RU2610534C1 - Method for treating defects of fourth metacarpal bone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: transplant of ulna on fascial-muscular-vascular pedicle, including anterior and posterior interosseous arteries with accompanying veins, interosseous membrane, as well as part of muscle - deep digital flexor, is transplanted.

EFFECT: method does not impair blood circulation of distal parts of extremity as main vessels of forearm are not ligated.

1 ex, 8 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used to treat defects of the IV metacarpal bone.

A known method of transplanting a bone autograft to replace a defect in the bone 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 (V. D. 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 the following disadvantages. The transplanted bone autograft resolves and secrete necrohormones that activate osteogenesis. This requires prolonged immobilization with a plaster cast. In addition, a fracture of the transplanted graft or its resorption may occur, which leads to an unsuccessful surgical intervention.

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 on the border of the proximal and middle third of the radial bone on the common proximal vascular leg - the radial vascular bundle. Bone grafts are moved while maintaining 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 autoplasty for defects and false joints of both bones of the forearm. RF patent No. 2360632. Publish. July 10, 2009, bull. No. 19). The disadvantages of the method are as follows. The formation of two bone grafts from the radius 10 and 6 cm long, 1/3 width and thickness of the radius causes a decrease in bone strength and the risk of developing a pathological fracture. The method involves the intersection of the radial artery. After crossing, the blood supply to the lower third of the forearm and hand decreases, as a result of which the strength of the hand decreases and trophic disorders occur. The 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 transplant the formed grafts into the region of defects of the metacarpal bones.

The technical result of the invention is the improvement of treatment results due to transplantation of the transplant of the ulna on the fascial-muscular-vascular pedicle, which includes the anterior and posterior interosseous arteries with accompanying veins, the interosseous membrane, as well as the muscle section of the deep flexor of the fingers. When performing surgery, the main vessels of the forearm are not bandaged, so the blood circulation of the distal extremities does not suffer.

The solution to this problem is provided by the fact that in the method of treating defects of the fourth metacarpal bone, including the transplantation of blood-supplied bone grafts, the transplant of the ulnar bone graft on the fascial-muscular-vascular leg, which includes a section of the muscle of the deep flexor of the fingers of the hand, the anterior and posterior interosseous arteries with the accompanying veins, as well as the interosseous membrane.

The figures illustrating the invention depict:

FIG. 1. The scheme of surgical intervention. The back surface of the left forearm and hand. Arrows indicate: 1 - ulnar bone; 2 - ulnar artery; 3 - transplant of the ulna; 4 - the edges of the fascial-muscular-vascular pedicle with a portion of the interosseous membrane; 5 - anterior interosseous artery (indicated by a dashed line); 6 - radial artery; 7 - radius; 8 - transplant rotation point on the fascial-muscular-vascular pedicle; 9 - square pronator; 10 - intramuscular vascular network of a square pronator; 11 - superficial arterial arch; 12 - transplanted bone graft; 13 - posterior interosseous artery.

FIG. 2. Radiographs of patient A. before surgery.

FIG. 3. Stage operation. An ulnar graft is formed.

FIG. 4. Stage of operation. The ulna transplant was transplanted into the defect of the IV metacarpal bone.

FIG. 5. View after bone graft transplantation on the muscular-vascular pedicle.

FIG. 6. Radiograph after transplantation of the transplant of the ulna.

FIG. 7. Radiograph after surgery. Front-rear projection.

FIG. 8. Radiograph after surgery. Side projection.

The operation was performed as follows. Cicatricial tissues were excised in the region of the defect of the IV metacarpal bone. A posterior interosseous artery was isolated in a figured incision in the dorsal surface of the forearm from its upper third to the fourth finger of the hand. The posterior interosseous artery with accompanying veins is located on the interosseous membrane. Filiform vessels depart from the artery to the radius and ulna, entering the periosteum at a distance of 1-1.5 cm throughout the membrane. An interosseous membrane was dissected, the course of the anterior interosseous artery and its anastomoses with the posterior interosseous artery were monitored. A muscle-vascular bundle consisting of the anterior, posterior interosseous arteries, accompanying veins, interosseous membrane, as well as a muscle site — a deep flexor of the fingers — was isolated. In the upper third of the ulnar diaphysis, a cortical graft corresponding to the size of the metacarpal defect IV was formed. The anterior interosseous artery and the accompanying veins were ligated and crossed above the proximal edge of the bone graft. The transplant of the ulna with the interosseous membrane and the muscular-vascular bundle was turned towards the metacarpal bones and transplanted into the defect of the IV metacarpal bone, and also fixed with knitting needles. The wound was sutured.

CLINICAL OBSERVATION

A. 38 years old, on April 27, 2014, received an explosive wound in his left hand with destruction of the III and IV metacarpals. On the day of the wound, surgical treatment of the wound and transosseous fixation of the bones of the hand were performed. Healed wounds without purulent complications. Regarding the defect of the III and IV metacarpal bones of the left hand in the clinic 03.03.2015, an operation was performed according to the developed technique. A cicatricial section 37 cm long along the dorsum of the left forearm and hand removed scar tissue and fragments of the metacarpal bones III and IV were isolated. The defect of the III metacarpal bone is 3 cm, the defect of the IV metacarpal bone is about 6 cm. The articular surface of the head of the IV metacarpal bone is partially preserved, the IV ray is in the internal rotation position. The deformation was eliminated and diafixed with a spoke. A groove was formed in the preserved portion of the capitate bone to place the end of the graft. On the back surface of the left forearm, the posterior interosseous artery with accompanying veins and the interosseous nerve were isolated. Dissected interosseous membrane to the upper third of the forearm. We traced the course of the anterior interosseous artery and its anastomoses with the posterior interosseous artery. The fascial-muscular-vascular bundle consisting of the anterior, posterior interosseous arteries accompanying the veins, the interosseous membrane, and also the muscle area, the deep flexor of the fingers, was isolated. A transplant was formed from the upper third of the ulnar diaphysis, measuring 70 × 14 × 5 mm with an oscillating saw on the fascial-muscular-vascular pedicle. The graft was isolated from surrounding tissues. The anterior interosseous artery was ligated with the accompanying veins in the upper third of the forearm, and the transplant formed was transplanted into the defect of the IV metacarpal bone and fixed with crossing knitting needles to the capitate bone and distal fragment of the 4th metacarpal bone. During visual inspection using optical augmentation tools, sufficient blood flow was found in the periosteum of the transplanted graft and the release of “blood dew” from the edges of the graft. The preserved bone fragments of the III metacarpal bone associated with soft tissues were compared and fixed with a plate with angular stability and knitting needles. Hemostasis. Aseptic dressing. Plaster cast. Healing of the surgical wound without complications.

According to the developed technique, 7 patients were operated on. Everyone has achieved a positive result. There were no complications. In the studied literature, no publications of the developed treatment methodology were found.

Claims (1)

A method for treating defects of the fourth metacarpal bone, including the transplantation of blood-supplied bone grafts, characterized in that the ulnar graft is transplanted on the fascial-muscular-vascular pedicle, which includes a section of the muscle of the deep flexor of the fingers of the hand, the anterior and posterior interosseous arteries with their accompanying veins, as well as the interosseous membrane.

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