RU2339327C2 - Method for treatment of chronic ishemia of extrimities - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: disruption of cortical plate is conducted only after osteoperforation having reached true elevation of blood-filling in the distad segment of extremity. The slab being formed is placed on the maternal bed without its further displacement. Operated segment is fixed with the help of apparatus. In patients with diabetic foot syndrome formation of longitudinal slab of the cortical plate is conducted simultaneously with osteoperforation of the foot bones. In absence of true elevation of the level of blood - filling in the distad segment by 10 - 14 days from the initially performed osteoperforation, repeated osteoperforation of the previously operated segment is performed simultaneously with perforation of the bone of the distad segment of the extremity.

EFFECT: ensures improvement of arterial blood flow in patients with diabetes mellitus.

3 dwg, 1 ex, 3 cl

Description

The invention relates to medicine, in particular to orthopedics and angiology, and can be used in the treatment of arterial blood flow disorders of various etiologies, combined with diabetes mellitus.

A known method of treating chronic ischemia of the lower extremities by multiple osteoperforations of limb bones (Application for the grant of a patent of the Russian Federation No. 93045689/14, publ. 20.03.96., Bull. No. 8).

However, the implementation of this technique in patients with impaired arterial blood flow in the presence of diabetes mellitus has a limited therapeutic effect, which is due to a decrease in the reparative capacity of the body due to impaired immune, endocrine and neuro-regulatory functions.

There is a method of treating chronic limb ischemia by forming flakes of bone segments and their metered displacement in order to stimulate collateral arterial blood flow (AS USSR No. 1767722 DSP).

However, in patients with diabetes mellitus, the use of methods of dosed bias of bone flakes, which cause permanent long-term trauma to the soft tissue case of segments, is associated with the development of postoperative, including infectious, complications. The relief of such complications is a complex clinical problem and requires a long time. Together, in patients with diabetes mellitus, this almost completely eliminates the possibility of using this method

The objective of the invention is to develop a method for the treatment of chronic limb ischemia, which provides the possibility of improving arterial blood flow in patients with diabetes mellitus by eliminating prolonged traumatic effects on soft tissues in the postoperative period.

This problem is solved by the fact that in the method of treating chronic limb ischemia, including performing osteoperforations, violation of the cortical plate of the bone with the formation of its longitudinal flakes and fixation of the operated segment using the compression-distraction apparatus, violation of the cortical plate is performed after performing osteoperforations with a significant increase in the level of blood supply distal the located segment of the limb, and the flap formed in this case is placed in the mother’s bed without its subsequent mixing eniya.

It is also envisaged that:

- in the presence of diabetic foot syndrome, at the same time as violation of the cortical plate, osteoperforation of the foot bones is performed;

- in the absence of a significant increase in the level of blood supply distal to the located segment by 10-14 days after the initial osteoperforation, the latter is performed throughout the diaphyseal part of the same segment and at the same time the bones are perforated distally to the located limb segment.

The invention is illustrated by a description, an example of clinical use and illustrative material, which shows:

Figure 1 - arteriogram (a) and view of the limb (b) of patient N. before treatment.

Figure 2 - radiograph of a patient N. in the course of treatment.

Figure 3 - arteriogram (a), radiograph (b) and view of the limb (c) of patient N. after treatment.

The method is as follows.

Upon admission, the patient undergoes a comprehensive examination to assess the blood circulation of the affected limbs, the degree of ischemia and compensation of ischemic disorders, including the performance of ultrasound scan, polarography, laser flowmetry, arteriography. At the same time, blood sugar is corrected to compensate for diabetes.

After carrying out standard preoperative preparation in an operating room under epidural anesthesia with an electric drill, Kirschner’s spoke, as a rule, 5-6 perforation holes are formed in both metaphysical sections of the bones of the segment with affected main arteries. Aseptic dressings are applied to the places of introduction of the needles.

In the postoperative period, drug therapy is carried out, which consists in the appointment of direct anticoagulants, antiplatelet agents and vasoactive drugs according to the standard scheme with regular monitoring of blood sugar levels. At the same time, according to well-known techniques, the clinical condition of the operated limb is regularly evaluated. Among the analyzed parameters can be attributed, in particular, instrumentally determined indicators of capillary blood flow, its linear and volumetric velocity, increased oxygen tension in the skin, as well as warming of the fingers and an increase in the painless distance traveled.

Upon reaching clinically reliable signs of increased blood supply to the distal segment — the hand or foot of the operated limb, which is usually observed on days 10–14, the patient undergoes the formation of a flake of the cortical plate of the previously perforated bone. To do this, under operating conditions under epidural anesthesia, according to a well-known technique, osteosynthesis of a segment is performed using an external fixation device, after which longitudinal corticotomy of the medial bone edge is performed through skin incisions using a chisel with the formation of a marginal flake, which is then placed in the mother’s bed. In cases of diabetic foot syndrome, along with a violation of the cortical plate of the tibia, perforation of the foot, for example, the calcaneus, and both metaphyses of the metatarsal bones are additionally performed. Wounds are sutured tightly.

If, by 10-14 days after the initial osteoperforation, the patient does not have a significant increase in the level of blood supply distal to the located segment, then the patient undergoes repeated osteoperforation of the same segment, but already during its diaphyseal part, and at the same time the bones are perforated distally to the located limb segment . Aseptic dressings are applied to the places of introduction of the needles. After receiving signs of improved blood supply to the patient, the integrity of the cortical plate is violated with the formation of flakes according to the method described above.

After the formation of flakes in the postoperative period, continue the course of previously prescribed drug therapy with regular monitoring of blood sugar levels and until the appearance of radiological signs of consolidation of flakes with the maternal bone, the segment is fixedly fixed by the apparatus. After its dismantling, additional immobilization of the limb is not required.

The practical use of the method is illustrated by the following clinical observation.

Patient N., 65 years old, was admitted to the hospital with a diagnosis of diabetes mellitus, type II, in the stage of decompensation; diabetic foot syndrome; chronic arterial insufficiency of the III degree on the left; trophic ulcer in the lower third of the left leg.

During the preoperative preparation of the patient, a course of drug therapy was conducted for ten days, aimed at improving the microcirculation and rheological properties of blood, as well as compensating for diabetes mellitus. At the same time, the patient underwent a comprehensive examination, including the performance of ultrasound scan, polarography, laser flowmetry and arteriography.

According to the results of studies, it was found: the linear velocity of blood flow through the femoral artery - 4.25 cm / s, along the popliteal artery - 3.25 cm / s; the oxygen tension in the skin of the lower third of the right lower leg - 36, carbon dioxide - 53; capillary blood flow of the rear of the right foot - 2.0. The right ankle index is 0.5.

Moreover, the patient complained of intermittent claudication after 50 meters.

To compensate for the patient’s ischemic disorders, the following operations were successively performed: osteoperforation of both metaphyses of the left tibia, formation of a flake of the cortical plate of the tibia, osteoperforation of the left calcaneus and both metaphyses of the metatarsals.

Initially, 5 perforation holes were formed using an electric drill with a Kirschner spoke in both metaphysical sections of the left tibia. Aseptic dressings were applied to the places of introduction of the needles.

In the postoperative period, drug therapy was carried out for 10 days with the appointment of direct anticoagulants, antiplatelet agents and vasoactive drugs according to the standard scheme. At the same time, constant monitoring of blood sugar levels was carried out.

After 10 days, we evaluated the clinical condition of the operated limb. By this time, the patient noted: an increase in blood flow through the femoral and popliteal arteries of the operated limb, an increase in oxygen tension in the skin of the leg, and an increase in capillary blood flow. This was accompanied by warming of the fingers and an increase in the painlessly traveled distance of up to 100 meters.

Taking into account the noted positive response from the state of the operated limb to osteoperforation of the patient, the second stage was the formation of a longitudinal flake of the cortical plate of the medial surface of the diaphysis of the left tibia, as well as osteoperforation of the calcaneus and metatarsal bones of the left foot.

To do this, under operating conditions under epidural anesthesia, according to a well-known technique, osteosynthesis of the left lower leg was performed with an external fixation device, after which longitudinal corticotomy of the medial edge of the tibia was performed through skin incisions using a chisel with the formation of a marginal flake, which was then laid in the mother’s bed. At the same time, with the help of an electric drill, a Kirschner spoke with a diameter of 1.5 mm perforated the calcaneus and both metaphyses of the metatarsal bones. The wounds are tightly closed. Aseptic dressings are applied.

In the postoperative period, the previously prescribed drug therapy was continued with regular monitoring of blood sugar levels.

Fixation with the apparatus was carried out for 35 days until the consolidation of the flake with the maternal bone. After dismantling the apparatus, additional limb immobilization was not performed.

At the time of discharge according to examinations, the state of blood circulation of the operated limb was characterized by the following data: linear velocity of blood flow in the femoral artery - 6.75 cm / s, in the popliteal artery - 4.4 cm / s; the oxygen tension in the skin of the lower third of the right lower leg is 61, carbon dioxide is 33; capillary blood flow in the rear of the right foot - 2.4. The right ankle index is 0.82.

Using the proposed method in the clinic RSC "WTO" them. Acad. G.A. Ilizarova showed that by eliminating the long-term traumatic effect on soft tissues in the postoperative period, it provides the opportunity to improve arterial blood flow in patients with diabetes mellitus.

Claims (3)

1. A method of treating chronic limb ischemia, including performing osteoperforation, violation of the cortical plate of the bone with the formation of its longitudinal flakes, as well as fixing the operated segment using the apparatus, characterized in that the violation of the cortical plate is performed after performing osteoperforation with a significant increase in the level of blood supply distal to the located segment limbs, and the flap formed at the same time is laid on the mother’s bed without its subsequent displacement. 2. The method according to claim 1, characterized in that in patients with diabetic foot syndrome, osteoperforation of the foot bones is performed simultaneously with the formation of a longitudinal flint of the cortical plate. 3. The method according to claim 1, characterized in that in the absence of a significant increase in the level of blood supply distal to the located segment by 10-14 days after the initial osteoperforation, repeated perforation of the previously operated segment is performed and, at the same time, the bones are perforated distal to the located limb segment.

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