RU2563957C1 - Method for transferring vascularised graft of third rib for humeral defect replacement - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to traumatology and orthopaedics and can be used to transfer a vascularised graft of a third rib to replace a humeral defects. A longitudinal approach 12-15 cm long is exercised in a projection of the third rib. A costal artery with a costal nerve is separated from the rib throughout 7-9 cm in an axillary region; the costal artery is ligatured, and the costal nerve is transected within a planned osteotomy; a costal muscle is transected. A pleura is separated from the rib along an inner surface. The osteotomy is performed. A bone graft is produced thereby; it has a vascular pedicle 7.5-9 cm long and consisting of the costal artery and homonymous assistant veins, a section of the intercostal muscles and an intercostal membrane. The graft is delivered in a musculosubcutaneous tunnel of the chest beckwards from a greater pectoral muscle and a neurovascular beam on the shoulder. The graft is integrated into intramedullary canals of humeral fragments. The humeral fragments are fixed with a plate.

EFFECT: method enables avoiding pleural cavity exposure, reducing a risk of graft displacement.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to replace defects of the humerus.

A known method of transplantation nekrovosnabzheniya bone autograft to replace the bone defect of the victim. The graft is formed from the bone of the patient himself and transplanted into the area of the bone defect. The limb is immobilized with a plaster cast until the graft merges with the recipient bone bed (VD Chaklin. Bone grafting. - M .: Medicine, 1971. - Chapter 4. Bone grafting with fresh fractures, delayed consolidation and pseudoarthrosis. - P.37 -63.). However, the described method has significant disadvantages. The transplanted bone autograft resolves and secrete necrohormones that activate osteogenesis. This requires prolonged immobilization with a plaster cast. Complications such as fracture of a transplanted graft or its resorption, which leads to failure of the surgical intervention, can occur.

Closest to the proposed method according to the technique of performing the operation is a method of non-free autoplasty with a blood-supplying bone graft formed from a distal metaepiphysis of the radius on the vascular pedicle, which includes the radial artery and the corresponding associated veins. Moreover, to mobilize the transplanted tissue complex, the radial artery is bandaged at the level of the distal radial metaepiphysis. The disadvantage of the described method is that the selected tissue complex can only be moved throughout the forearm, but cannot be transplanted onto the humerus. The specified disadvantage is deprived of the proposed method of transplanting a blood transplant of the third rib. The technical result of the invention is the possibility of transplanting a third rib transplant on a vascular pedicle consisting of a costal artery, a section of intercostal muscles, and also an intercostal membrane. The graft and leg are carried out in the subcutaneous muscle tunnel of the chest posterior to the pectoralis major muscle and the neurovascular bundle on the shoulder, and then the graft is introduced into the bone marrow channels of the humerus defect.

The basis of the invention is the creation of a method for transplanting a blood transplant of the third rib to replace the defects of the humerus, which provides greater transplant efficiency by choosing the optimal site for transplantation within the rib, determining the direction of the channel for the transplant, as well as the location and length of the graft vascular leg.

The solution to this problem is provided by the fact that in the method of transplanting a blood supply transplant of the third rib to replace the defects of the humerus, including ligation of the main vessel and the allocation of the bone graft on the vascular pedicle, which includes the artery and the same associated veins, the third graft graft on the vascular pedicle, consisting from the costal artery, the area of the intercostal muscles and the intercostal membrane, carried out in the subcutaneous muscle tunnel of the chest posterior to the pectoralis major muscle and osseous-neural bundle on the shoulder, and then implant the graft into the bone marrow channels of the fragments of the humerus.

To substantiate the possibility of transplanting the third rib graft into the region of the defect of the upper third of the humerus, 12 experiments were performed on 6 unfixed corpses of adults. There were 4 men and 2 women. As objects of study, individual sections of the II, III, and IV ribs were considered as possible bone grafts for their movement to the region of the upper third of the shoulder. The research objectives included the search for the optimal site for transplantation within a particular rib, determining the direction of the channel for the transplant, as well as the location and length of the graft vascular leg. Conducted morphometry, photographing and recording the results. A total of 12 experiments were performed.

The costal arteries (aa.costales) are branches of the vertebral artery (a.vertebralis). The costal artery is located in the lower part of the rib along with the costal nerve (n.costalis). The technique of the experiment. A longitudinal access of 12-15 cm in length in the projection of the 3rd rib exposed the rib. The costal artery along with the costal nerve was separated from the rib for 7-9 cm in the axillary region, where the rib has a relatively straight shape. Bandaged the costal artery and crossed the costal nerve at the level of the distal part of the rib at the site of the proposed osteotomy. Crossed the rib muscle at a distance of 0.5 cm from the lower edge of the rib. The pleura was separated from the rib along the inner surface for 3-4 cm. The rib osteotomy was performed. The ribs penetrated into the medullary canal with a sharp hook, they took him out and bluntly exfoliated the pleura from the rib. An osteotomy of the rib was performed in its proximal part. The length of the formed vascular pedicle was 7.5–9 cm and allowed the graft to be moved and transplanted to the region of the humerus defect (Figs. 1, 2, 3, 4). By accessing the inner surface of the shoulder in the axillary hollow, the neurovascular bundle of the upper limb was isolated, it was removed anteriorly, the subcutaneous canal was formed through which the transplant was formed, placing the vascular pedicle posterior to the neurovascular bundle, and the graft was also inserted into the bone marrow canals of the fragments the humerus. Fragments of the humerus were fixed with a plate.

The drawings depict the following.

Figure 1. The formation of a graft III ribs on the vascular pedicle. Operation scheme. Arrows indicate: 1 - transplant of the third rib; 2 - vascular pedicle; 3 - pleura.

Figure 2. The formation of a graft III ribs on the vascular pedicle. Operation scheme. The graft is placed in the defect of the humerus. Arrows indicate: 1 - transplant of the third rib; 2 - vascular pedicle; 3 - pleura.

Figure 3. The operation diagram presented on the skeleton. Arrows indicate: 1 - donor defect; 2 - vascular pedicle; 3 - defect of the humerus; 4 - transplanted graft of the third rib.

Figure 4. Anatomical preparation of the chest and right shoulder. The formation of a graft III ribs on the vascular pedicle. Arrows indicate: 1 - graft III ribs; 2 - vascular pedicle; 3 - the front edge of the skin; 4 - under the vascular leg summed Buyalsky's scapula.

Figure 5. Type of patient N. before surgery.

6. X-ray before surgery.

7. Suspension of the humeral head. Operation scheme. Arrows indicate: 1 - mylar ribbon; 2 - channel in the spine of the scapula; 3 - location of the node.

Fig. 8. Radiograph 1.5 years after surgery.

The proposed method was performed as follows. A longitudinal access of 12-15 cm in length exposed the third rib. The costal artery along with the costal nerve was separated from the rib for 7–9 cm in the axillary region. Bandaged the costal artery and crossed the costal nerve at the level of the distal part of the rib. Crossed the rib muscle at a distance of 0.5 cm from the lower edge of the rib. The pleura was separated from the rib along the inner surface for 7–9 cm. The rib osteotomy was performed. The rib was retracted outward and the pleura exfoliated from it for another 5-7 cm. The rib was crossed in its proximal part. The size of the formed vascular pedicle allowed the graft to be moved and transplanted into the region of the humerus defect. By accessing the inner surface of the shoulder in the axillary hollow, the neurovascular bundle of the upper limb was isolated, it was displaced anteriorly, a subcutaneous canal was formed in the direction of the humerus, through which the formed graft was placed, placing the vascular leg of the graft posterior to the pectoralis major muscle and neurovascular bundle on the shoulder , and also implanted a transplant into the bone marrow channels of the humerus defect. Fragments of the humerus were fixed with a plate.

CLINICAL OBSERVATION

N., 39 years old, received a gunshot wound to his left shoulder in the upper third of May 20, 1996. In the hospitals of the city of Makhachkala and Kostroma underwent surgical treatment and dermatome skin grafting. The limb was immobilized with a plaster cast for 2 months. One year after the injury, osteomyelitis developed. Two necrotic and sequestrectomy operations were performed. Fistulas closed. Subluxation of the humeral head has survived. There was no abduction. When flexing in the elbow joint, pain and deformation occurred at the level of the defect in the upper third of the shoulder. The patient held his hand brought to the torso (figure 5). In the clinic of military traumatology and orthopedics on 05/18/2004, regarding a defect in the upper third of the left humerus and paralytic subluxation of the head (Fig. 6) under endotracheal anesthesia with a linear access of 14 cm, the third rib is exposed for 12 cm. A bone is formed using microsurgical technique -muscular graft from the third rib section with a length of 5.5 cm with a supply vessel (costal artery), a section of intercostal muscles and intercostal membrane 5.5 × 2.5 cm in size. Figured access along the front surface of the shoulder was exposed and fragments of the humerus were isolated. There was severe osteoporosis. To the area of the defect of the humerus through the subcutaneous muscle tunnel of the chest posterior to the pectoralis major muscle and neurovascular bundle, a bone graft was placed on the shoulder, which was introduced into the bone marrow channels of the fragments of the humerus. Fragments of the humerus are fixed by a plate. The wound is stitched and drained in layers. Immobilization of the thoraco-brachial dressing continued for 3.5 months. The healing of the humerus defect has come. A subluxation of the head of the left humerus has survived downward. 06/20/05, regarding a paralytic subluxation of the head of the left humerus, the patient underwent an operation - suspension of the head of the humerus. The external access of 8 cm in the projection of the head of the humerus bones the surgical neck of the shoulder. Formed two channels converging in the center of the cartilaginous surface of the head of the humerus. Two channels are formed in the center of the articular surface of the scapula, directed towards the spine of the scapula. One of them is brought up, the other down from the spine of the scapula. Through the channels a lavsan ribbon was drawn, tied in a knot down from the spine (Fig. 7). The wounds are sutured. The limb is immobilized on the take-away tire. Healing by first intention. Immobilization continued for 8 weeks. Examined after five months. There are stronger scars in the shoulder joint. The muscle mass of the preserved part of the deltoid muscle has increased. Movement in the shoulder joint: flexion - 70 °; extension - 40 °, abduction - 50 °. On radiographs - the healing of the defect of the upper third of the humerus (Fig. 8).

According to the developed technique, 7 patients were operated on. Everyone has achieved a positive result.

Claims (1)

A method for transplanting a blood supply transplant of the third rib to replace the defects of the humerus, for which a longitudinal access of 12-15 cm in the projection of the III rib is performed, the costal artery with the costal nerve is separated from the rib for 7-9 cm in the axillary region, the costal artery is ligated and the costal is transected the nerve at the site of the proposed osteotomy, the costal muscle is crossed, the pleura is separated from the rib along the inner surface, the osteotomy is performed, and thus a bone graft is obtained on a vascular pedicle 7.5-9 cm long, consisting from the costal artery and the associated veins of the same name, the intercostal muscle area and the intercostal membrane, a transplant is performed in the subcutaneous muscle tunnel of the chest posterior to the pectoralis major muscle and neurovascular bundle on the shoulder, the graft is introduced into the bone marrow channels of the fragments of the humerus, fragments of the humerus the bones are fixed with a plate.

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