RU2264181C2 - Method for compensating defect of limb's nerve trunk - Google Patents

Abstract

FIELD: medicine, traumatology, neurosurgery.

SUBSTANCE: one should shorten a limb due to osteotomy followed by nerve suturing and gradual dosed distraction of limb's segment tissues with the help of compression-distraction apparatus till restoring desired osseous length and compensating the defect of nerve trunk. Moreover, during preparing nerve's ends for suturing it is necessary to perform circular coagulation incisions of epineurium along the line of which one should cross the bundles of nerve fibers. Then comes transneural suture, moreover, inter-bundle provisional suture should be tightened to achieve the contact of the edges of nerve fibers bundles and the onset of capillary liquid layer between them. Definitive sutures should be applied on retraction of plasmatic clot between connected ends of the nerve. Distraction should be started since the 8^th - 10^th d after suturing at the tempo of 0.75-1.0 mm daily, and after lengthening limb's segment for the value of nerve's elasticity value it is necessary to decrease daily tempo of distraction by 25-30%. The innovation provides decreased number of postoperational complications achieved due to developed suture of nerve and mode for its lengthening.

EFFECT: higher efficiency of compensation.

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Description

The invention relates to medicine and can be used in traumatology and neurosurgery in the treatment of anatomical breaks of nerve trunks, combined with bone fractures or pseudoarthrosis.

A known method of compensating for defects of nerve trunks of an extremity [1], including shortening a limb by osteotomy of the bone and performing neurography. However, the method does not provide for the subsequent restoration of the initial segment length, which reduces the functional result of the treatment.

A known method of compensating for defects of nerve trunks of an extremity [2], which involves shortening a limb by osteotomy, performing neurography and subsequent dosed distraction of a segment of a limb to restore the required bone length and compensate for a defect in the nerve trunk. However, when implementing this method, tissue distraction begins no earlier than 20-25 days after the connection of the ends of the nerve, which requires 4-6 days before the indicated period of repeated violation of the integrity of the bone. This makes the method traumatic, associated with the development of postoperative complications and requiring long periods of medical rehabilitation of patients.

The objective of the invention is to develop a method of compensating for a defect in a nerve trunk of a limb, which provides a reduction in morbidity and treatment time, improving conditions for the regeneration of a nerve trunk and bone.

This problem is solved in that in a method including shortening a limb by osteotomy, a nerve suture and gradual dosed distraction of tissues of a limb segment using a compression-distraction apparatus to restore the required bone length and compensate for a nerve trunk defect, circular coagulation is performed when preparing nerve ends for a suture an epineuric incision; when stitching, the inter-bundle provisional suture is tightened to the contact of the ends of the bundles of nerve fibers and the appearance of a capillary layer of fluid between them and, definitive sutures are applied after retraction of a plasma clot between the connected ends of the nerve, and distraction begins from 8-10 days after the suture and until the limb segment is lengthened by the value of the reserve of elasticity of the nerve, perform it at a rate of 0.75-1.0 mm per day , and then reduce the latter by 25-30%.

The invention is illustrated by a detailed description and an example of practical use.

After anesthesia and treatment of the surgical field with known techniques, osteosynthesis of the affected limb is performed with fixation, depending on the clinical situation, of one or two adjacent segments by compression-distraction apparatus. Carry out an audit of the zone of the damaged nerve trunk and, if indicated, perform neurography. With an anatomical break of the nerve no more than 1.5-2.0 cm, its proximal and distal segments are mobilized. After that, at the level of the supposed "refreshing" sections of both ends of the nerve, circular coagulation sections of the external epineuria are performed with an ultrasonic microsurgical scalpel, which serves as a preventive measure to prevent bleeding from the ends of the nerve, reduces trauma, and reduces the number and duration of surgical procedures. Bundles of nerve fibers are crossed along the lines of these sections with a sharp blade or serrated microscissors, and then, through the outer and inner epineuria of the nerve ends, the transneural provisional suture is made with the thread 7 / 0-8 / 0 on the atraumatic needle and pulling it together, bring the ends together as close as possible nerve, making sure that the ligature does not cut through. Based on the magnitude of the remaining diastasis, a resection of the corresponding portion of the bone is performed, the remaining bone fragments are brought together and fixed in the position of tight contact. Following this, using optical magnification by tightening the transneural suture, the ends of the nerve are finally brought together until the ends of the bundles of nerve fibers come into contact and a capillary layer of fluid appears between them, which ensures their plasma “gluing”. When the latter is achieved, that in conditions of good hemostasis and plasma clot retraction (the number of platelets in 1 ml of peripheral blood is not less than 170 thousand, the number of red blood cells is not more than 4.9 million, fibrinogen is not more than 270) occurs in 10-40 seconds, on the nerve impose epiperineural and epineural definitive sutures. The operation is completed by suturing the wound, performing control x-ray, stabilization of the apparatus and the application of aseptic dressings.

In the postoperative period, starting from 8-10 days, with the help of a device with a traditional average rate of 0.75-1.0 mm per day, dosed distraction of the tissues of the affected segment, including the stitched area of the damaged nerve, is performed. After lengthening the limb segment by the value of the reserve of elasticity of the nerve, which is usually observed after 14-20 days of distraction, the daily rate is reduced by 25-30% (to 0.5-0.75 mm) and is further maintained at this level until complete recovery limb lengths. The duration of the subsequent fixation period is determined by the time of consolidation of the endosteal regenerate and the formation of a continuous cortical plate.

The practical use of the method is illustrated in the following experimental observation.

Example 1

Dog with a thigh length of 13 cm; pseudoarthrosis in the middle third of the diaphysis of the femur was resected - limb shortening was 2.5 cm. Osteosynthesis was performed in a spoke-rod apparatus. Using a coagulation incision of the epineuria, a 2.5 cm long section of the sciatic nerve was resected. Diastasis between the ends of the nerve was 4 cm. After the bone fragments came closer together, a transneural provisional suture was made with 7/0 thread in the spoke-rod apparatus. The nerve stumps are brought together, the ends of the bundles of nerve fibers are brought into contact. Their distinct plasma bonding was noted. After that, definitive epiperineural sutures were made with 8/0 thread.

The distraction of fragments of the femur began on the 9th day after the operation at a rate of 0.75 mm per day, after 2 weeks of distraction, the daily rate was reduced to 0.5 mm. 70 days after surgery, limb shortening is eliminated. The device is removed after 4.5 months of fixation.

An EMG study 2.5 months after the operation showed: in the calf and anterior tibial muscles, a denervation background, low-amplitude M-responses. 5 months after surgery, there is no denervation background, M-responses are about 7 mV. This allows us to conclude that there is an active process of reinnervation and the absence of arrest of axonal growth at the level of anastomosis.

The developed technique was applied in 7 animals. In all cases, reliable electrophysiological and morphological signs of an active reinnervation process were obtained while reducing the morbidity and general treatment time.

Sources of information

1. Filippova R.P. Features of nerve regeneration, depending on the degree of tension after the suture. - S.36-40.

2. A.S. USSR No. 1082408, publ. 03/30/84. Bull. No. 12.

Claims (1)

A method of compensating for a defect in a nerve trunk of a limb, including shortening a limb by osteotomy, a nerve suture and gradual dosed distraction of tissues of a limb segment using a compression-distraction apparatus to restore the required bone length and compensate for a nerve trunk defect, characterized in that when preparing the nerve ends for a suture, circular coagulation sections of the epineuria, along the lines of these sections intersect the bundles of nerve fibers, then perform a transneural suture, while the provisional suture is tightened to the contact of the ends of the bundles of nerve fibers and the appearance of a capillary layer of fluid between them, definitive sutures are applied after retraction of the plasma clot between the connected ends of the nerve; distraction begins from 8-10 days after the suture at a rate of 0.75-1.0 mm per day, and after lengthening the limb segment by the value of the reserve of elasticity of the nerve, the daily rate of distraction is reduced by 25-30%.