RU2318461C1 - Method for surgical correction of complicated combined defects of bone and soft tissues of shin - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics.

SUBSTANCE: it is necessary to form a thoracodorsal transplant upon nourishing thoracodorsal artery at including an osseous costal fragment into its composition. Then one should transfer the obtained transplant into area of shin's defect, osteotomize proximal and/or distal tibial fragments, apply a costal fragment at length being sufficient for overlapping the area of tibial defect and that of osteotomy of the fragments onto osseous tibial fragments by forming the support for the transplant located above the defect area. One should suture the wound layer-by-layer. After wound healing one should start distraction with the help of compression-distraction apparatus till complete substitution of tibial defect. The innovation enables to decrease the risk of the development of coarse cicatrices, decrease the risk of traction lesion of transplant's soft tissue part.

EFFECT: higher efficiency of correction.

20 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used mainly in the treatment of gunshot defects of soft tissues and lower leg bones, after mine-explosive, bullet and fragmentation wounds.

Replacing extensive defects of the tibia is one of the most difficult and urgent problems in traumatology and orthopedics, which occupy one of the first places among other segments, ranging in frequency from 10.3% to 32.9%, and is characterized by the severity of pathological changes leading to persistent disability (S.F. Vasiliev, E.V. Nor, V.P. Kosenko. Analysis of temporary disability and disability due to injuries in traffic accidents. Medical and labor examination and 1 rehabilitation of disabled people. Kiev: Health. 1983 , Issue 15, pp. 45-48. Blinov BV Reconstruction of the proximal femur with a graft on a muscle leg during destructive dislocation of the hip. Orthopedics, traumatology. 1974, No. 4, pp. 72-73. Wave A.A., Kalashnikov VV, Statsenko OA Modern technologies in traumatology and orthopedics: Abstracts of the scientific-practical conference. M., 1999, pp. 61-62. Makushin VD, Kuftyrev LM Therapeutic and rehabilitation advantages of the Ilizarov method for pseudarthrosis and hip defects. Transosseous compression and distraction osteosynthesis in orthopedics and traumatology. Thematic collection of scientific papers. Mound. 1980, Issue 6, pp. 12-18. Novachenko N.P. The formation of bone regenerate to replace the proximal end of the thigh, destroyed by gunshot damage. Orthopedics, traumatology. 1955, No. 5, pp. 15-21. Khodosevich N.I., Popova L.A. The formation and development of transosseous osteosynthesis in the USSR. Experimental-theoretical and clinical aspects of the transosseous osteosynthesis method developed at KNIIEKOT. Abstracts of reports of the All-Union Symposium with the participation of foreign experts (Kurgan, September 20-22, 1983). Mound. 1983, p. 229-231. Chaklin V.D. Pseudoarthrosis and bone defects. Orthopedics, traumatology. 1973. N 3, p. 1-9. Shumada I.V., Rybachuk O.I. VIII International Symposium "Pseudoarthrosis and their treatment." Lucerne (Switzerland), January 1978. Orthopedics, traumatology. 1979. N1, pp. 74-76).

Various types of bone grafting, used alone or in combination with metal osteosynthesis in the replacement of tibial defects, do not always provide adequate medical and social-labor rehabilitation, while unsatisfactory treatment outcomes range from 13.4% to 50% (Gudushauri O.N. compression osteosynthesis in case of non-consolidated fractures and false joints. M., 1965. - 27 pp. Abstract of the dissertation of a doctor of medical sciences Zatsepin ST, Makhson NE, Burdygin VN Endoprosthetics in patients with pathologically and processes of the proximal end of the femur. Orthopedics, traumatology. 1978, No. 6, pp. 14-20. Imamaliev AS, Dadashev XD Resection of the tumor of the proximal femur with preservation of the head alloplasty. Orthopedics, traumatology. 1985, No. 2, p. 51-52. Kulish NI Reconstructive surgery of the hip joint. Orthopedics, traumatology. 1982, No. 8, p. 23-28).

The difficulty in ensuring a sufficiently effective rehabilitation of patients with leg defects is associated with the presence of a complex of concomitant anatomical and functional limb disorders in the form of circulatory failure, soft tissue scars, persistent joint contractures, deformations and anatomical shortening of the bone segment formed after injuries, diseases, and previous surgical interventions. In addition, with severe degenerative changes in soft tissues, a free bone graft transplant is contraindicated without preliminary excision of scars fused to the bone and skin grafting (Mikhelman M.D. Experience in surgical treatment of false joints of long tubular bones. Proceedings of the XVIII Scientific Conference of the Institute of Orthopedics and Traumatology named after Prof. M.I. Sitenko, Kharkov. 1962, pp. 105-109).

With the introduction into clinical practice of new original developments by G.A. Ilizarov using his apparatus, orthopedics and traumatology received a fundamentally new direction in reconstructive surgery of the consequences of injuries of long tubular bones (Ilizarov G.A. Some theoretical and clinical aspects of transosseous osteosynthesis from the perspective of open of general biological patterns Experimental-theoretical and clinical aspects of transosseous osteosynthesis developed at KNIIEKOT. International Conference, Kurgan, 1986, pp. 7-12, Ilizarov GA, Iryanov Yu.M., Petrovskaya NV Ultrastructural features of osteogenesis in the distraction diastasis of elongated bone Experimental-theoretical and clinical aspects of transosseous osteosynthesis being developed at KNIIEKOT: Abstracts of reports of an international conference, Kurgan, 1986, pp. 24–25. Ilizarov GA Possibilities of treating false joints and defects of long tubular bones by our method. V All-Union Congress of Orthopedic Traumatologists (Odessa, September 22-24, 1988). Abstracts of reports. M., 1988. Part II. p. 28-30. Kuzmenko V.V., Ushakova O.A. Treatment of improperly healed fractures and false joints of the femur. Orthopedics, traumatology. 1973, No. 2, p. 46-51. Mironov S.P., Oganesyan O.V., Zilov V.G. Bulletin of Traumatology. Orthopedics. 2002, No. 2, pp. 14-18. Oganesyan O.V. Basics of external transosseous fixation. M., 2004). However, with the combination of a bone defect and soft tissue, the problem of replacing such a complex multicomponent defect has not been resolved, which determines the relevance and significance of this proposal.

A known method of replacing a defect of the tibia with a bone graft with preliminary distraction and subsequent compression, in accordance with which a longitudinal osteotomy of the fibula is performed within the defect and the graft is transferred into the defect with thickening of the fibula with dosed traction (SU 596227, 1978).

There is also known a method of replacing a defect of the tibia by moving and connecting the upper end of the tibia with the tibia, in which, when lowering the fibula, it is simultaneously deployed to normal correction with subsequent correction in width to the end contact of its head with the end of the proximal fragment of the tibia and then compress and fixation of bones to fusion (SU 1042741, 1983).

The closest analogue to the present invention is a method for the treatment of chronic post-traumatic osteomyelitis of the leg with a bone defect by free autoplasty on the microvascular anastomoses of the thoracodorsal skin-muscle flap with a fence on the single vascular leg of the bone tissue of the ribs that overlap the defect zone (A.E.Belous .S. Tkachenko "Microsurgery in traumatology, Leningrad," Medicine ", 1988, p.168).

The indicated methods for replacing extensive diaphyseal defects of the tibia (according to the copyright certificates SU 596227 and SU 1042741) due to one or simultaneous lengthening of both fragments belong to G.A. Ilizarov, who replaced the diaphyseal defect of the tibia in a patient in 1966. In this case, the Ilizarov compression-distraction apparatus was applied to the damaged segment of the lower leg, osteotomy was performed in the proximal metaepiphysis or from both ends of the tibia. After this, distraction was performed starting from 7 days after the operation, at a rate of 0.25 mm 4 times a day, which totaled 1 mm per day. In the area of the defect, the bone fragments came close to full contact, which corresponded to the replacement of the defect. The widespread introduction of the technique was restrained by the fact that scars in the area of fragments to be elongated, undergoing distraction, reacted in the form of redness, etc. up to partial necrosis. In 1980, a modification of the technique was applied, which consisted of simultaneous decortication of scar growth sites. The authors report that, despite the application of the technique and its modification, necrotic changes in the area of the ends of the bone fragments still took place. These methods do not provide restoration of limb length and functional restoration of adjacent joints, especially with an existing soft tissue defect in the area of the bone defect.

The technical result achieved by using the proposed method is to increase the efficiency of the replacement of extensive diaphyseal defects of the tibia in combination with a wound defect of soft tissues or rough scars in the area of the bone defect to eliminate shortening of the limb and distraction to eliminate the defect of the tibia, restore movement in adjacent joints and reduce contractions terms of rehabilitation after surgical correction (full range of motion in the joint and support ability are restored limbs of the patient at the stage of his rehabilitation). This eliminates pain and movement restrictions in adjacent joints, eliminates the possibility of traction damage to soft tissue grafts during distraction of the tibia.

To achieve the technical result, a method for surgical correction of complex combined combined defects of the bone and soft tissues of the lower leg is proposed, which consists in the formation of a thoracodorsal graft on the thoracodorsal artery with the inclusion of a fragment of a rib long enough to overlap not only the tibial defect zone, but also osteotomy fragments, transfer the resulting graft to the lower leg defect area and lay a rib fragment on the bone fragments of the bolsheber the base bone, forming a support for the graft located above the defect area, a microvascular suture and soft tissue defect plasty with a thoracodorsal graft with a rib fragment are performed and the proximal and / or distal tibia fragments are osteotomized, the wound is sutured in layers, after wound healing, distraction is started using compression distraction apparatus until the tibial defect is completely replaced.

The essence of the proposed method is illustrated by drawings on a specific example, where:

- figure 1, 2 presents images showing shrapnel wound to the lower leg, a multi-fragmented fracture of the tibia in the middle third, complicated by osteomyelitis, and a resection of the tibia over 18 cm;

- figure 3, 4 performed osteotomy and distraction of the distal fragment of the tibia before surgery according to the proposed method;

- figure 5, 6 as a result of distraction, bone fragments perforated the skin (before surgery according to the proposed method);

- Fig.7, 8 performed excision of scars;

- figure 9 - planning of a thoracodorsal graft (free flap) and a fragment of the 8th rib;

- figure 10, 11 - transplantation of a thoracodorsal flap with a fragment of the 8th rib on the lower leg;

- in Fig. 12, 13, the rib performs the function of a support (bridge) for moving osteotomized fragments towards each other for joining;

- in Fig.14, 15 closed docking of the fragments is performed under the thoracodorsal flap, the rib fragment is involved in the fusion of the joined fragments;

- in Fig.16, 17 - anatomical result two months after removal of the apparatus;

- Fig.18-20 is a functional result two months after removal of the apparatus.

The method is as follows.

A patient with a gunshot defect in the middle third of the tibia in the middle third for 16 cm, the ends of the fragments of the tibia are sharply contoured under the skin along the front surface of the tibia, which is scarred, thinned and stretched. The Ilizarov compression-distraction apparatus is immediately applied or, if the apparatus has already been placed, it is re-mounted in such a way as to have good surgical access without loss of fixation stability and the possibility of subsequent distraction. Then the wound is longitudinally excised within healthy tissues with exposure of the end surfaces of the bone fragments, trying to keep the periosteum intact. Next, the extent of the bone defect is measured and access to the anterior tibial vascular bundle is taken, which is taken on the holder.

The next stage of the operation is linear access in the axillary region, the thoracodorsal neurovascular bundle is identified, mobilized from the mouth to the level of inflow into the thoracodorsal muscle, and taken to the holder. Then they perform mobilization of the thoracodorsal muscle and the skin above it, without separating the latter from each other, by the size and profile of the skin wound. The edges of the muscle and skin flap are separated to the level of the 8th rib, preserving its vascular connections with the musculocutaneous flap, then the intercostal muscles are crossed through the intercostal spaces, keeping the pleura intact, a fragment of the rib is isolated. Thus, a thoracodorsal graft (free flap) is formed on the thoracodorsal supply artery with the inclusion of fragment 8 of the rib, which is resected 3-4 cm longer than the distance between the fragments (i.e., longer than the defect of the tibial muscle; the length of the fragment of the rib should not be sufficient to overlap only tibial defect zones, but also fragments osteotomy zones). Then the wound in the axillary region is drained and sutured.

The graft is transferred to the anterior surface of the lower leg, where a fragment of the rib is placed on the bone fragments in the form of a bridge, stitching the musculocutaneous portion of the graft to the edges of the wound defect, after which the microvascular suture of the graft artery and veins with the anterior tibial vessels is performed, end-to-end type. The proximal and distal fragments of the tibia are ostomized from the common wound and in the transverse direction, departing 4 cm from the edge of the sawdust; spokes for distraction in the transverse direction or in the form of reins are passed through these fragments. After thorough hemostasis, the wound is drained and sutured, storing the wound in layers, leaving drainage under the fascia and graft for 48-72 hours.

After wound healing, one-sided or two-sided distraction replacement of the tibial defect begins by unilaterally or bilaterally moving the tibial fragment towards each other, while the costal graft allows distraction and sliding of fragments of the tibia and regenerates under it without the risk of corrugating or tearing off the soft tissue part of the graft. Distraction is carried out at 1 mm per day, under x-ray control 1 time in 10 days, until the tibia defect is completely replaced. After joining, which is also easily performed under the rib "bridge", a fragment of the rib participates in the osseointegration of bone fragments and regenerates, which accelerates the fusion process, which is monitored once a month until complete consolidation, after which the apparatus is removed, and a rehabilitation course is carried out until the wounded man recovers.

The main group - 3 wounded - operated on by the claimed method. The control group - 5 people - was operated by the prototype method. The follow-up period after surgery ranged from 1 to 5 years. In 3 patients of the main group, a good result was obtained - there is no pain and lameness, movements in the knee and ankle joints in full, go without the help of crutches and canes. In all patients operated on by the prototype method, limb shortening, lameness are preserved, while 4 patients (80%) constantly use crutches or a cane, fistula and trophic changes in the area of scars of the anterior surface of the lower leg periodically occur.

The examples confirm the implementation of the claimed method of surgical correction of post-traumatic and congenital deformities of the hip joint.

Example 1. Patient S., born in 1976, contract sergeant, taking part in a counter-terrorist operation on the territory of the Chechen Republic, 07.10.2000 was blown up by a mine, received a serious mine-blast wound, combined fragmentation wound to the head, chest, abdomen, limbs. Gunshot fragmentation blind penetrating wound of the skull and brain, fragmentation blind wound of the soft tissues of the chest and abdomen. Gunshot comminuted fracture of both bones of the left tibia in the middle third with displacement of fragments. Separation of the right lower limb at the level of the lower third of the right thigh. Conducted stage treatment, primary surgical treatment of wounds and the application of the Ilizarov apparatus on the left lower leg (Fig. 1), the wound process was complicated by osteomyelitis, resection of 18 cm of the tibia in the middle third (Fig. 2) was performed. Delivered to the Burdenko State Municipal Clinical Hospital, where they were performed on May 30, 01 - remounting of the compression and distraction apparatus of the left tibia due to its instability, osteotomy of the distal fragment and non-free vascularized plasticization according to Ilizarov with a distraction rate of 1 mm per day (Figs. 3-4) . The postoperative course was complicated by skin necrosis in the region of the end face of the elongated bone, as a result of which the distraction was stopped several times (Figs. 5-6). Therefore, on June 24, 02, free vascularized plastic surgery was performed with a thoracodorsal flap from fragments of the 8th rib, in the form of a bridge-like flap, and an osteotomy of the proximal fragment (Figs. 7-11). Subsequently, the bone fragments were closed in a closed manner and the fracture healed (Figs. 12-15). A prosthesis was made for the right lower limb, a course of rehabilitation therapy was carried out (Figs. 16-20). The wounded was discharged into the military unit and continues to serve in non-combatant positions.

Example 2. Patient C. diagnosis: Chronic gunshot osteomyelitis, defect of the tibia (8 cm) and soft tissues in the lower third of the left lower leg on the inner surface.

Anamnesis of the present disease: on August 29, 1999, during the conduct of hostilities in Chechnya, he received a gunshot wound to his right lower leg, a multi-fragmented fracture of both bones in the middle third. Delivered to the hospital, where on September 6, 1999 an open reduction was performed, osteosynthesis of KD Ilizarov of the right lower leg. The postoperative period was complicated by osteomyelitis. Postoperative wound drainage and flow-aspiration drainage were performed for 2 weeks, antibacterial, anti-inflammatory and symptomatic therapy. Postoperative wounds healed. Sutures were removed on day 16. For the staged treatment, he was transferred to the MCHG named after N.N. Burdenko.

01/25/2000, the operation was performed: Sequestrectomy of the pseudoarthrosis of the middle third of the right tibia, the formation of a bone flake of the right tibia for non-free bone grafting according to Ilizarov. Remounting KDA. In the postoperative period, antibacterial, infusion, vascular, symptomatic therapy, exercise therapy, physiotherapeutic treatment, and dressings were performed. However, chronic osteomyelitis of the right tibia worsened, a wound measuring 5.5 × 6.5 × 3.5 cm was formed in the middle third of the right tibia, the edges were hyperiminated, edematous, and the bottom of the wound was a tendon of the lateral group of the leg muscles. KDA is stable, there is no circulatory disturbance and innervation of the right lower limb.

For further surgical stage treatment, he was transferred to 32 CVMCG. On March 17, 01, a resection of the right tibia was performed in the middle third (8 cm) with the replacement of the defect with a musculoskeletal flap from the thoracodorsal muscle with a fragment of the 7th rib on the feeding vascular pedicle, osteotomy of the proximal fragment of the tibia. Autodermoplasty. The musculoskeletal flap has taken root, after 10 days a gradual distraction in the osteotomy zone and the replacement of the tibial defect have begun. After 90 days, the defect was replaced, closed docking of fragments of the tibia was made. Received a comprehensive rehabilitation and rehabilitation therapy, FTL, exercise therapy.

September 20, 2001 the device was removed, a comprehensive rehabilitation treatment course with positive dynamics was carried out. Discharged to the clinic at the duty station in satisfactory condition.

The inventive method allows the surgical replacement of combined gunshot defects of the tibia and soft tissues of the lower leg (with a defect more than 6 cm long) after bullet, fragmentation or mine-explosive wounds, completely restore the length and supportability of the limb, eliminate pain and restrictions on movements in adjacent joints, eliminates the possibility of traction damage to soft tissue grafts during distraction tibia repair.

Claims (1)

A method for surgical correction of complex combined combined defects of the bone and soft tissues of the lower leg, including the formation of a thoracodorsal graft on the thoracodorsal supply artery with the inclusion of a bone fragment of the rib, transfer of the resulting graft to the lower leg defect, the implementation of microvascular suture and soft tissue plastic defect with a thoracodorsal graft with ribs, characterized in that the proximal and / or distal fragments of the tibia osteotomize, a fragment of the rib is inserted long enough to overlap the tibial defect zone and the fragments osteotomy zone to the bone fragments of the tibia, forming a transplant support located above the defect area, the wound is sutured in layers, after wound healing, the distraction is started using the compression-distraction apparatus to complete replacement of a defect of the tibia.

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