Muscle Rupture Surgery
Introduction[edit | edit source]
One should exercise extreme caution in considering surgical intervention in the treatment of muscle injuries, as a properly executed nonoperative treatment results in a good outcome in virtually all cases. In fact, the phrase "muscle injuries do heal conservatively" could be used as a guiding principle in the treatment of muscle traumas.
Having said that, there are certain highly specific indications in which surgical intervention might actually be beneficial.
Indications for Surgery[edit | edit source]
- large intramuscular hematoma(s),
- a complete (III degree) strain or
- tear of a muscle with few or no agonist muscles, or
- a partial (II degree) strain if more than half of the muscle belly is torn.
- surgical intervention should be considered if a patient complains of persisting extension pain (duration, >4-6 months) in a previously injured muscle, particularly if the pain is accompanied by a clear extension deficit. In this particular case, one has to suspect the formation of scar adhesions restricting the movement of the muscle at the site of the injury, a phenomenon that often requires surgical debridement of the adhesions.
If surgery is indeed warranted in the treatment of an acute skeletal muscle injury, the following general principles are recommended:
Recommended Principles for Surgery[edit | edit source]
- The entire hematoma and all necrotic tissue should be carefully removed from the injured area.
- One should not attempt to reattach the ruptured stumps of the muscle to each other via sutures unless the sutures can be placed through a fascia overlying the muscle.Sutures placed solely through myofibers possess virtually no strength and will only pierce through the muscle tissue.
- Loop-type sutures should be placed very loosely through the fascia, as attempts to overtighten them will only cause them to pierce through the myofibers beneath the fascia, resulting in additional damage to the injured muscle. It needs to be emphasized here that sutures might not always provide the required strength to reappose all ruptured muscle fibers, and accordingly, the formation of empty gaps between the ruptured muscle stumps cannot always be completely prevented.
- As a general rule of thumb, the surgical repair of the injured skeletal muscle is usually easier if the injury has taken place close to the MTJ, rather than in the middle of the muscle belly, because the fascia overlying the muscle is stronger at the proximity of the MTJ, enabling more exact anatomical reconstruction.
- In treating muscle injuries with 2 or more overlying compartments, such as the muscle quadriceps femoris, one should attempt to repair the fascias of the different compartments separately, beginning with the deep fascia and then finishing with the repair of the superficial fascia.
- After surgical repair, the operated skeletal muscle should be supported with an elastic bandage wrapped around the extremity to provide some compression (relative immobility, no complete immobilization, eg, in cast, is needed).
- Despite the fact that experimental studies suggest that immobilization in the lengthened position substantially reduces the atrophy of the myofibers and the deposition of connective tissue within the skeletal muscle in comparison to immobilization in the shortened position, the lengthened position has an obvious draw-back of placing the antagonist muscles in the shortened position and, thus, subjecting them to the deleterious effects of immobility.
After a careful consideration of all the above-noted information, we have adopted the following postoperative treatment regimen for operated muscle injuries.
Post operative treatment[edit | edit source]
- The operated muscle is immobilized in a neutral position with an orthosis that prevents one from loading the injured extremity.
- The duration of immobilization naturally depends on the severity of the trauma, but patients with a complete rupture of the m. quadriceps femoris or gastrocnemius are instructed not to bear any weight for 4 weeks,
- Although one is allowed to cautiously stretch the operated muscle within the limits of pain at 2 weeks postoperatively.
- Four weeks after operation, bearing weight and mobilization of the extremity are gradually initiated until approximately 6 weeks after the surgery, after which there is no need to restrict the weightbearing at all.
Experimental studies have suggested that in the most severe muscle injury cases, operative treatment may provide benefits. If the gap between the ruptured stumps is exceptionally long, the denervated part of the muscle may become permanently denervated and atrophied. Under such circumstances, the chance for the reinnervation of the denervated stump is improved, and the development of large scar tissue within the muscle tissue can possibly be at least partly prevented by bringing the retracted muscle stumps closer together through (micro) surgical means. However, in the context of experimental studies, it should be noted that the suturation of the fascia does not prevent contraction of the ruptured muscle fibers or subsequent formation of large hematoma in the deep parts of the muscle belly.
References[edit | edit source]
- Tero AH Järvinen, Markku Järvinen, Hannu Kalimo; Regeneration of injured skeletal muscle after the injury; Muscles, Ligaments and Tendons Journal 2013; 3 (4): 337-345 (2A)