RU2266069C2 - Method for brachial reconstruction in children at traumatic aftereffects - Google Patents

Abstract

FIELD: medicine, orthopedics, traumatology.

SUBSTANCE: cicatricial tissues should be dissected along the whole brachial circumference. On dissecting vascular pedicle one should transfer isolated tissue complex into recipient area, fragment of scapular lateral edge should be introduced and fixed in brachial defect. Then one should apply anastomosis between transplant's vein and accompanying vein, brachial and thoracodorsal arteries that restores medullary canal in area of osseous defect.

EFFECT: higher efficiency of brachial reconstruction.

4 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to orthopedics and traumatology.

A known method of eliminating an extensive bone defect of the shoulder with the consequences of trauma, consisting in the transposition of the lateral edge of the scapula to the position of the diaphysis of the bone. In this case, a bone autograft from the scapula is transferred, which is transferred to the defect of the humerus in a non-free version, in which the vascular bundle does not cut off from the donor region (A.E. Belousov. Plastic, reconstructive and aesthetic surgery. - St. Petersburg. "Hippocrates". - 1998).

The disadvantages of this method are the reduced mobility of the autograft of the lateral edge of the scapula due to the insufficient length of the vascular pedicle, as well as the inability to use it with an extensive defect in soft tissues and bone of the shoulder.

The objective of the invention is to increase the effectiveness of treatment by increasing the mobility of the autograft by cutting off the vascular pedicle and creating vascular anastomoses in the desired region of the shoulder.

The therapeutic effect of the task is achieved by the fact that in the method of reconstruction of the shoulder in children with the consequences of trauma, which consists in excising coarse scar tissue, releasing free fragments of the humerus and moving to the recipient shoulder region an autograft containing a bone component and a complex of tissues based on the latissimus dorsi muscle on vascular pedicle. It is proposed to use the lateral edge of the scapula as a bone component of the autograft, to cut off the vascular pedicle and to freely move them to the recipient region of the shoulder.

Figure 1 presents the preoperative diagram of the patient’s shoulder and the X-ray diagram of the humerus D., 7 years old, with a diagnosis of post-traumatic defect of the humerus, soft tissue defect of the right elbow joint, compression-ischemic neuralgia of the radial and ulnar nerves with a complete violation of the conduction of the radial nerve, Pos.1 - soft tissue defect; Pos.2 - bone defect of the humerus.

Figure 2 - diagram of the shoulder and the diagram of the x-ray of the humerus during reconstructive surgery of the patient D., item 1 - soft tissue defect of the shoulder; pos.2 - bone defect of the humerus; pos.3 - an autograft based on the latissimus dorsi and blood supply to the lateral edge of the scapula (pos.4) on a common vascular pedicle. An autograft is presented in expanded form before moving and after transposition into the recipient region of the shoulder.

The method of reconstruction of the shoulder after injury is as follows.

Rough scar tissue is dissipated around the entire circumference of the lower third of the shoulder (Fig. 3, Item 1). On the inner surface in the middle third of the shoulder, the brachial artery with a commit vein is distinguished. The proximal and distal fragments of the humerus are exposed, between which the size of the bone defect is determined (Fig. 3, 2). An autograft is formed on the surface of the chest in the projection of the posterior axillary line, containing the lateral edge of the scapula (Fig. 3, Pos. 4) and a soft tissue complex based on the latissimus dorsi (Fig. 3, Pos. 3) on a common vascular pedicle, sizes and the shape corresponding to a wound defect on the shoulder. After cutting off the vascular pedicle, the isolated tissue complex is transferred to the recipient region. In this case, a fragment of the lateral edge of the scapula (Fig. 3, Pos. 4) is inserted into the defect of the humerus and is fixed by the axial spoke. The vascular pedicle of the autograft is anastomosed with the committing vein and brachial artery, respectively. After removing the clips from the vessels, blood flow in the graft is monitored. The surgical wound is sutured in layers. An aseptic dressing is applied to the operating area. Immobilization is carried out by a gypsum tire to the upper limb according to G.I. Turner.

Execution example

Patient D., 7 years old, with a diagnosis of post-traumatic defect of the humerus, soft tissue defect of the right elbow joint, compression-ischemic neuralgia of the radial and ulnar nerves with a complete violation of the conductivity of the radial nerve. The patient’s shoulder has coarse deforming scars (Fig. 3, pos. 1) in the lower third of the entire circumference of the segment, leading to neuralgia of the radial and ulnar nerves. Pathological mobility in the lower third of the shoulder and limitation of the function of the forearm and hand are noted. X-ray examination reveals a defect of the humerus in the lower third with a length of about 8 cm (Fig.3, pos.2), osteoporosis of the remaining bone fragments.

The child underwent the following surgery.

Scar tissue was excised around the entire circumference of the lower third of the right shoulder (Fig. 3, Item 1). The proximal and distal fragments of the humerus are exposed. On the inner surface in the middle third of the shoulder, the brachial artery with committing veins is distinguished. Diastasis between fragments of the humerus was 8 cm (Fig. 3, 2). On the right side of the chest in the projection of the posterior axillary line, a flap is selected based on the latissimus dorsi (Fig. 3, 3), the size and shape of which corresponds to a circular wound defect on the shoulder. The neurovascular bundle was isolated, the branches feeding the lateral edge of the scapula were preserved, after which a fragment of the lateral edge of the scapula 8 cm long (Fig. 3, pos. 4) was taken as part of a flap based on the latissimus dorsi. After cutting off the vessels, the flap was transferred to the recipient area. A fragment of the lateral edge of the scapula is embedded in the defect of the humerus and fixed longitudinally by a spoke (Fig. 3, item 4). The end-to-end anastomoses are placed between the graft vein and the committal vein, brachial artery and thoracic artery. After removing the clips from the vessels, steady blood flow in the graft was gradually obtained. The graft (figure 3, position 3) is fixed by sutures in the recipient area. An aseptic dressing is applied to the surgical suture. Immobilization of the upper shoulder girdle with a plaster tire according to G.I. Turner.

Thirty days after surgery, an X-ray control is performed, according to the results of which the spokes are removed. The plaster cast is removed after another week. A course of rehabilitation treatment. Figure 4 presents the remote functional and cosmetic result of the same patient D., 7 years old. In Fig. 4, pos. 3 - an implanted graft based on the latissimus dorsi, moved to the shoulder defect of patient D., 7 years old. In figure 4, item 4 is the lateral edge of the scapula in the graft during plastic surgery of the bone defect of the humerus. Figure 4, item 5 shows the long-term functional result of patient D.

The positive effect of the invention is to improve the functional and cosmetic condition of the upper limb, as well as to shorten the treatment time.

Claims (1)

A method of shoulder reconstruction in children with trauma, including excision of scar tissue, release of fragments of the humerus, displacement of a formed autograft into the bone defect containing the lateral edge of the scapula and a complex of tissues based on the latissimus dorsi and common vascular pedicle, characterized in that the scar tissue is excised over the entire circumference of the shoulder, after cutting off the vascular pedicle, the selected tissue complex is transferred to the recipient region, while a fragment of the lateral edge of the scapula is inserted and siruyut a humerus defect, impose vein anastomoses between the graft and komitantnoy vein, brachial and thoracodorsal artery.

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