RU2421168C1 - Method of treating severe form of dupuytren's contracture of fingers - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics and is intended for treating patients with Dupuytren's contracture of fingers. Method lies in dissection of pathologically changed aponeurosis on palm and fingers from two-level transversal skin incision and palm aponeurosis to subaponeurotic space. The first incision is made in middle part of palm on entire length of aponeurosis. The second incision is made parallel to the first one in distal part of palm on the width of degenerated cords. With additional oblique incision transversal incisions are connected and degenerated aponeurosis cords are dissected on palm. Longitudinal incision is made from distal transversal incision on palm to middle phalanx, on middle line of finger, which is in maximal flexion contracture. Finger-wide shaped incision is made, degenerated cords on it are dissected. From additional incision in lower third of forearm superficial flexor tendon is exposed, cut in Z-shaped way and elongated with application of interrupted adapting sutures on ends of tendon of superficial flexors. ^ EFFECT: method makes it possible to eliminate contracture in proximal inter-phalangeal joint. ^ 1 ex, 9 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of patients with Dupuytren's contracture of the fingers.

Known methods for the surgical treatment of Dupuytren's contracture are reduced to the excision of pathologically altered palmar aponeurosis and the elimination of flexion contracture of the fingers.

A known method of surgical treatment of Dupuytren's contracture, including excision of the palmar aponeurosis, through transverse incisions along the flexion folds in the palm and fingers, followed by healing of open wounds by secondary tension [1]. However, with this method, the healing time of open wounds is from 3 to 6 weeks, which for a long time significantly affects the quality of life of the patient; the formation of rough scars with the formation of contracture of the fingers is possible.

There is a “Method for the treatment of flexion contracture of fingers” [2], in which, with the aim of restoring the function of the hand by reducing the skin defect, before the operation for excising the pathologically altered palmar aponeurosis, redressing is performed using a compression-distraction apparatus. In this case, the reduction is performed until over-extension in the metacarpophalangeal joints and complete extension in the interphalangeal joints are achieved. For this purpose, a compression-distraction apparatus is superimposed on the forearm and hand, and closed redress is gradually carried out until hyperextension of 10 ° in the metacarpophalangeal joints and complete extension in the proximal interphalangeal joints (180 °) are achieved. The position achieved by the redresses is stabilized by the apparatus for 5-7 days, and then the operation for excision of the palmar aponeurosis is performed. The disadvantage of this method is the additional trauma when applying a compression-distraction apparatus to the forearm and hand before the main operation. Given the severity of the pathological process in which the skin, palmar aponeurosis, tendons and joints of the fingers of the hand are involved, with the occurrence of mixed contracture (dermatodedesmo-tenro-arthrogenic contracture), even with very long closed redress, hyperextension in the metacarpophalangeal joints cannot be achieved, and full extension in the proximal interphalangeal joints. Moreover, if it was possible to eliminate contracture in the joints of the fingers by distraction with an apparatus, then there is no need to excise a pathologically altered palmar aponeurosis.

The prototype of the claimed method is the "Method of treatment of flexion contracture of the fingers" [3]. In order to restore the function of the hand on the palm, a two-level cross-section of the skin and palmar aponeurosis is performed to the subaponeurotic space. The first is in the middle part of the palm, the entire width of the aponeurosis, with the elimination of flexion contracture by extension of the bent fingers to a possible angle. The second incision, parallel to the first, is made in the distal part of the palm to the width of the degenerated cords, with the further elimination of contracture of the fingers in the metacarpophalangeal joints. An additional oblique incision connects the transverse incisions, excises the degenerate aponeurosis strands in the palm of the hand, and makes a longitudinal incision from the distal transverse incision in the palm to the middle phalanx along the midline of the finger, which is in maximum flexion contracture. Make a shaped incision to the width of the finger, excised degenerate cords on it, skin wounds are sutured by moving the skin flaps. The disadvantage of this method is that the contracture of the finger in the proximal interphalangeal joint (PMPS) cannot be eliminated, due to which the function of the finger suffers.

The invention consists in a combination of features sufficient to achieve the desired technical result, consisting in a significant reduction in treatment time and restoration of the patient's ability to work by reducing the stages of the operation.

The aim of the invention is to restore the function of the hand by eliminating the pronounced flexion contracture of the finger in the proximal interphalangeal joint.

The essence of the invention lies in the fact that a method of treating severe Dupuytren's contracture of the fingers is to excise a pathologically altered aponeurosis in the palm and fingers from a two-level cross-section of the skin and palmar aponeurosis to the subaponeurotic space. The first dissection is in the middle part of the palm over the entire width of the aponeurosis. The second incision, parallel to the first, is made in the distal part of the palm to the width of the degenerated cords. An additional oblique incision connects the transverse incisions and excises the reborn aponeurosis cords in the palm of the hand. A longitudinal incision is made from the distal transverse incision in the palm of the hand to the middle phalanx, along the midline of the finger, which is in maximum flexion contracture. Make a shaped incision to the width of the finger, excised reborn cords on it. A tendon of the superficial flexor is isolated from an additional incision in the lower third of the forearm, a “Z” -section is dissected and lengthened with knotted adaptive sutures at the ends of the dissected tendon of the surface flexors. Stitches on the wound on the forearm. Limberg skin grafting on fingers.

The lengthening of the tendon of the superficial flexor of the finger in the lower third of the forearm, which has a pronounced contracture, after excision of the pathologically changed aponeurosis in the palm and fingers, allows to eliminate contracture in the proximal interphalangeal joint, which ensures restoration of the function of the hand.

Theoretically and practically pronounced flexion contracture in PMPS can be eliminated by crossing the legs of the superficial flexor within the tendon sheaths, but as a result of this intervention, cicatricial fusion occurs between the cut off legs of the superficial flexor and the deep flexor. Subsequently, this fusion leads to a limitation of the function of the finger.

The method is illustrated by illustrations. View of the hand before surgery: in Fig. 1 - from the palmar surface, in Fig. 2 - from the rear. The stages of the operation are shown in Fig.3 - Fig.8: Fig.3 is a view of the hand after excision of the middle part of the palmar aponeurosis and longitudinal cords on the 2nd finger; in Fig.4-5 - the allocation of the tendon of the superficial flexor of the 2nd finger; figure 6 - "Z" -shaped dissection of the tendon of the superficial flexor of this finger in the lower third of the forearm; Fig.7 - the position of the 2nd finger after elimination of flexion contracture; on Fig - overlay knotted sutures on an elongated tendon. Figure 9 is a view of the brush immediately after surgery.

The method is as follows. After appropriate treatment of the skin of the hand, under regional anesthesia Sol. Lidocaini 2% - 30 ml., A pathologically altered aponeurosis in the palm and fingers is excised from a two-level cross-section of the skin and palmar aponeurosis to the subaponeurotic space. The first dissection is performed in the middle of the palm of the entire width of the aponeurosis. The second incision, parallel to the first, is made in the distal part of the palm to the width of the degenerated cords. An additional oblique incision connects the transverse incisions and excises the degenerated aponeurosis strands in the palm of the hand, and makes a longitudinal incision from the distal transverse incision in the palm to the middle phalanx along the midline of the finger, which is in maximum flexion contracture. Make a shaped incision to the width of the finger and excised reborn cords on it. From an additional incision, in the lower third of the forearm, the tendons of the surface flexors are isolated, “Z” -sectionally dissect them and lengthen, with the application of knotty adaptive sutures at the ends of the dissected tendons. Stitches on the wound on the forearm. Limberg skin grafting on fingers. Palmar gypsum splint. Medication and physiotherapy.

Clinical example.

Patient D., born in 1954, medical history No. 6255, a pensioner, was admitted to the wrist department of the SRTT “WTO” with a diagnosis of Dupuytren's contracture of 1, 3, 4 fingers of the II degree, 2 fingers of the III degree, post-traumatic arthrogenic flexion contracture 5 fingers, over joint pillows (Garo nodules) 3-4 fingers of the left hand (see Fig. 1-2). Operated on 02/06/09. After appropriate treatment of the skin of the hand, under regional anesthesia Sol. Lidocaini 2% - 30 ml., Transverse incisions in the area of the distal palmar fold fold wedge-shaped incised degenerate aponeurosis strands of the first order to 1-2-3-4 fingers. "Z" -shaped incision on the 2nd finger, secrete and excise the degenerate cord of the aponeurosis of the second order (see figure 3). The pronounced finger flexion contracture in PMPS is eliminated by lengthening the tendon of the surface flexor of this finger, for which, in the lower third of the forearm, an additional incision is made to isolate the tendon of the surface flexor of the second finger (see Figs. 4-5), “Z” -section it ( see FIG. 6). After elimination of finger flexion contracture in PMPS (see Fig. 7), adaptive knotted sutures are applied to the ends of the dissected tendon of the surface flexor (see Fig. 8). Hemostasis during the operation; seams on the skin, local skin plastic according to Limberg on 2 fingers (see Fig. 9), rubber graduates, aseptic dressing, palmar plaster splint before removing the seams.

The postoperative period in patients with Dupuytren's contracture, operated on by the proposed method, is common for patients in this category.

Information sources

1. A.I. Ashkenazi - Elimination of contracture in Dupuytren’s disease using the “open palm and fingers” method. M., 1981, pp. 12-14.

2. Auth. testimonial. USSR No. 1398849, A61B 17/56, BI No. 20, 1988.

3. RF patent No. 2343867, А61В 17/56, BI No. 2, 2009

Claims (1)

A method for treating severe Dupuytren's contracture of the fingers by excising a pathologically altered aponeurosis in the palm and fingers from a two-level cross-section of the skin and palmar aponeurosis to the subaponeurotic space, the first in the middle part of the palm to the entire width of the aponeurosis, the second section parallel to the first is made in the distal part of the palm on the palm the width of the degenerated cords, an additional oblique incision connects the transverse incisions and excises the degenerated cords of the aponeurosis in the palm of your hand, conduct longitudinal the first incision from the distal transverse incision in the palm of the hand to the middle phalanx along the midline of the finger, located in the maximum flexion contracture, making a curved incision to the width of the finger, excised degenerate cords on it, characterized in that tendons of surface flexors are isolated from the additional incision in the lower third of the forearm , Z-shaped to dissect them and lengthen with the application of knotty adaptive sutures to the ends of dissected tendons of superficial flexors, sutures on the wound of the forearm, produce skin plastic surgery imbergu fingers.

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