RU2639021C1 - Method for surgical treatment of palmar fibromatosis of ii-iii degree of expression - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: two longitudinal incisions are made at the level of proximal and distal edges of the strands, while preserving the natural folds of the palm. A tunnel is formed on the palmar surface, in the course of which the skin is dissected and initial subcutaneous excision is performed. Then local point removal - subaponeurotic - excision of fibrotic tissues is performed. The strands with a part of palmar aponeurosis on the fingers are removed through separate additional C-shaped incisions along the palmar-lateral surface of the fingers. After contracture removal, aluminium modelled langettes are superimposed on each finger individually.

EFFECT: method avoids formation of extensive scars.

1 ex, 6 dwg

Description

The invention relates to medicine, in particular to hand surgery and orthopedics, and in particular to the treatment of contractures of the joints of the hand.

There is a method of treating Dupuytren's contracture, which consists in the destruction of the chords by percutaneous injection of needles. Before the operation, a high-frequency Doppler study of the affected palm is performed at the supposed needle insertion points, points are made that are free of blood vessels, outside the formed zones of white ischemia, outside of folds and nodes in the palm, as well as areas of the skin tightly welded with palmar aponeurosis. With the introduction of the anesthetic, hydrotreating is carried out, the skin is exfoliated from the scar-modified beam of the palmar aponeurosis, the points of anesthetic administration correspond to the ports intended for the introduction of needles; when dissecting cords of the palmar aponeurosis, the ends of the needles are moved in three planes - vertical, horizontal and sagittal. Needle movements do not exceed 2-3 mm. To intersect thin and flat cords, pendulum-like movements are made by the needle; when dissecting thick cords and knots, frequent needle movements in the vertical plane are used. After surgery at night, they are immobilized with a palm plaster cast, during the day the immobilization is stopped and active flexion and extension are performed in the joints of the fingers (Patent No. 2570769 RU. Publish. 12/10/2015).

However, the known method requires additional equipment and acupuncture technologies, when it is used, there is a high probability of damage to the neurovascular bundles, tendons and muscle tissues. In addition, the known method does not allow to completely remove the changed aponeurosis, which in turn can lead to repeated contracture. Needle technology does not allow to completely dissect a dense cord and remove its structure. In connection with these aspects, the time of surgical and postoperative treatment and recovery of the patient is lengthened, as well as the preparatory period based on an additional Doppler study.

A known method for the surgical treatment of Dupuytren's contractures is to excise a pathologically altered palmar aponeurosis through transverse incisions along the flexion folds on the palm and fingers, in addition, to cut out a skin flap corresponding to the size of the defect on the inner surface of the arch of the foot. When forming the flap, the including artery, vein and vascular pedicle are isolated. Close the defect formed after excision of the aponeurosis with a skin flap with the application of microsurgical anastomoses between the flap vessels and the superficial arterial arch of the hand (Patent No. 2180807 RU. Publish. February 27, 2001)

However, the known method is complex, increases the time of the operation, creates two operating areas and increases the duration of the postoperative recovery period.

A known method of subtotal resection, supplemented by periarterial cryoneurotomy of the arterial palmar arch, comprising performing a subtotal resection of the palmar aponeurosis, then the second stage is the implementation of desympatization of the superficial arterial arch with a cryodestructor (Application No. 99119690 RU. Publish. 20.06.2001).

However, the known method causes difficulties in its implementation. The operation time is lengthened, it has a complex technique for performing the operation, it requires special expensive equipment and tools. In addition, it is accompanied by damage, thrombosis of the superficial palmar arch.

A known method for the complex treatment of Dupuytren’s contracture of the III-IV degree, including a skin incision, subtotal excision of a scar-modified palmar aponeurosis, wound closure, splinting on the wrist and fingers, physiotherapy exercises, physiotherapy, antibiotic therapy and suturing, in which a skin incision is performed Z-shaped incision along the palmar surface of the finger, starting from the outer edge of the distal interphalangeal skin fold, then to the outer edge of the proximal, continuing the incision arcuate along the inner border of the hypotenes RA or tenor, dosed dissection of the scar-changed wall of the tendon sheath in the area of the proximal interphalangeal joint is performed on a site of 2.0-2.5 cm, the first ligation is performed 2-4 hours after surgery, a splint is applied for the first three days, and treatment is prescribed physical education on the third day after surgery, physiotherapeutic procedures are carried out by irradiating the area of the postoperative wound with low-intensity broadband electromagnetic radiation of the EHF range with a noise spectrum of 53.57-78.33 GHz, with a power zlucheniya 1.0-1.2 mW, starting from the second day after surgery for 30 min daily sessions of 7 (Patent №2290120 RU. Publ. December 27, 2006).

However, the known method is designed to eliminate the flexion contracture of the V finger, but it is not suitable for contracture of other palm-finger localizations, in particular, II-III degree of severity. In addition, the known method has an increased injury rate, Z-shaped incisions lead to non-critical changes in skin derivatives, which in turn leads to an increase in patient rehabilitation time and additional rehabilitation and antibacterial therapy.

A known method of surgical treatment of Dupuytren's contracture is that a pathologically altered palmar aponeurosis is phased out through incisions along the proximal and distal palmar folds and flexion folds on the fingers, then all wounds are sutured, leaving a defect in the distal palmar folds on the side surface the main phalanx of the third and fourth fingers cut out a skin flap on the vascular pedicle and bring it through the subcutaneous tunnel, formed by excision of the palmar aponeurosis, into wounds in the distal palmar crease sutured to the left edge of the defect, the defect formed on the finger free polnosloynym closed or split graft, taken from the volar surface of the forearm (Patent №2076643 RU. Publ. 10.04.1997 g).

However, the tunnel, in the known method, is produced not at the base of the cord itself, but in the center of the aponeurosis according to the natural folds, while a large wound surface appears, which in the future must be covered with a flap on the leg, which increases the trauma of soft tissues. The known method is complicated in technical execution, increases the time of the surgical period and recovery processes by increasing the wound surface and the additional artificially created wounded field.

A known method of surgical treatment of Dupuytren's contracture, in which the palmar aponeurosis is excised through incisions along the proximal and distal palmar folds of the fingers. Then the entire wound is sutured, leaving a defect in integumentary tissues with an area of more than 6 cm ² . On the middle third of the radial surface of the forearm, a skin flap is cut out on the distal vascular pedicle 8-12 cm long, including the radial artery and vein. An additional shaped incision is made, enveloping the elevation of the first finger, from the base of the leg located in the area of the "anatomical snuff box" to the proximal palmar fold. Then the flap is moved to the palm of the hand and sutured to the edges of the defect, and the donor wound is sutured (Patent No. 2085139 RU. Publish. 07.27.1997).

However, the known method is traumatic due to the wide boundaries of the section, namely, over the entire area of the altered aponeurosis, which is excised and removed in a single block, followed by its replacement with a flap on the leg. In addition, it is technically complex, increases the risk of injury to the neurovascular bundle, tendons and muscles and, as a result, increases the rehabilitation time, and also does not allow the patient to quickly return to work.

A known method of treating Dupuytren's contracture, in which an S-shaped incision is made along the palmar surface of the hand. A flap is formed, the base of which is 2-3 times longer than its length. Produce total aponeurectomy. The strands of palmar aponeurosis on the fingers are removed from individual additional club-shaped incisions along the palmar-lateral surface of the fingers. The wound is sutured. A skin defect that has arisen in the wound area after contracture has been removed is covered with “local” tissues. In the presence of Dupuytren's contracture of the III degree with the development of secondary changes, a distraction apparatus is imposed in the first stage. After elimination of contracture by dosed distraction in an apparatus of 1 mm per day, at the second stage, an aponerectomy is performed according to the described method (Patent No. 2384303 RU. Publish. March 20, 2010).

However, when performing the known method, a sufficiently large soft tissue damage is formed, which leads to the occurrence of repeated contractures (or relapses of contractures). In relapses of contracture, the known method of treatment can aggravate the condition of the tendons and neurovascular bundle due to the large trauma to the tissues adjacent to the cord during excision. In addition, as a result, it has sufficient traumatism and creates the basis for repeated contacts - at the site of cicatricial-trophic changes.

The objective of the present invention is to develop a minimally invasive method that allows to make minimal incisions, reduce damage to soft tissues, preserve the natural lines of skin folds, while the technical result is manifested in the ability to provide quick healing of tissues without the formation of extensive scars, leading to repeated contractures, ease, mobility and accessibility fixation, restoration of patients' disability as soon as possible.

The problem is solved in that in the method of surgical treatment of Dupuytren's contracture of the II-III degree of severity, including performing anesthesia, longitudinal sections on the palmar surface of the hand, removing fibrous cords, fixing the operated hand in the postoperative period, performing physiotherapy and physiotherapy, perform two longitudinal sections at the level of the proximal and distal edges of the cords, form a tunnel on the palmar surface, along which initially subcutaneous separation is performed, s Then they perform local point removal - subaponeurotic - excision of fibrotic involvement, remove the palmar aponeurosis strands on the fingers through separate additional C-shaped incisions along the palmar-lateral surface of the fingers, and after modeling contracture, apply aluminum simulated langets to each finger separately.

The present invention is illustrated by a detailed description, diagrams and photos of the patient, on which:

FIG. 1 - view of the right hand with the formation of two cuts and tunnel separation of fibrous cords;

FIG. 2 - brush, with a diagram of the formation of the tunnel and an additional C-shaped section;

FIG. 3 - view of the right hand with Dupuytren's contracture of the II degree of 2 fingers, in two projections;

FIG. 4 - copy of the R-gram of the patient before treatment;

FIG. 5 - photo of the right and left hands of the patient in lateral projection after treatment. Illustrates the function of the finger and hand one week after removal of the cord;

FIG. 6 - photo of the operated hand of the patient from the palmar side after treatment.

A method of surgical treatment of Dupuytren's contracture of the II-III degree of severity is as follows.

The patient (patient) is diagnosed with Dupuytren's contracture of varying severity (Fig. 1). Recommended treatment using minimally invasive surgery. Before surgery, the patient is hospitalized in a hospital, they take a clinical minimum and, after exclusion of contraindications, perform the operation.

With surgical intervention, a combination of local infiltration and conduction anesthesia is used. Initially, after treating the surgical field twice with an alcohol solution, conductive anesthesia with 2% lidocaine solution is performed. The median nerve is anesthetized at the level of the carpal canal. Landmarks are the skin fold that separates the palm from the forearm, tendon m. palmaris longus, under which lies the median nerve. Anesthesia of the ulnar nerve is performed according to the method of Brown, slightly above the radial edge of the pisiform bone. Subsequently, local infiltration anesthesia with 0.5% novocaine solution is used.

On the palm in the area of the proximal and distal edges of the cords, two longitudinal sections are performed with the calculation of the preservation of the natural folds of the palm (Fig. 1).

Form a tunnel on the palmar surface. Two longitudinal cuts are made at the level of the proximal and distal ends of the cords, a tunnel is formed on the palmar surface, along which the subcutaneous initially is separated from the aponeurosis by the "blunt" method, the funnel-like traction of skin folds and nodes are crossed with scissors. The skin itself, fused with an altered aponeurosis, is not excised. Then perform local point removal - subaponeurotic - excision of fibrosed tissues (Fig. 1). Fibrous cords with part of the palmar aponeurosis on the fingers are removed. After removing the fibrous cords, they are removed with surgical tweezers.

For excision of the cords and nodes on the fingers make an additional C-shaped incision, do not violate the palm-finger fold of the brush, along the palm-side surface of the finger (Fig. 2, 3). Produce the selection and excision of fibrous nodes and cords.

After removal of severe formations, thorough hemostasis is performed. In this case, hemostasis is achieved by pressing the wounds for several minutes with a napkin moistened with warm saline or hydrogen peroxide (prevention of suppuration and ligature fistulas).

After excision of the fibrous tissue, the edges of the wound are compared and reduced, avoiding skin tension. An aseptic dressing is then applied.

Each finger is individually immobilized in an unfolded position with aluminum spacers. Subsequently, a gypsum splint is placed on the operated limb along the palmar surface from the middle third of the forearm to the fingertips. Perform daily dressings. Sutures are removed on the 9-11th day. Plaster cast is applied for 1 week. After which the patient is prescribed physiotherapy in the form of mud therapy and exercise therapy.

An example of the clinical use of the method.

Patient X was admitted 10.09.15 to the first trauma unit of a clinical hospital with a diagnosis of Dupuytren's contracture of the left hand of the II degree.

09/11/15 the operation was performed: minimally invasive removal of funnel-like cords and nodes of the left hand of the II degree of severity to eliminate Dupuytren's contracture.

To do this, anesthesia was performed.

Two longitudinal sections were made on the palm of the hand at the proximal and distal edges of the strand with the calculation of the preservation of the natural folds of the palm.

Formed on the palmar surface of the tunnel. The skin was dissected and, along the tunnel, they initially subcutaneously separated it from the aponeurosis by the "blunt" method. The funnel-shaped retraction of skin folds and nodes were crossed with scissors. The skin itself, fused with an altered aponeurosis, was not excised. Then performed local point removal - subaponeurotic - excision of fibrosed tissues. Fibrous cords with part of the palmar aponeurosis on the fingers were removed. After removing the fibrous cords, they were removed with surgical tweezers.

For excision of the cords and nodes on the fingers, an additional C-shaped incision was made without violating the palm-finger folds of the brush on the palm-lateral surface of the finger. Made the selection and excision of fibrous nodes and cords. A thorough hemostasis was performed. Hemostasis was achieved by pressing the wounds for several minutes with a napkin moistened with warm saline or hydrogen peroxide to prevent suppuration and ligature fistulas.

After excision of the fibrous tissue, the edges of the wound were compared and reduced. Then put an aseptic dressing.

Each finger individually was immobilized in an unfolded position by aluminum spacers. Subsequently, a plaster cast was placed on the operated limb along the palmar surface from the middle third of the forearm to the fingertips. Dressings were performed daily. The plaster cast was removed after 1 week. Sutures were removed on days 9-11. After that, the patient was prescribed mud therapy and exercise therapy complex.

Scheduled inspection 09/22/15 showed a complete elimination of contracture (Fig. 5 and 6). Active and passive movements in the joints of the fingers are fully preserved, the strength of the hand is preserved, there are no neurovasal disorders of the right hand, the function of the hand is fully restored.

The proposed method prevents the occurrence of cicatricial contractures in the late postoperative period and prevents the occurrence of ischemic and neurological disorders on the operated hand.

In addition, the proposed method allows minimally damaging soft tissues, preserving the natural lines of skin folds. At the same time, it provides the fastest healing of tissues without the formation of extensive scars, leading to repeated contractures.

The proposed method has the ease, mobility and accessibility of fixation. Patient disability recovery was manifested as soon as possible.

Claims (1)

A method of surgical treatment of Dupuytren’s contracture of the II-III degree of severity, including performing anesthesia, longitudinal sections on the palm surface of the hand, removing fibrous cords, fixing the operated hand in the postoperative period, performing physiotherapy and physiotherapy exercises, characterized in that two longitudinal sections are performed, with the calculation preservation of the natural folds of the palm, at the level of the proximal and distal edges of the cords, form a tunnel on the palmar surface, along which the skin is cut and Initially, subcutaneous separation is performed, then local point removal - subaponeurotic - excision of fibrosed tissues is performed, the cords with part of the palmar aponeurosis on the fingers are removed through separate additional C-shaped sections along the palmar-lateral surface of the fingers, after modeling contracture, aluminum simulated langets are applied to each finger in separately.

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