination carried out 12 weeks later showed excellent cosmetic and functional results. No pain recurrence was noted.

Surgical intervention by the proposed method was performed in 350 patients. The results were assessed using the SSI - ASES Shoulder Assessment Form American Shoulder and Elbow Surgeons and The University of California - Los Angeles (UCLA) Shoulder Scale)

Good and excellent treatment results were observed in 322 (92%) operated patients.

The method of maintaining the isometric position of the tendon of the long head of the biceps brachii during arthroscopic suprapectoral tenodesis showed an excellent cosmetic effect in postoperative observation for more than 6 years. In all cases, there was no shoulder deformity associated with a loss of tension in the tendon of the long head of the biceps brachii. The terms of restoration of habitual physical activity are comparable to the literature data.

There were no neurovascular complications. Postoperative hematoma in the area of the shoulder joint was noted in 3 cases, which were treated with conservative therapy without repeated surgical intervention.

In two cases, there was a loss of fixation of the tendon of the long head of the biceps brachii with an interference screw. These facts are due to the violation of the recommendations for limiting the load and mobility of the operated upper limb and the early onset of the sports load by the patient, and in the second case, the loss of fixation occurred against the background of repeated injury.

Claims (1)

A method of maintaining the isometric position of the tendon of the long head of the biceps brachii muscle while performing its arthroscopic tenodesis, including examination of the tendon attachment point to the articular process of the scapula, cutting it off and fixing the tendon with an interference screw in the intraosseous canal formed in the humerus, characterized in that before cutting the tendon from the articular process of the scapula and before its final fixation to the humerus with an interferential screw, the tendon is sequentially fixed with spinal needles or Kirschner wires.

Images