RU2393806C1 - Surgical technique for necrotive suppurative complications of neuroischemic diabetic foot syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics. With considering the level of stenosing involvement of lower extremity arteries, there are formed 7 osteotrepanation apertures on the femur with a drill of diametre 5 mm, 9 osteotrepanation apertures on the shin bone with the drill of diametre 4 mm, 12-15 staggered osteotrepanation apertures of the iliac bone, and 8-10 open-end osteotrepanation apertures of the fibular bone with a K-wire of diametre 2 mm. Then on a foot, the K-wire of diametre 1 mm is used for osteotrepanation of the calcaneal bone, tarsal bones, and metatarsal bones in two points: at the interface of the proximal one-third and a middle one-third, and also at the interface of the middle and distal one-third. Thereafter, osteotrepanation of finger bones follows, and a tunnel of diametre to 2.5 mm, depth 5 cm is drilled within a tuberosity of tibia; therein a catheter of diametre 2 mm is introduced and fixed. It is followed with decompression epineurolysis of the tibial nerve on a segment not less than 5 cm with dissecting the tarsal canal ligaments and a surgical procedure of the foot nidus.

EFFECT: method provides indirect stimulation of the collateral blood flow on the lower extremity with considering the occlusion level of the arterial vessel with correcting neuropathy, discontinued extension of the pathological process, eliminated risk of early postoperative fracture with early activation of the patient.

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Description

The invention relates to medicine, namely surgery, traumatology and orthopedics, endocrinology and can be used for surgical treatment of purulent-necrotic complications in the neuroischemic form of diabetic foot syndrome.

In medicine, in patients with lower limb ischemia, in the absence of the possibility of direct vascular reconstruction, indirect limb revascularization methods are used, consisting in performing osteotrepanation of the lower limb bones with a drill or Kirschner spoke [E. Lutsevich, F. N. Zusmanovich, G. V. Chepelenko . Methods of stimulating collateral blood flow in obliterating diseases of the lower extremities. - M., 1999. - 194 p., Larionov A.A., Rechkin M.Yu., Schurova E.N., Filimonova G.N. Stimulation of blood circulation in the tissues of the limb by repeated perforations. Bulletin of Traumatology and Orthopedics. N.N. Priorova - 2004. - No. 1. - p. 53-56].

The disadvantages of analogues are:

- methods of indirect revascularizing operations, as a rule, are performed in patients only with an ischemic form of diabetic foot syndrome with I-IIIA degree of ischemia according to Fontaine-Pokrovsky;

- as a rule, methods of indirect revascularizing operations are performed in patients in the absence of purulent-necrotic lesions on the foot;

- used surgical methods are aimed at treating only one link of etiopathogenesis in diabetic foot syndrome - ischemia.

A close analogue is the method of revascularizing osteotrepanation according to copyright certificate No. 1061803, Bulletin of inventions 1983, No. 7.

The disadvantages of this method are:

- using the method only in patients with lower limb ischemia without purulent-necrotic complications;

- use only with ischemia of the II-IIIA degree;

- osteotrepanation of the fibula is not performed;

- osteotrepanation of all bones of the foot is not performed;

- for osteotrepanation only drills with a diameter of 5 mm are used without taking into account the size of the bone and segment of the lower limb;

- treatment of distal neuropathy syndrome on the foot is not performed.

The purpose of the invention: indirect stimulation of collateral blood flow in the lower limb, depending on the level of occlusion of the arterial vessel with correction of neuropathy in the neuroischemic form of diabetic foot syndrome.

The object of the invention is achieved by the fact that, depending on the level of stenotic lesion of the arteries of the lower extremity, 7 osteotrepanal holes on the femur with a 5 mm diameter drill, 9 osteotrepanic holes on the tibia of the lower leg with a 4 mm diameter drill; staggered 12-15 osteotrepanal openings of the ilium and 8-10 through osteotrepanic openings of the fibula with a Kirschner needle with a diameter of 2 mm, then on the foot with a Kirschner needle with a diameter of 1 mm perform osteotreparation of the calcaneus, tarsal bones, and metatarsal bones in two places: at the border the proximal third and middle third, as well as on the border of the middle and distal third, then osteotrepania of the bones of the phalanges of the fingers, then, in the area of the tibial tuberosity with a drill, create a tunnel with a diameter of up to 2.5 mm, g a 5 cm deep lobe into which a catheter with a diameter of 2 mm is inserted, fix it, then decompression epineurolysis of the tibial nerve is performed at a site of at least 5 cm with dissection of the ligaments of the tarsal canal with subsequent surgical intervention on the pathological focus of the foot.

In the present invention, indirect stimulation of collateral blood flow and removal of a purulent-necrotic focus with a neuro-ischemic form of diabetic foot syndrome are realized by the following steps: first, the "clean stage" of the operation is performed - revascularizing osteotrepanation of the lower limb bones and decompression epineurolysis of the tibial nerve, then the pathological osteopathy is removed;

- depending on the level of stenosis, osteosteptic openings are made above and below the level of stenosis, which allows stimulating the effect of indirect revascularization by creating collateral circulation above and below the level of stenosis;

- depending on the size of the bone, osteotrepanations on the lower limb are performed with drills (4; 5 mm) and Kirschner spokes (1; 2 mm) with different diameters, which allow to achieve the effect of indirect revascularization and eliminate the risk of fracture in the early postoperative period when the patient is activated on the second day after surgery;

- osteotrepanation of the fibula of the tibia is performed in order to enhance the stimulation of collateral blood flow, since in diabetes mellitus stenosis is mainly observed below the popliteal artery;

- osteotrepanation of all bones of the foot is performed in order to enhance the effect of indirect revascularization, moreover, on the calcaneus, fan-shaped and on the metatarsal bones in two places - in order to more stimulate collateral blood flow, as there is a distal stenosis of the arteries of the foot with the neuroischemic form of the syndrome of diabetic foot;

- complete dissection of the ligaments that form the tarsal canal, allows you to stimulate both saved direct and collateral blood flow on the foot,

- decompression epineurolysis of the tibial nerve can stimulate collateral blood flow, as well as stop neuropathy, eliminating the clinic of the tunnel syndrome;

- removal of a purulent-necrotic focus on the foot allows you to stop the spread of the pathological process.

The method was tested on 21 patients who received treatment in the purulent surgery department of the Municipal Clinical Hospital No. 3 of Astrakhan in the period 2005-2008. Below are the results of testing.

Example No. 1: patient S., 54 years old, was admitted to the surgical department on 09/19/06 with complaints: for pain, blueness, swelling of 2 fingers of the left foot. Three weeks before treatment, a wound appeared at the medial edge of the nail plate after treating the nail at home. She was self-medicating, using dressings with aloe leaves, periodically processing, tincture of iodine - without effect. A week later, suppuration began, and then redness and swelling of the skin of the nail phalanx with the spread to the rear of the foot. On the advice of a relative, she began to use ampicillin 0.5 grams 2 times a day. No effect. After a week the pain intensified, the finger turned blue, blackening appeared on the tip. I went to the clinic to a surgeon and was sent to an angiosurgeon for a consultation. With a diagnosis of gangrene of the left foot and the recommendation to perform high amputation at the hip level, she was sent to the surgical hospital of the Municipal Clinical Hospital No. 3 of Astrakhan.

From the anamnesis it is known that diabetes has been sick for 15 years. It is registered with the endocrinologist, however, the last time was at the reception 3 years ago. Maninil used irregularly, did not exercise glycemic control, explaining the specifics of work - she works as a teacher in a kindergarten. At admission: a state of moderate severity. In the mind, adequate. Skin and visible mucous membranes of normal color. Heart sounds are muffled. The rhythm is saved. HELL 120/80 mm tr.st., pulse 76 in one minute. Vesicular breathing. NPV - 16 in one minute. The tongue is moist, slightly overlaid at the edges with a white coating. The abdomen is soft, painless. Physiological administration is normal. Locally: 2 finger of the left foot is swollen, purple with marginal necrosis, hyperemia spreading to the rear of the foot to the border of the proximal and middle third. In the area of the nail plate, the wound is 0.5 · 0.5 cm with hemorrhagic discharge. There is no pulse on the arteries of the rear foot. The pulse on the back of the tibial is doubtful ?! On the popliteal weakened. On the thigh weakened. UZDG: Right ... Left: at the point of the femoral artery at the point of the popliteal artery, there is a 2-phase trunk type of blood flow, at the point of the posterior tibial artery - a monophasic collateral type of blood flow. At the point of the anterior tibital artery, blood flow is not determined. Conclusion: Hemodynamically significant (> 75%) stenosis of the femoral and popliteal with stenotic lesions of the arteries of the lower leg and foot on both sides. LPI <0.4. On the radiograph: destruction of the nail and middle phalanx of 2 fingers of the left foot. Complete blood count: hemoglobin = 140 g / l, red blood cells = 4.1 · 10 12 / l; leukocytes = 8.7 · 10 9 / l: n. = 8%, s = 60%, lymphocytes = 24%, m = 8%. Blood glucose = 11.2-12.5-10.8 mmol / L. Coagulogram and other biochemical analyzes without features. An increase in the level of pro-inflammatory cytokines was noted: FNO-α 30.12 pg / ml; IL-6 to 142.17 pg / ml; IL-16 up to 310.46 pg / ml; IL-8 to 118 pg / ml and anti-inflammatory lowering: IL-19 pg / ml. Consulted by a neurologist, endocrinologist - podiatrist of the Diabetic Foot cabinet.

Diagnosis: Diabetes mellitus, type 2, severe course, subcompensation. Diabetic foot, neuroischemic form, gangrene of the II toe of the left foot. Ischemia IIIB degree. Distal mixed polyneuropathy

Prescribed: broad-spectrum antibiotics, angioprotectors, antihypoxants, anticoagulants, neuroprotectors, vasaprostan, phlebotonics, short and prolonged insulin, detoxification and corrective therapy. Changing dressings with chlorhexidine.

09/22/06, an operation was performed under spinal anesthesia. After processing the surgical field, 2 cm long incisions were made on the thigh and lower leg, muscles were stupidly extended, and 7 osteotrepanal openings were made on the femur with a 5 mm diameter drill, 9 osteotrepanation holes were made on the tibia with a 4 mm diameter drill. Stitches on the skin, glove rubber drainage. After performing an additional soft tissue incision in the tibial tuberosity region, a tunnel 5 cm deep was created, into which a polyvinyl chloride catheter with a diameter of 2 mm was inserted and fixed. Then, in a checkerboard pattern without dissection of the skin and soft tissues, 12 osteotrepanal openings of the ilium and 8 through osteotrepanic openings of the fibula were made using a Kirschner spoke with a diameter of 2 mm. Kirschner spoke with a diameter of 1 mm on the foot of the heel bone osteotrepanation (fan-shaped), tarsal bones; metatarsal bones in two places - on the border of the proximal third and middle third, as well as on the border of the middle and distal third; osteotrepanation of bones of the phalanges. Then, at a distance of 2 cm below the inner ankle, a 7 cm skin incision was made around the ankle, a subcutaneous tissue. Ligaments forming the tarsal canal were found, and the last ligaments were completely dissected by 5 cm. The tibial nerve was isolated, taken to the holders and decompressed epineurolysis of the tibial nerve in the area up to 5 cm. Sutures on the skin, glove rubber drainage was introduced. Then exarticulation of the second finger was performed with resection of the head of the metatarsal bone. Rare seams on the skin, glove rubber drainage. Continued basic conservative therapy, physiotherapy. Primary healing. In satisfactory condition, she was discharged for outpatient treatment. Observation in dynamics. 30 months after surgery on the left foot. Deformation in the lower third of the right lower leg due to a consolidated fracture 12 years ago (Photo No. 1). There are no areas of hyperkeratosis, trophic ulcers on the plantar surface (Photo No. 2). It was examined in time 3; 6; 12; 18, 24, 30 months: every 6 months underwent a course of preventive therapy. Last hospitalization from 10.24.2008 to 10.29.2008 The examination showed an increase in the velocity of the main or collateral blood flow, as well as an increase in the index of resistance and pulsation. A decrease in the level of sensory neuropathy is noted.

Conclusion: the proposed method for the surgical treatment of purulent-necrotic complications in the neuroischemic form of diabetic foot syndrome allowed stimulating collateral blood flow in the lower limb, as well as stopping neuropathy and removing the pathological focus on the foot.

Example No. 2: patient S., 56 years old, was admitted to the surgical department on 6.12.06 with complaints: blueness, swelling of 1 finger of the right foot. Works as a truck driver. 2 weeks before hospitalization at the time of repair work in technical shoes (hard shoes), the first toe of the right foot was injured (blood corns formed). Damage to the skin with the development of inflammation was discovered by chance on the fourth day. He self-medicated using dressings with Vishnevsky ointment. In connection with the increase in edema on the foot, suppuration, turning the first finger blue, he turned to the clinic to the surgeon. Further directed to consultation with an angiosurgeon. With a diagnosis of gangrene of the right foot and the recommendation of high amputation, he was sent to the surgical hospital of the Municipal Clinical Hospital No. 3 of Astrakhan, hospitalized. From the anamnesis it is known that diabetes was diagnosed 8 years ago. In 2003, a foot-preserving operation on the left lower limb was performed - exarticulation of the first finger with resection of the metatarsal head. The last time an appointment with an endocrinologist was in 2004, motivating employment at work and the lack of complaints about the lower limbs. True, with errors in the diet, especially after drinking alcohol, I noted severe pain, a feeling of crawling “goose bumps”, and cooling of the extremities. Cramps when walking arose at a distance of 500-700 meters, periodically did not sleep at night due to pain in the foot. Maninil used irregularly, did not exercise glycemia control. At admission: a state of moderate severity. In the mind, adequate. Skin and visible mucous membranes of normal color. Heart sounds are clear, loud, clear. The rhythm is saved. HELL 115/80 mm Hg, pulse 74 in one minute. Vesicular breathing. NPV - 14 in one minute. Tongue dry, slightly overlaid with white coating. The abdomen is soft, painless. Physiological administration is normal. Locally: the first toe of the right foot is swollen, purple with a raised nail plate, from which pus flows. Upon examination, the nail plate fell away. Hyperemia, extending to the rear of the foot to the border of the proximal and middle third. There is no pulse on the arteries of the rear of the pillars. On the back of the tibia - dubious ?! On the popliteal weakened. On the femoral - weakened. Doppler ultrasound: In the area of femoral artery bifurcation, there are hyperechoic local plaques on both sides stenotic at least 35% of the vessel lumen. The blood flow in the common femoral artery is 3-phase, main: on the right is high-speed. In the popliteal artery, on both sides there is a 2-phase high-speed type of blood flow. Left ... Right: at the point of the posterior tibial artery - monophasic collateral type of blood flow. At the point of the anterior tibial artery, blood flow is not determined. Conclusion: Hemodynamically significant stenosis of the femoral and popliteal arteries with stenotic lesions of the arteries of the lower leg and foot on both sides. LPI <0.35. On the radiograph: destruction of the nail and middle phalanges of the first toe of the right foot. General blood test: hemoglobin = 115 g / l, red blood cells = 3.1 · 10 12 / l; leukocytes = 12.7 · 10 9 / l: n. = 1%, s = 60%, lymphocytes = 30%, m = 9%. Blood glucose = 15.2-17.5-16.8 mmol / L. Coagulogram and other biochemical analyzes without features. An increase in the level of pro-inflammatory cytokines was noted: FNO-α to 25.12 pg / ml; IL-6 up to 112.17 pg / ml; IL-1B up to 290.46 pg / ml; IL-8 to 101 pg / ml and anti-inflammatory lowering: IL-14 pg / ml. Consulted by a neurologist and endocrinologist - podiatrist of the Diabetic Foot Cabinet.

Diagnosis: diabetes mellitus, type 2, severe course, decompensation. Diabetic foot, neuroischemic form, gangrene of the first toe of the right foot. Ischemia IIIB degree. Distal mixed polyneuropathy.

Prescribed: broad-spectrum antibiotics, angioprotectors, antihypoxants, anticoagulants, neuroprotectors, vasaprostan, phlebotonics, short and prolonged insulin, detoxification and corrective therapy. Changing dressings with chlorhexidine.

12.12.06, the operation was performed under spinal anesthesia. After processing the surgical field, 2 cm long incisions were made on the lower leg, muscles were stupidly spread, and 9 osteotrepanation holes were made on the tibia of the lower leg with a drill with a diameter of 4 mm. Stitches on the skin, glove rubber drainage introduced. After performing an additional soft tissue incision in the tibial tuberosity region, a tunnel of 5 cm depth was drilled into which a polyvinyl chloride catheter with a diameter of 2 mm was inserted, was fixed. Then, without cutting the skin and soft tissues, 8 through osteotrepanic openings of the fibula were made with a Kirschner needle with a diameter of 2 mm and a Kirschner needle with a diameter of 1 mm on the heel of the calcaneus (fan-shaped), tarsal bones; metatarsal bones in two places - on the border of the proximal third and middle third, as well as on the border of the middle and distal third; osteotrepanation of bones of the phalanges. Then, at a distance of 2 cm below the inner ankle, an incision is made around the ankle of the skin, subcutaneous tissue. Ligamentous elements forming the tarsal canal and complete dissection of the ligaments were found. The tibial nerve was isolated, taken to the holders, and decompression epineurolysis of the tibial nerve was performed on a 5 cm site. Sutures on the skin, drainages from glove rubber were introduced. The last step was the removal of the pathological focus - exarticulation of the first finger with resection of the metatarsal head. Rare seams on the skin, glove rubber drainage. Continued basic conservative therapy, physiotherapy. Primary healing. In satisfactory condition, the patient was discharged for outpatient treatment. Observation in dynamics. 20 months after surgery on the right foot. (Photo No. 3). On the plantar surface, changes characteristic of the diabetic foot syndrome are visible. On the right foot there are areas of hyperkeratosis. When wearing shoes, uses silicone orthopedic insoles (Photo No. 4). Examined in time 3; 6; 12; 20 months with preventive therapy courses. At the examination and conduct of the examination and the course of preventive treatment after 18 months did not appear due to employment at the place of work. He independently conducted conservative therapy with vasonite, berlition, phlebodia 600 during the month. Last hospitalization from 10/14/2008 to 10/29/2008.

Conclusion: this method of surgical treatment of purulent-necrotic complications in the neuroischemic (mixed) form of diabetic foot syndrome allowed to stimulate collateral blood flow in the lower extremity, as well as to stop neuropathy, which is especially important for manifestations of the tunnel syndrome as a result of pathological processes in the tarsal canal and the tibial nerve membrane and remove the pathological focus on the foot.

The proposed method achieves indirect stimulation of collateral blood flow and elimination of the tunnel syndrome in patients with purulent-necrotic complications with a neuroischemic form of diabetic foot syndrome, which allows:

- stop ischemia on the lower limb, depending on the level of stenosis;

- stop distal neuropathy with the phenomena of the tunnel syndrome;

- eliminate purulent-necrotic focus.

Claims (1)

A method of surgical treatment of purulent-necrotic complications in the neuroischemic form of diabetic foot syndrome by indirect revascularizing osteotrepanation of the lower limb bones, characterized in that, depending on the level of stenotic lesion of the arteries of the lower limb, 7 osteotrepanic holes are made on the femur with a drill 5 mm in diameter, 9 osteotrepan tibia of the lower leg with a drill with a diameter of 4 mm; staggered 12-15 osteotrepanal openings of the ilium and 8-10 through osteotrepanic openings of the fibula with a Kirschner needle with a diameter of 2 mm, then on the foot with a Kirschner needle with a diameter of 1 mm perform osteotreparation of the calcaneus, tarsal bones, and metatarsal bones in two places: at the border of the proximal third and middle third, as well as on the border of the middle and distal third, then osteotrepania of the bones of the phalanges of the fingers, then in the area of the tibial tuberosity with a drill a tunnel is created with a diameter of up to 2.5 mm, g Ubin 5 cm, into which a catheter with a diameter of 2 mm, it is fixed, then produce decompression epinevroliz tibial nerve at the site at least 5 cm from the incision channel tarsal ligaments, followed by surgical intervention for the pathological focus foot.

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