RU2200491C1 - Method for treating the cases of mine explosion wounds on extremities resulting in crushing one of them and in bone fracture and tissue defects in the other one - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves performing surgical interventions in retaining utile tissues of stump end of ruptured or crushed extremity segment in reactive toxic, toxemic, and infectious toxic period to make them serve as not free autotransplants on two feeding pedicles during recovery period by cutting out utile flap from the stump end and attaching it by suturing to wound defect surface of counterlateral extremity. One extremity reamputation and plastic repair of wound defect of the other one are done in single stage 3.5-4.5 weeks later using the transplant from the utile material vascularized and trained to ischemia. EFFECT: enhanced effectiveness of treatment; reduced risk of complications. 3 dwg

Description

 The invention relates to medicine, in particular to methods for treating mine explosive injury (MVT) of limbs.

 Due to MVT, several damaging factors act on the human body at the same time: the direct shock of the blast wave, the effect of a gas flame, sharp fluctuations in atmospheric pressure (barotrauma) and sound waves (acutrauma), additional injuries when the body hits the soil and various objects at the time of rejection. As a result, a severe combined polytrauma with commissive-contusion syndrome occurs, and in case of contact mine-explosive wound (MVR), detachment and crushing of a segment of one limb, a severe fracture and an extensive tissue defect are observed in the other, and, moreover, wounds or closed injuries of other areas are often observed simultaneously body.

 A known method of treating a mine-explosive wound of the extremities with separation and crushing of one, bone fracture and tissue defect of another, described in the book edited by L.N. Bisenkova "Surgery of mine-explosive wounds." - St. Petersburg, 1993, 320 p. To implement the method, primary amputation is performed at the level of the superior segment in the area of molecular tissue concussion, with purulent necrotic complications, re-amputation is performed, repeated surgical treatments and plastic surgery of the stump wound are performed, and surgery is performed on the contralateral limb as in the treatment of non-contact MVT. However, using the known method of treatment for a mine-explosive wound with a leg tearing off even at its distal sections, the victim loses his knee joint due to primary amputation at the hip level, and disability is even more aggravated. Moreover, in almost half of cases, re-amputation is performed despite the typical amputation at the level of a higher limb segment. The terms of treatment are long; donor sites are required to treat a wound defect in the contralateral limb, which is problematic in patients with MVT.

 There is a method of surgical treatment of a contact mine blast wound with a separation of a limb segment, based on the results of fundamental clinical and experimental studies, which allows preserving the adjacent joint and part of a segment of a damaged limb (see pages 239-273 Nechaev E. A., Gritsanov A.I. , Fomin N.F., Minnulin I.P. Anatomical, physiological and experimental justification of some methods of surgical treatment of mine weapon injuries / In the book: Mine-explosive injury. - St. Petersburg. - 1994. 487p.). The method provides for early and adequate infusion and blood transfusion therapy, normalization of systemic hemodynamics and microhemocirculation, powerful antibacterial therapy, adequate drainage of affected bone-fascial spaces, economical necrectomy, taking into account the configuration of the wound and surgical anatomy of intrafutoral lesions. And although this method allowed 81.7% of the wounded to perform amputation within the destroyed segment of the limb, to preserve the adjacent joint with wound healing mainly by primary intention, the lack of plastic material necessary to eliminate the wound defect of other areas of the body during MVR leads to an extension of the treatment time. worsens the results of surgical rehabilitation of the wounded.

 Closest to the proposed technical solution is the method of surgical treatment for gunshot injuries of the limbs, proposed by N. N. Kukin and described in the book "Amputation of limbs in the field", Yu.G. Shaposhnikov, N.N. Kukin, A.V. .New. - M.: Medicine, 1980, 152 p. This method is as follows. After preparing the wounded for surgery, the surgical field is typically treated. At the beginning of the operation, a skin-fascial flap of a semi-oval shape is cut out from intact tissues on a portion of the limb to be amputated. After separating the flap from the underlying tissues, it is turned up. Amputation is performed in the usual way, leaving the wound of the stump open. The flap is sewn with two or three sutures into a tubular stem and, in order to avoid its bending, is drained with a thin rubber tube, which serves at the same time for the outflow of the discharge. A cotton-gauze swab is placed under the tubular stem, which holds the flap in an elevated position. An aseptic dressing is applied to the stump wound. In case of suppuration of the wound of the stump, antibiotics are introduced through the drainage and the wound is washed. A tubular flap closes the wound at various times, depending on the nature of the course of the wound process. It is deployed and subjected to appropriate processing, adapted to the contours of the defect and sutured to the skin edges of the wound of the stump as a primary delayed suture.

However, the clinical use of the prototype revealed a number of disadvantages:
1) the method is used only in connection with the massive destruction of bone, muscles and blood vessels during primary amputations of a limb within healthy tissues;
2) since the known method involves performing primary amputation in a typical way within healthy tissues, it is not possible to use it during primary surgical treatment of a stump wound with truncating it at the level of bruised tissues of the damaged limb segment due to the high probability of flap necrosis;
3) using the known method, it is possible to perform plastic surgery on the skin-subcutaneous-fascial flap on the feeding leg of only a wound defect of the stump itself;
4) it is not always possible to avoid the excess of the skin tube, and in connection with this comes gross circulatory disorders, necrosis of the flap;
5) a cotton-gauze swab used to hold the flap in an elevated position is a “plug” for a gunshot wound, disrupts the outflow of the wound, aeration of the wound, contributing to the development of anaerobic infection;
6) since when creating skin-fascial flaps, one has to adapt to the level of amputation, in accordance with the degree of damaged tissue, their viability, length and width of the flap, its location depends on the nature of the damage, the location of gunshot wounds and other conditions, the application of the method becomes limited;
7) the flap should be created only in those cases when there is confidence in its sufficient blood supply.

 The objective of the proposed technical solution is the early and effective medical rehabilitation of victims with contact mine-explosive wounds of the extremities, the prevention of complications and consequences.

 This problem is solved due to the fact that, in the reactive-toxic, toxemic and infectious-toxic periods of wound disease, surgical interventions are carried out by preserving the salvage tissue of the stump end of the torn or crushed limb segment and turning them in the recovery period into a non-free autograft on two feeding legs by cutting at the end of the stump of a scrap flap with the free end attached to the surface of the wound defect of the contralateral limb, and after 3.5-4.5 weeks, one tapnite reamputatsiyu a plastic wound defect and other vascularized limb ischemia and trained to autograft from scrap fabric.

 The implementation of the method can be considered by the example of surgical treatment of a mine-explosive wound of the lower extremities with separation and crushing of one, a broken bone and a defect in the tissues of the other. In the reactive-toxic period, a tourniquet is applied to a limb with a torn segment at the level of an adjacent segment (molecular concussion zone). After anti-shock measures, a typical amputation is not performed within healthy tissues, and under anesthesia, primary surgical treatment of the wound with truncation of the limb stump in the zone of late secondary necrosis or at the level of the conditional border between it and the zone of early secondary necrosis is performed. In this case, the scrap tissue from the end of the stump is not cut off. After the toilet of the neurovascular bundle on the lateral and medial surface of the end face of the stump, decompressive fasciotomy or, if indicated, myofasciotomy is performed. The wound is loosely swabbed with napkins soaked in water-soluble ointment. Impose the posterior plaster cast with fixation of the adjacent joint. On the contralateral limb and other parts of the body, the existing wounds are subjected to the usual primary surgical treatment, dressings with water-soluble ointments are applied, and Kramer splint, plaster bandage or external fixation are immobilized. In the period of toxemia and in the infectious-toxic period of MVT, intensive general and local pathogenetic therapy is continued taking into account the features of all links in the pathogenesis of MVT, including its neurodystrophic component. On dressings, necrectomies are performed daily, if necessary, repeated surgical treatment of wounds is carried out with intraosseous perfusion of the affected tissues, including the stump. In this case, the scrap tissue from the end of the stump does not cut off as well as during the initial surgical treatment of the wound. Prior to the recovery period of traumatic disease, multilayer hydrophilic-hydrophobic dressings with a multicomponent medicinal composition are applied to the wounds, which simultaneously have a pronounced dehydration, necrolytic, antibacterial and trophic effect (proteolytic enzymes dissolved in a 30% aqueous solution of urea, water-soluble ointments based on polyethylene glycol) . With the aim of early full plastic closure of the wound defect of the other limb at the beginning of the recovery period, the scrap tissue of the butt end of the stump is transformed into a non-free autograft (cutaneous, cutaneous-subcutaneous, cutaneous-subcutaneous-fascial, cutaneous-muscular, muscle, bone, soft-bone, according to indications) on two feeding legs. Depending on the nature and size of the defect tissue of the contralateral limb at the end of the stump, a corresponding flap is cut from scrap tissues on the feeding leg with the proximal direction of its base relative to the axis of the limb. After surgical debridement of the wound on the surface of the wound defect of the contralateral limb, the free end of the flap cut out at the end of the stump of the other limb is sutured, which simultaneously prevents retraction of the flap. Both limbs are fixed to each other with a plaster cast or an external fixation apparatus, while simultaneously performing bone fracture osteosynthesis. Continue general and local treatment. After 3.5-4.5 weeks, reumputation of the stump at an adequate level of the damaged donor limb segment is carried out in one step, plastic surgery of the wound defect of the recipient limb is supplied to the blood supply already through the tissues of the recipient limb with a salvage autograft trained for ischemia. In the postoperative period, general and local treatment is continued according to the usual method until wounds are healed and bone fragments are consolidated. When using this method, wounds usually heal by first intention at the usual time. One of the main advantages of the proposed method of treatment in comparison with the known technical solutions is that the scrap material of the stump, converted into a blood supply autograft, is trained for deep hypoxia due to pathomorphological changes in the tissues of the stump as a result of MVT. This is evidenced by the fact that in the transplanted graft despite its bending, even at an acute angle, macro- and microcirculatory disorders are not observed (see Fig. 2a and 26).

 Clinical example. Affected A., ist. Bol-ni 745. As a result of an explosion on an anti-personnel mine, on 01/07/1997 he received a contact mine-explosive wound (MVR). Two hours after the injury, he was delivered to the stage of qualified surgical care with a diagnosis of severe combined contact ICBM with detachment of the right lower limb at the ankle joint level, with fragmentation of soft tissues of the anterior inner surface of the left ankle joint and left foot with exposure of the tarsal bones, an open comminuted fracture of the heel bone and talus of the left foot, fragmentation wound of the perineum with a defect in the tissues of the external genital organs, traumatic shock of the III degree, contusion. In the reactive-toxic period of the ICBM, 3 hours after the injury, in parallel with anti-shock measures, primary surgical treatment of wounds of the lower extremities and perineum with suturing of the urethral wound on the drainage tube was performed. Primary classical amputation of the right lower limb has not been performed. Primary necrotic tissues were excised with truncation of the right lower leg at the level of the margin of the separation zone, crushing and uncooling of tissues with the zone of tissue contusion of the saved part of the damaged segment, and decompressive myofasciotomy was performed on the medial and lateral side of the butt stump.

 Intensive general and local treatment was carried out in the period of toxemia and at the beginning of the infectious-toxic period of MVR. After relative stabilization of the general condition, the victim was evacuated to the stage of specialized surgical treatment.

 Clinical and radiological diagnosis at admission - infectious-toxic period of contact MVR: sluggish wound of the amputation stump of the right lower leg at the border of the middle and distal sections of the diaphyseal segment; soft tissue defect of the anteroposterior surface of the left ankle joint and the medial edge of the left foot with exposure of the bones of the tarsus and purulent arthritis of the scaphoid-navicular joint; open fracture of the calcaneus and posterior process of the talus of the left foot; sluggish wound with a defect in the tissues of the scrotum and the anterior surface of the external opening of the urethra. General condition - moderate, due to intoxication syndrome. The skin is pale, tongue with a whitish-gray coating, a slight increase in peripheral lymph nodes. Blood pressure 110 and 70 mm Hg, pulse 100-105 beats per 1 minute, satisfactory filling and tension. From the internal organs pathology is not detected. In laboratory analyzes, moderate anemia, increased ESR, a tendency to hypercoagulation were noted.

 Prior to the recovery period, general pathogenetic therapy was performed. In the local treatment, repeated surgical treatment of wounds, daily necrectomy of tissues with leaving scrap tissue at the end of the stump of the right lower leg were performed. Multilayer hydrophilic-hydrophobic dressings with a multicomponent drug composition, which simultaneously have a pronounced dehydration, necrolytic, antibacterial and trophic effect (proteolytic enzymes dissolved in a 30% aqueous solution of urea, water-soluble ointments based on polyethylene glycol) and naphthalne, were applied to the wounds.

 The recovery period of the MVR began 5 weeks after the injury. The wounds were cleansed of purulent-necrotic tissue and covered with granulation tissue, intoxication syndrome was stopped. In the area of the wound defect of the left ankle joint and the inner edge of the left foot, there is a fistula with purulent discharge due to osteoarthritis of the scaphoid-navicular joint (see Fig. 1). On the right lower leg, reamputation is shown at the level of its middle third, and on the left lower limb, repeated surgical treatment of wounds with sanitation of the purulent-necrotic focus and plastic surgery of the cutaneous-subcutaneous-fascial wound defect is shown. The lack of tissue resources does not allow plastic grafting from the surrounding tissue wound defect. The transplantation of free split skin grafts or free skin grafts to the entire thickness is not shown because of the possibility of their melting due to poor blood supply and suppurative process in the receiving bed. In addition, a wound defect in the ankle and foot is subject to significant mechanical stress, and therefore in the period of consequences after 4-6 months there is a need for reconstructive surgery. Free transplantation of flaps with the application of a microvascular anastomosis requires microsurgical technique, there is a risk of transplant necrosis due to impaired hemodynamics in the victim in the early period of the ICBM. The implementation of plastic grafts on the feeding leg of tissues close to the wound is not possible due to insufficient tissue resources due to the large size of the wound defect. The traditional direct transplantation of the flap on the feeding leg or plastic by the filatov stem is also not shown, because the victim in the recovery period of ICBM of the extremities with combined damage to the perineal region cannot be in a forced position for a long time, there is a risk of necrosis of the flap at one of the stages of surgery. In connection with the foregoing, it was decided to convert the scrap tissues (trained for ischemia as a result of MVT) of the butt stump of the right lower leg into a non-free autograft on two feeding legs by cutting and sewing its free end to the wound surface of the contralateral limb, then after 3.5-4.5 weeks in one step, perform re-amputation of the right lower leg and plastic surgery of the wound defect of the left lower limb with a blood-supplied scrap flap.

 Operation 02/13/1997 (37 days after the injury): repeated surgical treatment of wounds, transformation of a scrap skin-subcutaneous-fascial flap of the butt stump of the right lower leg stump into an autograft on two feeding legs; transosseous extra focal osteosynthesis of bone fractures and fixation of limbs between themselves by external fixation apparatus.

 During the audit of the wound of the left ankle joint and the left foot, it was noted that under purulent granulations in the middle of the wound there is a purulent fistula that communicates with the ram-navicular joint. Around the fistula, the bones of the tarsus are bare, covered with purulent granulations. Surgical sanitation of a purulent-necrotic focus was performed with the removal of non-viable tissues, washing of the wound surface with antiseptic solutions, hemostasis.

 From scrap tissues formed after the alleged reamputation of the vicious stump of the right lower leg, a skin-subcutaneous-fascial autograft is formed on two feeding legs by cutting it and suturing it to the wound defect of the left lower limb. In a functionally advantageous position, the lower limbs are fixed between themselves by the apparatus of G.A. Ilizarov (see Fig. 2a and 2b). Hydrophilic-hydrophobic dressings are applied to wound surfaces.

 In the postoperative period, general strengthening and general treatment were performed. Due to the fact that the dermal-subcutaneous-fascial graft from scrap tissues from the time of the mine-blast injury to the recovery period of the MVR was trained for ischemia, there were no signs of microcirculation disturbance and other complications. The perineal wounds healed by secondary intention.

 The final stage of surgical treatment is surgery on March 11, 1997 (27 days after the previous operation): re-amputation of the stump of the right lower leg of the middle part of the diaphyseal segment, plastic surgery of the wound defect of the left ankle joint and left foot using a depleted blood supply to the skin-subcutaneous-fascial autograft, and remounting of the device G.A. Ilizarova on the left leg and foot.

 An extra focal fixation apparatus was removed from the stump of the right lower leg and the cutaneous-subcutaneous-fascial transplant was sharply separated, which, for 4 weeks, had grafted with the other feeding leg to the wound defect of the left lower limb. Repeated surgical treatment and plastic surgery of the wound defect of the left ankle joint and left foot area using scrap stump tissues, turned 4 weeks ago into a blood-supply autograft that was sewn along the edges of the wound with atraumatic vertical sutures. Remounting the apparatus of G.A. Ilizarov with fixation of the talar scaphoid articulation of the left foot. Re-amputation and the formation of a full-fledged functionally beneficial stump of the right lower leg at the level of the middle section of the diaphyseal segment were performed in one step.

 In the postoperative period, general strengthening and symptomatic therapy were performed. Antibiotics are not applied. Locally used hydrophilic-hydrophobic dressings. The course of the wound process is smooth. Purulent necrotic, circulatory and any other complications were not noted. Wound healing by primary intention (see Fig. 3). The stump of the right lower leg was prosthetized 85 days after receiving the contact MVR, and the extrafocal fixation device was removed after 3 months due to the consolidation of fragments of the foot bones. 10 days from the moment of injury. Moves freely without a cane, shoes in the area of the skin-subcutaneous-fascial transplant on the left foot do not bother. Discharged on 04/21/1997. Long-term result after 4 years. There was no relapse of suppurative process, stump disease, graft ulceration, and any other complications. Walking without a cane no complaints. Employed.

 Thus, in a mine-blast wound with separation and crushing, severe fractures and extensive defects of limb tissues, combined damage to other areas of the body, the proposed method, in contrast to known solutions, prohibits purulent-necrotic and other complications and consequences in the recovery period, reduces the periods traumatic disease (excludes the period of consequences), avoids amputation of the contralateral limb, fully restore its lost anatomical structures beyond otky period of time, without resorting to expensive microsurgical technique or multistage prolonged surgery stem Filatov. The method is valuable not only for military medical institutions, but also for civilians, because At present, civilians also suffer from explosive injuries (especially during terrorist acts, catastrophes, etc.), in which a separation of a limb segment and extensive destruction and tissue defect of adjacent areas of the body are noted. The consequences of mine-explosive wounds of limbs, especially contact ones, require long-term treatment with repeated hospitalizations. The proposed method prevents these consequences in a short time, the time of complete surgical rehabilitation of such a heavy contingent of patients is only 2-3 months. Unlike well-known methods, the method allows you to turn the scrap material (from any tissue) of the re-amputated limb into a blood-supply autograft, trained for ischemia, to eliminate in one step the extensive defects of the tissue complex of the contralateral limb that cannot be eliminated by local plastic without additional trauma and causing a donor wound and tissue defect in healthy areas of the body.

Claims (1)

 A method for the treatment of mine-explosive wounds of limbs with separation and crushing of one, bone fracture and tissue defect of the other, including stage-wise surgical interventions on pathological foci, characterized in that the operative interventions are carried out in the reactive-toxic, toxemic and infectious-toxic periods, while preserving the scrap tissue the end face of the stump of a torn or crushed limb segment and turning them in the recovery period into a non-free autograft on two feeding legs by cutting I am at the end of the stump of a scrappy flap and suturing its free end to the surface of the wound defect of the contralateral limb, and after 3.5-4.5 weeks one-stage re-amputation of one and plastic of the wound defect of the other limb is performed by a vascularized and autologous graft trained to ischemia.

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