RU2355341C2 - Knuckle repair method - Google Patents

Abstract

FIELD: medicine; orthopaedics and traumatology.

SUBSTANCE: substance of the method consists in replacement of missing small knuckles by prepared toe phalanxes. A donor graft is prepared tissue complex based on a radial fasciocutaneous flap transplanted to foot while wrapping the specified toes phalanxes with a fascial graft, including interphalangeal and/or metatarsophalangeal with applying end-to-end anastomoses on radial artery of the flap, dorsal artery of foot and related comitant veins. Three weeks later free transplantation of prepared toe phalanxes being separated by osteotomy in a position of missing knuckles with applying anastomoses on vessels of formed vascular pedicle and recipient vessels within a repair point.

EFFECT: formation of axial blood supplied flaps in any favourable donor zone, hand repair and reconstruction of missing knuckles.

1 ex, 2 dwg

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used for reconstruction of the joints of the fingers.

An analogue of the invention is a method of reconstructing a joint of a hand, in which a free transplant of one of the joints of the toe to a position of the lost joint of the toe of the hand is performed (Tsai TM Vascularized Whole-, Hemi, and Double Joint Transfers in the Hand / TM Tsai, D. Bobb // In JR Urbaniak (Ed.), Microsurgery for Major Limb Reconstruction. - St. Lots: Mosby, 1987. - 282 p .; Serafin D. Atlas of microsurgical composite tissue transplantation. - Philadelphia etc .: WB Saunders Co., 1996 - 813 p.).

The disadvantage of this method is the difficulty of distinguishing the branches of the digital arteries of the foot, which supply the joint with blood, due to their small diameter. Another disadvantage is venous insufficiency of tissues of the transplanted tissue complex due to damage to the venous vessels of the joint when it is excreted. In case of transplantation of two joints of the toe to the position of the lost joints of different fingers, it is necessary to isolate a block of tissues, 2 and 3 toes, which leads to significant trauma and, as a result, a pronounced violation of the function of the foot.

The prototype is a method of transplanting a previously prepared one interphalangeal joint of 2 toes to the position of the lost joint of the toe of the hand (Khouri RK Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study / RK Khouri, J. Upton, WW Shaw // Plast. Reconstr. Surg. - 1991. - V. 87, No. 5. - P.108-115). This method of reconstruction allows you to transplant only one of the joints of the toe.

The proposed method allows you to create flaps with an axial type of blood supply in any favorable donor area, suitable for subsequent free transplantation, in particular for the reconstruction of lost small joints of the hand. Preliminary preparation of the joints of the toe simplifies the selection of the formed tissue complex at the second stage of reconstruction, and also makes it possible to use two joints of the same toe for transplantation. The formed vascular pedicle of such flaps has the required length, which is especially important in the absence of axial recipient vessels in the reconstruction zone (as a result of previous injuries or operations).

The result of the invention is achieved by the fact that as a donor flap, a pre-prepared tissue complex based on a radiation skin-fascial flap is used, which is transplanted onto the foot, wrapping the selected joints of the toe (interphalangeal and (or) metatarsophalangeal) with the end-to-end anastomosis applied with the fascial part of the flap. the end ”to the radial artery of the flap and dorsal artery of the foot, as well as to the corresponding committing veins. After three weeks, they perform a free transplant of previously prepared joints, dividing them by osteotomy of the phalanx of the toe, to the position of the lost joints of the fingers of the hand with the application of anastomoses on the vessels of the formed vascular pedicle and recipient vessels in the reconstruction zone.

The drawings show:

Figure 1 - transplantation of a blood supply fascial flap in the area of the formation of the graft on the foot;

Figure 2 - the second stage of treatment is the transplantation of previously prepared joints of the toe to the hand.

The method is as follows.

I Stage. Vascular pedicle formation of selected toe joints

1. Preparation of the foot. Before the operation, pulsation of the dorsal artery of the foot is determined and the course of the artery is marked. Then a tourniquet is applied to the limb. The dorsal vascular bundle of the foot and saphenous vein are layered in layers along the dorsal surface of the foot with a curly cut. The incision is extended distally by 2 fingers, the skin on the finger is separated circularly in the area of the interphalangeal and (or) metatarsophalangeal joint.

2. The formation of the flap. On one of the forearms, the next stage is performed - the preparation of a fascial and fascial flap based on a radial vascular bundle. On the palmar surface of the forearm, a curly cut reveals the fascia of the forearm. A T-shaped fascial flap is cut out in the lower third of the forearm with the radial vessels included in it, a skin buoy flap 2 × 4 cm in size. After raising the skin-fascial flap on the proximal vascular pedicle, isolated for a sufficient length, and perfusion, it is ligated and intersection of the vascular pedicle. The required leg length is measured on the recipient hand from the damaged joint to the recipient vessels (radial artery at the wrist level). Then the flap is transferred to the foot. A donor defect is sutured in a line.

3. The formation of the vascular pedicle of the donor joint. The flap is placed on the foot so that the distal fascial part of the flap was held under the skin at the level of the interphalangeal and (or) metatarsophalangeal joints of the 2nd finger in the previously formed tunnel, wrapped around the joint and sewn onto itself (Figure 1). In this case, the finger vessels along the medial side of the finger are included in the flap and their joint branches are retained. Lateral finger vessels are maintained for blood supply to the finger. A “buoy” skin flap is placed in the wound on the finger and sutured to the edges of the wound. The vascular leg of the flap is removed to the place of the recipient vessels of the dorsal bundle of the foot. Then, using microsurgical technique, anastomoses are applied between the radial artery of the flap and the recipient dorsal artery of the foot “end to end”. The flap veins anastomose “end to end” with veins on the foot. The wound is sutured and drained. Immobilization is carried out with a plaster cast for 3 weeks.

Stage II. Transplantation of prepared joints of the toe to the position of the joints of the fingers

1. Preparing the brush. Figured incision in layered out damaged joints. Bone fragments are isolated from scars. The size of the resulting bone defects is measured.

2. Isolation of the joints of the toe on the formed vascular pedicle. On the back surface of the foot, pulsation is determined and the course of the formed vascular pedicle is noted, a tourniquet is applied. The incision is performed along the old scar and the bordering incision at the base of 2 fingers with a triangular flap on the plantar surface. The vascular bundle of a previously transplanted tissue complex is mobilized from the base of the finger throughout. An osteotomy of the second metatarsal bone is performed, a finger is raised on the formed vascular pedicle. Remove the tourniquet and evaluate its blood supply. The vascular leg of the required length is bandaged and crossed. The finger is transferred to the brush. The wound on the foot is sutured. A distinguished finger from the foot is prepared for transplantation: the skin along the plantar surface is dissected and separated to the lateral surfaces of the finger, the nail phalanx is removed, exarticulated in the distal interphalangeal joint, the articular surfaces are resected. An osteotomy of the main phalanx is performed to separate the interphalangeal and (or) metatarsophalangeal joints, without disconnecting their blood supply due to the formed vascular pedicle.

3. Transplantation of prepared joints. The incision is extended along the dorsum of the hand to the anatomical snuff box, where the dorsal branch of the radial artery and two saphenous veins are isolated. A block of tissues of the toe is placed in the recipient bed, fixed with needles transarticularly (Figure 2). The skin part of the transplanted flap is sutured along the edge of the wound defect on the hand. The vascular pedicle is removed to the site of the recipient vessels. Then, using a microsurgical technique, a suture of the vessels is performed. The wound is sutured and drained. Immobilization is carried out with a plaster cast for 5 weeks.

An advantage of the invention is the possibility of forming an axial tissue complex with desired properties and using it for a free transplant in order to replace complex defects on the hand (reconstruction of lost joints of the hand).

Clinical example

Patient T., 39 years old, source of illness No. 1689, injury with a milling cutter 4 months before hospitalization. As a result, the patient has a defect of 3, 4 metacarpal bones and metacarpophalangeal joints of the left hand, chronic damage to extensor tendons of 1-5 fingers, soft tissue defect of the dorsum of the hand, replaced by a rotational dorsal flap of the forearm. The defect of 3, 4 metacarpophalangeal joints was replaced by previously prepared joints of 2 toes (proximal interphalangeal and metatarsophalangeal). A transposition of the short radial extensor of the wrist to the position of the long extensor 1 of the finger was also performed. After 6 months, alloplasty of extensor tendons of 2-5 fingers was performed.

Literature:

1. Serafin D. Atlas of microsurgical composite tissue transplantation. - Philadelphia etc .: W.B. Saunders Co., 1996 .-- 813 p.

2. Tsai T.M. Vascularized Whole-, Hemi, and Double Joint Transfers in the Hand / T.M. Tsai, D. Bobb // In J.R. Urbaniak (Ed.), Microsurgery for Major Limb Reconstruction. - St. Lois: Mosby, 1987 .-- 282 p.

3. Khouri R.K. Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study / R.K. Khouri, J. Upton, W.W. Shaw // Plast. Reconstr. Surg. - 1991. - V. 87, No. 5. - P. 108-115.

Claims (1)

A method for reconstructing small joints of the hand, which consists in replacing the lost small joints of the hand with pre-prepared joints of the toe, characterized in that as a donor flap, a pre-prepared tissue complex based on a radiation skin-fascial flap is used, which is transplanted onto the foot, wrapping selected toe joints - interphalangeal and / or metatarsophalangeal with the application of end-to-end anastomoses on the radial artery of the flap, dorsal artery the foot and to the corresponding komitantnye vein, and after three weeks transplantation produce free joints previously prepared, separated by an osteotomy phalanx of the toe in the position of lost joints brush anastomosis receptacle formed pedicle and recipient vessels in the zone of reconstruction.

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