RU2571233C1 - Method for first metacarpal bone repair in extensive defects of soft tissues of hand stump - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely reconstructive hand surgery. An adipocutaneous coverage flap is presented by a double adipocutaneous flap. After the first metacarpal bone is formed, it is placed into the double flap in the adduction position. After consolidation of the bone fragments, a thumb and first web space are formed by cutting out leaved flaps on the back of the hand with their base on the first metacarpal bone, and on the palmar surface of the hand with their base on the second metacarpal bone. Opposite U-flaps with a proximal base on the back and palm of the hand are formed within an expected first web space; the repaired first metacarpal bone is abducted; the tissue defects on the first and second metacarpal bones are closed by means of the leaved flaps. A bottom of the first web space is creased by suturing apexes of the U-flaps. To close the wounds in the areas where the U-flaps have been taken, the leaved flaps are sutured to lateral sides of the U-flaps within the web space.

EFFECT: method reduces the stages and length of treatment, minimises a donor defect formed during the hand repair and formation of the thumb and appropriate first web space.

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Description

The invention relates to medicine, namely to reconstructive surgery of the hand.

A known method of reconstructing a finger in the presence of a defect in the soft tissues of the hand, which consists in using two tissue complexes: the second toe and the radial graft of the forearm (RF patent No. 2345726, 2009).

However, this method is accompanied by a cosmetic flaw on the foot and forearm, is technically complicated, traumatic, and the likelihood of thrombosis of microvascular anastomoses remains.

As a prototype, a method was selected that includes replacing a tissue defect with a sharp Filatov stalk with the formation of a soft tissue reserve in the area of the stump end, stretching the tissues of the transplanted graft using an endoexpander, moving the skin-bone radiation graft to the stump of the finger and forming soft tissues of the finger using a stretched graft ( RF patent 2479260, 2013).

However, the method has the following disadvantages: 1) restoration of adequate skin of the hand and the formed finger is possible only with limited (single-plane) defects, which requires the implementation of additional patch grafting, since the reserves of the soft tissue of the flap are insufficient to replace the tissue defect and the formation of soft tissue of the finger; 2) the formation of several flaps inevitably leads to an increase in the donor flaw and the invasiveness of the operation; 3) the use of expander dermatotension is often accompanied by complications; 4) the method involves increasing the number of stages and lengthening the duration of treatment; 5) the stretched flaps are dense, rigid, which makes them not very suitable for the formation of the first interdigital gap.

The task of the invention is to improve the method.

The technical result is a reduction in stages and a reduction in treatment time, the formation of the first finger and the first interdigital gap with a minimum donor flaw.

The technical result is achieved due to the fact that in a method that includes plastic with a non-free skin-fat flap and a radiation skin-fat flap, the soft tissue defect of the hand is replaced with a double skin-fat flap, after it has been grafted, the skin-bone radiation complex formed on the forearm , move to the position of the first metacarpal bone with its placement in the transplanted double flap, after the consolidation of bone fragments from the double flap, fold flaps with lateral bases are formed and STREČNO U-shaped patches with proximal bases withdrawn recovered metacarpal bone tissue defect and closed on it and the second metacarpal bone hinged flaps and the bottom of the interdigital length of U-shaped flaps.

The essence of the method is illustrated by drawings, where in FIG. 1 shows the state of the brush after excision of scars; in FIG. 2 - a double-skin flap transplanted onto a brush; in FIG. 3 - skin-bone radial complex, moved to the position of the first metacarpal bone and into the transplanted flap; in FIG. 4 - formed the first finger and the first interdigital gap.

The method is as follows.

Scars are excised on the back and palmar surfaces of the stump of the hand (Fig. 1). The resulting defect is replaced by a double Converse-Blokhin 1 skin-fat flap formed on the abdomen. After engraftment, the flap is cut off from the abdomen with the creation of an excess of soft tissue in the area of the butt end of the stump (Fig. 2). At the next stage, the reconstruction of the first metacarpal bone is performed by moving the skin-bone radial flap on the peripheral vascular pedicle with a small skin flap. For this, after isolation of the skin-bone complex of tissues on the forearm, an incision is made along the radial edge of the transplanted double flap 1 along the postoperative scar. The end face of the stump of the first metacarpal bone is exposed. The skin-bone-radial complex 2 is moved to the position of the first metacarpal bone, osteosynthesis of bone fragments is performed. The formed first metacarpal bone is placed in the double flap 1 in the position of its reduction, and the skin-fat flap of the skin-bone radiation complex 2 is placed on the lateral surface of the stump of the hand (Fig. 3). The donor wound on the forearm is sutured primarily. After the consolidation of bone fragments is achieved, the first finger and the first interdigital gap are formed. For this, leaf flaps 3 and 4 with bases on the first and second metacarpal bones are cut out on the transplanted double flap 1. On the back surface of the hand, a flap 4 is formed with a base on the first metacarpal bone, and on the palmar - a flap 3 is formed with a base on the second metacarpal bone. In addition, on the back and palmar surfaces of the hand in the area of the alleged first interdigital space, counter U-shaped rags 5 with proximal bases are formed. The restored first metacarpal bone is removed. Tissue defects on the first and second metacarpal bones are closed with the help of flaps 3 and 4. As a result, the first finger is closed by the flaps 3 and 4 and the skin-fat flap of the radial skin-bone complex 2. Using the U-shaped flaps 5, the bottom of the first interdigital gap, stitching their tops. For suturing wounds in the area of borrowing U-shaped flaps 5, the flaps 3 and 4 are displaced in the proximal direction, due to the presence of their excess in the area of the ends of the stumps. Next, the flaps 3 and 4 are sutured with the sides of the U-shaped flaps 5 in the area of the interdigital gap (Fig. 4).

Clinical example. B-Ya EN, 38 years old, was admitted to the NIIITO on 2.08.11 with a diagnosis of severe pressure injury to the right hand: subtotal detachments of 2-5 fingers, crushing of the first finger, multiple open fractures of 1-5 metacarpal bones of the right hand . Upon admission, primary surgical treatment of wounds, the formation of the stump of the first metacarpal bone, osteosynthesis of fractures of the metacarpal bones, dissection of the carpal ligament of the right hand were performed. In the postoperative period, necrosis of 2-5 fingers and soft tissues of the dorsal and palmar surfaces of the hand occurred, in connection with which necrectomy of the fingers and soft tissues was performed on the dorsal and palmar surfaces of the hand, the formation of the stump of the second metacarpal bone at the level of the proximal third, and the third metacarpal bone at the level of middle third, fourth metacarpal bone at the level of the head, fifth metacarpal bone at the level of the distal third (08/25/11), followed by free skin grafting with a split skin graft of the resulting wounds of the hand (09/02/11). Upon repeated admission, there were extensive soft tissue defects on the palmar and dorsal surfaces of the stump of the hand. The defects were replaced using a double Converse-Blokhin skin-fat flap formed on the abdomen (11/29/11), with the formation of a reserve of soft tissues in the distal stump during cutting off the feeding leg (12/27/11). Subsequently, a skin-bone radial flap was moved on the distal vascular pedicle with a small islet flap to the position of the first metacarpal bone (03.10.12). The bone fragment was almost completely immersed in the previously grafted flap with the formation of artificial syndactyly. The displaced tissue complex has completely taken root. Wounds in the donor and recipient areas healed by primary intention. The next step was the separation of artificial syndactyly of the first and second metacarpal bones with the formation of the first finger (02/14/13) and the first interdigital gap completely from the previously grafted graft. As a result of the treatment, the first finger was restored, which allowed to restore the grip of the hand. 1 year after the operation, the depth of the first interdigital gap is 4 cm, the opening of the first finger is 5 cm, and its reduction function is complete. On the palmar surface of the forearm there is a linear, inconspicuous and mobile postoperative scar. A cosmetic flaw in the area of abdominal flap formation is also minimal. The patient holds objects of various sizes with the help of a formed finger and uses a brush in everyday life and at work. The need for corrective interventions on the restored finger did not arise.

The method allows to replace extensive multiplanar defects of soft tissues and restore adequate skin of the formed finger using only one double skin-fat flap.

Using the method reduces the complexity and invasiveness of the intervention.

The ductility of a double flap (a flap on a temporary supply leg) allows not only to replace the defect, but also to restore the first finger and form an adequate first interdigital gap.

When implementing the method, the donor flaw is reduced, since only one flap is used and only one donor area is used to borrow the flap, and the donor wound in the area of borrowing the radiation flap closes initially.

Claims (1)

 A method for reconstructing the first metacarpal bone with extensive defects of soft tissues of the stump of the hand, including plastic surgery with a non-free skin-fat flap and a radial skin-fat flap, characterized in that a double skin-fat flap is used as a non-free skin-fat flap after the formation of the first metacarpal bone place it in a double flap in the casting position, after the consolidation of the bone fragments, 1 finger and 1 interdigital gap are formed by cutting out the flaps on the back surface of the cysts and with their base on the 1st metacarpal bone and on the palm surface of the hand with their base on the 2nd metacarpal bone, counter U-shaped flaps are formed with the proximal base on the back and palmar surfaces of the brush in the region of the supposed 1 interdigital gap, the restored 1 metacarpal bone is removed, closed tissue defects on the 1 and 2 metacarpal bones with the help of folding flaps, create the bottom of the 1 interdigital gap by stitching the vertices of the U-shaped flaps, for suturing wounds in the area of borrowing the U-shaped flaps, the flap flaps they appear with the lateral sides of the U-shaped flaps in the area of the interdigital space.

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