RU2215480C2 - Method for prolonged distraction local autoplasty of wound cutaneous defects - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: one should apply two Kirschner's needles to string the skin of both wound edges onto them so that the ratio of sub- and supracutaneous sections of needles to be equal. Distraction is carried out till complete removal of defect due to multi-stage tension of both ends of ligament applied under supracutaneously protruded sections of needles. EFFECT: higher efficiency and shortened duration of therapy. 4 dwg, 1 ex

Description

 The invention relates to medicine, namely to surgery, i.e. to methods for replacing wound skin defects.

 The value of dermatoplasty is undeniably large and is due to the possibility of closing wounds with a beneficial effect on their healing. Skin plastic surgery can significantly reduce the time of wound regeneration, reduce the severity or completely avoid the formation of a rough scar with the provision of functional and cosmetic rehabilitation of patients. The determination of indications for a particular type of skin grafting is dictated by specific conditions: the area, configuration and depth of the wound defect, the presence of contamination, infection or suppuration of the wound, the phase of the wound process, the elasticity of the skin surrounding the wound, the proximity of important anatomical structures, etc. When choosing indications for surgery from the whole variety of types of skin grafting, the most optimal is the one that in the shortest possible time will give the most complete closure of the wound (NN Blokhin, 1955; G.A. Danielyan, 1957; V.S. Antipenko , 1962, 1975; V.G. Weinstein, 1969; M.V. Gromov, 1975; M.I. Kostyuchenok, 1981; M. lselin, 1962; H. Cosse, 1964; ML Lewin, 1969; Ch. Radovas, 1976 and others).

 Free skin grafting with a full-layer or split flap is of great importance in plastic surgery, and its main advantage is simultaneous closed rather large skin defects.

 However, this type of skin grafting is unpromising for infected and purulent wounds due to the likelihood of rejection or fusion of the flap. Non-free skin grafting is preferable to free plastic due to more optimal biological healing conditions (adequate vascularization of the flap, more complete correspondence to its recipient area, etc.). However, it also has significant disadvantages, which include the possibility of replacing only relatively small skin defects, the need to mobilize the edges of the wound and perform additional incisions. Sh. Radovas (1976) proposed a very promising and effective method for the gradual compensation of a skin defect by creating its reserve by implantation and inflating with a physiological saline solution of a sclycone balloon, and from the created skin reserve to cut out the flap necessary for plastic surgery. This method has found wide application, in particular in the plastic replacement of skin defects of the scalp, but it is not without drawbacks: frequent exposure of soft silicone canisters and frequent trophic disorders at the site of implantation, as well as the need for subsequent complex calculations to cut out the curly flaps.

 As one of the analogues, the method of skin plasty with local tissues described by Z.F. Nelsina (1980). It captivates with its simplicity and reduces to the simultaneous closure of a wound defect by mobilizing the edges of the skin around the defect, and if this is not enough, to additional cuts and movement of the skin from neighboring areas: counter triangular flaps according to Limberg (1929, 1935), rotational method of skin grafting and etc. The method of skin grafting is carried out as follows. After the PHO of the wound, its edges are mobilized, as well as laxative cuts, which make it possible to close the defect, and for the greater mobilization of the skin, the latter is often separated from the fascia. Often you have to make several weakening cuts.

 The disadvantages of the above method are the following: the ability to close only small skin defects; the compulsion to mobilize the edges of the wound and one or more debilitating incisions, which, along with cosmetic perversity, leads to trophic tissue disorders, delaying healing time and the development of gross scars in the future. In addition, in the presence of a purulent process, plastic tissue is deposited by local tissues until the wound is completely healed from necrotic tissues, purulent discharge and relief of local inflammation.

 As the closest analogue or prototype, we present a method of distraction local autoplasty of wound skin defects using intradermal fixatives (RU 2143227 C1, 12/27/1999).

 The purpose of the invention is to improve the effectiveness and outcome of the treatment of skin defects, as well as reduce its duration.

 The goal is realized by the fact that, without waiting for the complete suppression of the purulent process in the wound (if there is one), the wound edges are framed by two Kirschner spokes and the lace is “laced” in permissible tension, after which the wound is further tightened by the same way down until it is completely closed.

 The technical implementation of the invention is as follows. Under local anesthesia along both edges of the wound, 0.7-1.5 cm departing from them, a pair of Kirchner spokes is carried out so that they pass under and under the skin, i.e. so that the skin along the edges of the wound was fractionally strung on them (Fig. 1). In this case, the ratio of the length of the subcutaneous and cutaneous segments of the spokes is essential. So, if most of the spokes are immersed under the skin, then the load per unit length of the edges of the wound during their subsequent retraction is distributed more evenly. However, with this ratio, the likelihood of trophic disorders of the edges of the wound due to pressure on their vessels increases. Therefore, with good blood supply and a small thickness and density of the skin, it is advisable to adhere to a ratio of 1: 1. Then the ends of the needles bite and bend, and under the protruding segments of both knitting needles, any monofilament thread (preferably dacron or thin fishing line) is carried out, spreading from one side to the other and vice versa, i.e. produced "lacing" of the wound (figure 2). By pulling at both ends of the thread, the Kirschner spokes are brought together and the edges of the wound are pulled together with a decrease in the area of the wound defect. In order to avoid trophic disorders and teething on the knitting needles, this tension should not be excessive. The ends of the thread are connected together by a pharmacist unit. After some time, the skin tension weakens due to its elastic properties, as well as the action of the Ilizarov effect (regeneration and increase in tissue volume by tensile stress). Therefore, every 2-3 days produce “lacing” of the wound with the resumption of tension (figure 3). Thus, the extensional closure of the skin defect is made until the wound edges are in full contact. When the latter is reached, without relaxing the thread tension, secondary sutures are applied to the wound (Fig. 4), and the “lining” is carried out gradually as the wound heals and the scar is strengthened.

The advantages of the proposed method of skin plastics are the following:
1) the ability to eliminate large enough skin defects without the need for additional incisions and free transplants;
2) the absence of the need to mobilize the edges of the wound, in which their vascularization decreases due to a violation of communication with the underlying tissues, as well as cutting out complex curly flaps to close the defect;
3) the possibility of use on infected and purulent wounds, without waiting for the relief of inflammation and the completion of the rehabilitation phase of the wound process.

 As an example of the application of the proposed method of dermatoplasty, the following observation.

 Patient X. 39 years old was admitted to the Republican Orthopedic and Traumatology Center (RTC) on March 15, 1999 with a diagnosis of a gunshot through bullet wound of the upper third of the right thigh with comminuted fracture of the femur and a defect in the skin of the posterior surface of the damaged segment.

 From the anamnesis: I received a gunshot wound on March 13, 1999 at the place of residence (Dakhadaevsky district), where first aid was provided to the Central Clinical Hospital, skeletal traction was applied for the tibial tuberosity, gunshot wounds were left behind with tubular drainage, and from where, at the insistence of relatives, they were transported to the RTC .

 At admission to the RTC, skeletal traction and flow drainage with antiseptic solutions are established. On March 18, 1999, tubular drainage was removed and under local infiltration anesthesia along the wound edges along the posterior outer surface of the upper third of the thigh (the size of the wound is 5.5 by 6.0 cm), a pair of Kirschner spokes was inserted subcutaneously and subcutaneously. In this case, the ratio of the sub- and cutaneous segments of the spokes was equal. The ends of the needles are bitten and bent, and under the cutaneous segments of the needles the ends of a sterile thin fishing line are drawn. The wound is “laced” and moderately healed with a decrease in the defect by half (3.0 by 6.0 cm). Disorders of vascularization of the edges of the wound were not observed. Secondary sutures were placed on the wound of the anterior-internal surface (inlet of the through wound) under local anesthesia. Aseptic dressings were applied to both wounds. Then, every 3 days during the dressings, "lacing" of the posterior wound was carried out until the skin defect was completely closed. 03/26/99 under local anesthesia secondary sutures were applied to the wound. The wound healed without complications, and a complete “lining” with the removal of both Kirschner spokes was performed on 02.04.99. Skeletal traction was removed on 05/12/99 in the presence of an adequate "primary coverage" of the fracture zone of bone marrow of good density, and the patient was discharged for outpatient treatment in a coxite plaster cast. In place of the healed gunshot wounds, there is a thin and undesired scar with the underlying tissues. The result of the treatment is regarded as good.

 Thus, the proposed method of prolonged distraction local autoplasty of wound skin defects is effective, simple and economical, which allows us to rely on the fact that it will replenish the arsenal of treatments for this pathology.

Claims (1)

 A method of prolonged distraction local autoplasty of wound skin defects, including carrying out two Kirschner spokes, reducing the area of wound defects until they are completely eliminated, characterized in that the skin of both wound edges is strung onto Kirschner spokes so that the ratio of subcutaneous and cutaneous spokes is equal, and distraction is carried out by multi-stage tension of both ends of the thread, held under the protruding cutaneous segments of the spokes.

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