RU2760844C1 - Method for cross-tendon stitching of the anterior sections of the supraspinatus tendon with incomplete (partial) ruptures from the articular surface - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used for cross-linking of the anterior sections of the supraspinatus tendon with incomplete ruptures from the articular surface. The bone bed of the large humerus tubercle is treated. An anchor is installed to fix the tendon through the anterior upper lateral port, preserving the rotator cuff tissue. The anterior sections of the supraspinatus tendon are stitched in the rupture zone using an 18G needle through skin punctures, keeping the tendon fibers intact. A monofilament thread with a loop at one of the ends is passed through it, after which, by means of a monofilament thread, with a loop at one of the ends, according to the shuttle method: changing the direction of thread traction by means of a loop, it is passed through the tendon tissue into the subacromial space. Anchor ligatures are tied, forming arthroscopic knots.

EFFECT: method ensures maximum preservation of fibers from the subacromial space of the supraspinatus tendon, due to the peculiarities of the thread.

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Description

The invention relates to medicine, namely to traumatology: arthroscopic surgery of the shoulder joint during refixation of incomplete (partial) rotator cuff ruptures.

Partial upper urinary tract ruptures are treated conservatively and results are generally favorable. If conservative treatment is unsuccessful for 3 months or a complete rupture of the upper urinary tract, surgical treatment is indicated - stitching the tendon ends [Epifanov VA, Epifanov A.V. Rehabilitation in traumatology. - M., 2010. - S. 410].

An open method for the surgical treatment of chronic rupture of the supraspinatus tendon is known from the prior art. For this, the acromial process is dissected in a Z-shaped manner, the torn tendon is sutured, the transverse fold of the shoulder joint capsule is formed, the fascia of the supraspinatus muscle is dissected, a terylene mesh in the shape of a tennis racket is sutured to the posterior surface of the supraspinatus muscle, a narrow part of the mesh is thrown through the joint space, overlapping the level of the tendon suture the supraspinatus muscle and the fold of the joint capsule in the shoulder abduction position, sew the mesh to the joint capsule, form channels in the humerus, pass a terylene tape through them, sew the mesh with it grabbing the fibers of the supraspinatus muscle, pull and tie the tape. Next, the acromial process is restored, the wound is sutured and an abduction splint is applied [RU 2150246 C1, 06/10/2000].

There is a known method for refixing a severed tendon (GB EP 0744165), in which the end of the severed tendon of the supraspinatus muscle is fixed using an original double loop, one part of which is passed through a pre-formed canal in the head of the humerus, and the second part is passed over the head of the humerus. The common end of the loop is fixed to a screw introduced into the area of the surgical neck of the humerus, and the ends of the loop at the site of suturing the supraspinatus tendon are reinforced with two transverse interrupted sutures.

There is also a known method for the surgical treatment of transosseous ruptures of the tendons of the rotator muscles of the shoulder, including the restoration of the destroyed apophysis and extramedullary fixation of the apophysite-tendon stump, characterized in that the restoration of the destroyed apophysis is carried out by repositioning bone fragments in combination with reinforcing their thickness with porous implants made of titanium nickelide, apophysical fixation carried out with staples from titanium nickelide with shape memory [RU 2244522 C2].

From the article by N.V. Zagorodny. and others ("Experience of using a subacromial balloon in the combined treatment of patients with ruptured rotator cuff of the shoulder", Genius of Orthopedics, Volume 25, No. 3, 2019), a method of arthroscopic treatment of rupture of the rotator cuff of the shoulder using a combined technique is known: 15 patients (average age 54 ± 4 years, without pronounced fatty degeneration of the rotator cuff muscles), shoulder arthroscopy was performed with stitching of the rotator cuff with a single or double row suture and implantation of an InSpace balloon into the subacromial space. The following results were obtained in the work: the mean score on the UCLA scale before surgery was 16 ± 2 (13-18), after 12 months. after surgery - 30 ± 3 (26-33), in most cases, good and excellent results were obtained. The authors concluded that preliminary results make it possible to characterize the used technique as relatively simple, low-traumatic and effective, contributing to the elimination of pain and restoration of the function of the shoulder joint in this group of patients.

Thus, the currently used methods for this involve either transosseous refixation using various reinforcing implants, or the use of anchor fixators of various diameters, single / double-row sutures with the use of additional devices (implantation of the InSpace balloon).

However, the known methods of treatment cannot be used to treat a partial-thickness rupture of the supraspinatus tendon, due to the complexity of its visualization (especially with the open technique of surgery), the need to use special instruments for the trans-tendon placement of anchors during arthroscopy of the shoulder joint, which severely injure the tendon, as well as repeated holding instruments for suturing the tendon, also severely injuring the tendon tissue.

The indicated technical difficulties associated with the indicated stages of stitching significantly lengthen the operation, and therefore many surgeons prefer to dissect the preserved fibers of the supraspinatus tendon, convert the rupture to a full-thickness (full) one and perform a technically simpler refixation of the obtained full-thickness rupture (using various techniques, in including those described above).

The objective of the present invention is to maximize the preservation of fibers from the side of the subacromial space of the supraspinatus tendon in the treatment of partial-layer tears without converting the tear to full-layer (full).

The technical result of the claimed method consists in the ability to avoid dissection of the preserved tendon fibers. The specified technical result is realized through the following techniques.

Surgical treatment is performed using the arthroscopic method. At the first stage, the bone bed of the greater tubercle of the humerus is processed. Then, an anchor is installed to fix the tendon through the anterior superior lateral port (1) without damaging the rotator cuff tissue. After that, the anterior sections of the supraspinatus tendon are sutured in the zone of rupture using an 18G needle through skin punctures without installing medial ports and without damaging the intact tendon fibers, and passing through it a monofilament thread with a loop at the end. Using the specified monofilament suture with a loop at one end according to the shuttle technique - changing the direction of traction of the suture by means of a loop, without using retrograde stitchers, four anchor ligatures are carried out through the tendon tissue into the subacromial space, where then the ligatures are tied in pairs with the formation of two U-shaped sutures, forming arthroscopic nodes (Figure 1). Thus, depending on the extent of the tear in the medial-lateral direction, single-row or double-row fixation is performed.

Thus, the anterior location of the gap, in contrast to the posterior one, makes it technically possible to install the anchor through the specified port when performing internal rotation in the shoulder joint. Keeping the anchor ligatures in the anterior superior lateral port is also an advantage, since it does not require moving them from port to port during further sewing.

During the suturing of the tendon with an 18G needle, damage to its preserved fibers is also excluded, due to the small diameter of the specified tool. In addition, the installation of a medial cutaneous port is not required, through which the anchor and retrograde suturing instruments are inserted according to the generally accepted technique, which also reduces the invasiveness of surgery.

The invention is illustrated by drawings, Fig. 1 - stages of surgical treatment of a partial-thickness rupture of the supraspinatus tendon, where 1 is the antero-upper lateral port; 2A - the direction of the anchor lock; 2B - threads of the anchor lock; 2B is a sectional view of the capsule to form an antero-upper-lateral port; 3 - needle for stitching the tendon 18G; 4 - the tendon of the subscapularis muscle; 5 - the small tubercle of the humerus; 6 - tendon of the long head of the biceps; 7 - supraspinatus tendon; 8 - zone of rupture of the supraspinatus tendon; 9 - the tendon of the infraspinatus muscle; 10A - the head of the humerus, red indicates the direction of rotation of the head of the humerus when performing the maneuver to install the anchor; 10B - perforations in the supraspinatus tendon; 10B - stitched supraspinatus tendon (4 sutures); 10G - fixed supraspinatus tendon (2 U-shaped sutures), anchor fixator;

FIG. 2 - arthroscopic picture of the stages of suturing and refixation of the tendon of the supraspinatus muscle, where a - trocar for the installation of the anchor fixator is passed through the anterior-upper-lateral port; 6 - installation of the anchor lock; c - stitching the tendon of the supraspinatus muscle with a needle, holding the conductor; d - the tendon is stitched, 4 sutures are made; d - the appearance of the stitched threads; e - view from the subacromial space; g - the tendon is fixed.

Example

Patient L., 33 years old, came to the clinic due to pain in the right shoulder joint for 8 months during physical exertion. The patient underwent a course of conservative therapy, a course of rehabilitation therapy for the right shoulder joint for 3 months. However, the pain syndrome persisted during physical exertion. The patient was examined, MRI of the right shoulder joint was performed, and surgical treatment was recommended.

Arthroscopic revision intraoperatively diagnosed instability of the tendon of the long head of the biceps, incomplete rupture of the supraspinatus tendon from the articular surface (PASTA, Ellman 2), hypertrophy of the subacromial bursa of the right shoulder joint. Performed tenodesis of the long head of the biceps brachii tendon in the proximal intertubercular sulcus with a fixator. Next, the anatomical bed of the supraspinatus tendon attachment was processed, a bleeding surface was formed, trans-tendon refixation of the supraspinatus tendon was performed according to the described technique, 4 threads were carried out, and 2 U-shaped sutures were applied, with anchor threads installed through the anteroposterior-lateral port. Subacromial decompression was performed using an ablator and a shaver (Figure 2).

In the postoperative period, immobilization was carried out in the shoulder bandage for 6 weeks. Further, the patient was engaged in rehabilitation therapy for 3 months from the date of the operation. At the final follow-up examination 12 months after the operation, the patient had full range of motion, no pain in the shoulder joint, full function of the shoulder joint, maximum values according to orthopedic scales.

Claims (1)

The method of transtendinous suturing of the anterior sections of the tendon of the supraspinatus muscle with incomplete ruptures on the side of the articular surface, including the treatment of the bone bed of the greater tubercle of the humerus, after which an anchor is installed to refix the tendon through the anterior superior lateral port, preserving the tissue of the supraspinatus cuff, then the stitching of the anterior sections of the tendon is performed muscles in the zone of rupture using an 18G needle through skin punctures, keeping the tendon fiber intact, and passing through it a monofilament thread with a loop at one of the ends, then using a monofilament thread, with a loop at one of the ends according to the shuttle technique - changing the direction of traction of the thread through a loop, it is passed through the tendon tissue into the subacromial space, where anchor ligatures are tied, forming arthroscopic nodes.

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