RU2384303C1 - Method of treating dupuytren's contracture - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: "S" incision is performed on palm of hand. A flap is formed with its base 2-3 times exceeding its length. Total aponeuroectomy follows. Bands of palm aponeurosis on fingers are removed from separate additional rabble-like incisions on palmary-collateral surface of fingers. The wound is closed. The skin defect within the wound after the contracture has been removed, is close with "local" tissues. If Dupuytren's contracture of III degree combined with development of secondary changes, the first stage involves application of a distraction apparatus. After the contracture has been removed by graduated distraction in the apparatus by 1 mm a day, the second stage includes aponeuroectomy according to the described technique.

EFFECT: method allows preventing formation of pointed skin flaps prone to necrosis.

4 cl, 1 ex, 3 dwg

Description

The invention relates to medicine, in particular to hand surgery and orthopedics, and in particular to the treatment of contractures of the joints of the hand.

A known method for the treatment and prevention of capsular contracture, in which transdermally soft tissues surrounding a mammoprosthesis, is laser irradiated in a pulsed mode in the range of 10-20 ns with a repetition rate of 25 Hz simultaneously at wavelengths of 1.064 and 0.532 μm. The average power of light energy is not more than 10 J per session 5-10 minutes The number of sessions is 10 with an interval of 1-2 days (RF Application No. 95109638. Publ. 1997.06.10).

However, the known method uses physiotherapeutic treatment based on laser light irradiation, it is not surgical and does not allow to achieve treatment results that satisfy patients.

There is a method of surgical treatment of Dupuytren's contractures with subtotal resection, supplemented by periarterial cryoneurotomy of the arterial palmar arch, including performing a subtotal resection of the palmar aponeurosis, then the second stage is the implementation of the sympathetic surface arterial arch desympathization (Application of the Russian Federation No. 99119690, Publ. 2001.06.20).

However, the known method causes difficulties in its implementation. The operation time is lengthened, the technique of performing the operation is complicated, special expensive equipment and tools are required. In this case, there may be damage, thrombosis of the superficial palmar arch.

There is a method of treating Dupuytren's contracture, in which subcutaneous, staged and segmental fibro-fasciotomy is used in the direction from the proximal hand to the main phalanx of each affected finger to its full extension (RF Patent No. 2066137. Publ. 1996.09.10).

However, its use does not allow to obtain a treatment result that satisfies the patient socially. This method of surgical treatment can be attributed to palliative interventions. It often leads to a relapse of the disease (57% according to Volkova) and damage to blood vessels, nerves and tendons.

There is a method of surgical treatment of Dupuytren's contractures, in which the palmar aponeurosis is excised through incisions along the proximal and distal palmar folds of the fingers, then the entire wound is sutured, leaving a defect in integumentary tissues with an area of more than 6 cm ² , a skin flap on the distal vascular is cut out on the middle third of the radial surface of the forearm the leg 8-12 cm long, including the radial artery and vein, produce an additional figured incision, enveloping the elevation of the first finger, from the base of the leg located in the region the anatomical snuff box to the proximal palmar fold, then the flap is moved to the palm and sutured to the edges of the defect, and the donor wound is sutured (RF Patent No. 2085139. Publ. 1997.07.27).

However, the known method is highly traumatic, and also technically difficult to perform (there is a risk of damage to the surface branch of the radial nerve when the radial artery and vein are excreted, when the flap is moved, an inflection, thrombosis of the vascular pedicle is possible, because the flap unfolds almost 180 °). The skin transplanted from the s / s forearm in its anatomical and physiological characteristics differs from the skin on the hand and cannot withstand heavy physical exertion.

A known method of surgical treatment of Dupuytren's contracture, in which stepwise excision of a pathologically altered palmar aponeurosis is performed through incisions along the proximal and distal palmar folds and flexion folds on the fingers, then all wounds are sutured, leaving a defect in the distal palmar fold, on the side surface of the main phalanx III and IV fingers cut a skin flap on the vascular pedicle and bring it through the subcutaneous tunnel formed by excision of the palmar aponeurosis into the wound in the region d steel palmar crease sutured to the left edge of the defect, the defect formed on the finger free polnosloynym closed or split graft, taken from the forearm velar (RF Patent №2076643. Publ. 1997.04.10).

The known method is quite traumatic, time-consuming to perform. When using it, they resort to free skin plastic to close the defect on the finger. A free skin flap transplanted from another part of the body may become ulcerated after engraftment under the influence of mechanical stresses, the sensitivity of the flap may not recover or not fully recover, it should be borne in mind that the flap taken from another part of the body has anatomical and physiological features, different from the skin on the hand.

There is a method of surgical treatment of Dupuytren's contracture, in which a pathologically altered palmar aponeurosis is excised through transverse incisions along the flexion folds, the opposite corners of the transverse incisions are joined by oblique incisions, forming triangular rags, the transverse incisions are sutured with the fingers half bent, and the oblique incisions are sutured (when the fingers are maximally bent) RF patent No. 2170549. Published. 2001.07.20).

However, the known method leads to the formation of pointed flaps, the disadvantage of which is poor blood supply to the top of the flap. The top of the acute-angled flap can necrotic, which greatly lengthens the duration of treatment and contributes to the formation of a constricting scar, suppurative complications are possible.

A known method is Bryantseva L. N. surgical treatment of Dupuytren's contractures, in which separate longitudinal bayonet-shaped incisions or an incomplete S-shaped incision and excision of an aponeurosis are performed ("Dupuytren's contracture", Bryantseva L.N. Medgiz, 1963, pp. 59-60).

However, the known method is accompanied by damage to the palm-finger fold, which can lead in the long term to the formation of cicatricial contracture. It is designed to excise cords of the palmar aponeurosis and eliminate contracture of one or two fingers. With the defeat of more fingers, the known method is not suitable.

There is a method of complex treatment of Dupuytren’s contractures of the III-IV degree, in which a skin incision is made, subtotal excision of the scar-modified palmar aponeurosis, suturing of the wound, application of a splint on the wrist and fingers, physiotherapy exercises, physiotherapy, antibiotic therapy and suturing. Moreover, as a skin incision, a Z-shaped incision is made along the palmar surface of the finger, starting from the outer edge of the distal interphalangeal skin fold, then to the outer edge of the proximal, continuing the arcuate incision along the inner border of the hypotenor or tenor. In addition, a metered dissection of the scar-changed wall of the tendon sheath in the area of the proximal interphalangeal joint in the area of 2.0-2.5 cm is performed, the first ligation is performed 2-4 hours after surgery, a splint is applied for the first three days, and physiotherapy exercises are prescribed 3 days after surgery. Physiotherapeutic procedures are carried out by irradiating the area of the postoperative wound with low-intensity broadband electromagnetic radiation of the EHF range with a noise spectrum of 53.57-78.33 GHz, with a radiation power of 1.0-1.2 μW, starting from 2 days after surgery for 30 minutes daily in the amount of 7 sessions (RF Patent No. 2290120. Publ. 2006. 12. 27).

However, the known method can be used in the treatment of desmogenic contractures of the hand, which reduces the risk of postoperative complications, reduces the patient’s hospital stay to 7-10 days, reduces the period of temporary disability to two weeks, but from this section it is impossible to eliminate contractures of all fingers and leads to the formation of pointed flaps, which on top often die.

The objective of the present invention is the possibility of total aponeurectomy from the access, which allows to close the skin defect that has arisen after eliminating the counteractures of the fingers with local tissues (plastic with a local skin flap). At the same time, it is possible to avoid the formation of peaked skin flaps, strong tension of the wound edges and to prevent the development of secondary changes, to eliminate contractures by means of dosed distraction.

The problem is solved in that in a method for treating Dupuytren's contracture, including performing anesthesia, using a combination of conductive and local infiltration anesthesia, performing an S-shaped incision along the palmar surface of the hand, the formation of a skin flap, the width of which is 2-3 times greater than its length , aponerectomy, then after excision of the palmar aponeurosis, the skin is straightened, suturing of the wound, skin defect that has arisen in the wound area, after elimination of contracture is closed with "local" tissues, fixation after the operating period of the hand with a plaster cast, physiotherapy and physiotherapy exercises.

It is advisable to excise the cords and nodes on the fingers to perform an additional “club-shaped” incision on the palm-lateral surface of the finger without violating the palm-finger-like fold of the hand, excise the aponeurosis in the palm and fingers with a single block, in addition, save the skin area between the S-shaped and “ club-shaped "cuts.

It is advisable, to eliminate Dupuytren's contractures of the III degree, initially to apply a distraction apparatus to the finger, to eliminate the contracture of the fingers by means of dosed distraction, then to carry out aponeurectomy.

To prevent ischemic and neurological disorders, it is advisable to perform surgery on the hand without applying a tourniquet.

The present invention is illustrated by a detailed description, a clinical example of its implementation with reference to the drawings, in which:

figure 1 depicts a brush on the palmar side and the lines of the S-shaped and "club-shaped" cuts plotted on it;

figure 2 - photo brush before treatment;

figure 3 - photo brush after treatment.

The method is as follows.

In cases where the skin on the operated palm is quite soft and mobile, it does not require preoperative preparation. If the skin is dense, hard, then preoperative preparation includes washing hands in hot water with soap and a brush, and baths with a solution of drinking soda.

Before surgery, the patient is hospitalized in a hospital, they take a clinical minimum and, after exclusion of contraindications, perform the operation.

With surgical intervention, a combination of local infiltration and conduction anesthesia is used. Initially, after treating the surgical field twice with iodopyron solution, conductive anesthesia with 2% lidocaine solution is performed. The median nerve is anesthetized at the level of the carpal canal. Landmarks are the skin fold that separates the palm from the forearm, tendon m. palmaris longus, under which lies the median nerve. Anesthesia of the ulnar nerve is performed according to the method of Brown, slightly above the radial edge of the pisiform bone. Subsequently, local infiltration anesthesia with 0.5% novocaine solution is used.

On the palm of the hand in the area of the cords, an S-shaped incision is made with the expectation that after cutting out skin grafts it will be possible to completely close the wound surface without resorting to plastic with a free skin graft ("local" skin grafting) (Figure 1). In this case, its own "local" skin flap has a width of 2-3 times the length and does not have sharp corners.

The skin in the area of folds and funnel-like retracts is separated from the underlying tissues (palmar aponeurosis) in the acute way. The remaining nodes of the altered palmar aponeurosis on the skin are excised. The skin itself, fused with an altered aponeurosis, is not excised.

Under the proximal palmar aponeurosis fail Kocher curved clamp. The aponeurosis is dissected between the jaws of the clamp and taken to the clamp. With constant sipping carefully, using the sharp path (with a scalpel and scissors), the aponeurosis is separated from the underlying tissues (tendons, neurovascular bundles, muscles).

For excision of the cords and nodes on the fingers, an additional club-shaped incision is made along the palm-lateral surface of the finger. In this case, do not violate the palm-finger fold of the brush. The cords and nodes likewise isolate and excise. Aponeurosis in the palm and finger is excised in a single block. The skin between the incisions on the palm and finger is separated from the underlying tissues in the form of a bridge.

After aponerectomy, thorough hemostasis is performed (prevention of subcutaneous hematomas in the early postoperative period). Often, for hemostasis, it is enough to squeeze the wound for several minutes with a napkin moistened with warm saline or hydrogen peroxide (prevention of suppuration and ligature fistulas).

After excision of the palmar aponeurosis, the skin is completely straightened, which allows the wound to be sutured, avoiding skin tension. An aseptic dressing is then applied.

Usually, after performing an aponerectomy, it is possible to completely straighten the affected fingers on the operating table. But with III degree contracture according to Volkova’s classification, especially with a long course of the disease (20-30 years), full extension of the fingers on the operating table does not reach due to the attachment of secondary changes in the joint (arthrogenic contracture, subluxation in the joint, ankylosis). In this case, the first step on the affected finger and hand impose a distraction apparatus such as Volkov-Hovhannisyan, Ilizarov, etc. Within a month, a gradual dosed distraction is performed in the apparatus. This eliminates finger contracture. After that, an aponerectomy is performed as described above. If necessary, capsulotomy, tenolysis is performed.

Subsequently, a gypsum splint is placed on the operated limb along the palmar surface from the middle third of the forearm to the fingertips. The fingers are immobilized in an extended position. Perform daily dressings. Sutures are removed on 12-14 days. Plaster cast is applied for 1 week. After which the patient is prescribed exercise therapy. If necessary, and physiotherapy.

An example of the clinical use of the method.

Patient Martemyanov V.V. entered 2.04.07 in 1 trauma unit of the Design Bureau No. 2 of Tyumen with a diagnosis of Dupuytren's contracture of the right hand of the II degree. Medical record No. 5545 (Fig. 2).

04/03/07 the operation was performed: aponerectomy of the right hand. At the scheduled examination on January 30, 2008, contracture was completely eliminated, active and passive movements in the joints of the fingers were fully preserved, the strength of the hand was preserved, there were no neurovasal disorders of the right hand, and the function of the hand was fully restored (Fig. 3).

The proposed method for the treatment of Dupuytren's contracture allows to perform total aponeurectomy from the access, which makes it possible to close the resulting skin defect with “local” tissues (plastic with a local skin flap) when suturing the wound. In this case, it is possible to avoid the formation of peaked skin flaps, strong tension of the edges of the wound. In addition, the proposed method significantly reduces the duration of treatment and prevents the formation of a constricting scar.

The use of the distraction apparatus in the proposed method allows the complete elimination of contracture, secondary changes in the joint (arthrogenic contracture, subluxation in the joint, ankylosis) to avoid complications arising from intraoperative forced forced extension of the fingers - thrombosis and rupture of blood vessels, rupture of nerves, avoids the occurrence a large skin defect after extension of the fingers. In addition, the elimination of contracture simplifies the technique of performing aponeurectomy, since the affected finger does not interfere with the surgeon

The proposed method prevents the occurrence of cicatricial contractures in the late postoperative period and prevents the occurrence of ischemic and neurological disorders on the operated hand.

The proposed method is used in the Regional Clinical Hospital No. 2 of Tyumen.

Claims (4)

1. A method of treating Dupuytren's contracture, including performing anesthesia, incisions on the palmar surface of the hand and aponeuroctomy, fixation of the operated limb, performing physiotherapy and physiotherapy exercises, characterized in that a combination of conductive and local infiltration anesthesia is used, an S-shaped incision is made along the palmar surface of the brush in the area of the cord, a skin flap is formed, the width of which is 2-3 times greater than its length, then after excision of the palmar aponeurosis, the skin is straightened, the wound is sutured, the defect is Ms arising in the wound, after removal of contracture is closed with local tissues, postoperative brush fix plaster splint. 2. The method according to claim 1, characterized in that an additional club-shaped incision is made on the palm-lateral surface of the finger without violating the palmar-finger-like fold of the hand, the aponeurosis in the palm and fingers is excised in a single block, in addition, they save the skin area between the S-shaped and club-shaped cuts. 3. The method according to claim 2, characterized in that in the presence of Dupuytren's contracture of III Art. with the addition of secondary changes, a distraction apparatus is initially applied to the finger, dosed distraction is performed, then an aponerectomy is performed. 4. The method according to claim 1, characterized in that the surgical intervention on the hands is performed without applying a tourniquet.

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