RU2307604C2 - Device for distraction dermatoplastics - Google Patents

Abstract

FIELD: traumatic surgery; orthopedics; reconstructive surgery.

SUBSTANCE: device for distraction dermatoplastics is made for mounting onto external frame of Ilizarov's apparatus. It has nuts, bolts, plates, threaded rods for putting ends of wound closer to each other, needles with hook-shaped fragments and needles for under-skin pass. Needles with hook-shaped fragments are mounted for putting them at both sides of wound behind needles for under-skin pass and for dosed closing by meet thrust of needles for under-skin pass.

EFFECT: improved efficiency; better results of treatment of patients with defects of skin.

4 cl, 1 ex, 4 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics and reconstructive surgery.

Skin plastic surgery can significantly reduce the healing time of wounds, avoid the formation of gross scars with the provision of anatomical, functional and cosmetic rehabilitation of patients. The definition of indications for a particular type of skin grafting is dictated by specific conditions: the area, configuration and depth of the skin defect, infection or suppuration of the wound, the phase of the wound process, the elasticity of the skin surrounding the wound, proximity of important anatomical structures, etc. The optimal type of skin grafting is which in the simplest way ensures complete closure of the wound (N.N. Blokhin, 1955; V.S. Antipenko, 1962, 1975; M.I. Kostyuchenok, 1981; M.Iselin, 1962; H. Cosse, 1964; MLLewin, 1969; Ch. Radovas, 1976 et al.).

One of the main advantages of free skin grafting with a full-layer or split skin graft is the possibility of simultaneous closure of large enough skin defects. However, this type of dermatoplasty is unacceptable in conditions of infection due to rejection or melting of the skin flap in a purulent wound. Non-free plastic is preferable due to the optimal biological conditions of healing: adequate vascularization of the flap with the greatest correspondence to its recipient area. With all its advantages, this type of plastic is not free from disadvantages, which include the possibility of replacing only relatively small skin defects, the need to mobilize the edges of the wound and perform additional skin incisions near the wound.

As a prototype, we chose a device that was first proposed by Charles Newman (1957) and described by Yu. R. Skvortsov. (2005), which is a hypodermic implantable silicone can. Gradually inflating the can with air or pumping saline into it creates a supply of skin, from which then the flap that is needed for dermatoplasty is cut out. This device is widely used in reconstructive and plastic surgery. However, due to trophic disorders at the site of implantation, the use of the can is often accompanied by suppuration and exposure of it from under soft tissues. In addition, it is associated with the need to cut out complex curly flaps, which means that it is inevitably accompanied by scarring.

The purpose of the invention is to increase efficiency and improve outcomes of treatment of patients with skin defects in the Ilizarov apparatus. The goal is realized by the use of a device (Fig. 1, a), which allows metered to replace skin defects with an area exceeding the capabilities of their simultaneous elimination without the use of free grafts. The device consists of fragments of knitting needles and parts of a standard 1 set of Ilizarov apparatus (Fig. 1, b). It includes fragments of Kirschner spokes 1, 2, 3, nuts 4, bolts 5, threaded rods 6 and plates 7. Dimensions, quantity and configuration of component parts of the device, three versions of which (a, b, c) are shown above and from the side in the figures 2 and 3, vary depending on the length of the wound and the area of the skin defect. So, the hook-shaped fragments of the spokes can be either single 2 or double 3 (Fig. 1, b). The use of double fragments of knitting needles can reduce their required number from three (Fig. 2 and 3, a, b) to two (Fig. 2 and 3, c) pairs. The length of the hook-like fragments also depends on the width of the wound, usually ranging from 4 to 10 cm.

When choosing the length of the threaded rods of the device, it should be assumed that the total length of both peripheral parts of each of the rods (i.e., those segments of the threaded rods that are peripheral to the nuts installed on them) must exceed the width of the wound minus the length of the initial moderate intraoperative contraction of the edges wounds. Therefore, in order to rationally use the length of the threaded rods, it is desirable to bring together the attachment points of the pair of hook-shaped fragments of the spokes to 1.5-2.0 cm (figure 2, c). The distraction device is assembled to the outer frame of the Ilizarov apparatus using either brackets, or plates and bolts with nuts, using any free opening of the plate or the end of the threaded rod of the device.

The device is used as follows (figa, b, c). Along both edges of the wound, departing from them by 0.7-1.5 cm, a pair of Kirschner spokes are carried out on which the skin is strung along the entire length of the wound so that their subcutaneous part is located along the entire length of the wound. Schematically, the application of the device is shown above and in cross section in figure 3 (a, b, c). The overcutting protruding excess knitting needles of more than 1.5-2.5 cm are biting (Fig. 3, a), and then the hook-like curved fragments of the knitting needles of the device on both sides of the wound are wound for a pair of hypodermic needles. By oncoming thrust, the latter draw together, which reduces the area of the wound (Fig. 3, b). In this case, the length, shape (single or double) and the number (from one pair or more) of hook-shaped fragments of spokes are determined by the area and shape of the skin defect. The loops of the hook-shaped fragments of the spokes are thrown onto the threaded rods or bolts of the device and fixed in moderate tension with nuts. The diameter of these loops (7-8 mm) was chosen with the expectation of slightly exceeding the diameter of the threaded rods (6 mm), but be smaller than the nuts fixing them, the smallest diameter of which is 9 mm. After a day or two, the initial tension of the skin around the wound weakens: firstly, due to its elastic properties, and, secondly, due to the action of the Ilizarov law, according to which tensile stress stimulates the regeneration and growth of dosed stretched tissue structures (in particular skin) . Therefore, every day or two with dosed distraction of the hook-shaped fragments of the spokes, the initial moderate tension of the skin is resumed with a gradual decrease in the area of the wound. The angle between the loop and the length of the hooked fragment of the needle varies between 30 and 50 degrees and is determined, firstly, by the area of the skin defect, and secondly, by the nature and phase of the wound process. So, on the one hand, the larger the skin defect, the sharper this angle should be, because the opposite draft of the edges of the wound in this case is most aimed at reducing the area of the wound. On the other hand, if the rehabilitation of the wound surface is not completed, then for better aeration and drainage, the wound should be left open. Therefore, the distraction of its edges must be performed not only in the opposite direction, but also upward relative to the bottom of the wound, which, without closing the wound, creates a reserve of skin. In the future, as the infection is stopped, the angle of traction should be reduced, giving it a more opposite direction, and the wound should be closed (Fig. 3, c) both with the created reserve of the skin and with the ongoing distraction. 2-3 days after the complete elimination of the skin defect, the device is dismantled, a pair of Kirschner spokes inserted subcutaneously is removed, and the edges of the wound are mutually adapted with secondary skin sutures applied to them.

As an example of the application of the proposed device, the following observation.

Patient K., 32 years old, was admitted to the Republican Orthopedic and Traumatology Center (RTC) with a transfer from the Khasavyurt Central City Hospital on 05/20/03 with a diagnosis of Gunshot comminuted fracture of both bones of the upper third of the right lower leg with displacement of fragments, damage to the peroneal nerve and soft tissue defect.

From the anamnesis: May 12, 2003 received a through gunshot wound to the right lower leg from automatic weapons. In the traumatology department of the Central City Hospital, PHO of the wound was performed, anti-gangrenous serum was introduced, and skeletal traction over the calcaneus was applied. The last day was replaced by the Ilizarov apparatus of a lightweight design of two rings. Despite adequate PCP, flow drainage of the wound with antiseptic solutions and antibiotic therapy, the wound of the lower leg was suppurative, and the skin defect due to marginal necrosis increased. On examination, a purulent wound was measured, measuring 8.0 by 6.5 cm, with necrotic plaque and atrophic pale easily vulnerable granulations. The bottom of the wound was the distal end of the proximal bone fragment of the tibia, exposed for 3.5 to 2.0 cm.

On May 22, 2003, an operation was performed at the ROTC: reconfiguration of the Ilizarov apparatus with two repair knitting needles with a thrust pad and installation of a device for distraction skin plastics, consisting of fragments of knitting needles and parts of a standard set of Ilizarov apparatus. The device included two 8 cm Kirschner needle fragments drawn along the edges of the wound, two 110 mm threaded rods, two 82 mm plates, nuts and four hook-shaped knitting needles. The length of the latter was determined by the width of the wound and amounted to about 4 cm. The choice of the length of the threaded rods was determined by the fact that the total length of both peripheral parts of each of them (more peripheral than the hook-shaped fragments of the spokes fixed with nuts) should exceed the width of the wound, i.e. 6.5 cm. The device was used as follows. Along both edges of the wound, 1.0 cm departing from them, a pair of Kirchner knitting needles were drawn on which the skin was strung throughout the wound so that their subcutaneous part was located along the entire length of the wound. Then, hooked curved fragments of the device spokes on both sides of the wound were brought in for a pair of hypodermic spokes and the opposite thrust brought them closer by 1.0-1.5 cm, thereby reducing the area of the wound. The loop of each of the four hook-shaped fragments of the spokes was thrown onto the threaded rods of the device and fixed with nuts. This device was installed to the outer frame of the Ilizarov apparatus (to its lower parafracture ring) with a bracket and nuts. The angle between the loop and the length of the hooked fragment of the knitting needle was about 45 degrees. Thus, distraction of the edges of the wound was performed not only in the opposite direction, but also upward relative to the bottom of the wound, creating a reserve of skin, but at the same time not preventing the outflow of wound discharge until the completion of the rehabilitation phase. With antibiotic therapy and daily dressings with a solution of dioxidine and proteolytic enzymes, rehabilitation and elimination of wound skin defects were completed synchronously in two weeks. The device was dismantled on 10.06.03 g, and secondary sutures were removed on the wound, removed a week later, when the wound had completely healed. The Ilizarov apparatus was removed after 7 months with complete consolidation of the fracture of the leg bones. Subsequently, the patient was treated in the neurosurgical department, where the surgery was performed to restore the peroneal nerve, the violation of the conductivity of which was partially stopped.

Therefore, the advantages of the device are the following:

1) The ability to eliminate skin defects with dimensions that exceed the likelihood of simultaneous closure of the wound without excessive tension of the skin surrounding the wound and the need for additional incisions;

2) No need to mobilize the edges of the wound, reducing their vascularization due to a violation of communication with the underlying tissues;

3) No need to cut out curly skin flaps that increase the requirements for the accuracy of their correspondence to the area and shape of the skin defect and are inevitably accompanied by postoperative scars;

4) The optimal use of the Ilizarov effect: stimulation of the regeneration and growth of tissue structures (in particular the skin) by tensile stress;

5) The possibility of application on infected and purulent wounds until the completion of their rehabilitation and outside the phase of regeneration of the wound process. This allows you to simultaneously increase the skin supply in conjunction with wound sanitation, which significantly (on average, doubles) reduces the time of treatment of patients.

6) Prevention of skin eruption when tightening the edges of the wound due to the dosage of tension, the optimal area of contact with the pair of fragments of needles drawn along the edges of the wound and, accordingly, the smallest load per unit area of the skin, as well as the absence of the need to use suture material until the completion of the rehabilitation phase and elimination of the defect wounds;

7) Simplicity, efficiency and the absence of the need to search for parts for manufacture, since the Ilizarov apparatus kit is a necessary accessory of the trauma and orthopedic departments of medical institutions not only in Russia but also abroad.

Thus, a device for distraction dermatoplasty can improve the effectiveness of the treatment of patients with skin defects in the Ilizarov apparatus.

Claims (4)

1. Device for distraction dermatoplasty containing nuts, bolts, plates and threaded rods for rapprochement of the edges of the wound, characterized in that it is made for installation on the external frame of the Ilizarov apparatus and additionally contains knitting needles with hook-like fragments and knitting needles for subcutaneous conduction, and knitting needles with hook-shaped fragments were installed with the possibility of wounding on both sides of the wound behind the needles for hypodermic conduction and with the possibility of metered approach of the spokes for subcutaneous conduction with oncoming thrust. 2. The device according to claim 1, characterized in that it consists of parts of a standard set of Ilizarov apparatus. 3. The device according to claim 1, characterized in that the hook-shaped fragments of the spokes are made double. 4. The device according to claim 1, characterized in that the spokes for subcutaneous conduction are made in the form of Kirchner spokes.

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