RU2224478C1 - Method for conducting plasty of postresectional defect in tibial proximal department with fibular autotransplant upon area of nourishing tissues - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: in children at detecting malignant tumors in tibial proximal department, during one stage after resection of tumor-affected tibial proximal department and removing it out of a knee joint, one should form a bed in articular femoral surface according to the shape of fibular caput, the bottom of which is represented by spongy substance. Canal of tibial distal stump should be broadened up to fibular diameter, fibula should be crossed perpendicularly against its axis in distal department with the help of special saw at maximum distance against fibular caput, the latter should be than removed out of tibiofibular articulation to liberate it against cartilage, then the bone should be mobilized and together with area of nourishing tissues it should be replaced into position of resected tibial proximal department with tumor by placing the caput of fibular transplant into the bed in articular femoral surface by, thus, developing ankylosis in knee joint, distal end of fibular transplant should be deepened for 2- 3 cm into a canal in tibial stump, then Ilizarov's apparatus should be used by applying per two pairs of Kirschner's needles in mutually perpendicular planes through distal femoral department and tibial stump and one pair of needles of 1.5 mm diameter through middle third of the transplant, then one should suture postoperative wound by layers by leaving helpful polyvinylchloride drainage that enables to keep the limb with its capacity for support. EFFECT: higher efficiency of plasty. 1 dwg, 3 ex

Description

 The invention relates to medicine and can be used as an organ-preserving technique for malignant tumors of the proximal tibia.

 Currently, high survival rates have been achieved for malignant bone tumors in children. This allowed introducing into the practice of oncology organ-preserving surgeries for malignant bone tumors in children, which led to a significant improvement in the quality of life of these patients (V. Fernandez-Trigo, P.Kh. Shugabaker. Sarcomas of bones and soft tissues in children. In Sat: P .Kh. Shugabaker, MM Malauer, Surgery of sarcomas of soft tissues and bones. - M: Medicine, 1996. - S. 432, 433).

 In orthopedics and traumatology, the Ghana-Codiwill-Huntington operation is known. During the Gan-Codilleville-Huntington operation, the knee joint does not close, the operation is performed in 2 stages, only the diaphysis of the tibia moves, the graft is not deepened into the tibial canal, the sawdust of the articulated bones is oblique, the size of the resected fragment of the tibia is not more than half the diaphysis , immobilization is carried out using a plaster cast (I. A. Movshovich. Operational orthopedics. - M: Medicine, 1994. - S. 316, 317).

 This operation cannot be used for malignant tumors of the tibia, since it does not take into account the requirements of ablasty and does not provide the necessary fixation of the graft, that is, it does not comply with the principle of the adequacy of surgical intervention (N. E. Makhson, AN Makhson. Adequate surgery for tumors shoulder and pelvic girdles. - M: RPO "Gella-print", 1998. - S. 15).

 The aim of the invention is the preservation of the limbs in patients with malignant tumors of the proximal metadiaphysis of the tibia, subject to the rules of ablastic and achieving maximum functional effect.

 This is achieved by the fact that in children with the detection of malignant tumors of the proximal tibia, at one stage after resection of the proximal tibia affected by the tumor and its isolation from the knee joint, a bed is formed in the joint surface of the femur in the shape of the head of the fibula, the bottom of which is cancellous bone, the channel of the distal stump of the tibia is expanded to the diameter of the fibula, the fibula is crossed perpendicular to its axis in the distal m section with a Jigley saw, as far as possible from the head of the fibula, isolate the head of the fibula from the tibial joint and release it from the cartilage, then mobilize the bone and, together with an array of nourishing tissues, move it to the position of the resected proximal tibia, placing the head of the fibula transplant in the articular surface of the femur and thereby create ankylosis in the knee joint, the distal end of the fibula transplant is buried 2-3 cm into the canal in the culture e of the tibia, then the Ilizarov apparatus is superimposed, passing two pairs of Kirschner spokes in the mutually perpendicular planes through the distal femur and through the stump of the tibia and one pair of spokes 1.5 mm in diameter through the middle third of the graft, and the postoperative wound is sutured in layers, leaving safety polyvinyl chloride drainage (see drawing).

 The method is illustrated in the following clinical examples of its implementation.

 Example 1

 Patient A., 11 years old. Clinical diagnosis: osteogenic sarcoma of the proximal right tibia. He entered the oncology department of the Russian Children's Clinical Hospital in May 1994. A radiography and magnetic resonance imaging were diagnosed with a tumor originating from the proximal metadiaphysis of the right tibia, the length of the bone lesion from the articular surface of the tibia was 13 cm.

 After conducting 4 courses of effective chemotherapy in September 1994, the patient underwent plastic surgery of the post-resection defect of the proximal tibia with a fibular autograft on an array of nourishing tissues. A skin incision was made around the knee joint along the anterior surface of the lower leg; the tibia with a tumor was layered in layers. Based on x-ray data, the length of the bone resection was determined, which amounted to 23 cm from the plane of the knee joint (lesion length 13 cm + 10 cm). At the chosen level of intersection, the tibia was freed from the soft tissues along the entire circumference, the periosteum was separated and the bone was crossed with a Jigley saw. The proximal tibia epiphysis was separated from the tibia head. Then, the proximal tibia was finally isolated from the surrounding healthy tissues while maintaining the neurovascular bundle of the lower leg closely adjacent to the posterior surface of the tibia. A cavity of the knee joint was opened, intraarticular ligaments were crossed. The resected tibia site was removed. Then, a fibula transplant was isolated together with its head, with the exception of trauma to the fibula that throws through the last and a fracture of the neck of the fibula. The level of intersection of the fibula in its distal section was determined. The bone was crossed at a maximum distance from the head up to the area above the ankle joint, which amounted to 24 cm. The fibula was mobilized and moved to the position of the resected area of the tibia. On the articular surface of the femur in the shape of the head of the fibula, a bed was formed, the bottom of which was the spongy substance of the bone. The head of the fibula was freed from cartilage and placed in a bed in the articular surface of the femur with a 2 cm deepening. The distal end of the graft was 2 cm deepened into the tibial stump canal. The intraoperative shortening of the limb was 1 cm. The periosteum of the graft and stump of the tibia were sewn with catgut. Then the Ilizarov apparatus was overlaid. Two pairs of Kirchner spokes were drawn through the distal epiphysis of the femur and through the stump of the tibia. A pair of 1.5 mm diameter spokes was inserted through the middle third of the graft. Each pair of spokes was fixed by the rings of the Ilizarov apparatus. The rings of the Ilizarov apparatus were connected by threaded rods. The wound was sutured in layers, leaving a polyvinyl chloride safety drainage. In conclusion, the final correction of the axis of the limb was performed using the rods of the Ilizarov apparatus. To prevent equino-varus deformation of the foot, the latter was fixed to the lower rings of the Ilizarov apparatus with a supporting bandage.

 A full physiological load on the operated limb was carried out 3 weeks after the operation with additional support on 2 crutches. Radiological bone marrow formation at the junction of the graft with the tibia stump was noted after 3 months. after surgery, and at the junction of the graft with the femur - after 3.5 months. after operation. After 9 months. after the operation, the Ilizarov apparatus was removed, immobilization in a circular plaster cast was continued. 11 months later after the operation, the child independently moved in support of one crutch. After 14 months after surgery - relying on a cane. After 21 months. after the operation, the immobilization is continued in the external fixation device of the "orthosis" type, the child moves without additional support.

 In the postoperative period, 2 courses of chemotherapy were carried out and in December 1994 the child was withdrawn from special treatment. As of June 2002, there was no evidence of local recurrence and metastases. Moves independently with full load on the operated limb without additional support using orthopedic shoes. The limb is shortened to 4 cm. Socially adapted, good quality of life.

 Thus, the use of ablasty for a tumor of the proximal tibia in this patient's method of plastic surgery of a post-resection defect of the proximal tibia with an autograft of the tibia with an array of nourishing tissues made it possible to carry out radical organ-preserving surgery in compliance with the principles, to ensure rapid motor rehabilitation, to carry out social adaptation and achieve high quality of life.

 Example 2

 Patient R., 14 years old. Clinical diagnosis: malignant fibrous histiocytoma of the proximal left tibia. She entered the oncology department of the Russian Children's Clinical Hospital in September 1996. A tumor originating from the proximal metadiaphysis of the left tibia was diagnosed with X-ray and magnetic resonance imaging, the lesion length was 18 cm from the plane of the knee joint.

 In October 1996 - January 1997 4 courses of effective chemotherapy were performed. In January 1997, an operation was performed according to the method described above. The size of the resected fragment of the left tibia with the tumor was 26 cm. The length of the fibula transplant was 25 cm. The intraoperative limb shortening was 5 cm.

 For 7 days. after the operation, distraction by the Ilizarov apparatus began at the site of the deepening of the distal end of the fibula transplant into the canal of the tibia stump. Fifteen daily distraction sessions were performed at a rate of 1 mm / day. After the end of distraction, the shortening of the limb was 3.5 cm.

 A full physiological load on the operated limb was carried out 4 weeks after surgery with additional support on 2 crutches. Radiological bone marrow formation at the junction of the graft with the tibia stump was noted after 3.5 months. after surgery, and at the junction of the graft with the femur - after 4 months. after operation. After 13 months. after the operation, the Ilizarov apparatus was removed, immobilization in a circular plaster cast was continued. After 13.5 months. after the operation, the child independently moved in support of one crutch. After 17 months. after surgery - relying on a cane. After 19 months. after the operation, the immobilization is continued in the external fixation device of the "orthosis" type, the child moves without additional support.

 In the postoperative period, 2 courses of chemotherapy were carried out and in March 1997 the child was withdrawn from special treatment. As of June 2002, there was no evidence of local recurrence and metastases. Moves independently with full load on the operated limb without additional support using orthopedic shoes. The limb is shortened to 5 cm. Socially adapted, good quality of life.

 Thus, the use of a proximal right tibia tumor in this patient for plastic surgery of the post-resection defect of the proximal tibia defect with an autograft of the tibia with an array of nourishing tissues made it possible to carry out a radical organ-preserving operation in compliance with the principles of ablasty, and made it possible to eliminate intraoperative shortening of the limb using distraction Ilizarova allowed for rapid motor rehabilitation, about ensured social adaptation and high quality of life.

 Example 3

 Patient Sh., 12 years old. Clinical diagnosis: Ewing's sarcoma of the proximal right tibia. He entered the oncology department of the Russian Children's Clinical Hospital in July 1998. A tumor originating from the proximal metadiaphysis of the right tibia was diagnosed with X-ray and magnetic resonance imaging. The length of the lesion from the plane of the knee joint was 14 cm.

 After conducting 12 courses of effective chemotherapy in July 1998 - June 1999 and in April 1999 radiation therapy for the tumor area, in July 1999 an operation was performed according to the method described above. The length of the resection of the right tibia was 24 cm. Intraoperative shortening was not noted.

 A full physiological load on the operated limb was carried out 3 weeks after surgery with an additional time of 2 crutches. Radiological bone marrow formation at the junction of the graft with the tibia stump was noted after 2.5 months. after surgery, and at the junction of the graft with the femur - after 3 months. after operation. After 8 months. after the operation, the Ilizarov apparatus was removed, immobilization in a circular plaster cast was continued. After 10 months after the operation, the child independently moved with the support of one crutch. After 12 months after surgery - relying on a cane. After 17 months. after the operation, the immobilization is continued in the external fixation device of the "orthosis" type, the child moves without additional support.

 In the postoperative period, 2 courses of chemotherapy were carried out and in August 1999 the child was withdrawn from special treatment. In June 2000, after 11 months. after surgery, during x-ray of the operated limb, a false joint was diagnosed at the junction of the femur with the graft. In July 2000, a pseudoarticular joint was resected, an Ilizarov apparatus was placed, and the last compression of the transplant to the femur was performed. The consolidation of the graft and femur was achieved after 4 months. After 6 months after application, the Ilizarov apparatus was removed. Immobilization of the limb for 5 months. continued in a circular plaster cast, then immobilization in an external fixation device of the "orthosis" type was used.

 As of June 2002, there was no evidence of local recurrence and metastases. Moves independently with full load on the operated limb without additional support using orthopedic shoes. The limb is shortened to 1 cm. Socially adapted, quality of life is good.

 Thus, the use of a proximal right tibia tumor in this patient for plasty of a post-resection defect of the proximal tibia defect with an autograft of the tibia with an array of nourishing tissues made it possible to carry out a radical organ-preserving operation in compliance with the principles of ablasty, to ensure rapid motor rehabilitation, while diagnosing a false joint, it ensured the possibilities of its treatment, which allowed for social adaptation and to achieve high th quality of life.

 In 1993-2002 In the oncology department of the Russian Children's Clinical Hospital, surgery for plastic surgery of the post-resection defect of the proximal tibia defect with a fibular autograft with an array of nourishing tissues was performed in 23 patients aged 4-15 years (17 patients with osteogenic sarcoma, 1 patient with malignant fibrous histiocytoma and 5 patients with Ewing sarcoma) . All patients in a period of 2-4 months. X-ray formation of bone corns was recorded at the junction of the graft with the femur and the stump of the tibia. Full integration of the transplant with the maternal bones was achieved after 11-14 months. (Wednesday = 12.3 months). In the period of 2-2.5 g (median = 2.1 g) after surgery, an increase in the diameter of the fibula transplant was achieved to 2/3 of the diameter of the resected fragment of the tibia at this level. Within 6–13 months (median = 8.3 months) after the operation, the Ilizarov apparatus was removed for 6–8 months. (medium = 7.2 months), the immobilization continued in a circular plaster cast, then an orthosis-type external fixation apparatus was used to immobilize the operated limb. Refusal of additional support when walking occurred in the period of 12-18 months. (wednesday = 13.6 months) after surgery. False joints in the area of the connection of the proximal graft with the femur were noted in 3 (13%) patients in the period of 7-24 months. after operation. This complication was cured in all patients by means of resection of the pseudoarthrosis and compression by the Ilizarov apparatus. Postoperative local tumor relapses were noted in 2 (8.7%) patients. As of June 2002, 17 patients were observed (mean follow-up was 4.5 years). The shortening of the operated limb is 1-5 cm (medium = 3.4 cm). All patients carry a full load on the operated limb and move without additional support using orthopedic shoes.

 Despite the apparent simplicity, the claimed method of plastic surgery of a post-resection defect in the proximal tibia with a fibular autograft on an array of nourishing tissues is not obvious to specialists working in this field.

 In the practice of orthopedics and traumatology for defects of the tibia diaphysis, the Gan-Codiwill-Huntington operation is traditionally used. As our practice has shown, this operation is not applicable for malignant bone tumors in children, because it does not meet the principles of ablasticity, that is, it does not provide for the removal of a fragment of the tibia with a tumor and the isolation of the proximal articular end of the tibia from the knee joint.

 In addition, as it turned out, the use of the Gan-Codiwill-Huntington operation in 2 stages lengthens the time of inpatient treatment, requires additional surgical intervention, slows down motor rehabilitation and worsens the quality of life of patients.

 Also, as our practice has shown, the fixation of the graft to the articular surface of the femur and the tibial stump after removing a fragment of the tibia with a tumor using screws or wire is not feasible, and the immobilization of the operated limb in a circular plaster cast does not ensure the stability of the graft and the conditions for its consolidation with a femur and a stump of the tibia, which leads to the formation of false joints, requires repeated operations and reduces the quality of life ny patients.

 Thus, for each specialist working in the field of pediatric oncology, it becomes obvious that the method of plastic surgery of the post-resection defect of the proximal tibia with a tibia autograft on an array of nourishing tissues allows us to adhere to the principles of ablastic surgery when removing a tumor of the proximal tibia, to ensure effective immobilization of the operated limb, reduce the duration of treatment and reduce the number of operations, and also provides the fastest motor re habilitation and improves the quality of life of patients.

 The invention was developed due to lengthy research in the process of scientific and practical activity. As practice has shown, the invention has been very effective in organ-preserving surgical treatment of malignant tumors of the proximal tibia in children.

 The proposed method for plastic surgery of a post-resection defect of the proximal tibia with a fibula autograft on an array of nourishing tissues allows to expand indications for organ-preserving surgical treatment in children due to patients with tumors of the proximal tibia, to avoid postoperative relapse of the tumor, reduce the duration of treatment and avoid the second stage of the operation, reduce the number of postoperative complications and provide rapid motor rehabilitation on the background of high quality of life for patients.

 Currently, the method of plastic surgery of a post-resection defect of the proximal tibia with a tibia autograft on an array of feeding tissues is the method of choice in the treatment of malignant tumors of the proximal tibia in children.

 The method of plastic surgery of a post-resection defect of the proximal tibia with a fibula autograft on an array of nourishing tissues does not require any additional tools and equipment and can be reproduced directly according to the present description.

Claims (1)

Method for plastic surgery of a post-resection defect of the proximal tibia with a fibular autograft on an array of feeding tissues, characterized in that in children with detection of malignant tumors of the proximal tibia in one step after resection of the proximal tibia affected by the tumor and its isolation from the knee joint in the joint the femur in the shape of the head of the fibula form a bed, the bottom of which is the spongy substance of the bone, the distal stump of the tibia is expanded to the diameter of the fibula, the fibula is perpendicular to its axis in the distal section with a Dzhigli saw to the maximum extent from the head of the fibula, the head of the fibula is separated from the tibia and freed from the cartilage, then mobilized feeding tissues are moved to the position of the resected proximal tibia with the tumor, placing the head of the fibula transplant in the bed in the joint thigh surface of the femur, thereby creating ankylosis in the knee joint, the distal end of the fibula transplant is buried 2-3 cm into the canal in the tibial stump, then the Ilizarov apparatus is placed, passing two pairs of Kirchner spokes through mutually perpendicular planes through the distal section the femur and through the stump of the tibia and one pair of spokes with a diameter of 1.5 mm through the middle third of the graft and sutured in a layer-wise postoperative wound with the provision of safety PVC drainage.