Luận án nghiên cứu một số yếu tố ảnh hưởng và kết quả điều trị phục hồi gấp khuỷu bằng phẫu thuật steindler cải biên tt

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENSE MILITARY MEDICAL UNIVERSITY TRAN DUY HUNG STUDY ON SOME INFLUENCING FACTORS AND OUTCOMES OF ELBOW FLEXION REHABILITATION WITH MODIFIED STEINDLER[.]

TRAN DUY HUNG

STUDY ON SOME INFLUENCING FACTORS AND OUTCOMES OF ELBOW FLEXION REHABILITATION WITH MODIFIED STEINDLER SURGERY.

Specialization: SURGERY Code: 9 72 01 04

MEDICAL DOCTORAL THESIS

HA NOI - NĂM 2022

Science Instructors:

1 Prof PhD Nguyen Tien Binh

2 Assoc Prof PhD Vu Nhat Dinh

Opponent 1: Ass Prof PhD Vo Thanh Toan

Opponent 2: Ass Prof PhD Nguyen Xuan Thuy

Opponent 3: Ass Prof PhD Luu Hong Hai

The thesis has been defended at University-level Thesis

Evaluation Council

Held in Military Medical University

At, (hour), / /2022 (date)

This thesis may be found at:

1 National Library

2 Library of Military Medical University

INTRODUCTION THESIS

1 Introduction

Loss of elbow flexion seriously impairs working capacity.Adversely affecting the patient's quality of life should be prioritizedfor diagnosis, treatment and rehabilitation The most common cause

is damage to the motor nerve in the brachial plexus region There aremany methods of treatment In situ tendon and muscle transfersurgery is a fairly common method because it is easy to perform andhas relatively good results It is a last resort for elbow flexionrehabilitation when it is not possible or when other treatments havefailed Steindler surgery is to move the muscle mass attachment point

on the pulley to the upper arm With the modifications of Mayer L.,Green W (1954), surgery is chosen by many surgeons today Theresults after surgery are very good and good is 60% - 80%, not good(moderate, poor) is 20% - 40% Some related factors affectingsurgical results are nerve damage, position of bone fragment fixation,post-operative rehabilitation

Objectives of the study:

- Comment on pathological characteristics of cases of elbowflexion loss due to motor nerve damage treated by modified Steindlersurgery

- Evaluation of results and identification of several relatedfactors affecting the results of modified Steindler surgery to treatelbow flexion loss due to motor nerve damage

2 The urgency of the thesis

In the world, the results of treatment of elbow flexion loss bymodified Steindler surgery have been evaluated by many authors

In Vietnam, treatment of elbow flexion with modified Steindlersurgery according to Mayer L., Green W (1954) has been performedfor many years with a large number However, the characteristics ofthe pathology of loss of elbow flexion due to damage to the kneecap,treatment results, related factors, good and bad effects on surgicalresults have not been studied and evaluated fully.

Therefore, it is necessary to conduct research on the abovecontents to have solutions to improve the results of the treatment ofelbow flexion recovery of modified Steindler surgery

3 New contributions of the thesis

Through the results of the study, the basic characteristics of thepathology of loss of elbow flexion due to motor nerve damage wereindicated for treatment by modified Steindler surgery

Evaluation of the results of treatment of elbow flexion loss due tomotor nerve damage by modified Steindler surgery

Identify some factors related, good or bad influence on surgicalresults

4 Dissertation layout

The thesis consists of 117 pages, including the following parts:Problem statement (02 pages), overview (30 pages), research objectsand methods (20 pages), results (32 pages), discussion (30 pages),conclusion (02 pages), recommendations (01 page)

The thesis has 36 tables, 22 figures, 05 charts and 117references, including 102 English documents, 14 Vietnamesedocuments, 01 French document

Chapter 1 OVERVIEW

1.1 Applied anatomy of the elbow

1.1.1 Anatomy of the elbow joint

The elbow joint is a flexor extensor joint of the forearm,consisting of the medial epicondyle joint, the condylar joint, and theupper radius-ulna joint

Elbow movement: Flex and extend the forearm Amplitude:Fold 1500, stretch 00 can reach -100, especially for women andchildren Pronation, supination 800 When the amplitude is reduced

by 50%, the upper limb function will decrease by 80% Impairedelbow mobility is an absolute indication for surgery in many cases.1.1.2 Role of elbow muscles

- Elbow extension: Performed by triceps The elbow helps theradial nerve (C7, C8)

- Elbow flexion: Performed by biceps, forearm muscles Thesetwo muscles are controlled by the musculocutaneous nerve (C5, C6).The bronchioradialis muscle is controlled by the radial nerve (C5, C6)and the pronator teres muscle is controlled by the middle nerve (C6).1.1.3 Nerves in the elbow area: By the brachial plexus

1.1.3.1 Anatomical structure: The brachial plexus comprisesanterior branches of C4, C5, C6, C7 and T1 The sacral divisionincludes the cutaneous, medial, ulnar, medial cutaneous of the arm,medial cutaneous of the forearm, axillary, and radial dermis

1.1.3.2 Nerves that govern elbow joint movement: Themusculocutaneous nerve is the motor nerve of the muscles in theanterior arm When the musculocutaneous nerve is damaged, theforearm flexion will be very weak due to the loss of function of the

biceps and forearm muscles The nerve innervating the elbowextensor is the radial nerve (C7 and part of C5, C6, C8, and D1).

1.2 Disease of elbow flexion dysfunction

1.2.1 Reason

1.2.1.1 Injury to the muscles that have the function of flexingthe elbow due to trauma, broken wounds, detachment of attachmentpoints, and muscle sclerosis Some muscle diseases cause sequelae ofloss of function

1.2.1.2 Injury to elbow joint components

Wounds, trauma, joint surgery, prolonged joint fixation.Infection of the joints, rheumatoid arthritis, congenital joint disease causes sequelae of stiffness, ankylosing spondylitis

1.2.1.3 Motor nerve damage

Motor nerve damage is the most common cause When the nerveplexus is damaged in the BP, the upper trunk (C5, C6), the second bodyanteriorly, the musculocutaneous nerves will cause the loss of elbowflexion in varying degrees and accompanied by different symptoms.motor nerve damage is common in the following cases: Head andshoulder trauma due to obstetric accidents, daily-life accidents, trafficaccidents In which traffic accidents are the leading cause Upper limbsurgery, wound, pinched nerves Polio disease; inflammation,degeneration, disc herniation, cervical spine tumor; Nervous roottumor… Toxic substances such as heavy metals and some drugs

1.2.2 Treatment of elbow flexion loss due to motor neuron damage1.2.2.1 Non-surgical treatment: Using drugs to enhance nerveconduction, enhance peripheral circulation, anti-inflammatory andrelieve pain Acupuncture, massage, physiotherapy…

1.2.2.2 Nerve rehabilitation Surgery: This is the optimalmethod for the treatment of motor nerve damage, allowing the re-establishment of Nervous transmission pathways

Splicing, grafting musculocutaneous nerve: Connecting nervesdirectly when indicated and conditions Early joining usually gives goodresults Autologous Nerve Transplantation when the Nerve section ismissing more than 1.5 cm, unable to pull the two ends together.

Transplantation from benign nerve to musculocutaneous: Whenthe nervous system injury is too severe and multi-site, it is necessary

to surgically transfer the healthy nerve such as the XI nerve,diaphragmatic nerve, and intercostal nerves into themusculocutaneous nerves to restore the function of elbow flexion.1.2.2.3 Free muscle transfer surgery: This is a surgery to transfermuscles from a distance, such as latissimus dorsi muscles,gastrocnemius muscles, serratus muscles with vascular connection,and microsurgical nerves to replace the function of the elbow flexormuscle

1.2.2.4 Surgery to transfer muscles in the vicinity: Transfer ofbundles under the pectoralis major with accompanying vascular andnerve bundles for the biceps muscle Transfer latissimus dorsimuscles to biceps

1.2.2.5 Tendon transfer surgery of adjacent muscles: Transfer

of triceps tendon Transfer the supracondylar muscles to the anteriorsurface of the humerus Transfer of sternocleidomastoid tendon

1.3 Restoration of elbow flexion by Steindler surgery

1.3.1 History: Steindler A first performed in 1918 The authortransferred the flexor, pronation, and hand muscles from the medialepicondyle and sutured it to the medial intermuscular septumbetween the triceps and anterior arm muscle about 5 cm above thearm In 1954, Mayer L and Green W introduced two modificationsthat are used by most surgeons today:

- The incision starts from the anterior surface of the humerus 7.5

cm from the elbow crease, goes around the posterior aspect of themedial epicondyle at the center of the elbow joint, and ends in themiddle of the forearm 10 cm below the elbow crease

- Transfer the attachment point of the muscle mass on the medialepicondyle together with the bone fragment of the upper process of thefixed medial epicondyle to the anterior surface of the humerus

1.3.2 Advantages and disadvantages: The technique is notdifficult and does not require expensive equipment The surgicalresults were quite good in terms of limb rehabilitation However, it ispossible to cause wrist flexion, finger flexion and forearm pronationwhen performing elbow flexion Risk of injury to the ulnar nerve andbranches of the median nerve during the procedure

1.3.3 Surgery results

- Evaluation criteria: In 1984, Alnot J Y and Abols Y evaluatedthe elbow joint's muscle strength and range of motion Very good whenmuscle strength M4, amplitude ≥1200 Good when muscle strength M4,amplitude <1200 Average when muscle strength M3, amplitude ≥800.Poor when muscle strength M0 - M2 or amplitude <800

- The surgical results of the authors in the world according to thestandards of Alnot J Y and Abols Y (1984): Very good rate, goodmortality <60% to 80% Average, poor in the range of 15% - 40% InVietnam, since 2000, Nguyen Tien Binh, Tran Dinh Chien, and NguyenViet Tien have performed rehabilitation treatment of elbow flexion withmodified Steindler surgery Up to now, the number of surgeries is quitelarge and has not been fully summarized and evaluated

1.4 Factors related to the outcome of Steindler surgery

Through reference to domestic and foreign documents, factorsrelated to, good and bad influences on the results of modified Steindler

surgery have not been studied Based on the characteristics of Steindlersurgery, there are four groups of factors involved and influencing:

- Patients: age, sex, general condition (pathology, combinedlesions) Local condition, extent and location of motor nerve damage,muscle strength of the motor block (wrist flexion, forearmpronation)

- Indications, surgical conditions, time of surgery, preoperativetreatment methods

- Implementation technique: incision; original dissectiontechnique of flexor and pronation muscle mass; size, thickness,position, the technique of fixation of bone fragments

- Process of rehabilitation after surgery: Time, method, form

Chapter 2 RESEARCH SUBJECTS AND METHODS

2.1 Research subjects

Cases were treated with elbow flexion loss due to motor nervedamage by modified Steindler surgery at 108 Military CentralHospital from January 2005 to December 2019

2.1.1 Selection criteria

- Comment on pathological characteristics of elbow flexion lossand close results evaluation: Maintain complete medical records.Perform the same surgical procedure

- Evaluate distant results and identify some related factors,affecting surgical results: Cases where the above two conditions aremet, have had surgery for 6 months or more Participate fully in thetesting, evaluation process

2.1.2 Exclusion criteria

- Combined cranial nerve damage or disease affectingconsciousness and upper extremity movement.

- Cases of injury or surgery to the joint limit passive movement

of the elbow joint

2.1.3 Sample size

Including cases according to selection criteria The sample size

is calculated by the formula: n = [Z2(1-α/2).p.(1-p)]/d2

n: is the minimum number of cases the study must achieve

Z2(1-α/2): Confidence factor at 95% probability level (=1.96)p: The recovery rate is good and very good after surgery

d: Allowed error (absolute accuracy) = 0.1

According to Brunelli A.G and Vigasio A (1995) very goodresults, good at 81.25%, by other authors in the range of 60% to 80%.They were substituting the formula to get n = 48 Thus, for theresearch results to be reliable, the number of cases should be at least

53 cases with an error of 10%

- Invite patients to check and evaluate according to research criteria

- Synthesize, analyze and evaluate

2.2.3 Modified Steindler Engineering Process

2.2.3.1 Indications: Loss or limitation of elbow flexion (musclestrength M0, M1, M2) due to irreversible motor nerve damage due todamage to the biceps tendon, anterior forearm that cannot be sutured.2.2.3.2 Contraindications: Muscle strength of the muscle mass

on the medial epicondyle, especially the large palmar muscle andweak anterior ulnar muscle (from M3 and below) Limit passivemovement of the elbow joint due to various causes The skin of thesurgical area is infected with bacteria, skin defects, and stretchmarks Motor nerve damage is reversible

2.2.3.3 Preparation: According to the procedure of preparingfor surgery session

2.2.3.4 Surgical Skill

- Anesthesia method: Anesthesia of the BP

- Surgical method: Perform tendon transfer according to theSteindler method modified by Mayer L and Green W

Incision of the skin 10-12 cm from the anterior in the lower third ofthe forearm, looping the posterior process of the medial epicondyledown to the anterior in the upper third of the forearm Expose the medialepicondyle and the ulnar nerve at the elbow-medial epicondyle groove.Use a sharp chisel or a hacksaw to cut a piece of the process bone

on the medial epicondyle with a diameter of 1.2 cm, a thickness of

5-7 mm with the origin of the flexor muscle mass, pronation of the wrist.Release the muscle mass to the periphery about 5cm

Exposing the anterior surface of the humerus, chisel thehumerus at a position about 5-7 cm from the superior lateralepicondyle process, corresponding to the forearm flexion 600-700 Fixthe bone fragment to the prepared position with two screws (3.5 mm

x 32 mm) with black washers (gaskets) or one 3.5 mm x 32 mmscrew with black washers (gaskets) and fasten 1 round of reinforcingsteel wire Set drain Close the incision 3 layers.

2.2.3.5 Treatment and follow-up after surgery

After surgery, fixed with splints of wings, legs and hands inmedium position, elbow flexed at 900, duration of 06 weeks Useantibiotics, anti-edema from 5-7 days or use prophylactic antibioticsbefore surgery Pain relief and sedation for the first three days.Change the first dressing after 24 h Withdraw drainage after 48-72 h.Thread trimming after 12 days

Rehabilitation after surgery: On the 2nd day, practice passivemovement of joints without immobilization: shoulder, metatarsal andknuckle joints On the 5th day, practice active flexion and extension

of the interphalangeal joints and fingers Practice static contractions

in the pulley block brace On the 12th day, practice forearmpronation, elbow flexion and extension between 90o and 140o 2-3times a day, then immobilize again with a brace After 06 weeks ofsurgery, remove the fixed brace and practice active movement on thepronation, flexion and extension of the forearm with increasingintensity and amplitude in four stages: Phase of independent staticmuscle contraction, elbow flexion eliminates gravity Practice assistedactive elbow flexion to overcome limb gravity Exercise resistanceelbow flexion, exercise with weights with increasing weight usuallyfrom 8-10 weeks after surgery Practice coordinated movements toincrease dexterity and strengthen muscles; practice daily activities(drinking water, combing hair…) Practice time 2-4 times a day for 15minutes Each phase is from 1-3 weeks depending on the case Stagefour may take longer

2.2.4 Research criteria, materials, measurement methods

2.2.4.1 Pathological characteristics of cases of elbow flexionloss indicated for modified Steindler surgery, including age, gender,cause of injury, mechanism of injury, time of indication for surgery,previous treatment methods surgery, systemic status (pathology,associated lesions), distribution of lesions, method of lesionidentification, lesion characteristics, preoperative elbow flexorstrength, surgical time.

2.2.4.2 Evaluation of near-term results: When the patient wasdischarged from the hospital, including the following criteria: Length

of stay (in days), wound healing process

2.2.4.3 Evaluation of distant results: At the time of surgery ≥ 06months Including Time to re-examine after surgery, Elbow flexionamplitude, Limitation of elbow extension, Elbow flexion strength.Overall results (according to the criteria of Alnot J Y and Abols Y.1984) The effect of flexing the wrist, pronation forearm when flexingthe elbow Performance of labor and daily life functions: Based on thedisability assessment scale of the arm, shoulder and hand (DASH),assess the ability to perform labor and daily activities using aquestionnaire

2.2.4.4 Some related factors influence surgery result

Age, gender Preoperative treatments Time of surgery body condition Features of motor nerve damage (determined at thetime of re-examination by clinical examination andelectromyography) Surgery time Position of fixation of bonefragments in the upper/lower, inner/outer directions Rehabilitationafter surgery: Method, time, form Muscle strength flexes wrist,pronation forearm, triceps

Whole-2.2.5 Data processing: The collected data were entered usingExcel 2016 software, processed and analyzed using SPSS 22.0 software

2.2.6 Error control: The Ph.D student directly collected thedata of each patient in the research sample with the confirmation of aspecialist doctor; Research medical records were made on the spot.Specialists performed all testing steps and techniques with a newequipment system of the same type Data entry twice andindependent analysis according to the table available for comparison.

2.3 Research ethics: Strictly comply with international

regulations and guidelines and the Vietnam Ministry of Health on ethics

in biomedical research for humans

Chapter 3 STUDY RESULTS 3.1 Pathological characteristics of cases of loss of elbow flexion due to motor nerve damage

3.1.1 Age: Mean is 31.3 ± 11.4 years old (11 - 59 years old).3.1.2 Gender: Male 94.4%, female 5.6%

3.1.3 Causes of injury: Traffic accidents accounted for 84.5%.Other accidents: 13.3% The sequelae of polio: 2.2%

3.1.4 Mechanism of injury: Injury causes stretch (indirectforce): 94.5% Wound (direct force): 3.3% and nerve cell damagecaused by virus (pathology): 2.2%

3.1.5 Preoperative treatments: Conservative, non-surgical:61.1% Surgery to check and repair motor nerve damage: 7.8%.Other surgery to treat combined injury (closed abdominal trauma,closed fracture, soft wound): 5.6% No treatment: 25.5%

3.1.6 Time indicated for surgery: Mean 21.1 ± 17.3 months (06

- 192 months)

3.1.7 Condition before surgery