RU2168953C1 - Surgical method for treating chronic extremity ischemia - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves forming bone fragment of the same length with diaphysis. The medullary canal is opened. The regenerate is acted with alternating distraction and compression with distraction tempo being higher than that of compression. The distraction and compression process is stopped on achieving subjective and objective improvement of blood circulation in the extremity. The distraction apparatus is taken off. Physical load is applied to the extremity with regenerate being not ossified. EFFECT: enhanced effectiveness of treatment; increased number of vessels formed. 2 dwg

Description

 The invention relates to medicine, namely to vascular surgery, can be used to treat patients with chronic ischemia of the lower extremities, mainly III-IV art. It is intended to enhance regional, collateral circulation in the limbs with occlusive arterial diseases with a predominant lesion of the distal arterial channel, when the use of reconstructive surgery on the vessels is impossible, and pharmacological, physical and biological methods of stimulating collateral circulation remain ineffective.

 Known methods of surgical treatment of patients with obliterating diseases of the vessels of the lower extremities: Zatevakhin II Transplantation of a large omentum using microsurgical technique for thromboangiitis obliterans. Surgery. 1984, 5, pp. 61-66; RF patent N 21244313, A 61 B 17/00, Method for the surgical treatment of peripheral circulation disorders with occlusive diseases of lower limb arteries (Poyarkov VD, Baykov AN); RF patent N 2136222, A 61 B 17/00, 17/56, Method for surgical treatment of obliterating diseases of vessels of the lower extremities (Nevash E. Ye., Pulin A.G., Nefedov I.P.), which consist in increasing the volume of collateral blood flow in the distal extremities due to implantation of a vascularized omental graft on the lower limb.

 The disadvantages of these surgical interventions are the complexity of surgical treatment associated with the need to perform laporotomy. During transplantation of a free lock of an omentum and application of arterial and venous anastomoses due to frequent discrepancies in the diameter of stitched vessels, thrombosis and graft necrosis may develop. Moving the omentum from the abdominal cavity to the thigh contributes to the formation of a canal with subsequent formation of a hernia, as a result of which vascular thrombosis can also develop with subsequent necrosis of the omentum. In addition, small vessels that occur in the fusion between the omentum and thigh tissues cannot provide the level of blood flow necessary for the functioning of the limb. When transplanting a vascular flap from the greater omentum to the lower extremity, revascularization of ischemic tissues and blood circulation compensation in some cases may be ineffective due to the inevitably developing cicatricial process that prevents the omental vessels from growing into the soft tissues of the lower leg.

 Methods of surgical treatment of patients with lower limb ischemia are also known: a. from. USSR N 1680092, class A 61 B 17/00, Zusmanovich V.I. and RF patent N 2093085, A 61 B 17/00, 17/56, A method for stimulating blood circulation in obliterating diseases of limb arteries, proposed by V. Shatohin. and Maryev A.Yu.

 The principle of treatment is to stimulate blood circulation by trepanation of the bone and causing injury to the bone marrow. In the second patent, a conductor is inserted into the distal trepanation opening, to the end of which a special device is attached for causing a dosed mechanical injury to the bone marrow (Babcock probe). The conductor along with the device is conducted along the bone marrow canal, which causes a dosed injury to the bone marrow.

 However, the problems of these surgical interventions are the lack of a stimulating effect on blood circulation and microcirculation and their uncontrollability and short duration. Trepanation holes in the bones applied by a thin drill cannot ensure full bone marrow decompression, and mechanical trauma is minimal, therefore, the period of blood circulation stimulation is limited.

 The closest of the proposed methods on the technical nature and mechanisms of improving blood circulation in the ischemic limb is a method of treating chronic limb ischemia - and.with. 1061803 USSR, MKI A 61 B 17/00 (G.A. Ilizarov, F.N. Zusmanovich). This method of distraction osteosynthesis allows you to control the duration of the resulting compensatory-adaptive reactions. Under the influence of dosed distraction followed by fixation of the bone and soft tissues of the limb, performed using a special apparatus, its vascular bed undergoes distraction reconstruction, resembling the process of natural growth. An increase in the number and caliber of small arteries of bones and soft tissues is observed, due to which blood supply improves and regenerative processes are activated.

 In the treatment according to this method, a medial corticotomy is performed with the creation of a tibia flake in the upper and middle third of the leg. To do this, small incisions are made on the legs and, without injuring the soft tissues, one or more fragments are separated from the tibia with a chisel or saw so that the bone marrow is not damaged and bone continuity is maintained. Through the separated bone fragment, conduct spokes with thrust pads. The spokes are fixed to the rods that are attached to the Ilizarov apparatus.

 In the process of treatment by distraction osteosynthesis, three periods in treatment are distinguished. The pre-distraction period is 7–9 days, the period of distraction is 40–60 days, and the period of fixation is 14–28 days, which is carried out before compaction of the bone regenerate, i.e., after the onset of ossification and bone mineralization. Then the device is removed. The duration of the treatment load is 2-3 months. However, due to insufficient neoangiogenesis, delayed ossification and mineralization of bone regenerate, the periods of the distraction and fixation periods can be significantly increased.

 The disadvantages of this method are: the duration of treatment, the lack of effectiveness of revascularization of the lower extremities, due to the inadequate effect on the reparative regenerate, the inability to initiate reparative regenerate after removal of the apparatus, the fixation period required in treatment is difficult to form a bone fragment from small incisions, not affecting the support function of the limb.

 The objective of the invention is to increase the effectiveness of the treatment of chronic ischemia of the limbs while reducing treatment time.

 The essence of the invention lies in the fact that in the method of surgical treatment of chronic ischemia of the extremities by the formation of new vascular connections, including the formation of a bone fragment from the base bone proximal to the lesion and directing the regenerate by distraction, providing a gap between the bone fragment and the base bone, with the completion of treatment dosed load under control, during the formation of a bone fragment provide the length of the bone fragment to the length of the diaphysis, and the impact and the regenerate is carried out alternating distraction with compression in turn, with a different magnitude of the effect: with an excess of the rate of distraction over the rate of compression, and the termination of distraction-compression is carried out after an objective and subjective improvement of blood circulation in the limb, removal of the distraction apparatus is carried out before the onset of ossification and mineralization of the regenerate, followed by impact on the regenerate without a distraction apparatus.

The method is illustrated using FIG. 1 and 2, where the positions indicated:
1 - tibia (basic);
2 - bone fragment;
3 - screw rods;
4 - a support plate;
5 - nuts;
6 - spoke-rod distraction apparatus (Fig. 1);
7 - rod distraction apparatus (Fig. 2).

 The method is as follows.

 Under the spinal or epidural anesthesia, proximal to the lesion, on the medial surface of the tibia 1 - base on the length of the diaphysis, an incision is made in the skin and soft tissues to the periosteum. The periosteum is cut into the length of the incision of the soft tissues. After separation of the upper and lower periosteum flap, along with the fascial and fascial flap, mainly the pendulum, a saw and a chisel, the tibia 1 is osteotomy 1 to the depth of the cortical bone layer, an elongated bone fragment 2 is formed. Stabilizing threaded rods-screws 3 are inserted into the tibia 1 above and below the bone fragment 2. The base plate 4 is mounted on them with the help of nuts 5. Two threaded rods-screws 3 are inserted into the cortical fragment, which are mounted to the base plate 4 by the nuts 5. Soft fabrics are sutured in layers. Rare interrupted sutures are placed on the periosteum and skin. The threaded rods-screws 3 for controlling the bone fragment 2 can be mounted on the support plate 4 of the spoke-rod apparatus 6 (in Fig. 2). Skin sutures are removed 10-14 days after surgery until the period of distraction-compression. From 10-14 days after the operation, a bone fragment 2 is distilled by 1 mm in the first day in 4 doses. The next day, compression by 0.5 mm per day, also in 4 doses. On day 3 - again 1 mm distraction. On the 4th day - compression by 0.5 mm. This alternation of distraction with compression, carried out with a different magnitude of impact on the regenerate, with an excess of the rate of distraction over the rate of compression, with constant provision of the gap between the bone fragment 2 and the base bone 1, allows for faster improvement of blood circulation in the ischemic limb. Subjectively, this manifests itself in the relief of pain, objectively, patients have an increase in locomotor activity: the length of the non-stop path, the daily motor activity increase. The temperature of the skin of the lower leg and foot rises. In the presence of ulcerative necrotic changes there is a persistent tendency to cleanse and heal ulcers. In conditions of increasing blood flow in the limbs and improving the patient's condition, the effect on the regenerate in the form of different temp, sequential distraction-compression is stopped before the onset of ossification and mineralization of the regenerate. 2-3 days after the end of distraction-compression, the distraction rod 7 or spoke-rod 6 apparatus is removed, the timing of uneven, alternating exposure in the form of distraction compression varies from 20 to 30 days and depends mainly on the degree of limb ischemia and the nature of the damage arteries.

 Further influence on the regenerate to continue the excitation of the processes of neoangiogenesis and the development of compensatory-adaptive mechanisms in the oxygen transport system occurs naturally. This is due to the slight oscillatory movements of the unsecured regenerate that occur during dosed physical activity - walking. The exercise therapy and limb massage after removal of the distraction apparatus continues.

 Example 1

 Observation 1. B. Sh. (Source. Bol. N 4193), 44 years old, was admitted to the Department of Vascular Surgery with a diagnosis of obliterating atherosclerosis of the vessels of the lower extremities, occlusion of both lower leg arteries, decompensation of impaired circulation of the III stage, occlusion of the lower leg arteries, subcompensation impaired blood circulation stage IIB. Sick for 2 years, when an alternating claudication first appeared after 500 m. He was treated on an outpatient basis. The deterioration came about six months. The painless distance traveled decreased to 200 m. For about a month, pains in the left lower limb, in the foot, and toes of the feet at rest began to disturb.

On external examination, there are no trophic ulcers. There was a lack of hair on both feet and on the left lower leg. The left foot is cooler to the touch than the right. With thermography, the temperature on the left foot is 2 ^° C lower than that on the right. Ripple on the femoral and popliteal arteries is distinct. Systolic noise is not heard. Ripple in the arteries of the feet is not detected on both sides. Radiologically expressed signs of osteoporosis were not detected. Serum Ca is normal.

 When rheovasography revealed a sharp decrease in the rheographic index (RI). RI - 0.01. The sample with nitroglycerin did not lead to an increase in the rheographic index. According to veno-occlusion plethysmography, the volumetric blood flow on the left leg was 1.1 ml per min / 100 g. After a 3-minute ischemic test, there was no increase in blood flow.

According to UDG, V _max + (m / s) above the posterior tibial artery was 0.14. V _max - (m / s) - 0. The ripple index (IP) was 2.80. The ankle-brachial index (LPI) was 0.21 on the left and more than 0.3 on the right. When performing laser Doppler ultrasound, the capillary blood flow index was 0.38 on the left and 0.68 on the right. Based on the results of duplex scanning, an extended occlusion of both lower leg arteries was established on the left and right. This patient had an isolated atherosclerotic lesion of the tibial arteries of both limbs with decompensation of impaired blood circulation in the left lower limb. Reconstructive surgery was not feasible.

 The patient underwent an indirect revascularizing operation on the left lower leg: an open corticotomy, the application of the pivotal apparatus on the left lower leg. The operation was performed according to the method described above.

 Distraction began to be performed from 10 days to 1 mm per day in 4 doses. The next day, compression by 0.5 mm in 4 divided doses. Daily alternating temp alternation of distraction with compression lasted 20 days. The fixation period was 3 days. Pain at rest stopped immediately after surgery. The patient began to walk on crutches from 2 days. To step on the foot from 3 days. Starting from the middle of the distraction-compression period, the pain-free distance traveled gradually increased from 20 m to 200 m upon discharge from the hospital. The increase in RI on the foot and lower leg was insignificant. LPI increased by 30%. The capillary blood flow index increased to 0.68.

 Six months after surgical treatment, blood circulation in both lower extremities is subcompensated. Passable pain-free distance 200 m. LPI is more than 0.3. RI compared with the original increased by 40%. Due to the deterioration of blood circulation in the right lower limb, the patient was hospitalized in the hospital and a year after surgery on the left lower leg an open corticotomy was performed with the application of a rod distraction apparatus 7 (Fig. 2) on the right lower leg.

 33 days after surgery with improvement, the patient was discharged for outpatient treatment.

 The patient was examined 3 years after the first operation and 2 years after the second operation. Blood circulation in both lower extremities is compensated. There is a stage I circulatory disturbance. Passable pain-free distance more than 1000 m.

 Example 2. Patient I., 60 years old, medical history N 16941, was admitted to the department of vascular surgery with complaints of pain in the right foot, a long-term healing ulcer on the back of the foot. From the anamnesis it is known that he was ill for about 3 years, when pain in the lower extremities first appeared when walking. The painless distance traveled was 400 m. Subsequently, the patient developed pain at rest and a trophic ulcer formed, which later turned into necrosis of the phalanx of 1 finger. Due to the lack of effect of outpatient treatment, he was hospitalized in the Department of Vascular Surgery. During the examination, the diagnosis was established: atherosclerosis obliterans of the lower extremities, occlusion of both superficial femoral arteries, anterior occlusion of the tibial artery on the left, subcompensation of impaired blood circulation in the left lower limb, occlusion of both tibial arteries on the left, necrosis of the claw phalanx of the thumb, regional lymphangensitis, regional lymphangensitis left lower limb stage IV.

 On the survey R-gram of the leg bones there are signs of osteoporosis - enlightenment of bone tissue, thickening of the compact layer of the tibia. With ultrasound dopplerography, LPI is 0.11. According to rheovasography, RI on the foot 0.01, on the lower leg 0.02. With laser Doppler ultrasound, the index of capillary blood flow is 0.18. An angiography was performed in which contrasting of the superficial femoral artery in the guenter canal did not occur. Both tibial arteries also do not contrast. Due to the impossibility of reconstructive surgery, the patient after short-term preoperative preparation underwent a left-sided lumbar L2-L3 sympathectomy and amputation of the big toe with exarticulation of the metatarsal head. In the early postoperative period, the patient's condition improved, the pain syndrome stopped, warming, redness and hyperemia of the limb were clinically noted. The wound on the foot healed by primary intention. In satisfactory condition, the patient was discharged for outpatient treatment. Upon discharge from the hospital, the pain-free distance traveled was more than 50 m. However, the patient's condition soon worsened again, 2 months after discharge from the hospital, pain in the foot appeared at rest, and a weeping ulcer appeared on the back of the foot.

 Re-entered the Department of Vascular Surgery. After intensive preoperative preparation aimed at improving the rheological properties of blood and sanitizing an ulcer (local treatment was carried out - antibiotic therapy taking into account the flora, baths with antiseptics and ultrasound treatment of the ulcer), the patient underwent surgery No. 432 under the spinal anesthesia: open tibial corticotomy on the left and application spoke-rod apparatus on the left shin.

 A decrease in pain was noted towards the middle of the distraction-compression period. At the same time, epithelization of the trophic ulcer of the rear foot began. The pre-distraction period was 12 days. Control radiographs to clarify the standing of the bone fragment were performed before the start of distraction. Distraction-compression of the controlled bone fragment was carried out according to the established scheme - 1 mm per day in 4 doses, distraction, the next day compression of 0.5 mm in 4 doses. Distraction - compression lasted 22 days. The fixation period was 3 days. After removal of the apparatus, complete healing of the ulcer was noted. The pain-free distance traveled at this time was more than 150 m. When discharged from the hospital, an increase in LI by 20% was noted. The infographic index on the foot and lower leg increased by 50%. The index of capillary blood flow in the foot with laser Doppler ultrasound increased to 0.84.

 Long-term results in this patient were checked one year after surgery.

 A year after surgical treatment, the state of blood circulation in both lower extremities is subcompensated. The pain-free distance traveled is more than 500 m. The LPI has increased to 0.4. RI increased 4 times and amounted to 0.04 and 0.05 on the foot and lower leg. The index of capillary blood flow in the foot with laser Doppler ultrasound was 0.1.

 The therapeutic effect when using the proposed method is provided by opening the bone marrow canal and dosed bone marrow injury with a pendulum saw during the formation of a controlled bone fragment from the base bone. Thus, there is an increase in reflexes from bone marrow receptors involved in the regulation of regional blood circulation and an increase in blood flow to the irritated limb.

 Reducing increased intraosseous pressure in the ischemic limb after the formation of a bone fragment contributes to the normalization of microcirculation in the operated limb.

 Dosed bone marrow injury contributes to the formation of bone regenerate, mainly by the mesenchymal and enchondral type, to form a larger bundle of blood vessels.

 A bone fragment equal to the length of the diaphysis provides a large area of the regenerate, which also leads to an increase in the number of vessels formed during distraction, and a large area of the regenerate when exposed to it by distraction-compression allows you to enhance the effect of tensile stress to create new blood paths. The alternation of distraction and compression different in rate increases the effect of the effect on the regenerate.

 Early removal of the distraction apparatus before the onset of ossification and mineralization and the continuation of dosed physical activity: walking, exercise therapy allows you to naturally continue to affect the regenerate.

 The artificially induced slowdown in the formation of dense bone marrow allows prolonged enhancement of reflexes from the bone marrow involved in the regulation of regional blood circulation.

 This method of treatment provided assistance to 35 patients in the 1st city clinical hospital in Saratov. In 27 patients, the cause of the disease was atherosclerosis obliterans, in 8 patients, obliterating endarteritis. Of 23 patients with III tbsp. limon ischemia according to Fontaine, after treatment with the proposed method, a positive result for the first 6 months was observed in 21 patients. Long-term results (1-2 years after treatment) were monitored in 17 patients. Of these, only three patients experienced a return to their original state. Of 12 patients with IV tbsp. limb ischemia, limb amputation was avoided in 8 patients. In case of damage to the arteries of the lower leg and superficial femoral artery, successful operation of this method requires the preservation of blood flow in the basin of the deep femoral artery, the optimal blood flow in the deep femoral artery should be more than 200 ml / min.

Claims (1)

 A method of surgical treatment of chronic limb ischemia by the formation of new vascular connections, including the formation of a bone fragment from the base bone with the opening of the bone marrow channel and directing the regenerate through distraction to provide a gap between the bone fragment and the base bone, characterized in that the bone fragment is formed length of the diaphysis, the effect on the regenerate is carried out by alternating distraction with compression when the distraction rate is exceeded over the rate of compression, the compression-distraction is stopped after the subjective and objective improvement of blood circulation in limbs, distraction apparatus is removed and then, if neossifitsirovannom regenerate, physical activity performed limb.

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