RU2692663C1 - Method for treatment of open delaminating soft tissue injuries - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to surgery, traumatology and orthopedics, and can be used for treatment of open delaminating soft tissue injuries. That is ensured by primary surgical treatment of the wound. Wounds with delaminated cover tissues are inspected, and underlying muscles and bands are inspected. Blood supply of delaminated covering tissues is evaluated. Non-vascularized delaminated skin grafts are dissected. Full-skin grafts are formed from delaminated covering skin grafts. That is ensured by treating them by removing all subcutaneous fat, leaving the epidermis with derma. Full-skin grafts are placed in a sterile container with physiological saline and stored at temperature of 3 to 4 °C. After preparing the recipient bed, with no purulent process and necrotic tissues in the wound, between the fifth and eighth day after the injury, a wound repair operation is performed, replacing full-skin grafts previously preserved in physiologic saline.EFFECT: method provides wound healing with maximum functional, aesthetic and minimal complications.5 cl, 6 dwg, 1 ex

Description

The field of technology.

The invention relates to the field of medicine and can be used in traumatology and orthopedics, plastic surgery, surgery, for the treatment of patients with open exfoliating (scalping) soft tissue injuries.

The level of technology.

From the current level of technology known method (patent RU 2015686. Published: 07.15.1994), which includes cutting off flaps, their processing and replantation after the removal of non-viable tissues. The operation is carried out in two stages: primary surgical treatment is limited to cutting off scalped flaps, wound toilet and hemostasis, and the cut-off flaps are placed in a refrigeration chamber where they are stored at a temperature not lower than 0 ° C until the second surgical treatment of the patient is stabilized. During the second operation, repeated surgical treatment of the wound is performed, during which nonviable tissues are radically removed, the detection of which by this time is not difficult due to their demarcation. Scrapskin skin, stored until re-surgical treatment in the refrigerator of a domestic refrigerator, is treated with a manual dermatome to a thickness of 0.45-0.55 mm (split skin flap), then laid on the wound surface and fixed to it with rare catgut sutures. According to Gerard M. Doherty (2009), the indicated thickness of the skin flap corresponds to a thick split skin flap.

There is also known a method of skin autoplasty of a group of authors (patent RU 2301636. Published: 27.06.2007). First, dermo-epidermal grafts (split skin flap) are cut in layers, then dermal grafts. Available dermo-epidermal grafts are obtained with a thickness of 0.4-0.6 mm, which corresponds to a thick split skin graft. Produce preservation of dermo-epidermal grafts. Covered with dermal grafts the wound is primary. Replace the primary grafts dermo-epidermal grafts after the onset of positive dynamics in the patient's condition.

These methods have several disadvantages: the replantation of split skin grafts on the wound is always less effective not only in aesthetic terms, but also in the functional one. Wounds covered with split skin flaps, after healing, often turn into rough hypertrophic and keloid scars, which causes considerable discomfort for patients. Accordingly, the location of coarse scars in the projection of the joints leads to the restriction of their movements, the formation of persistent contractures, which ultimately leads to a significant reduction in the quality of life of the victim.

The closest to the claimed technical solution is a method for the treatment of scalped wounds, described by Krasovitov V.K. [Krasovitov V.K. Primary plastics with detached flaps of skin // Krasnodar, 1947. - 236 s] in which the stripped flaps are cut off, treated with iodine on both sides, after which the subcutaneous tissue is cut from the flaps with a scalpel, turning them into free full-layer grafts. After the initial surgical treatment of the wound, the grafts are immediately placed on the wound surface and sewn with separate sutures.

The disadvantage of this technical solution is the limited time of use, since this method is possible in fresh (up to 24 hours) wounds, when the wound has bacterial contamination obtained during the trauma itself, but there is no infectious process. On the other hand, not only detachment of integumentary tissues is often found, but also with crush of deeper tissues, separation of fascias from muscles. In this case, to perform the replantation of skin grafts during the primary surgical treatment of the wound is not washed away, since the recipient wound is not ready for plastic surgery.

The essence of the technical solution.

The problem to which this invention is directed is to optimize the treatment of wounds resulting from the extensive detachment of integumentary tissues and crushing of the underlying soft-tissue structures (fascia, muscle).

The technical result consists in the healing of wounds in patients with flaking soft tissue injuries with a maximum functional, aesthetic result and a minimum number of complications.

The technical result is achieved by the fact that in the method of treating open exfoliating soft tissue injuries, primary surgical treatment of wounds is performed, wounds are inspected with exfoliated integumentary tissues, underlying muscles and fascia are inspected, blood supply of exfoliated integumentary tissues is evaluated, unvascular exfoliated skin flaps are cut off, and exfoliated epidermal skin flaps; full-layer skin flaps; for this purpose, they are processed, in which the entire subcutis is removed from the flaps. the fatty tissue is left to the epidermis with the dermis, the full-layer skin flaps are placed in a sterile container with physiological saline and kept at a temperature ranging from 3 to 4 ° C, then after preparation of the recipient bed, in the absence of purulent process and necrotic tissue in the wound, plastic surgery wounds, perform replantation of full-thickness skin grafts previously stored in saline.

The method is illustrated by a description, an example of practical use and illustrations, which depict:

FIG. 1 - Photograph of the patient T., 9 years before the revision of delaminated tissues from 10/16/2012 before the operation. The emerging zones of necrosis of the epithelial tissues of the right thigh and buttocks are visible;

FIG. 2 - Photograph of patient T., 9 years old, during the revision of delaminated tissues dated 10/16/2012. exfoliated skin-subcutaneous fat flap with scraps of fascia from the anterior, outer thigh, and right gluteal region;

FIG. 3 - Photograph of patient T., 9 years old, during the revision of delaminated tissues dated 10/16/2012. exfoliated skin-subcutaneous fat, while bending the flap of exfoliated integumentary tissues, fibrous thigh muscles are visualized, the gluteus maximus is torn off;

FIG. 4 - Photos of the patient's right thigh, T., 9 years old on 10/18/2012, at the stage of skin plasty, using full-thickness skin grafts;

FIG. 5 - Photos of the patient's right thigh, T., 9 years old on 10/18/2012, after closing the remaining wounds with split skin grafts;

FIG. 6 - Photos of the right thigh of the patient T., 9 years old. Long-term outcome of treatment. Pos. 1 and 3 indicate full-thickness skin grafts, pos. 2 - scar tissue at the site of use of split skin grafts.

The method is as follows.

In patients with open flaking soft tissue damage, primary surgical treatment of the wound is performed, wounds are inspected with delaminated integumentary tissues, and the underlying muscles and fascia are inspected. During the surgical treatment, the wound is abundantly washed with saline, all foreign bodies, hematomas, and crushed tissues are removed. Produce a thorough hemostasis. Treat with soapy water, chlorhexidine digluconate 0.05% aqueous solution, betadine. Then the wound is reexamined, the blood supply of exfoliated integumentary tissues is assessed by performing polarography with determining the level of gases (oxygen and carbon dioxide) in the tissues (more objective assessment), or by determining capillary blood flow at several points (less objective assessment), in the absence of blood supply nonvascularized exfoliated skin is cut off. A full-thickness skin flap is formed from peeled epithelial skin grafts. To do this, with the use of scissors, they are processed, in which the entire subcutaneous fatty tissue is removed from the flaps and the epidermis is left with the dermis. Next, full-layer skin flaps are placed in a sterile container with saline solution and kept at a temperature in the range of 3 to 4 ° C, then after preparation of the recipient bed, in the absence of purulent process and necrotic tissues in the wound, wound plasty is performed, full-thickness skin grafts are replanted previously stored in saline.

In contrast to the known methods, in the course of the second operation, wound plastic surgery is performed after preparation of the recipient bed using a full-thickness skin flap, which was stored in a refrigerator at a temperature of 3-4 ° C, immersed in physiological saline, until the wound was ready for plastic surgery. The main criteria for wound readiness for plasticity is the absence of a purulent process and necrotic tissue in the wound. Severe condition of the patient, a state of sepsis is not a contraindication for skin replantation. A contraindication is only the development of an active purulent process in a wound or an extremely serious general condition of the patient.

As a rule, the second plastic surgery of the wound is performed during the period between the fifth and eighth days after the injury, full-thickness skin grafts are removed from the container with physiological solution transferred to the wound and fixed with sutures around the perimeter. Additionally, full-layer skin flaps can be fixed with anchor sutures. Next, the wound is closed aseptic dressings. The injured limb is fixed with a plaster Longuet or an external fixation device (if there are concomitant bone fractures).

Proper implementation of all stages of surgical treatment, taking into account the microflora in the wound and its sensitivity to antibiotics, allows, in most cases, wound healing and complete engraftment of full-thickness skin flaps in a short time without using additional skin grafts from donor wounds. After engraftment of the skin, it has an aesthetic appearance and is less prone to scarring, which is the prevention of the occurrence of desmogenic contracture of the joints.

The practical application of the method illustrates the following clinical observation.

As a clinical example, we present the experience of treating a patient T., 9 years old, who was injured on 10/14/2012 during a fall from a moving motorcycle. An ambulance crew in severe unconscious condition was taken to the emergency department of the Chelyabinsk Regional Clinical Hospital No. 3 with a diagnosis of polytrauma, closed head injury, closed fracture of the right pubic bone without displacement, closed fracture of the scaphoid bone of the right foot without displacement, rupture of the posterior wall vagina, extensive open detachment of the soft tissues of the thigh, buttocks and lumbar region on the right (S = 10% of the body surface). On the background of the ongoing anti-shock therapy by traumatologists-orthopedists, treatment of wounds of the right thigh was performed. At the same time, a separation of the large gluteus muscle on the right was diagnosed, which was then hemmed to the wing of the ilium. All wounds are sutured tightly with the installation of drainage. Two days later, the patient "was transferred from the intensive care unit to the casualty department due to the stabilization of the general condition.

In the casualty department on 10/16/2012, a beginning necrosis of the hemmed flap of the right thigh was detected (Fig. 1). On examination, it was revealed that the patient had undiagnosed extensive detachment of integumentary tissues of the right lower limb and buttocks (Fig. 2). At the same time, strained hematomas with a total volume of up to 300 ml were under the damaged skin. As a result, the total lesion area was 20% of the body surface. When revision of wounds revealed necrosis and rupture of the gluteus maximus, which were closed by the fibrous fascia lata of the right thigh (Fig. 3). Considering that such tissue damage inevitably causes endogenous intoxication and the development of septic complications, it was decided to perform surgery. They performed surgical treatment of wounds, conducted an audit of wounds with exfoliated integumentary tissues, revision of underlying muscles and fascias. Evaluated the blood supply to the detached integumentary tissues, by performing polarography with the determination of the level of gases (oxygen and carbon dioxide) in the tissues, cut off the non-vascularized exfoliated skin flaps. All necrotic tissues were removed, 3/4 of the area of the skin flaps was unsuitable for plastics. Full-layer skin flaps were formed from delaminated skin flaps, for this purpose they were processed, during which all subcutaneous fat was removed from the flaps with scissors, leaving the epidermis with the dermis. They placed full-layer skin flaps in a sterile container with saline and kept at a temperature in the range from 3 to 4 ° C. Installed active drainage, suggestive stitches for fixing the flap. At the end of the operation, the wounds are closed with multi-layer antiseptic dressings to prevent the wound from drying out. On the fifth day of 10/18/2012, the purulent process and necrotic tissues were absent in the wound, wound plasty was performed, replantation of full-thickness skin flaps previously stored in saline into the area of functionally significant zones was made (Fig. 4). On the remaining wound surfaces (anterior surface of the middle third of the thigh), in the absence of full-fledged skin grafts, the plastic was made with split skin grafts (Fig. 5). The patient was observed during the week in the intensive care unit, where up to 500 ml of sero-hemorrhagic discharge was discharged by drainage per day.

In the postoperative period, laboratory tests were regularly carried out, including the procalcitonin test, which gave a positive reaction. Daily infusion therapy included, in addition to the corresponding antibacterial drugs, 150 ml of red blood cell mass, 400 ml of plasma, 500 ml of aminogen. Engraftment was 100%. From 11/17/2012, the patient began to get up, gradually increasing physical activity. Discharged from the hospital 27.11.2012, the period of treatment of the patient in the hospital was 33 days. From November 30, 2012, the patient began to attend school and gradually practiced physical therapy in compression underwear. FIG. 6 shows the long-term outcome of treatment. Pos. 1 and 3 are marked full-thickness skin flaps, pos. 2 - scar tissue at the site of use of split skin grafts. As can be seen, full-thickness skin patches after healing of wounds have an even color, are close in appearance and texture to normal skin.

The proposed method is used by the authors in the Ilizarov Center in Kurgan.

Claims (5)

1. A method of treating open exfoliating soft tissue injuries, in which the primary surgical treatment of a wound is performed, wounds are inspected with delaminated integumentary tissues, the underlying muscles and fascia are revisited, the blood supply to exfoliated integumentary tissues is evaluated, unvascular exfoliated skin grafts are cut off skin grafts full-layer skin grafts, for this purpose, they are processed, in which all subcutaneous fat is removed from the grafts, leaving epidermis with dermis, characterized in that they place full-thickness skin grafts in a sterile container with saline solution and are kept at a temperature in the range from 3 to 4 ° C, then after preparation of the recipient bed, in the absence of a purulent process in the wound and necrotic tissue, between the fifth and eighth days after injury, the operation of plastics wounds, perform replantation of full-thickness skin flaps, previously stored in saline. 2. The method according to p. 1, characterized in that during surgical treatment the wound is abundantly washed with saline, remove all foreign bodies, hematomas, crush tissue, process with soapy water, 0.05% chlorhexidine digluconate water, betadine. 3. The method according to p. 1, characterized in that assess the blood supply to the detached integumentary tissues by performing polarography to determine the level of gases, oxygen and carbon dioxide in the tissues. 4. The method according to p. 1, characterized in that assess the blood supply to the detached integumentary tissues by determining the capillary blood flow at five points. 5. The method according to p. 1, characterized in that the full-layer skin flaps fixed anchor seams around the perimeter.

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