RU2581355C1 - Method for replacing defects ii, iii of metacarpal bone and soft tissues of hand - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to traumatology and orthopedics. Method comprises forming on back surface of upper third of forearm, skin-fascial graft oval skin bridge to middle third of the forearm. From edges of skin and fascial graft dissection is carried out in depth. Perimysium exfoliate from back surface of ulnar extensor of wrist and finger extensor. Method includes removing ulnar extensor elbow in, and finger extensor - in radial direction, exposing interosseous membrane located on back of interosseous artery, peeled artery and accompanying veins of interosseous membrane and cross them at upper edge of skin and fascial graft in upper third of forearm. Edges of intermuscular septum sutured to edges of skin and fascial graft in upper right corner of cut at skin-fascial graft is applied to a cross section of interosseous membrane length of 1 cm, which is determined by position of anterior interosseous artery. Traverse artery and accompanying veins, allocate vessels to interosseous membrane to edges of bone grafts. Configure transplants radius and ulna, distal bone grafts dissected interosseous membrane of radius and ulna bones before expected rotation point so that it is positioned at 5-6 cm above middle of wrist crease. Turning radius and ulna grafts with interosseous membrane and skin-fascial graft 180°, while last turn is carried out on frontal plane. Placing graft into defect beam II of, ulnar graft - in defect III metacarpal bone, and skin-fascial graft - a defect in soft tissue hand, at same time during operation main vessels ligated.

EFFECT: method enables to preserve mechanical strength of bones, preventing occurrence of risk of pathologic fracture.

1 cl, 12 dwg, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to treat defects of the metacarpal bones and soft tissues of the hand.

A known method of transplanting a blood-supplying 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. - Ch. 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 is the treatment of defects and pseudoarthrosis of the forearm bones, when two blood-supplying bone grafts are isolated from the radial bone, from the distal metaepiphysis and from the site at the border of the proximal and middle third of the radial bone on a single proximal vascular leg, the radial vascular bundle, bone grafts with the preservation of the supply vessels and fix them in areas of damage to the radius and ulna (PM Tikhilov et al. Method of simultaneous non-free bone ay plastics for defects and pseudoarthrosis of both bones of the forearm. Patent of the Russian Federation No. 2360632. Publish. July 10, 2009, Bull. No. 19). The disadvantages of the described method is the following. The formation of two bone grafts from the radius of 10 and 6 cm long, 1/3 width and thickness of the radius of the radius leads to a decrease in the strength of the radius and the risk of developing a pathological fracture. After the intersection of the radial artery, the blood supply to the lower third of the forearm and hand decreases, which manifests itself in a decrease in the strength of the hand, as well as the occurrence of trophic disorders. The described method is proposed to be used only for the treatment of pseudoarthrosis of the upper and middle third of the forearm and it is impossible to move the formed grafts to the region of defects of the metacarpal bones.

The technical result of the invention is the improvement of treatment results due to the fact that they form one bone graft from the radius and ulna. This preserves their mechanical strength and there is no danger of a pathological fracture. When performing surgery, the main vessels do not bandage, so the blood supply to the distal extremities does not decrease.

The solution to this problem is provided by the fact that in the method of replacing defects of the II, III metacarpal bones and soft tissues of the hand, including transplantation of bone and skin-fascial grafts on a vascular pedicle, an oval-shaped fascial graft with a skin bridge is formed on the dorsum of the upper third of the forearm up to the middle third of the forearm, from the edges of the fascial-fascial transplant, preparation is carried out in depth, the perimizium is exfoliated from the back surface of the ulnar extensor of the hand and extensor of the fingers, retraction the ulnar extensor to the ulnar, and the extensor of the fingers to the radial side, expose the interosseous membrane with the posterior interosseous artery located on it, exfoliate the artery and accompanying veins from the interosseous membrane and intersect them at the level of the upper edge of the fascial-fascial transplant in the upper third of the forearm, the edge the intramuscular septum is sutured to the edges of the fascial and fascial transplant; in the upper corner of the incision, at the level of the fascial and fascial transplant, a transverse section of the interosseous membrane is 1 cm long, through which They determine the position of the anterior interosseous artery, cross the artery and its accompanying veins, isolate vessels with an interosseous membrane to the edges of the bone grafts, form transplants of the radius and ulna, distal to the bone grafts cut off the interosseous membrane from the radius and ulna to the supposed rotation point so that it was located 5-6 cm above the average fold of the wrist, turn the radial and ulnar grafts together with the interosseous membrane, as well as the skin-fascial graft 180 °, while the latter is rotated in the frontal plane, the radiation graft is placed in defect II, the ulnar graft in the defect III of the metacarpal bones, and the skin-fascial transplant is placed in the defect of the soft tissues of the hand, while the main vessels are ligated during the operation. To justify the method of replacing defects of the II and III metacarpal bones with radial and ulnar bone grafts, an experiment was performed on the 6 upper limbs of 3 unfixed corpses. The arterial bed of the upper extremities was filled by puncturing the brachial artery and introducing a mixture of liquid latex with a solution of black mascara in a ratio of 5: 1. After 18 hours, the study was completed. An intermuscular septum between the brachioradialis muscle, the radial flexor of the wrist, and also the flexors of the fingers were distinguished by a shaped section in the area of the palmar surface of the forearm from the elbow to the wrist. The anterior interosseous artery is located on the anterior surface of the interosseous membrane. Filamentous vessels extend from the artery to the radius and ulna, interwoven into the periosteum at a distance of 1-1.2 cm throughout the membrane from the circular pronator proximal to the square pronator distally. 2 cortical grafts of the radius and ulna were formed 6 × 1.5 cm in size. An interosseous membrane was cut from the level of the grafts to the level of the square pronator, maintaining its connection with the grafts and vessels located on it. Transplants with an interosseous membrane were rotated towards the metacarpal bones at a rotation point located 5 cm proximal to the average fold of the wrist. Bone grafts were placed in pre-formed defects of the metacarpal bones - a transplant of the metacarpal bone transplant of the radial bone and a transplant of the metacarpal bone transplant III. Bone grafts were fixed with needles (Fig. 1, 2).

Thus, the discovered fact of the location of filamentous vessels on the interosseous membrane, going to the periosteum of the radius and ulna, allows the formation of blood supply bone grafts of the radius and ulna, as well as replanting them into defects of the metacarpal bones.

The method was performed as follows. An oval-shaped skin-fascial transplant with a skin bridge up to the middle third of the forearm measuring 9.5 × 3.5 cm was formed by a shaped incision along the dorsal surface in the upper third of the forearm. In-depth preparation was performed from the edges of the fascial-fascial graft, the perimizium was peeled from the dorsal surface of the ulnar extensor of the hand and extensor of the fingers, the ulnar extensor was taken to the ulnar, and the extensor of the fingers was to the radial side, the interosseous membrane with the posterior interosseous artery located on it was exposed, the artery was exfoliated and the accompanying veins from the interosseous membrane, were ligated and crossed at the level of the upper edge of the fascial-fascial transplant in the upper third of the forearm. The edges of the intramuscular septum were sutured to the edges of the fascial-fascial graft to avoid damage to the filiform septal vessels coming from the posterior interosseous artery to the horizontal vessels of the skin. The forearm was supine. To prevent damage to the anterior interosseous artery in the upper corner of the incision at the edge of the fascial-fascial graft, a transverse incision of the interosseous membrane 1 cm long was applied, through which the position of the vessel was determined. Crossed the artery and its accompanying veins. Vessels with an interosseous membrane were isolated to the edges of bone grafts using means of optical magnification. A radius bone graft of 5 × 1.5 cm and an ulna 5.5 × 1.5 cm were formed. Distal to the bone grafts, an interosseous membrane was cut from the radius and ulna to the supposed rotation point, which should be 5-6 cm above the average wrinkles of the wrist. Radial and ulnar grafts were rotated together with the interosseous membrane, as well as a blood-supplied fascial and fascial graft by 180 °, while the latter was rotated in the frontal plane. A radiation graft was placed in defect II, and an ulnar graft in defect III of the metacarpal bones. Bone grafts were fixed with needles. The edges of the skin-fascial graft were sutured to the edges of the defect of the skin of the rear of the hand. To completely close the defect of integumentary tissues, a split dermatome graft was taken from the hip. The wound was treated with antiseptic solutions. An aseptic dressing was applied. The limb was immobilized with plaster casts. The drawings show:

FIG. 1. The layout of the main vessels and places for taking bone grafts. Arrows indicate: 1 - brachial artery; 2 - radial artery; 3 - ulnar artery; 4 - anterior interosseous artery; 5 - posterior interosseous artery; 6 - palmar carpal branch of the radial artery; 9 - ulnar transplant; 10 - radiation graft; 11 - defect of the metacarpal bones.

FIG. 2. Formed bone grafts rotated 180 ° and placed in the defect of the II and III metacarpal bones. Scheme. Arrows indicate: 9 - ulnar transplant; 10 - radiation graft; 12 - the location of the elbow graft; 13 - place of intake of a radiation graft; 14 - bandaged proximal ends of the interosseous arteries; 15 - points of rotation of the interosseous arteries.

FIG. 3. The location of bone and skin-fascial transplants after their transplantation into defects of the metacarpal bones and soft tissues. Scheme. Arrows indicate: 4 - anterior interosseous artery; 5 - posterior interosseous artery; 7 - a back skin-fascial graft; 9 - ulnar transplant; 10 - radiation graft;

FIG. 4. Defect of the metacarpal bones of the right hand. Radiographs before surgery.

FIG. 5. Type of limb before surgery. Marking the surgical field.

FIG. 6. The formation of the rear skin-fascial graft. The site of ligation of the posterior interosseous artery is indicated by forceps.

FIG. 7. The formation of blood-supplied bone grafts. A bone graft from the ulna was formed.

FIG. 8. The formation of blood-supplied bone grafts. A radial bone graft was transplanted into a defect of the II metacarpal bone.

FIG. 9. The formation of blood-supplied bone grafts. The ulnar bone graft was transplanted into a defect of the III metacarpal bone.

FIG. 10. Type of brush after surgery. The rear skin-fascial and cleaved dermatome transplants were transplanted into the area of the soft tissue defect of the hand.

FIG. 11. View of the hand one month after surgery.

FIG. 12. Radiographs 2.5 months after surgery.

According to the developed technique, 5 patients with defects in the metacarpal bones and soft tissues of the hand were operated on. All had the engraftment of transplanted blood transplants and the blood flow remained. Complications were the development of marginal necrosis in two patients who did not affect the outcome of the treatment.

In the published scientific articles, it was not possible to find the proposed method for the replacement of defects of the metacarpal bones.

CLINICAL OBSERVATION

K., 31 years old, received a fragmented fracture of the right hand with the destruction of the soft tissues of the rear of the hand. Soft tissue necrosis occurred. Necrectomy and transplantation of split dermatome transplants were performed. Surgical treatment and transosseous fixation by the device were performed. After wound healing on 12.11.2014, the scar tissue of the rear of the hand was excised and the operation was performed according to the developed technique. The engraftment of the transplanted grafts began and their blood supply remained (Fig. 3-12).

Claims (1)

A method for replacing defects of the II, III metacarpal bones and soft tissues of the hand, including the transplantation of bone and skin-fascial transplants on a vascular pedicle, characterized in that an oval-shaped fascial transplant with a skin bridge to the middle third of the forearm is formed on the dorsum in the upper third of the forearm , from the edges of the fascial-fascial transplant, preparation is carried out in depth, the perimizium is peeled off from the back surface of the ulnar extensor of the hand and the extensor of the fingers, the ulnar extensor is removed to the elbow and the extensor extremities - to the radial side, expose the interosseous membrane with the posterior interosseous artery located on it, exfoliate the artery and accompanying veins from the interosseous membrane and cross them at the level of the upper edge of the fascial-fascial graft in the upper third of the forearm, the edges of the intermuscular septum are sutured to the edges a fascial and skin transplant, in the upper corner of the incision at the level of the fascial and fascial transplant, a transverse section of the interosseous membrane 1 cm long is applied, through which the position of the anterior the interosseous artery, cross the artery and its accompanying veins, secrete vessels with the interosseous membrane to the edges of the bone grafts, form transplants of the radius and ulna, distal to the bone grafts cut off the interosseous membrane from the radius and ulna to the proposed rotation point so that it is located at 5 -6 cm above the average fold of the wrist, turn the radial and ulnar grafts together with the interosseous membrane, as well as the skin-fascial transplant 180 °, while the rotation of the last o exist in the frontal plane, place the radiation graft in defect II, the ulnar graft in the defect III of the metacarpal bones, and the skin-fascial transplant in the defect of the soft tissues of the hand, while during the operation the main vessels are ligated.

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