RU2212850C2 - Method for vascularized autonervous plasty in defect of radial nerve - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: the present innovation deals with vascularized autonervous plasty in defect of radial nerve at brachial level. Transplant of radial nerve's surface branch is taken up together with that of lateral cutaneous nerve of antebrachium, upon radial nutritive vessels. One should substitute defect of radial nerve with two parallel vascularized transplants. The present innovation enables to substitute about two thirds of radial nerve's section area, improve functional results in patients with extensive defects of radial nerve. EFFECT: higher efficiency of operation. 1 ex

Description

 The invention relates to medicine, namely to neurosurgery, reconstructive surgery, and specifically relates to the replacement of defects of peripheral nerve trunks.

 There is a method of replacing defects of peripheral nerves using free (non-vascularized) autologous plastic [1], in which grafts of skin nerves (usually gastrocnemius) are sutured into the defect of the damaged nerve trunk with perineural sutures. The disadvantages of this method are the danger of developing necrosis of nerve grafts before their adequate blood supply is restored due to the newly formed vessels, and the presence of two suture lines makes it difficult for the regenerating axons to grow into the distal segment of the nerve. In addition, some patients for a long time experience discomfort in the area of innervation of the donor nerve.

 The closest in technical solution to the proposed one is the method adopted for the prototype, which consists in replacing the defect of the radial nerve on the shoulder with transplantation or transposition of its surface branch in the composition of the radial flap of the forearm on the radiation supply vessels [2]. However, in the presence of a nerve defect of more than 10 cm, this method allows you to get only one blood supply transplant, which significantly reduces the chances of getting a beneficial reinnervation of the muscles of the extensor group of the forearm, since it is possible to replace no more than 1/3 of the cross section of the radial nerve.

 The essence of the invention lies in the combination of essential features sufficient to achieve the desired technical result, namely, improving functional results in patients with extensive defects of the radial nerve on the shoulder. This essence consists in the fact that a graft of the lateral cutaneous nerve of the forearm is taken and transplanted into the defect area with one transplant of the surface branch of the radial nerve on the radial supply vessels.

 Replacing the defect of the radial nerve on the shoulder with two parallel-stitched vascularized grafts allows replacing about 2/3 of the cross-sectional area of the radial nerve.

 The method is as follows.

 The proximal and distal fragments of the damaged radial nerve are isolated, and the diastasis between them is measured. In the case of a defect of more than 10 cm, a radiation flap is isolated on the radiation supply vessels from the forearm, which, in addition to the superficial branch of the radial nerve, includes the lateral cutaneous nerve of the forearm. After isolation of the flap, hemostasis is performed and the viability of the flap on the non-intersected vascular pedicle is assessed. After making sure that the flap has good blood supply, it is transplanted into the upper third of the shoulder. With a defect in the radial nerve in the middle or lower third of the shoulder, transposition of the flap is possible. When a radiation flap is transplanted, it is included in the bloodstream, superimposing microvascular anastomoses between the radiation vessels (an artery and two veins) and the brachial artery and commitinous veins. In this case, the blood supply to the lateral cutaneous nerve of the forearm, which passes through the radial flap in transit, is automatically restored with the resumption of blood flow in the flap itself. After the restoration of blood supply, autologous plastic surgery of the radial nerve defect is performed with two vascularized grafts (the superficial branch of the radial nerve and the lateral cutaneous nerve of the forearm) strictly in accordance with the schemes of intra-stem topography. A skin defect in the donor area is closed using autodermoplasty.

 Clinical example.

 Patient Gev, born in 1974, medical history 1121, was admitted to the Microsurgery Department of the NTCT “WTO” on March 31, 1999 with a diagnosis of fused fracture of the left humerus, traumatic damage to the posterior muscle group of the left shoulder 8 months ago, damage to the radial nerve in the middle third of the left shoulder, neuropathy of the ulnar nerve, cutaneous deformity of the posterior surface of the shoulder.

 04/06/99 an operation was performed: excision of scars of the posterior surface of the left shoulder, autotransplantation of a radial flap from the right forearm (including the brachioradialis muscle, superficial branch of the radial nerve, lateral cutaneous nerve of the forearm) in the position of the middle and upper third of the left shoulder, vascularized autologous radial nerve plastic, ulnar neurolysis.

Under general anesthesia, scars of the posterior shoulder surface were excised. During the audit, a defect of the radial nerve on the shoulder 13 cm long, an extensive defect of the triceps, was revealed. The ulnar nerve is located in the scar tissue along the entire length of the shoulder. After hydrotreating with a 0.25% solution of novocaine, the ulnar nerve was neurolyzed. A free graft of a radial flap was taken from the right forearm from separate access with the inclusion of the brachioradial muscle, the superficial branch of the radial nerve and the lateral cutaneous nerve of the forearm 14 cm long, a skin area of 30 cm ² . This flap was taken on a vascular pedicle consisting of a radial artery with a diameter of 2 mm, two veins with a diameter of 0.8 and 0.6 mm. The transplant was transferred to the left shoulder, microvascular anastomoses of its vessels with brachial artery and end-to-side vein were produced. When starting blood flow, patency of the anastomoses is determined. Vascularized autologous plastic surgery of the radial nerve by the proposed method made it possible to obtain two blood-supplied nerve grafts with a length of 14 cm, replacing about 60% of the cross-sectional area of the radial nerve. It was also possible to replace the defect of the triceps muscle of the shoulder, included in the flap of the brachioradialis muscle, and to produce skin plasty of the area of the defect of the soft tissues of the shoulder due to the skin area of the radial flap.

 In the postoperative period, the patient received diadynamic currents, magnetotherapy, acupuncture, massage, manual therapy, muscle electrical stimulation, vitamins, proserin, trental, reopoliglyukin, antibiotics. Surgical wounds healed by first intention, the sutures were removed after 2 weeks. The transplanted radiation graft fully survived; there were no complications.

Control examination 1.5 years after surgery showed the restoration of active extension of the left hand in the wrist joint in a volume of 90 ^o .

Sources of information
I. Millesi N., Meissl G., Berger A. The interfascicular nerve grafting of the median and ulnar nerves. J. Bon and Joint Surg., 1972, v. 54-a, 4, p. 727-750.

 2. Belousov A.E., Tkachenko S.S. Microsurgery in traumatology. L .: Medicine, 1988, p. 60-63.

Claims (1)

 A method of vascularized autologous plastic surgery of a radial nerve defect at the shoulder level, comprising transplanting a graft of the superficial radial nerve branch on the radial supply vessels, characterized in that a transplant of the lateral cutaneous nerve of the forearm is taken in one block with a graft of the superficial radial nerve branch on the same vessels, and the defect is replaced two parallel stitched vascularized grafts.