Малоінвазивне лікування звичного вивиху плеча у хворих старших вікових груп: автореферат дисертації на здобуття наукового ступеня кандидата медичних наук

Abstract

Дисертацію присвячено розробці малоінвазивної технології підвішування плеча до акроміального відростку лопатки в оптимальних точках для хворих старшого віку з високим ступенем операційного ризику. Досліджено превалюючі види травматизму та гендерні, вікові особливості при звичному вивиху плеча. Проаналізовано залежність ступеня зношеності суглобових елементів плечового суглоба від кількості вивихів в анамнезі. Вивчено діагностичну цінність тестів під час клінічного та функціонального дослідження. Проаналізовано результати рентгенографії, комп’ютерної томографії, артросонографії та електроміографії (ЕМГ). Розроблено комп’ютерно-навігаційний комплекс та проведено хірургічне лікування шляхом підвішування плеча до акроміального відростку лопатки в оптимальних точках.

The dissertation is devoted to the development of a minimally invasive technology for hanging the shoulder to the acromial process of the scapula at optimal points for age-related patients with a high degree of operational risk. There were investigated in this research the prevalent types of traumatism and gender/age features of the recurrent shoulder dislocation. It has been analyzed the dependence between degree of shoulder articular elements deterioration and the number of dislocations in the anamnesis. The diagnostic value of tests was studied during clinical and functional research. The results of X-ray, arthrosonography and electromyography (EMG) have been analyzed. Surgical treatment was performed by hanging the shoulder to the acromial process of the scapula at optimal points. It was established that the first place in the structure of injuries is trauma after falling on the abducted arm (12 cases, 33.3%), the second place - the falling on the shoulder joint (8 cases, 22.2%). In the vast majority of cases (29 patients, 80.6%) there was an indirect mechanism of injury. A greater proportion of right-sided pathology (58.3%) was established, compared to the left-hand side (38.9%). Important clinical and diagnostic features were the presences of specific clinical symptoms – Jobe`s test (72.2%), symptom of Leclerc (63.9%),the symptom of Hitrov F.M. (13.9%), symptom of deltoid muscle retraction (36.1%), symptom of Drobotun V.Ya. (5.6%), hypotrophy of the shoulder joint area (52.8%), symptom of Babich B.K. (36.1%), symptom of Weinstein V.G. (50.0%), symptom of Golyakhovsky Yu.V. (16.7%) symptom of "relative elongation of the limb", proposed by Stutin A.Ya. (52.8%), the second symptom of Stutin A.Ya. "reduction of the resistance to adduction" (50.0%). According to the goniometry of the shoulder joint, it was verified that the amplitude of movements on the side of the recurrent shoulder dislocation is lower than normal (p<0.05). Radiographic signs of the recurrent shoulder dislocation were characterized by the presence of impressed fracture of the anterior part of the scapula articular process (47.2%), regional sclerosis of the anterior part of the scapula articular process (61.1%), incongruity of the articular surfaces (36.1%) and damage of Hill-Sachs (38.9%). During arthrosonography, it was found that the most probable indirect sonographic signs of the recurrent shoulder dislocation are hypotrophy and visual defect of the rotator cuff muscles (47.2%), thinning of the tendon and decreasing of thickness of the rotator cuff muscles (58.3%), the presence of scars in the structure of rotator cuff muscles (66.7%). It was established that on comparative electromyograms of the affected and healthy upper extremities there was a significant decrease in the amplitude and frequency of the M-response on the side of the damage (p<0.05). It was suggested a minimally invasive method of treatment of the recurrent shoulder dislocation for the patients of older age groups in the way of hanging the humerus to the acromial process of the scapula. It was carried out an experimental research about strength of anchor screw fixation in the head of the humerus by an end-element method. It is proved that the optimal angle of anchor insertion is an angle 60°, in which a pair bone-screw can withstand a load of 44N. It was developed a computer-navigational system based on the Arduino controller with the ATmega328P chip and software written in the C++ programming language using ARToolKit, Visualization Toolkit and OpenGL package libraries. The complex is used for determination the correct position of the upper limb during the proposed method of treatment. To evaluate the results of surgical treatment of the recurrent shoulder dislocation it was performed a comparative analysis of open and closed methods of hanging shoulder to the acromial process of the scapula at optimal points. It was determined the increase of movements volume in the shoulder joint in both treatment groups up to the level of normal values (p<0.05) and recovery of EMG parameters to values of healthy limb (p<0.05). In comparison with the open method, after the closed hanging of the shoulder, it was noted the shortening of the average terms of staying in the hospital in 3.8 times (p˂ 0.05) and the mean time of rehabilitation for restoring the function of the shoulder joint in 2.3 times (p<0.05). It was found that the average index of evaluation of the results of treatment after closed hanging was 90.9±0.6 (p<0.05) after the Rowe scale and 85.3±2.0 (р<0.05) after Constant-Murley scale. It was developed indications for the closed method of hanging the shoulder to the acromial process of scapula at the optimal points. Based on this scientific research two patents of Ukraine were received: the patent of Ukraine No. 102348, A61V/17/56, bullet. № 20 dated October 26, 2015 "Method of minimally invasive treatment of the usual dislocation of the shoulder" and the patent number 103515, A61V8/13, bullet. №24 dated 25.12.2015 "Device for intraoperative bones visualization".

Диссертация посвящена разработке малоинвазивной технологии подвешивания плеча к акромиальному отростку лопатки в оптимальных точках для больных старшего возраста с высокой степенью операционного риска. Исследованы превалирующие виды травматизма и гендерные, возрастные особенности при привычном вывихе плеча. Проанализирована зависимость степени изношенности суставных элементов плечевого сустава от количества вывихов в анамнезе. Изучено диагностическую ценность тестов во время клинического и функционального исследования. Проанализированы результаты рентгенографии, компьютерной томографии, артросонографии и электромиографии (ЭМГ). Разработан компьютерно-навигационный комплекс и проведено хирургическое лечение путем подвешивания плеча к акромиальному отростку лопатки в оптимальных точках.