RU2534851C1 - Method for thumb reconstruction in total defects of radial border of hand - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: at the first stage, restoring a ball of the thumb and forming a soft-tissue finger frame are ensured by a repair of the radial border of hand with using a double skin-fat flap. After the flap survives, a fragment of the second instep bone on microanastomosis with a small skin-fat flap is grafted in a position of the first metacarpal bone. A transverse osteotomy of the restored first metacarpal bone is performed in the middle one-third. A pin is brought through its distal fragment; a bearing plate for formed on a proximal end of the pin. A distal end of the pin is brought out through the soft-tissue thumb frame and fastened to a screw rod of an external fixation apparatus applied to a forearm. That is followed by a distraction of a distal fragment; thereafter a nonvascular cortical-spongious bone autograft is placed between the bone fragments of the metacarpal bone with preserving the formed distraction regenerate, and an osteosynthesis of the bone fragments is performed.

EFFECT: method enables forming the thumb of the adequate length and provides the bone frame stability.

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Description

The present invention relates to medicine, namely to reconstructive hand surgery.

There is a method of reconstruction of the first finger of the hand, including the transplantation of the skin-nail flap of the first toe on microvascular anastomoses in combination with avascular bone grafting of the solid base of the restored finger (Morrison WA, (O'Brien B. McC., Macleod AM Thumb reconstruction with a free neurovascular wrap-around flap from the big toe // J. Hand Surg. - 1980. - Vol.5, No. 8. - P.575-583).

However, the method has the following disadvantages: 1) the walking function and the appearance of the first finger are violated, since part of its nail phalanx is taken; 2) trophic disorders can be noted on the first and second toes of the donor foot; 3) there is a resorption of an avascular bone graft, which leads to a decrease in the length of the restored finger; 4) the method does not allow you to restore the first finger with total defects of the first finger and metacarpal bone; 5) there is a real danger of developing soft tissue necrosis remaining on the medial edge of the first toe, which exacerbates a donor flaw.

As a prototype, the method of reconstruction of the first finger with total defects of the radial edge of the hand was chosen, including the transplantation of the second toe together with a fragment of the metatarsal bone on microvascular anastomoses to the position of the first finger (Morrison WA, O'Brien B. McC., Macleod AM Experience with thumb reconstruction // J. Hand Surg. - 1984. - Vol. 9 - B, No. 3. - P.223-233).

The disadvantages of the method are: 1) the presence of a donor flaw, since the number of fingers on the foot decreases, the front section of the foot narrows, which leads to its cosmetic and functional disorders; 2) deformations of the transplanted finger develop, which requires corrective interventions on its various structures; 3) in most cases there is a cosmetic mismatch of the restored finger to a healthy one; 4) inadequate areas of the tenar and the first interdigital gap are formed.

The task of the invention is to improve the method.

The technical result is the formation of the first finger of adequate length and ensuring the stability of its bone skeleton with a minimum donor flaw.

The technical result is achieved due to the fact that in the method, including transplantation of the skin-skeletal complex of the foot with a fragment of the second metatarsal bone on microvascular anastomoses, the first step is the plastic of the radial edge of the hand with a double skin-fat flap with the creation of a soft tissue skeleton of the first finger and the tenar region, at the second stage, a fragment of the second metatarsal bone is transplanted into the formed soft-tissue skeleton of the radius of the hand in the position of the first metacarpal bone, after consolidation and bone fragments produce a transverse osteotomy of the restored first metacarpal bone in the middle third, an intramedullary spoke is inserted through its distal fragment, at the proximal end of which a thrust pad is formed in the form of an asymmetric letter P, and the distal end of the spoke is brought out through the center of the end surface of the created soft tissue skeleton of the first finger and attached to the screw rod of the external fixation device superimposed on the forearm, then the distal fragment is gradually distilled into the precursor but the created soft-tissue skeleton of the radial edge of the hand, after the bone fragment is displaced into the soft-tissue skeleton, continues its distraction together with the surrounding tissues by the required amount, then an avascular cortical-spongy autograft is placed between the bone fragments of the metacarpal bone with the preservation of the resulting distraction regenerate and bone fragments are osteosynthesis.

The essence of the method is illustrated by drawings, where figure 1 shows the formation of a soft tissue skeleton of the tenar and the first finger; figure 2 - transplanted to the position of the first metacarpal bone fragment of the second metatarsal bone; figure 3 - transverse osteotomy of the first metacarpal bone in the middle third, holding the needle through the distal fragment of the first metacarpal bone, shifting it into the formed soft tissue skeleton of the finger; figure 4 - bone grafting of the distraction defect of the first metacarpal bone using a cortical-spongy autograft.

The method is as follows.

The first step is the plastic surgery of the radial edge of the brush with a double skin-fat flap 1 to restore the tenar region and the formation of the soft tissue skeleton of the finger (Figure 1). When the flap is cut off, a soft-tissue skeleton 2 is created in the region of the first finger. After the engraftment of the flap, a fragment of the second metatarsal bone 3 is transplanted on microanastomoses with a small skin-fat back flap to the position of the first metacarpal bone (Figure 2). To do this, a double flap 1 is divided into two leaves along a scar in the area of their radial edge, the area of osteosynthesis is refreshed. Perform osteosynthesis of a fragment of the metatarsal bone with the bones of the wrist, restore blood flow in the graft (Figure 2). The skin-fatty flap of the metatarsal bone is placed between the sheets of the double flap 1. The donor wound on the foot is sutured with primary sutures. After the onset of consolidation, transverse subperiosteal osteotomy of the transplanted metatarsal bone 3 is performed at the level of its middle third. Through the formed distal fragment of the metatarsal bone 3, Kirschner’s spoke 4 is inserted intramedullary, at the proximal end of which a thrust pad is formed in the form of the asymmetric letter P, and the distal — lead outward through the end of the formed soft tissue skeleton 2 of the radial edge of the hand, and an excess of soft tissues in the region of the end face of the transplanted fragment, and the spoke is passed through the center of the formed fold of the flap 1 (Fig.3). The distal end of the spokes is attached to the screw rod of the external fixation device, superimposed on the forearm. Next, a gradual distraction of the distal bone fragment in the vertical direction into the formed soft tissue skeleton is carried out 2. After the bone fragment enters the thickness of the soft tissue skeleton, the bone fragment is continued to be distracted along with the surrounding soft tissues. At the end of the distraction of the bone fragment and soft tissue of the finger skeleton, plastic surgery of the resulting distraction defect of the formed first metacarpal bone is performed using a cortical-spongy non-vascular autograft 5 taken from the iliac wing (Figure 4). Bone fragments and the graft are fixed with needles while preserving the resulting distraction regenerate. Immobilize the hand with a plaster splint for the duration of transplant consolidation.

Clinical example.

B-th L-s S.Yu., 24 years old, and.b. No. 254408, was at the NNIIITO regarding total defects of the first, second fingers and metacarpal bones, a defect in the distal row of wrist bones. From the anamnesis it is known that 3 months ago the patient received a severe mechanical injury to his right hand. On admission, there is a cicatricial defect in soft tissues in the area of the radial and dorsal surfaces of the third metacarpal bone. Hand grip is completely absent. At the first stage, the patient underwent excision of scars on the radial surface of the third metacarpal bone and replacement of the resulting tissue defect with a double Converse-Blokhin flap (1.06.11 g) with the formation of a soft-tissue skeleton of the tenar region and the first finger. At the next stage, a fragment of the second metatarsal bone with a length of 4 cm was transplanted on microvascular anastomoses to the position of the first metacarpal bone (09/28/11). After the onset of consolidation of the transplanted fragment of the second metatarsal bone, a periosteal transverse osteotomy was performed at the level of the middle third (05/22/12). A needle was inserted through the distal fragment intramedullary with a thrust pad in the form of an asymmetric letter P at the proximal end. The distal end of the spoke is brought out through the center of the end surface of the soft tissue skeleton of the first finger and is attached to the screw rod of the external fixation device superimposed on the forearm. After the operation, a gradual distraction of the distal fragment into the previously formed soft-tissue skeleton of the first finger is started. After distraction of the bone fragments and soft tissues of the finger was completed, plastic surgery was performed on the resulting defect in the transplanted metatarsal bone with a cortical-spongy non-vascular autograft. The graft length was 4 cm. During the operation, the formation of a pronounced distraction regenerate was noted, which was stored and used to cover the graft. 6 months after surgery, complete transplant consolidation and the formation of a distraction bone regenerate connecting fragments of the metatarsal bone are noted. The length of the formed first finger along with the first metacarpal bone was 8 cm. A good cosmetic result was achieved due to the formation of the tenar region, the first interdigital gap and the creation of an adequate uniform thickness of the soft tissues of the first finger over its entire surface. The finger maintains a functionally advantageous position and provides the ability to grasp the brush. One year after the operation, the finger retains its length. There are no signs of bone resorption.

Thus, the method allows the formation of the first finger of adequate length and ensures the stability of its bone skeleton.

When implementing the method, minimization of the donor flaw is achieved, since the number of fingers on the foot is preserved, and the donor wound is sutured with primary sutures.

Good blood supply to the fragments of the transplanted metatarsal bone provides the formation of a distraction regenerate and favorable conditions for the consolidation and reconstruction of the graft, which excludes the development of deformities of the skeleton of the finger.

A bone regenerate formed during the gradual dilution of fragments provides prophylaxis for graft subsidence.

The applied method of distraction of a fragment of the metatarsal bone into a preformed soft-tissue skeleton ensures the creation of uniform shelter with soft tissues of the bone base (adequate skin integument) of the restored finger. At the same time, prophylaxis of teething of soft tissues with knitting needles, reduction of trauma of distraction is provided.

Also achieved is the distraction of the soft tissue skeleton, an increase in the volume and area of its soft tissues, which ensures uniform thickness of the soft tissues of the restored first finger without performing additional corrective interventions on them.

The use of flaps with diffuse blood supply also allows the formation of an adequate first interdigital gap and tenar region.

Claims (1)

A method for reconstructing the first finger for total defects of the radial edge of the hand, including transplantation of the skin and bone complex of the foot with a fragment of the second metatarsal bone on microvascular anastomoses, characterized in that the first step is plastic surgery of the radial edge of the hand with a double skin-fat flap with the creation of a soft tissue skeleton of the first finger in of the tenar region, at the second stage, a fragment of the second metatarsal bone is transplanted into the formed soft tissue skeleton of the radius of the hand at the position of the first metacarpal bone, Before the onset of consolidation of bone fragments, a transverse osteotomy of the restored first metacarpal bone is made in the middle third, an intramedullary needle is inserted through its distal fragment, at the proximal end of which a thrust pad is formed, and the distal end of the spoke is brought out through the center of the end surface of the created soft tissue core of the first finger and attached to the screw rod of the external fixation device superimposed on the forearm, then the distal fragment is gradually distilled into the preliminary o the created soft-tissue skeleton of the radial edge of the hand, after the bone fragment is displaced into the soft-tissue skeleton, continue its distraction together with the surrounding tissues by the required amount, then an avascular cortical-spongy autograft is placed between the bone fragments of the metacarpal bone with preservation of the resulting distraction regenerate and bone fragments are osteosynthesis.

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