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[.]
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 SURGERY Specialization: SURGERY Code: 72 01 04 MEDICAL DOCTORAL THESIS HA NOI - NĂM 2022 THE WORK HAS BEEN SUCCESSFULLY COMPLETED AT MILITARY MEDICAL UNIVERSITY Science Instructors: Prof PhD Nguyen Tien Binh 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: National Library Library of Military Medical University INTRODUCTION THESIS Introduction Loss of elbow flexion seriously impairs working capacity Adversely affecting the patient's quality of life should be prioritized for diagnosis, treatment and rehabilitation The most common cause is damage to the motor nerve in the brachial plexus region There are many methods of treatment In situ tendon and muscle transfer surgery is a fairly common method because it is easy to perform and has relatively good results It is a last resort for elbow flexion rehabilitation when it is not possible or when other treatments have failed 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 The results after surgery are very good and good is 60% - 80%, not good (moderate, poor) is 20% - 40% Some related factors affecting surgical results are nerve damage, position of bone fragment fixation, post-operative rehabilitation Objectives of the study: - Comment on pathological characteristics of cases of elbow flexion loss due to motor nerve damage treated by modified Steindler surgery - Evaluation of results and identification of several related factors affecting the results of modified Steindler surgery to treat elbow flexion loss due to motor nerve damage The urgency of the thesis In the world, the results of treatment of elbow flexion loss by modified Steindler surgery have been evaluated by many authors In Vietnam, treatment of elbow flexion with modified Steindler surgery according to Mayer L., Green W (1954) has been performed for many years with a large number However, the characteristics of the pathology of loss of elbow flexion due to damage to the kneecap, treatment results, related factors, good and bad effects on surgical results have not been studied and evaluated fully Therefore, it is necessary to conduct research on the above contents to have solutions to improve the results of the treatment of elbow flexion recovery of modified Steindler surgery New contributions of the thesis Through the results of the study, the basic characteristics of the pathology of loss of elbow flexion due to motor nerve damage were indicated for treatment by modified Steindler surgery Evaluation of the results of treatment of elbow flexion loss due to motor nerve damage by modified Steindler surgery Identify some factors related, good or bad influence on surgical results Dissertation layout The thesis consists of 117 pages, including the following parts: Problem statement (02 pages), overview (30 pages), research objects and 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 117 references, including 102 English documents, 14 Vietnamese documents, 01 French document Chapter 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 the upper radius-ulna joint Elbow movement: Flex and extend the forearm Amplitude: Fold 1500, stretch 00 can reach -100, especially for women and children Pronation, supination 800 When the amplitude is reduced by 50%, the upper limb function will decrease by 80% Impaired elbow 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 the radial nerve (C7, C8) - Elbow flexion: Performed by biceps, forearm muscles These two 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 comprises anterior branches of C4, C5, C6, C7 and T1 The sacral division includes 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: The musculocutaneous nerve is the motor nerve of the muscles in the anterior arm When the musculocutaneous nerve is damaged, the forearm flexion will be very weak due to the loss of function of the biceps and forearm muscles The nerve innervating the elbow extensor 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 flexing the elbow due to trauma, broken wounds, detachment of attachment points, and muscle sclerosis Some muscle diseases cause sequelae of loss 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 nerve plexus is damaged in the BP, the upper trunk (C5, C6), the second body anteriorly, the musculocutaneous nerves will cause the loss of elbow flexion in varying degrees and accompanied by different symptoms motor nerve damage is common in the following cases: Head and shoulder trauma due to obstetric accidents, daily-life accidents, traffic accidents In which traffic accidents are the leading cause Upper limb surgery, wound, pinched nerves Polio disease; inflammation, degeneration, disc herniation, cervical spine tumor; Nervous root tumor… Toxic substances such as heavy metals and some drugs 1.2.2 Treatment of elbow flexion loss due to motor neuron damage 1.2.2.1 Non-surgical treatment: Using drugs to enhance nerve conduction, enhance peripheral circulation, anti-inflammatory and relieve pain Acupuncture, massage, physiotherapy… 1.2.2.2 Nerve rehabilitation Surgery: This is the optimal method for the treatment of motor nerve damage, allowing the reestablishment of Nervous transmission pathways Splicing, grafting musculocutaneous nerve: Connecting nerves directly when indicated and conditions Early joining usually gives good results Autologous Nerve Transplantation when the Nerve section is missing more than 1.5 cm, unable to pull the two ends together Transplantation from benign nerve to musculocutaneous: When the 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 the musculocutaneous nerves to restore the function of elbow flexion 1.2.2.3 Free muscle transfer surgery: This is a surgery to transfer muscles 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 flexor muscle 1.2.2.4 Surgery to transfer muscles in the vicinity: Transfer of bundles under the pectoralis major with accompanying vascular and nerve bundles for the biceps muscle Transfer latissimus dorsi muscles to biceps 1.2.2.5 Tendon transfer surgery of adjacent muscles: Transfer of triceps tendon Transfer the supracondylar muscles to the anterior surface 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 author transferred the flexor, pronation, and hand muscles from the medial epicondyle and sutured it to the medial intermuscular septum between the triceps and anterior arm muscle about cm above the arm In 1954, Mayer L and Green W introduced two modifications that 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 the medial epicondyle at the center of the elbow joint, and ends in the middle of the forearm 10 cm below the elbow crease - Transfer the attachment point of the muscle mass on the medial epicondyle together with the bone fragment of the upper process of the fixed medial epicondyle to the anterior surface of the humerus 1.3.2 Advantages and disadvantages: The technique is not difficult and does not require expensive equipment The surgical results were quite good in terms of limb rehabilitation However, it is possible to cause wrist flexion, finger flexion and forearm pronation when performing elbow flexion Risk of injury to the ulnar nerve and branches of the median nerve during the procedure 1.3.3 Surgery results - Evaluation criteria: In 1984, Alnot J Y and Abols Y evaluated the elbow joint's muscle strength and range of motion Very good when muscle strength M4, amplitude ≥1200 Good when muscle strength M4, amplitude