RU2781611C1 - Method for applying a tendon suture in case of damage to the flexor tendons of the fingers in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used for applying a tendon suture in case of damage to the flexor tendons of the fingers in children. The first conditional dial of the cross section is determined at the first end of the tendon. A needle with a loop thread is injected at 11 o'clock with a prick at 8 o'clock of the first conditional dial. Next, pass the needle through the loop of thread and tighten the loop. Then, an injection is made at 09:30 hours of the first conditional dial, the needle is passed inside the trunk along the tendon and brought out to the butt area. The second conditional dial of the cross section is determined at the second end of the tendon. The needle is injected into the butt end of the second end of the tendon symmetrically to the previous puncture, the needle is inserted inside the trunk and the puncture is performed at 9:30 o'clock of the second conventional dial. Then the needle is injected at 11 o'clock and the needle is punched out at 8 o'clock of the second conditional dial, leaving a double loop. After passing the needle through the formed loop, an injection is made at 09:30 hours of the second conditional dial and an injection is made at 2:30 hours of the second conditional dial with the loop tightened. Next, the needle is injected at 1 o'clock and punctured at 4 o'clock of the second conditional dial, leaving a double loop. After passing the needle through the formed loop, an injection is made at 2:30 o'clock of the second conditional dial, the needle is passed intra-stem with a prick in the area of ​​its end, the loop is tightened. Then the needle is injected into the butt end of the first end of the tendon symmetrically to the previous puncture and punctured at 2:30 o'clock of the first conventional dial. A separate twisting suture is applied to the edges of the peritendinium. Then the needle is injected at 1 o'clock and the needle is punctured at 4 o'clock of the first conditional dial, leaving a double loop, then one of the threads is crossed and the needle is inserted into the formed loop. After tightening the loop, the ends of the thread are tied together.

EFFECT: method provides high mechanical strength of the suture, prevention of development of flexion contractures and scars due to the fact that the suture material is located both inside the shaft and above the shaft with alternating longitudinal and transverse stitches in mutually perpendicular directions, as well as due to the equidistant location of the anchor points of the tendon and sufficient grip tendon fibers into a suture.

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Description

The invention relates to medicine, in particular to pediatric surgery, and can be used in the treatment of finger flexor injuries in children with hand injuries.

There are many different recommendations and views on the surgical tactics of treating fresh injuries of the flexor tendons of the fingers in the second zone in adults, which are sometimes ambiguous and often opposite.

If we talk about surgical tactics for the treatment of fresh injuries of the flexor tendons of the fingers in the second zone in children, then in general there are also no clear recommendations on this matter, and often pediatric patients are equated with adult groups of patients.

So, throughout the history of hand surgery, certain requirements have been formed for the ideal suture of the flexor tendons. It should be noted that for the first time the requirements for the tendon suture were clearly defined by Yu.Yu. Dzhanelidze and supplemented by a number of proposals of modern authors [Patrikeev D.V. Surgical treatment of patients with finger flexor tendon injuries in the critical zone: Ph.D. dis.cand. honey. Sciences. - Samara, 2007. - 24 p.]. According to these requirements, the suture should be simple and easy to perform with minimal disruption of the blood supply, should be strong and, at the same time, with a small number of knots. The adaptation of the tendon segments should be as anatomical as possible.

Based on these requirements, there are currently several sutures that can be used for damage to the flexor tendons of the fingers. However, each of the proposed methods for repairing the flexor tendons of the hand has certain disadvantages.

The first classic flexor tendon repair in the second zone, which has been used by surgeons for decades, is the Cuneo suture. When using this suture, 14 injections and injections of the needle are made at each end of the tendon, which makes it durable, thanks to three internal crossovers of the thread [Strafun, S.S. Surgery of the tendons of the fingers /S.S. Strafun, I.N. Kurinnaya, A.A. Angleless. E.P.// - Kyiv: Makros, 2012. - 320 s]. The disadvantages of the Cuneo suture is that the created strength compresses the tendon, disrupting the blood supply to each of its ends, and also disrupts its sliding in the fibrous canal of the finger.

A known method of applying a tendon suture using two threads located inside the trunk to the damaged surfaces of the tendon, forming at the insertion site and along the course of 4 loop-like knots on each thread through the surface of the outer sheath (RU 2459592, C1). In the known method, the threads lead the threads over the edge of the outer sheath. The ends of the threads are tied with knots. The method provides increased reliability and strength of the connection of the damaged tendon.

The disadvantages of this method are that the seam does not take into account the children's anatomy of the structure of the tendon and is designed for tendons of a larger diameter. The suture is performed inside the trunk, which further leads to wrinkling of the ends of the tendon, disruption of their trophism.

There is a method of applying a looped double-thread intratubular suture using atraumatic needles, in which both ends of the damaged tendon are stitched alternately, then the ends of the threads of the proximal and distal fragments are tied with two surgical knots immersed between the cross sections of the tendon trunks (RU 2500356, C1).

The disadvantage of this method is the low mechanical strength, since the suture is double-stranded, as well as the reduced contact area of the cross sections due to the presence of two surgical knots.

A known method of applying a tendon suture according to Cuneo, which consists in passing a thread with two straight needles at the ends in the transverse direction through the tendon, retreating 1.5-2 cm from its end, piercing the tendon obliquely with one and the other needle with crossing the thread in the thickness of the tendon, removing the ends of the thread through the end of the tendon, passing the thread in the same way at the other end of the tendon and tying the ends of the threads with the formation of intra-stem sutures /A.F. Krasnov, V.M. Arshin, V.V. Arshin. Traumatology. Directory. Rostov-on-Don, publishing house "Phoenix". - 1998. - 608 p. pp. 252-254/.

The disadvantage of this method is the deformation of the tendon, the violation of the sliding tendon apparatus, the violation of intrastem blood flow.

A known method of surgical treatment of flexor tendons in children using the Kessler suture [Gritsyuk A.A., Sereda A.P. Achilles tendon. RANS; 2010. 314 s]. The seam is performed inside the barrel, using two threads, each of which has two needles at the ends. The tendon is sutured in the transverse direction with one needle, 2 cm away from the end of the tendon, then the tendon is sutured in turn along its axis with each needle, making the needle prick somewhat more proximal and ventral to the exit point of the thread from the tendon. The needle is punctured through the site of tendon rupture. The same technique is repeated at the other end with tendons, the threads are tied together, eliminating diastasis and immersing the knots between the sutured ends of the tendon.

The disadvantages of the seam, despite the ease of execution and the longitudinal orientation of the threads inside the tendon, is its lack of strength. Ligature nodes are located at the junction, which does not allow to qualitatively restore the integrity of the tendon.

As a prototype, we chose the method of applying a looped tendon suture no Tsuge (Zolotov A.S. Analysis of the outcomes of complex surgical treatment of injuries of the flexor tendons of the fingers using a looped suture // Pacific Medical Journal, 2003, No. 3, publishing house "Medicine DV".) (Fig. 1).

With this method, the needle is passed through the tendon in the transverse direction, while forming an intra-stem transverse stitch with the formation of a loop, then the needle is injected behind the loop, the ends of the thread are passed through the center of the crossed tendon, similarly, threads are passed at the other end of the tendon and tied with intra-stem sutures. With further imposition of an adaptive twisting seam.

The disadvantages of this method are that the suture material covers only a part of the tendon fibers in the transverse plane and has insufficient strength in a two-strand design, which leads to breaks when using the early active and passive mobilization protocol.

The objective of the proposed invention is to improve the method of loop suture of the flexor tendons of the fingers in children.

The technical result achieved in the implementation of the invention consists simultaneously in:

- ensuring high mechanical strength of the suture, preventing rupture of the ends of the tendon, its rupture due to the original threading both inside the shaft and above the shaft with alternating longitudinal and transverse stitches in mutually perpendicular directions, as well as due to the equidistant location of the anchor points of the sutured tendon from each other and sufficient capture in the seam of its fibers;

- preventing the development of flexion contractures and scars, ensuring gliding in the fibrous canal of the finger by creating conditions for the early development of passive and active hand movements in children with injuries of the flexor tendons of the fingers, including in the critical zone II of the hand, by minimizing the use of suture material and formation of knots, minimization of circulatory disorders of the tendon, exclusion of stitches in the mesentery zone (posterior sections of the tendon), accurate axial and rotational comparison of the ends of the tendon, clear adaptation of their epitendinium.

The essence of the invention is as follows.

To apply a tendon suture in case of damage to the flexor tendons of the fingers of the hand in children, the first conditional dial of the cross section is determined at the first stitched end of the tendon, remote from its end at a distance equal to the width of the tendon. A needle with a loop thread is injected at 11 o'clock with a prick at 8 o'clock of the first conditional dial. Next, pass the needle through the loop of thread and tighten the loop. Then, an injection is made at 09:30 o'clock of the first conditional dial, the needle is passed inside the trunk along the tendon and brought out to the butt area of the first end of the tendon.

Further, the second conditional dial of the cross section is determined at the second end of the tendon, remote from its end at a distance equal to the width of the tendon. The first injection of the needle into the end face of the second end of the tendon is performed symmetrically to the previous injection, the needle is passed inside the trunk along the second end of the tendon and the first injection is performed at 9:30 o'clock of the second conventional dial. Then the second needle injection is performed at 11 o'clock and the subsequent second needle injection at 8 o'clock of the second conditional dial, leaving a double loop between the first needle injection and the second needle injection. After passing the needle through the formed loop, a third injection is made at 09:30 hours of the second conventional dial and a third injection at 2:30 hours of the second conventional dial, followed by tightening the loop.

Next, the fourth needle prick is made at 1 o'clock and the fourth prick at 4 o'clock of the second conditional dial, leaving a double loop between the third prick and the fourth needle prick. After the needle is passed through the formed loop, the fifth injection is made at 2:30 o'clock of the second conditional dial, the needle is passed inside the trunk along the second end of the tendon with the fifth puncture in the area of its end, after which the loop is tightened.

Then, the sixth injection of the needle into the butt of the first end of the tendon is performed symmetrically to the previous injection and the sixth injection at 2:30 o'clock of the first conventional dial.

After that, the ends of the tendon are compared by applying a separate twisting suture to the edges of the peritendinium using microsurgical techniques.

Then the stitching of the first end of the tendon is continued, while the seventh injection of the needle is carried out at 1 o'clock and the seventh injection is performed at 4 o'clock of the first conditional dial, leaving a double loop between the sixth injection and the seventh injection of the needle, then one of the threads is crossed in the area of their connection with the needle and wound needle into the formed loop. After tightening the loop, the ends of the thread are tied together with interrupted sutures.

The essence of the invention is illustrated in the figures.

In FIG. 1 shows a method for applying a tendon suture according to the prototype method.

In FIG. 2 - 11 shows the steps of applying a tendon suture according to the proposed method.

The method is carried out as follows.

One of the methods of regional anesthesia or general anesthesia is performed with obligatory preoperative bleeding and the imposition of a pneumatic tourniquet in the upper third of the shoulder. With the help of rational incisions, a sufficient exposure of the ends of the tendon in the wound is ensured. The seam is performed within the front and middle third of the cross section of the tendon in its more palmar part.

Puncture with an atraumatic needle with a looped thread is performed, departing from the edge of one of the ends of the tendon prepared for suturing at a distance equal to the width of the tendon, at 11 o'clock of the first conditional dial with a prick at 8 o'clock of the first conditional dial (see Fig. 2, where a is the width tendon) followed by passing the needle with threads through the thread loop, forming and tightening the blocking loop on the anterior-lateral surface of the tendon. In this case, the conditional dial is located along the edges of the cross-section of the stitched end of the tendon, which is located indented from the end of the tendon by a distance equal to its width. Then, an injection is made at 09:30 hours of the first conditional dial, a needle with threads is passed along the tendon and taken out to the end of the first end of the tendon to be stitched (Fig. 3).

Further, the needle is injected into the end of the second end of the tendon symmetrically to the previous puncture, the needle with threads is passed along the second end of the tendon, the second conditional dial is selected at the second end of the tendon, which is located along the edges of the cross section of the second end of the tendon being stitched, also located indented from the end of the second end tendon for a distance equal to its width. The vykol is performed at 9:30 o'clock of the second conditional dial (Fig. 4).

Then the needle is injected in the region of the anterior surface of the tendon at 11 o'clock of the second conventional dial and the subsequent needle is punctured at 8 o'clock of the second conventional dial (along the anterior-lateral surface of the tendon) (Fig. 5), leaving a double free loop of two threads when they are carried out between previous puncture and injection of the needle (at 9:30 and 11 o'clock, respectively).

Next, a needle with threads is passed through the formed loop, after which the needle with threads is injected at 09:30 of the second conventional dial and punctured onto the opposite side surface of the tendon at 2:30 of the second conventional dial, then the blocking loop is tightened. Next, the needle is injected on the ventral surface of the tendon at 1 o'clock of the second conventional dial and the needle is punctured at 4 o'clock of the second conventional dial along the anterior-lateral surface of the tendon, leaving a free loop of two threads during their passage between the previous needle puncture and injection (at 2:30 and 1 hour respectively). Next, a needle with threads is passed through the formed loop, after which the needle with threads is injected at 2:30 o'clock of the second conventional dial, the needle with threads is passed along the second end of the tendon with a prick in the area of its end, then the blocking loop is tightened (Fig. 6).

Then they are injected into the first end of the tendon at a point symmetrical to the previous puncture, and punctured at 2:30 o’clock of the first conditional dial along its anterior-lateral surface, also indented from the end of the first end of the tendon by a distance equal to its width (Fig. 7) .

Prior to tying the superimposed tendon suture, both ends of the tendon must be matched with a separate twist suture. The execution of a twisted seam is started from the end of one of the ends of the tendon with a further comparison of the two ends, leaving a distance of 1 mm between the stitches. When applying a separate twisting suture to the edges of the peritendinium, a microsurgical technique is used (Fig. 8).

After the twisting suture is completed, the first end of the tendon is sutured with an atraumatic needle with a looped thread, while the needle with threads is injected at 1 o'clock of the first conditional dial and the needle is punctured at 4 o'clock of the first conditional dial, leaving a free loop of two threads when they are carried out between the previous puncture and needle injection (at 2:30 and 1 o'clock, respectively) (Fig. 9).

Then one of the threads is cut off in the area where the needle is connected to the threads and the needle is inserted into the formed loop (Fig. 10). After that, the entire tendon suture is tightened, ensuring complete adaptation of the tendon suture. Both ends of the thread are tied with interrupted sutures to each other (Fig. 11).

This method increases the strength of the tendon suture, allows for earlier active-passive mobilization in the early stages in full and eliminates the possibility of the formation of flexion contractures and scars.

Clinical example.

A 13-year-old girl received a cut wound on the fingers of her right hand on a metal layer after falling into a snowdrift. On the same day, she went to the emergency department of surgery. The child underwent emergency surgery. During the revision, damage to the tendon of the deep flexor of the 3rd finger in the critical zone was determined. The tendon of the deep flexor of the finger was restored using the proposed modified loop suture, the wound was sutured, and a plaster splint was applied. On the 1st postoperative day, the development of passive movements of the 3rd finger of the right hand was started, on the second postoperative day and beyond, the development of not only passive, but also active movements and observation in the rehabilitation center was carried out. The girl was examined 2 months after the operation. Normotrophic scars were noted on the palmar surface. Active and passive finger movements in full.

The proposed method of applying the tendon suture provides a high mechanical strength of the suture, prevents the ends of the tendon from flaking, and ensures good adaptation between the proximal and distal fragments of the tendon. The modified loop suture has sufficient mechanical strength due to the fact that the suture material is located both inside the trunk and above the trunk with alternating longitudinal and transverse stitches in mutually perpendicular directions. The strength of the tendon suture is achieved due to the equidistant location of the anchor points of the tendon and sufficient capture of the tendon fibers in the suture. In the proposed method, suture material is minimally used, which increases the mechanical strength of the suture and accelerates the period of active rehabilitation of the tendon, already from the second day after the operation. The suture material runs in the longitudinal direction, which does not disturb the blood supply and allows you to create optimal conditions for the primary restoration of the tendon.

Claims (7)

A method for applying a tendon suture in case of damage to the flexor tendons of the fingers in children, characterized in that on one of the ends of the tendon, the first conditional dial of the cross section of the first stitched end of the tendon is determined, remote from its end at a distance equal to the width of the tendon; a needle with a looped thread is injected at 11 o'clock with a prick at 8 o'clock of the first conditional dial, then the needle is passed through the loop of the thread; then an injection is made at 09:30 o'clock of the first conventional dial, the needle is passed inside the trunk along the tendon and brought out to the end of the first end of the tendon, followed by tightening the loop; then the second conditional dial of the cross section is determined at the second end of the tendon, remote from its end at a distance equal to the width of the tendon, the first needle is injected into the end of the second end of the tendon symmetrically to the previous puncture, the needle is inserted intrastem along the second end of the tendon and the first puncture is performed at 9: 30 hours of the second conditional dial; then the second injection of the needle is performed at 11 o’clock and the subsequent second injection of the needle at 8 o’clock of the second conventional dial, leaving a double loop between the first injection and the second injection of the needle, after passing the needle through the formed loop, the third injection is performed at 09:30 hours of the second conventional dial and the third vykol at 2:30 o'clock of the second conditional dial with the subsequent tightening of the loop; then the fourth injection of the needle is made at 1 o'clock and the fourth injection is made at 4 o'clock of the second conditional dial, leaving a double loop between the third injection and the fourth injection of the needle, after passing the needle through the formed loop, the fifth injection is made at 2:30 o'clock of the second conditional dial, the needle is inserted into the trunk along the second end of the tendon with the fifth puncture in the area of its end, after which the loop is tightened; then, the sixth injection of the needle into the end face of the first end of the tendon is performed symmetrically to the previous injection and the sixth injection at 2:30 o'clock of the first conventional dial; after that, the ends of the tendon are compared by applying a separate twisting suture to the edges of the peritendinium using microsurgical techniques; then the sewing of the first end of the tendon is continued, while the seventh injection of the needle is carried out at 1 o'clock and the seventh injection is performed at 4 o'clock of the first conditional dial, leaving a double loop between the sixth injection and the seventh injection of the needle, then one of the threads is crossed in the area of their connection with the needle and wound needle into the formed loop, after tightening the loop, the ends of the thread are tied together with interrupted sutures.

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