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Biceps Muscle Severe Cut-split by an Electrical Saw - Tips & Tricks for Optimal Muscular Suturing
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Biceps Muscle Severe Cut-split by an Electrical Saw - Tips & Tricks for Optimal Muscular Suturing
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Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, here from shoulder planet, from São Paulo, Brazil. In this video, I'm showing you a very interesting case, of a serious saw cut, in the middle of the biceps, in a heavy, hard working man. And I'm showing you tips and special ideas to manage this serious muscular open lesions, in order to achieve good final clinical results. There are established ideas in literature about how to manage these cases,
and this is what this video is about. So I hope you like the video, please subscribe, leave your comment. Give us your thumbs up. And let's see the video. Hello, my friends, how are you? So this is a very nice case.
This case is about a 60-year-old man, I'm going to show you now, so here we start. This case is about a 60-year-old man, who was very used to work in building buildings and constructions, and, in July 2015, he had a severe accident, as I am showing here, with a circular saw, in the mid-anterior part of the right arm. His biceps was torn in two pieces, with a very sharp blade, and incredibly and hopefully, this patient evolved with absolutely no neurovascular injuries.
So here we are seeing a picture of the affected arm, there was absolutely no bone issues, here, as I am pointing with my arrow, this is the proximal part of the biceps, and here below the very distal part of the biceps. What I am showing here, now, is a portion of the brachialis muscle, which was partially affected by this cut. But the whole biceps was here,
I am showing the upper part, and here below the inferior part was fully affected by this severe lesion with a circular saw, as we are seeing here. So the thing is that there are very important principles that, once we follow, we can achieve, I would say, good or even very good final clinical results in these severe scenarios, and this is what this video is about. So I want to show some of these ideas,
I want to show you guys what I have done, and then a little discussion, with what we have, in terms of articles and publications in literature. So the first thing is exactly this, there are two important points that shall be highlighted here. So here we are seeing, here, the muscle in two pieces, the biceps, the "BI", here, and "CEPS" inferiorly. So the muscle was absolutely cut into pieces.
So there are two important principles that must be understood, for us to achieve success in operating these open muscular lesions. So the first one is this, there is absolutely no consensus in literature about what kind of suture shall we use to better suture all of these cases. So we can use simple sutures, we can use, modified Mason-Allen sutures, we can use modifier Kessler sutures,
it doesn't matter. As long as we reattach the muscle units, and as long as we do the job, that is absolutely enough and this is what we must do. So the idea is, we must do a meticulous reconnection of the muscular units. It doesn't matter with which kind of suture. And it's very important, also, for us to incorporate and to suture the epimysium. As we are seeing here, in this image, in this photo,
The epimysium is the external part of all muscles, and the incorporation of the epimysium is very important in any muscular laceration open wound, in order for us to achieve a good result. So that was, I would say, a long surgery, we used a lot of different sutures. Here I am pointing, with my arrow, the meticulous suture that was done. We used Kessler,
we used modified Mason-Allen, we used a lot of simple sutures, with number two, number 3 and number four Ethilon nylon sutures, and the epimysium was very well incorporated in this suture. So this is the final aspect, this is a video, in which I am showing you how the whole biceps is now working again under flexo-extension of the elbow, and under prono-supination.
So now we are seeing that the biceps is moving as a unit, under prono-supination, and a very, very well-done suture of the whole lesion, and especially the whole epimyseum. Because of skin problems, we had to take, as I am showing here, with my arrow, a piece of skin, as a free skin graft, from the anterior medial proximal third of the forearm, and we used it here,
in between the skin lesion. And what we are seeing, here, is a technique in which I made some small perforations in the skin graft, which is called the pie crushing technique. This is used to much in inferior limb, in the foot, in the leg, in very serious injuries, as we are seeing, here, in these photos, but the thing is, you can use it in any place in the human body. So we used here, the pie crush technique, just to give some relief and to avoid necrosis of the skin piece, of the skin graft.
Now we are seeing the final construction in which we are seeing that we have done, here, is the donor area from the anterior part, the volar part of the proximal third of the forearm. Here we are seeing the free skin graft, and also we have done a zetaplasty, in order to make all of that situation better. This is the patient 10 days post-op, moving freely and with basically no pain.
The hand was moving quite good, this is what we are seeing, now, the patient now is doing what we call the Kiloh-Nevin sign. The Kiloh-Nevin sign is a sign, is a test for us to evaluate the integrity of the median, the median nerve, especially the anterior interosseous nerve, and because we were quite afraid of the median nerve over that lesion, but hopefully nothing happened.
So the Kiloh-Nevon was absolutely positive, what means the patient was doing the flexion of the distal interphalangeal joint of the fourth and the fifth finger, and also the flexion of the whole thumb, in the affected hand. So that was a normal test, but what we are seeing here is that the patient was moving quite freely and 2 months, he was absolutely OK.
Literature says to all of us that we can easily allow the patient, after a few days of immobilization, of immobility, to start moving, and he can start early rehabilitation as long as the final construction, I would say, in the end of this surgery, looks very well, and this is exactly what happened in this case. So two months he was in a very good state, no necrosis of the skin graft, as we are seeing, here, pointed by my arrows.
The patient, at that moment, was doing, as we are seeing here, very good pronation and supination of the affected limb. And this is the final view, three years after the procedure, in which the patient was absolutely OK, with a very good flexion, a very good extension. Obviously, the patient had, when into flexion, a very bad aspect, here, from a cosmetic point of view, which basically meant nothing in that whole scenario.
So that was a very, very good final clinical result. The patient was indeed very happy. And now let's see some important aspects of what literature tell us about these cases, for us to improve our results and to give the best possible results for our patients, in this challenging scenarios. So when we analyze literature about this issue, it's quite easy for us to understand that, in fact, we have many, many few articles about this, which means, we have very poor literature about how to manage and operate open muscular tears and laceration.
Nevertheless, I found a very, very nice article, together with a very nice chapter of a book, which, I would say, in summary says the same aspects. So, in this beautiful article, which is "Surgical repair of muscle laceration", which was published in this nice journal, which is "Muscle, Ligaments and Tendons Journal", we find very interesting, important information. The first one is exactly this, which is, there are different suture techniques that have been described in literature, but still the best is to be debated, which means, still we don't know which is the best suture technique to be used.
And the article is quite clear. Whenever you feel comfortable with simple sutures, you can add simple sutures to another more complex sutures, when doing these muscle sutures. And this is exactly what we have done in this case. We we used modified Kessler sutures together with simple sutures, and our results were, as shown in this case, quite good. This is another important information, which is, when you do a very good suture, you can allow early rehabilitation of the patient, of the affected muscle and joint, with a very low risk of re-rupture.
And this is exactly what happened in this case. So we kept this arm in an axilo-palmar cast for only one week, and after that the patient was feeling very, very comfortable, to start rehabilitation and using his arm, and that was, for sure, due to a very good suturing of the whole muscular lesion. In the same way, it's very important for us to understand this The incorporation of the epimyseum dramatically improves the biomechanical properties of the repair, and still the preservation and the incorporation and the suture of the epimyseum, in the repair, increases the resistance of such repair to tensile forces.
So this is something very important, which also explains why we had such a lovely result in such challenging case. And in this chapter, published in a sports medicine book, we find basically the same informations. So here we see the very same idea a well executed suture allows early rehabilitation with a very low risk of re-rupture,
just as the other article was saying. Here we have this information the preservation of the epimyseum, and the possibility of suturing it, makes the repair more resistant. So essentially the same thing as we were seeing, two minutes ago, in the other article. In fact, the epimyseum is the key to a robust suture, and this is something that is written in all of the few articles that I could find.
And, nevertheless, we know that there are, in literature, no significant differences between the sutures used. So this chapter says, basically, the same information that I have found in the other article. So having said that, this is the take-home message of this presentation. Whenever you have a big, serious muscular laceration as an open wound, meticulous suturing is elemental to achieve a good result.
There is no evidence of the best suture technique, so you can use mattress sutures, you can use Kessler sutures, you can use modified Mason Allen sutures, or even simple sutures. But as long as you do the job, a meticulous suture is the elemental point. And still, obviously suturing the epimyseum is absolutely a key point for you to achieve success. And of course, with a good suture of the lesion, and especially the epimyseum, you can allow your patient to early rehabilitation and to achieve the best possible
final clinical result. So having said that, thank you, my good friends, thank you for watching. I hope you liked this video, please, if you have any doubt, don't forget, leave a comment on this video, or you can even send me an email. It's a pleasure for me to reply you whenever you wish. And please help me spreading this channel to your friends, it's difficult to keep such high quality videos, but I'm counting on you, my friends, always to help me spread in YouTube shoulder planet channel.
OK, thank you a lot, my friends. Bye bye. So I hope you liked this nice video, about a complex lesion of the biceps with a saw cut, so please don't forget, my friends. subscribe, leave your comment, show it to your friends, give us your thumbs up.
And as Dr. Sergio always says, never stop flying. See you, my good friend.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, here from shoulder planet, from São Paulo, Brazil. In this video, I'm showing you a very interesting case, of a serious saw cut, in the middle of the biceps, in a heavy, hard working man. And I'm showing you tips and special ideas to manage this serious muscular open lesions, in order to achieve good final clinical results. There are established ideas in literature about how to manage these cases,
and this is what this video is about. So I hope you like the video, please subscribe, leave your comment. Give us your thumbs up. And let's see the video. Hello, my friends, how are you? So this is a very nice case.
This case is about a 60-year-old man, I'm going to show you now, so here we start. This case is about a 60-year-old man, who was very used to work in building buildings and constructions, and, in July 2015, he had a severe accident, as I am showing here, with a circular saw, in the mid-anterior part of the right arm. His biceps was torn in two pieces, with a very sharp blade, and incredibly and hopefully, this patient evolved with absolutely no neurovascular injuries.
So here we are seeing a picture of the affected arm, there was absolutely no bone issues, here, as I am pointing with my arrow, this is the proximal part of the biceps, and here below the very distal part of the biceps. What I am showing here, now, is a portion of the brachialis muscle, which was partially affected by this cut. But the whole biceps was here,
I am showing the upper part, and here below the inferior part was fully affected by this severe lesion with a circular saw, as we are seeing here. So the thing is that there are very important principles that, once we follow, we can achieve, I would say, good or even very good final clinical results in these severe scenarios, and this is what this video is about. So I want to show some of these ideas,
I want to show you guys what I have done, and then a little discussion, with what we have, in terms of articles and publications in literature. So the first thing is exactly this, there are two important points that shall be highlighted here. So here we are seeing, here, the muscle in two pieces, the biceps, the "BI", here, and "CEPS" inferiorly. So the muscle was absolutely cut into pieces.
So there are two important principles that must be understood, for us to achieve success in operating these open muscular lesions. So the first one is this, there is absolutely no consensus in literature about what kind of suture shall we use to better suture all of these cases. So we can use simple sutures, we can use, modified Mason-Allen sutures, we can use modifier Kessler sutures,
it doesn't matter. As long as we reattach the muscle units, and as long as we do the job, that is absolutely enough and this is what we must do. So the idea is, we must do a meticulous reconnection of the muscular units. It doesn't matter with which kind of suture. And it's very important, also, for us to incorporate and to suture the epimysium. As we are seeing here, in this image, in this photo,
The epimysium is the external part of all muscles, and the incorporation of the epimysium is very important in any muscular laceration open wound, in order for us to achieve a good result. So that was, I would say, a long surgery, we used a lot of different sutures. Here I am pointing, with my arrow, the meticulous suture that was done. We used Kessler,
we used modified Mason-Allen, we used a lot of simple sutures, with number two, number 3 and number four Ethilon nylon sutures, and the epimysium was very well incorporated in this suture. So this is the final aspect, this is a video, in which I am showing you how the whole biceps is now working again under flexo-extension of the elbow, and under prono-supination.
So now we are seeing that the biceps is moving as a unit, under prono-supination, and a very, very well-done suture of the whole lesion, and especially the whole epimyseum. Because of skin problems, we had to take, as I am showing here, with my arrow, a piece of skin, as a free skin graft, from the anterior medial proximal third of the forearm, and we used it here,
in between the skin lesion. And what we are seeing, here, is a technique in which I made some small perforations in the skin graft, which is called the pie crushing technique. This is used to much in inferior limb, in the foot, in the leg, in very serious injuries, as we are seeing, here, in these photos, but the thing is, you can use it in any place in the human body. So we used here, the pie crush technique, just to give some relief and to avoid necrosis of the skin piece, of the skin graft.
Now we are seeing the final construction in which we are seeing that we have done, here, is the donor area from the anterior part, the volar part of the proximal third of the forearm. Here we are seeing the free skin graft, and also we have done a zetaplasty, in order to make all of that situation better. This is the patient 10 days post-op, moving freely and with basically no pain.
The hand was moving quite good, this is what we are seeing, now, the patient now is doing what we call the Kiloh-Nevin sign. The Kiloh-Nevin sign is a sign, is a test for us to evaluate the integrity of the median, the median nerve, especially the anterior interosseous nerve, and because we were quite afraid of the median nerve over that lesion, but hopefully nothing happened.
So the Kiloh-Nevon was absolutely positive, what means the patient was doing the flexion of the distal interphalangeal joint of the fourth and the fifth finger, and also the flexion of the whole thumb, in the affected hand. So that was a normal test, but what we are seeing here is that the patient was moving quite freely and 2 months, he was absolutely OK.
Literature says to all of us that we can easily allow the patient, after a few days of immobilization, of immobility, to start moving, and he can start early rehabilitation as long as the final construction, I would say, in the end of this surgery, looks very well, and this is exactly what happened in this case. So two months he was in a very good state, no necrosis of the skin graft, as we are seeing, here, pointed by my arrows.
The patient, at that moment, was doing, as we are seeing here, very good pronation and supination of the affected limb. And this is the final view, three years after the procedure, in which the patient was absolutely OK, with a very good flexion, a very good extension. Obviously, the patient had, when into flexion, a very bad aspect, here, from a cosmetic point of view, which basically meant nothing in that whole scenario.
So that was a very, very good final clinical result. The patient was indeed very happy. And now let's see some important aspects of what literature tell us about these cases, for us to improve our results and to give the best possible results for our patients, in this challenging scenarios. So when we analyze literature about this issue, it's quite easy for us to understand that, in fact, we have many, many few articles about this, which means, we have very poor literature about how to manage and operate open muscular tears and laceration.
Nevertheless, I found a very, very nice article, together with a very nice chapter of a book, which, I would say, in summary says the same aspects. So, in this beautiful article, which is "Surgical repair of muscle laceration", which was published in this nice journal, which is "Muscle, Ligaments and Tendons Journal", we find very interesting, important information. The first one is exactly this, which is, there are different suture techniques that have been described in literature, but still the best is to be debated, which means, still we don't know which is the best suture technique to be used.
And the article is quite clear. Whenever you feel comfortable with simple sutures, you can add simple sutures to another more complex sutures, when doing these muscle sutures. And this is exactly what we have done in this case. We we used modified Kessler sutures together with simple sutures, and our results were, as shown in this case, quite good. This is another important information, which is, when you do a very good suture, you can allow early rehabilitation of the patient, of the affected muscle and joint, with a very low risk of re-rupture.
And this is exactly what happened in this case. So we kept this arm in an axilo-palmar cast for only one week, and after that the patient was feeling very, very comfortable, to start rehabilitation and using his arm, and that was, for sure, due to a very good suturing of the whole muscular lesion. In the same way, it's very important for us to understand this The incorporation of the epimyseum dramatically improves the biomechanical properties of the repair, and still the preservation and the incorporation and the suture of the epimyseum, in the repair, increases the resistance of such repair to tensile forces.
So this is something very important, which also explains why we had such a lovely result in such challenging case. And in this chapter, published in a sports medicine book, we find basically the same informations. So here we see the very same idea a well executed suture allows early rehabilitation with a very low risk of re-rupture,
just as the other article was saying. Here we have this information the preservation of the epimyseum, and the possibility of suturing it, makes the repair more resistant. So essentially the same thing as we were seeing, two minutes ago, in the other article. In fact, the epimyseum is the key to a robust suture, and this is something that is written in all of the few articles that I could find.
And, nevertheless, we know that there are, in literature, no significant differences between the sutures used. So this chapter says, basically, the same information that I have found in the other article. So having said that, this is the take-home message of this presentation. Whenever you have a big, serious muscular laceration as an open wound, meticulous suturing is elemental to achieve a good result.
There is no evidence of the best suture technique, so you can use mattress sutures, you can use Kessler sutures, you can use modified Mason Allen sutures, or even simple sutures. But as long as you do the job, a meticulous suture is the elemental point. And still, obviously suturing the epimyseum is absolutely a key point for you to achieve success. And of course, with a good suture of the lesion, and especially the epimyseum, you can allow your patient to early rehabilitation and to achieve the best possible
final clinical result. So having said that, thank you, my good friends, thank you for watching. I hope you liked this video, please, if you have any doubt, don't forget, leave a comment on this video, or you can even send me an email. It's a pleasure for me to reply you whenever you wish. And please help me spreading this channel to your friends, it's difficult to keep such high quality videos, but I'm counting on you, my friends, always to help me spread in YouTube shoulder planet channel.
OK, thank you a lot, my friends. Bye bye. So I hope you liked this nice video, about a complex lesion of the biceps with a saw cut, so please don't forget, my friends. subscribe, leave your comment, show it to your friends, give us your thumbs up.
And as Dr. Sergio always says, never stop flying. See you, my good friend.
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