RU2741954C1 - Method of treating local head wounds with osteonecrosis of skull bones - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to plastic surgery, combustiology, traumatology, neurosurgery. Osteonecrectomy is performed radially to the dura mater, to active haemorrhage from the viable bone tissue forming the wound wall. Skin grafts are simultaneously covered with edges, walls and a bottom of a wound formed after surgical treatment and osteonecretomy, overlapping to healthy skin. Skin transplants are fixed by means of a vacuum dressing with a constant pressure of 70 mm Hg.

EFFECT: method enables in one operation to restore integrity of skin on head wounds with osteonecrosis of bones of cranial vault, reducing cicatrisation processes in the area of free skin plasty by preventing formation of granulation tissue, ensure tight contact of skin autografts with the wound bottom, prevent the probability of the autografts migration, as well as the appearance of hematomas under the autografts, to provide the patient with the possibility to take any position in the bed, with the possibility of lying on the wound, without fear of the dressing dislocation.

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Description

The proposed invention relates to medicine, namely to plastic surgery, combustiology, traumatology, neurosurgery and can be used in patients with deep burns of the head and their consequences, as well as with post-traumatic wounds with osteonecrosis of the bones of the cranial vault.

The main goal of treating patients with wound defects is plastic restoration of the integrity of tissues, primarily the skin. Damage to the bones of the cranial vault most often occurs from the action of high voltage current. Self-rejection of dead bone areas takes a very long time, sometimes even after a year they are firmly fixed (Burns: A Guide for Physicians. Edited by B.S.Vikhriev and V.M. Burmistrov. L .: Medicine, 1981. - S. 182- 183).

Surgical treatment of deep burns comes down to performing two main types of operations: removal of dead tissue (necrectomy) and restoration of the lost skin (Paramonov B.A., Porembsky Y.O., Yablonsky V.G. Burns: A Guide for Physicians. - St. Petersburg. : SpetsLit, 2000. - P. 226). Best of all, the engraftment of skin flaps occurs when they are transplanted onto granulation and muscle tissue (Paramonov B.A., Porembsky Y.O., Yablonsky V.G. Burns: A Guide for Physicians. - SPb .: SpetsLit, 2000. - P. 244 ).

With electric burns of the bones of the cranial vault in severe cases, the entire thickness of the bone dies (Orlov A.N., Sarkisov M.A., Bubenko M.B. Electrotrauma. L .: Medicine, 1977. - P. 102).

An analogue of the alleged invention, we adopted a method for the treatment of contact burns with osteonecrosis of the skull (Ginzburg RL Burns. M .: Medicine, 1971. - S. 114). The method provides for the surgical treatment of osteonecrosis by performing multiple craniotomies. For this, multiple holes are made with a cutter in the necrotic bone to the dura mater. The dead bone is rejected after 1.5-2 months, by which time the dura mater is covered with granulations and the wound is ready for skin transplantation, which is performed in the second stage.

The disadvantages of this method include:

1. Duration of treatment (2 months or more) with the development of infection in the wound.

2. The need for two stages of surgical treatment (osteonecrectomy and delayed skin grafting).

3. Performing skin grafting on a granulating wound, which is accompanied by a more coarse scarring of the restored skin.

4. Uneven pressure on the grafts when applying bandages with a simple medical bandage.

5. Application of uncontrolled pressure on the head.

6. Possibility of slipping of the bandages when the patient moves his head.

The closest analogue of the alleged invention we have adopted the method of one-stage radical osteonecrectomy (Burns: A guide for doctors. Edited by B. S. Vikhriev and V. M. Burmistrov. L .: Medicine, 1981. - S. 187-188). Bone resection is performed by making holes in the bone, which are connected with cuts made with a Jigli saw, the edges of the bone defect are leveled with nippers. This concludes the first stage. Subsequently, after the preparation of the wound surface with granulations, the second stage is performed - plastic closure of the wound using free or non-free skin plastic.

The disadvantages of this method include:

1. Duration of treatment with the development of infection in the wound.

2. The need for two stages of surgical treatment (osteonecrectomy and delayed skin grafting).

3. Performing skin grafting on a granulating wound, which is accompanied by a more coarse scarring of the restored skin.

4. Uneven pressure on the grafts when applying bandages with a simple medical bandage.

5. Application of uncontrolled pressure on the head.

6. Possibility of slipping of the bandages when the patient moves his head.

Tasks:

- to improve the restoration of the skin in the presence of local head wounds with osteonecrosis of the bones of the cranial vault;

- reduce the time of treatment;

- to improve and facilitate the dressing technique;

- to create conditions for engraftment of free skin autografts by ensuring uniform pressure on skin grafts and the dura mater;

- to reduce the scarring processes in the area of free skin grafting;

- to improve the results of surgical treatment of head wounds with osteonecrosis of the bones of the cranial vault.

The essence of the invention, including treatment of the operating field, surgical treatment of wounds, osteonecrectomy, free skin autoplasty, application of a vacuum bandage, is the following: osteonecrectomy is performed radically to the dura mater until active bleeding from the viable bone tissue forming the wound walls, skin grafts simultaneously cover the edges, the walls and bottom of the wound formed after surgical treatment and osteonecrectomy, overlapping the healthy skin, and the fixation of skin grafts is carried out using a vacuum bandage with a constant pressure of 70 mm Hg.

EFFECT: this method allows in one operation to restore the integrity of the skin integuments on head wounds with osteonecrosis of the bones of the cranial vault, to reduce scarring processes in the area of free skin grafting by preventing the formation of granulation tissue. The vacuum bandage ensures a tight contact of the skin autografts with the bottom of the wound, which in turn minimizes the likelihood of migration of autografts, as well as the appearance of hematomas under the autografts, which can slow down their engraftment. Thanks to the vacuum dressing, the patient can take any position in bed, with the ability to lie on the wound without fear of displacement of the dressings.

The implementation of the method for the treatment of local head wounds with osteonecrosis of the bones of the cranial vault is performed as follows. In the operating room, after standard treatment of the operating field, surgical treatment of wounds is performed: a bordering incision is made with a scalpel at the border of healthy skin, necrotic altered soft tissues or granulations along the edges of the wound are economically excised, hemostasis is performed with an electrocoagulator and pressing bandages. Then, in the area of osteonecrosis with an oscillating saw, chisel and nippers, osteonecrectomy is performed radically to the dura mater until active bleeding from the viable bone tissue forming the wound walls. The DE-60 electrodermatome is used to collect split skin autografts of the size required for the area, with a thickness of 0.45-0.5 mm. Skin grafts simultaneously cover the edges, walls and bottom of the wound formed after surgical treatment and osteonecrectomy, placing them overlapping the healthy skin. Then, mesh atraumatic dressings, a vacuum system sponge and a film are applied to the head wounds. Connect a vacuum apparatus and set the pressure parameters (70 mm Hg). The first bandaging is performed 5-6 days after the operation. The vacuum bandage is removed, the area of the performed skin plastic is sanitized. Full adaptation of skin grafts is observed 10-12 days after surgery.

According to this method, in a clinical setting, two patients with local post-burn wounds of the head with osteonecrosis of the bones of the cranial vault were operated on.

Clinical example. Patient M., 46 years old, was admitted to the burn department of GBU3-NII KKB No. prof. S.V. Ochapovsky with a diagnosis of 0.75% electric burn of the head (Fig. 1). He was transferred 4 weeks after the injury from the Central District Hospital, where staged necrectomy with bandages was performed. In the operating room, after standard treatment of the operating field, surgical treatment of the wounds was performed: a bordering incision was made with a scalpel at the border of healthy skin, granulation along the edges of the wound was economically excised, hemostasis was performed with an electrocoagulator and pressure bandages. Then, in the area of osteonecrosis with an oscillating saw, cuts were made on the outer cortical plate to the spongy layer, osteonecrectomy was performed with a chisel to the inner cortical plate (Fig. 2), in connection with its osteonecrosis, the inner cortical plate was radically removed with nippers to the dura mater until active bone bleeding from viable tissue forming the walls of the wound (Fig. 3). Electrodermatome DE-60 was used to collect split skin autografts of the required size, 0.45 mm thick. Skin grafts simultaneously covered the edges, walls and bottom of the wound formed after surgical debridement and osteonecrectomy, placing them overlapping the healthy skin (Fig. 4). Then, mesh atraumatic dressings, a vacuum system sponge, and a film were applied to the head wounds (Fig. 5). We connected a vacuum apparatus and set the pressure parameters to 70 mm. rt. Art. (Fig. 6). The first bandaging was performed 5 days after the operation. The vacuum bandage was removed (Fig. 7), the zone of the performed skin grafting was sanitized (Fig. 8). Complete adaptation of skin grafts was observed 11 days after surgery (Fig. 9).

Claims (1)

A method of treating local head wounds with osteonecrosis of the bones of the cranial vault, including treatment of the operating field, surgical treatment of wounds, osteonecrectomy, free skin autoplasty, vacuum dressing, characterized in that osteonecrectomy is performed radically up to the dura mater before active bleeding from viable bone tissue that forms the walls of the wound, skin grafts simultaneously cover the edges, walls and the bottom of the wound formed after surgical treatment and osteonecrectomy, overlapping the healthy skin, and fixation of skin grafts is carried out using a vacuum bandage with a constant pressure of 70 mm Hg.

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