RU2336838C2 - Method for plastic repair by insular muscle flap after radical surgical debridement of osteomyelitis focus in lower third of calf bone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: insular muscle flap is made of myogaster part of short fibular muscle on proximal vascular pedicle including braches of the fibular artery and vein. Flap is relocated in distal direction to the lower third of calf bone preserving feeding vessels.

EFFECT: reliable blood supply of transplanted muscular tissue, maintenance of proximal point of short fibular muscle fixation, traumatic rate and treatment period reduction.

9 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology, orthopedics and surgery, and can be used during surgical treatment of patients with osteomyelitis localized in the lower third of the fibula.

Plastic replacement of tissue defects formed after radical surgical treatment of osteomyelitis foci is a difficult reconstructive task, especially when they are localized in the distal parts of the lower extremity (Belousov A.E., 1998; Akzhigitov GN, Yudin Ya.B., 1998) . The difficulties of its solution are determined by the defeat of both the superficially located bone and the soft tissues covering it, the limited resources of plastic material near the pathological focus and the need to fill in the defects with well-supplied healthy tissues. The views on the surgical treatment of this category of patients are ambiguous according to the data of domestic and foreign scientific literature (Pshenisnov KP, 2003; Cordeiro P.G. et al., 1994). However, most authors consider it necessary to carry out radical surgical treatment of the osteomyelitis focus in such cases and replace the defect with a well-supplied muscle tissue (Nikitin G.D. et al., 2000; Ogun T.C. et al., 2001).

An analogue of the proposed method can be considered a technique for replacing tissue defects in the lower third of the fibula with a rag from a tailor muscle taken from the other extremity on a temporary proximal muscle-vascular feeding leg (Aryev T.Ya., Nikitin G.D., 1955). However, this method has the following significant drawbacks: when it is used, it requires a long (more than 3 weeks) immobilization of both lower limbs of the patient in an extremely uncomfortable position, as well as repeated surgery to cross the temporary feeding leg, which significantly increases the hospitalization period.

There is also a method of replacing tissue defects in the lower third of the fibula with a flap of the short fibula, transplanted on a constant distal wide muscular-vascular feeding leg (Ersen S., Ghofmani A., 2001), which can be considered as a prototype. However, when using this method, there are also a number of disadvantages: when it is performed, it is necessary to cut off the short fibular muscle from the place of its proximal fixation to the fibula, to separate it from the tendon of the long fibular muscle and to use almost the entire muscle abdomen for the purpose of plasty. In addition, the nutrition of such a muscle flap is carried out by a wide distal muscular-vascular feeding leg, which is formed without identification of the vessels feeding the flap. Therefore, a relocated muscle flap does not have a guaranteed blood supply due to isolated and stored blood vessels. It should also be noted that in order to replace tissue defects in the lower third of the fibula with the considered method, the supplying muscular-vascular leg of the flap has to be bent by 120-150 °, which negatively affects the blood supply to the transplanted area of the short fibula.

These shortcomings are deprived of the proposed method of plasty with an islet muscle flap formed from the part of the abdomen of the short peroneal muscle without cutting off the proximal fixation point of the muscle and intersecting its distal tendon. Blood supply to such a flap is provided by the constant branches of the peroneal artery and vein, passing in the posterior intermuscular septum of the lower leg.

The features of the topography of these feeding vessels were studied during an applied topographic and anatomical study performed on the 18 lower extremities of unfixed corpses using latex injection of the arterial bed and subsequent precision preparation. The study showed that the largest and most constant source of nutrition of the short fibular muscle in the artery and two associated veins departs from the fibular vascular bundle, passes in the posterior intermuscular septum of the lower leg between the fibula and the long flexor of the I toe, and then penetrates into the specified muscle into zone from 7 to 11 cm above the top of the lateral ankle (figure 1). The diameter of the muscle artery varies from 1.2 to 2.6 mm, and the caliber of the accompanying veins is slightly larger. The data obtained made it possible to substantiate the possibility of forming an islet flap from a part of the abdomen of the fibula on the indicated vascular bundle, as well as the technique of moving it to the lower third of the fibula on a constant proximal exclusively vascular feeding leg.

The technical result of the invention is to improve the outcome of surgical treatment of patients with osteomyelitis in the lower third of the fibula and reduce the morbidity of reconstructive surgery due to:

- moving a fragment of the short peroneal muscle on a constant vascular feeding leg, providing reliable blood supply to the transplanted muscle tissue;

- high ability of well-supplied blood muscle tissue to suppress the infectious process;

- the use of only a part of the abdomen of the donor muscle that is optimal for reconstruction, maintaining the proximal fixation point of the short peroneal muscle and its distal tendon;

- lack of need for prolonged immobilization and reoperation.

The result of the invention is achieved by the formation of an islet muscle flap from the abdominal part of the short fibular muscle (without cutting off the proximal fixation point and intersecting the distal tendon) on its own proximal vascular feeding leg, including the constant muscle branch of the fibular artery and two associated veins passing in the posterior intermuscular septum of the leg and displacement of the selected flap in the distal direction to the osteomyelitis focus in the lower third of the fibula after about radical surgical treatment with preservation of the vessels feeding the flap, providing reliable blood supply to the displaced area of muscle tissue.

Lack of information in the patent and scientific literature on the possibilities of replacing a tissue defect in the lower third of the fibula, formed as a result of radical surgical treatment of the osteomyelitis focus, with a muscle flap from the abdomen of the short fibular muscle on a permanent exclusively vascular pedicle containing the muscular branch of the fibular artery and associated veins, indicates the conformity of the claimed technical solution to the criterion of "novelty."

Isolation on the lateral surface of the tibia of the islet muscle flap, which includes part of the abdomen of the short fibular muscle and eats due to its own constant proximal vascular pedicle, as well as its subsequent displacement with preservation of the supply vessels in the distal direction - to the site of tissue defect in the lower third of the fibula new effect: allows you to improve treatment results and reduce the invasiveness of surgery through the formation and non-free transplant fragment that muscle tissue perfusion with guaranteed, predetermined size and shape, optimally respective tasks reconstruction.

It should be noted that, unlike the prototype, the proposed muscle flap does not include the entire abdomen of the short fibular muscle, but only that part of it that is necessary to replace a tissue defect that occurs after radical surgical treatment of the osteomyelitis focus in the lower third of the fibula. Due to this, it is possible to reduce the invasiveness of the operation by preserving part of the abdomen of the donor muscle, the place of its proximal attachment to the fibula and distal tendon. In addition, a distinctive feature of the proposed islet muscle flap is its feeding leg, which includes anatomically constant and fairly large branches of the fibular artery and veins that are included in the proximal part of the flap, providing reliable nutrition of the selected fragment of muscle tissue and allowing it to be moved distally to the lower third fibula with preservation of the nourishing vessels. With this movement, it is not necessary to bend the feeding leg of the flap by 120-150 °, which is inevitable with plastic surgery with a short peroneal muscle on the distal muscular-vascular leg (as in the prototype). Therefore, the blood supply of the proposed islet muscle flap will be more reliable.

Thus, the proposed technical solution meets the criterion of "significant differences".

The indication for performing the proposed operation is chronic osteomyelitis of the lower third of the fibula, after radical surgical treatment of which it is supposed to form a defect in the bone tissue (bone cavity).

The method is illustrated by drawings.

Figure 1 - Anatomical preparation of the right lower leg and foot, injection of arteries with black latex. The arrow indicates the constant branch of the fibular artery, which is the dominant source of blood supply to the short fibular muscle.

Figure 2 - View of the left lower leg before surgery.

Figure 3 - X-ray of the left leg before surgery.

Figure 4 - The moment of operation. The stage of islet flap formation from the short peroneal muscle. A dominant vascular bundle supplying blood to the donor muscle has been identified.

Figure 5 - The moment of operation. The islet flap is formed from the part of the abdomen of the short peroneal muscle on the proximal vascular feeding leg.

6 is a view of the surgical wound after moving the islet flap from the short fibula to the lower third of the fibula and fixing it in the bone cavity.

Fig.7 - View of the left leg at the end of the operation. The wound is sutured in line.

Fig. 8 - The result of treatment 11 months after surgery.

Figure 9 - X-ray of the left lower leg 11 months after surgery.

The method was carried out as follows.

Before the operation, staining of fistulous passages was performed by injection of a brilliant green solution. Then, according to generally accepted methods, an audit and sanation of the purulent foci was performed with the mandatory removal of all affected tissues. The wound was abundantly washed with antiseptic solutions. The sizes of the bone cavity formed during the operation were determined, and the optimal sizes of the muscle flap were calculated. The surgical incision was extended in the proximal direction. Then an islet muscle flap was formed from the part of the abdomen of the short peroneal muscle, corresponding in size to reconstruction tasks. At the same time, the proximal attachment point of the muscle to the fibula and its distal tendon were maintained. We found in the zone 7-11 cm above the apex of the lateral ankle the dominant feeding leg of the short peroneal muscle, which included the artery and two associated veins extending from the peroneal vascular bundle and located in the posterior intermuscular septum of the lower leg. The vascular pedicle of the flap was isolated at the required length (up to 4 cm). Next, the formation of the islet flap was completed, isolating, bandaging and crossing all the additional feeding arteries and veins that entered it. The next stage displaced the selected muscle flap from the short fibular muscle in the distal direction up to the formed defect of the fibula, preserving the nourishing vascular pedicle. Then, the bone cavity was tightly filled with the displaced muscle. For this, the islet muscle flap was fixed in the bone cavity with separate transossal sutures, removed and fixed on the skin with gauze balls. The surgical wound was drained with a perforated PVC tube and sutured in layers in a line. The operated limb was immobilized by a posterior plaster cast for a period of three weeks. The discharge from the hospital was made 4 weeks after sufficient activation of the patient.

CLINICAL EXAMPLE

Patient K., 59 years old, medical history No. 9923. Diagnosis: Fused fracture of the fibula of the left lower leg in the lower third with the displacement of fragments. Metal osteosynthesis for a fracture of both bones of the left lower leg of 04/08/2005. Deep infection in the field of surgical intervention. Chronic postoperative osteomyelitis of the left lower leg, fistulous form.

Prior to admission to the purulent surgery department of FGU "RNIITO named after P.P. Vredena Roszdrav "the patient underwent three operations for postoperative osteomyelitis of the left lower leg, including the removal of metal structures. However, the chronic purulent-necrotic process was not stopped.

Figure 2 and 3 shows the clinical and radiological picture at the time of admission of the patient to the purulent surgery department.

After a clinical and radiological examination on October 13, 2005, an operation was performed: radical surgical treatment of the osteomyelitis focus in the lower third of the left leg. After treatment of the osteomyelitis lesion, a defect formed on the outer surface of the lower third of the left fibula with dimensions of 8 × 4 × 2 cm. In accordance with the dimensions of this bone defect, the dimensions of the insular muscle flap were planned.

Next, the surgical incision was extended in the proximal direction, the islet muscle flap was isolated and formed from the proximal abdomen of the short peroneal muscle without cutting it off from the site of proximal fixation and intersection of the distal tendon. A dominant vascular bundle feeding the muscle was detected at the posterior edge of the muscle 10 cm above the apex of the lateral ankle (Fig. 4) and was mobilized for 4 cm. Next, the formation of the islet muscle flap was preserved while maintaining its proximal vascular feeding leg (Fig. 5). The size of the selected flap was 9 × 4 × 2 cm.

The next stage, the islet muscle flap, which was adequately supplied with blood due to the isolated vascular pedicle, was displaced by 5 cm in the distal direction and placed in the cavity formed in the lower third of the fibula as a result of radical surgical treatment of the osteomyelitis foci. The transplanted fragment of the short peroneal muscle was fixed with separate transossal sutures, brought out and tied to the skin on gauze balls (Fig.6). The surgical wound was drained with a perforated PVC tube and sutured in layers in a line (Fig. 7).

The operated limb was immobilized in the postoperative period by the posterior plaster cast. Drainages were removed on the seventh day, seams were removed on the fourteenth day. After the operation, complete engraftment of the flap, relief of the chronic purulent-necrotic process was noted. The inpatient treatment period was 23 days.

At the follow-up examination 11 months after the operation, the patient did not complain, there were no signs of recurrence of the osteomyelitis process. The clinical and radiological results of the performed surgical intervention at the indicated time are presented in Figs. 8 and 9.

The proposed method of islet muscle flap plastic surgery after radical surgical treatment of the osteomyelitis lesion in the lower third of the fibula can be used at the final reconstructive stage of surgical intervention in adult patients after radical surgical debridement of the osteomyelitis lesion of the indicated localization.

References

1. Akzhigitov G.N., Yudin Ya.B. Hematogenous osteomyelitis. - M .: Medicine, 1998 .-- 285 p.

2. Aryev T.Ya., Nikitin G.D. Muscular plastic bone cavities. - M .: Medgiz, 1955 .-- 174 p.

3. Belousov A.E. Plastic, reconstructive and aesthetic surgery. - St. Petersburg: Hippocrates, 1998 .-- 744 p.

4. Nikitin G. D., Cancer A. V., Linnik S. A., Saldun G. P., Kravtsov A. G., Agafonov I. A., Fakhrutdinov R.Z., Khaimin V.V. Surgical treatment of osteomyelitis. - SPb .: Russian graphics, 2000 .-- 286 p.

5. Pshenisnov K.P. Principles of reconstruction of the lower limb // Selected issues of plastic surgery. - 2003 - T.1, No. 9 - S.23-24.

6. Cordeiro P.G., Neves R.I., Hidalgo D.A. The role of free tissue transfer following oncologic resection in the lower extremity // Ann. Plast. Surg. - 1994. - Vol. 33, No. 1. - P.9-16.

7. Ersen S., Ghofmani A., Reifenrath M. The distally pedicled peroneus brevis muscle flap: A new flap for the lowel leg // Plast. Reconstr. Surg. - 2001. - Vol. 107, No. 6. - P.1443-1448.

8. Ogun T.C., Arazi M., Kutlu A. An easy and versatile method of coverage for distal tibial soft tissue defects // J. Trauma. - 2001. - Vol.50, No. 1. - P.53-59.

Claims (1)

Method of plasty of an islet muscle flap after radical surgical treatment of an osteomyelitis lesion in the lower third of the fibula by isolating the flap from the short fibular muscle and its subsequent transplantation into the reconstruction area, characterized in that the islet muscle flap is formed from the part of the abdomen of the short fibular muscle on the proximal vascular feeding knife including the branches of the fibular artery and vein, and displace it in the distal direction in the lower third of the fibula with preservation m of supply vessels.

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