RU2751283C1 - Method for reconstruction of calcaneal region with complete or partial loss of calcaneal bone - Google Patents

Abstract

FIELD: medicine, traumatology and orthopedics in particular.SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be used for the reconstruction of the calcaneus in case of its loss. The method involves replacing the defect with a musculoskeletal tissue complex from the iliac wing, which is isolated on the basis of the deep envelope of the iliac artery, and plasticizing the soft tissues of the calcaneal region with a sural skin-fascial flap. The size and shape of the bone graft is determined during preoperative planning in proportion to the height of the healthy calcaneus of the contralateral limb. In the recipient zone, a longitudinal groove in the talus bone is pre-formed, coinciding in shape and size with the bone part of the transplanted graft, into which the graft is inserted, adapting it in the defect so that the cortical layer of the bone part of the iliac wing graft faces the plantar side, and its opposite edge is wedged with a spongy substance into the pre-formed groove in the talus bone. It is fixed with Kirschner spokes, which are passed through it into the talus block from the bottom up. The size of the muscle part of the flap on the inner side of the calcaneal region, which is subsequently covered by a split skin graft, is chosen to be sufficient for suturing to the edges of the soft-tissue defect. The defect formed on the posterior surface of the calcaneal region in the area of the passage of the vascular pedicle of the graft is replaced by an insular sural skin-fascial flap.EFFECT: method provides the restoration of the limb's support ability due to the reconstruction of the calcaneal region by transplanting a blood-supplied musculoskeletal graft from the wing of the ilium with a fragment of the internal oblique abdominal muscle.1 cl, 7 dwg, 1 ex

Description

The invention relates to medicine, in particular to traumatology and orthopedics, and can be used for the reconstruction of the heel region with complete or partial loss of the calcaneus.

Calcaneus resection is not popular, but a necessary measure in patients with osteomyelitis or tumors. Removal of the heel bone, even partial, significantly reduces the support ability of the limb, leads to the development of deforming arthrosis of the joints of the foot and ankle joint, as well as the development of pain syndrome.

A known method of replacing the total defect of the calcaneus by G- (T) -shaped osteotomy of the talus and dosed movement of the selected fragment first downward to the level of the plantar surface of the foot, and then posteriorly until the contours of its posterior part are restored [1]. However, this method is feasible only if the talus is completely intact with an unchanged structure. In the conditions of a post-osteomyelitic defect of the calcaneus, the formation of a fragment of the talus, sufficient in volume, its directed movement in the defect is difficult and does not exclude the development of recurrence of osteomyelitis.

There is a method for the reconstruction of the hindfoot in conditions, for example, of chronic osteomyelitis, including arthrodesis of the ankle and talo-navicular joints, osteotomy of the tibia, dosed movement and reversal of the selected fragments in the defect from top to bottom until the contours of the hindfoot are restored [2]. However, this method does not provide restoration of the load axis of the foot due to the discrepancy between the size of the formed rear section and the size of the front section, which contributes to the development of pain in patients, and also requires wearing orthopedic shoes.

There is a known method of reconstruction of the hindfoot in the absence of the calcaneus [3], which consists in arthrodesis of the ankle and talonavicular joints in the position of the displacement of the forefoot posteriorly until the cuboid bone contacts the tibia and overlaps the last talonavicular joint. The arthrodesisable segment is fixed in an external fixation apparatus. The disadvantage of this method is a change in the stereotype of movements in connection with arthrodesis of the ankle joint, which may result in a shortening of the foot, shortening the length of the limb due to the wedging of the tibia into the talus.

In the foreign literature, there are few publications on the results of the use of microsurgical reconstruction of the calcaneus with its subtotal and total defects. A few researchers describe clinical examples of successful reconstruction of the calcaneus with a costal autograft with a site of the serratus anterior muscle [5; eight]. At the same time, in cancer patients who underwent total calcanectomy, from the point of view of restoring the support function and the appearance of the foot, most researchers for many years have considered non-free plastic surgery to be a skin-bone peroneal flap on the distal vascular pedicle [9; 10]. However, there are also negative aspects here, one of which is that this type of plasty practically leaves no technical possibilities for the reconstruction of the Achilles tendon, which is required in some patients with tumor lesions of the calcaneus [6; 7].

Closest to the claimed is a method in which the lost calcaneus is restored by free transplantation of blood-supplied skin and bone autograft from the wing of the ilium [4]. However, transplantation of a bone graft with a skin fragment is accompanied by a high risk of necrosis of the latter in the postoperative period; in addition, a small graft was used in the described method. This made it possible to adapt the complex of tissues in the recipient bed and cover its bone part with soft tissues. When using a large-volume graft, the replacement of the soft tissue defect cannot be performed without additional plasty. This operation is a prototype of our proposed method.

The technical result consists in restoring the supporting ability of the limb due to the reconstruction of the heel region.

The result is achieved due to the fact that the reconstruction of the heel area is realized by free transplantation of a blood-supplied musculoskeletal graft from the wing of the ilium with a fragment of the internal oblique muscle of the abdomen and fixing it with two Kirschner wires. At the same time, in patients with a calcaneus defect of more than 90%, it is necessary to take the bone part of a large blood-supplied graft and its stable attachment to the talus. For this, in the region of the posterior calcaneal articular surface of the talus, a longitudinal groove is formed along the width of the bone part of the free iliac crest graft, which increases the stability of the transplanted graft installation. After that, the vascular pedicle and the muscular part of the blood-supplied musculoskeletal graft are covered with an insular fascial-skin sural flap, which allows replacing the soft tissue defect along the posterior surface of the calcaneal region and isolating the supply vessels of the free complex of tissues. This method of reconstruction of the calcaneus with its loss, in our opinion, is considered optimal.

The illustrations show:

FIG. 1. - Scheme of isolation of the musculoskeletal graft of the wing of the ilium, where: 1- graft of the wing of the ilium; 2 - a fragment of the external oblique abdominal muscle; 3 - the ascending branch of the deep envelope of the iliac bone of the artery; 4 - deep artery enveloping the iliac bone; 5- inguinal ligament; 6 antero-superior iliac spine; 7 - external iliac artery and veins;

FIG. 2. - view of the foot after calcanectomy, where: 8 - recipient zone;

FIG. 3. - X-ray of the foot, where: 8 - recipient zone (calcaneus defect); 9 - talus;

FIG. 4. - X-ray of the foot after the transplantation of the musculoskeletal graft, fixation with two wires, where: 1 - the graft of the iliac wing; 9 - talus; 10 - Kirschner needles;

FIG. 5. - the formed defect of the soft tissues of the posterior-inner surface of the calcaneal region after transplantation of the musculoskeletal graft of the iliac wing, where: 11 - the muscular part of the graft; 12 - Achilles tendon; 13 - vascular anastomoses;

FIG. 6. - view of the foot after reconstruction, where: 14 - split skin graft; 15 - fascial sural flap;

FIG. 7. - X-ray of the foot 1 year after reconstruction, where: 1 - bone part of the iliac wing graft.

The method is carried out as follows: in the course of preoperative planning, the size and shape of the bone part of the graft is determined in proportion to the height of the healthy calcaneus of the contralateral limb; in addition, the corresponding size of the slot on the talus is determined for fixing the bone part of the transplanted graft in it. Access is performed along the outer surface of the calcaneal region with excision of the fistulous passages in case of osteomyelitis. Then the recipient bed is prepared: removal of the remains of the calcaneus, if any, of the cartilage and the cortical layer of the talus to the cancellous substance (Fig. 2.). In the area of the posterior calcaneal articular surface of the talus, using an oscillatory saw and chisels, a longitudinal rectangular groove is formed along the width of the bone part of the free graft, which increases the contact area of the bone part of the graft and the talus, and also provides greater stability of the transplanted flap. After that, the recipient vessels are isolated (posterior tibial artery and comitant veins). Then mark the musculoskeletal complex of tissues on the side with a more advantageous direction of the feeding vascular pedicle. The axial feeding vessel of the tissue complex is the deep artery enveloping the iliac bone and the paired associated veins of the same name (which, in turn, is a branch of the external iliac artery). When the tissue complex is isolated, the incision is made parallel to the iliac crest, layer by layer dissecting the muscles of the anterior abdominal wall and highlighting the vascular bundle at the level of the superior anterior iliac spine. With the help of an oscillatory saw and chisels, the bone part of a complex of tissues is taken, including both cortical layers of the ilium and a fragment of the internal oblique abdominal muscle adjacent to the bone (Fig. 1.). The donor wound is sutured in a line layer by layer. Then the graft is transferred to the recipient bed and adapted in the defect so that the cortical layer of the bone part of the iliac wing graft is facing the plantar side, and the opposite edge is wedged with a cancellous substance into the pre-formed groove on the talus. The graft is fixed with two Kirschner wires in the direction from the iliac crest to the talus block from bottom to top (Fig. 4). Restoration of blood supply in the flap is carried out by performing microsurgical anastomoses between the artery of the tissue complex and the posterior tibial artery in the end-to-side manner, as well as between the accompanying veins of the autograft and the corresponding recipient veins in the end-to-end manner.

After fixation of the tissue complex in the recipient bed, a soft tissue defect remains along the posterior surface of the calcaneal region, partially exposing the posterior part of the bone fragment of the graft and the feeding vascular pedicle of the transplanted tissue complex. At the same time, the muscular part of the blood-supplied flap remains uncovered along the inner surface of the heel area (Fig. 5.). To replace the soft tissue defect, after preliminary marking, the cutaneous-fascial sural flap is isolated on the perforating branches of the peroneal artery, the skin part of which corresponds to the size of the resulting defect in the posterior surface of the calcaneus. The flap is rotated on the vascular pedicle to the area of the defect and sutured to the edges of the wound, covering the vascular anastomoses and the posterior part of the bone fragment of the transplanted tissue complex. At the same time, the donor site on the lower leg is sutured in line.

The size of the muscle part of the tissue complex, which is subsequently covered with a split skin graft, should be sufficient to suture to the edges of the defect along the inner surface of the heel area. The muscular part of the tissue complex is fixed with sutures to the edges of the defect, isolating the bone fragment of the graft from the external environment and closed with a split skin autograft (commensurate with the muscle part of the flap) taken from the thigh using a dermatome. The skin autograft is perforated and sutured to the edges of the skin in tension, completely covering the muscle part of the flap (Fig. 6.). With adequate restoration of the blood supply to the tissue complex, active drainage of the wound is performed. The operation ends with the immobilization of the operated segment with a plaster cast until the bone block is formed for at least 3 months, after which a dosed load on the operated limb is started.

Clinical example.

Patient N., 57 years old, was admitted to the clinic of the Institute 01.10.19, with a diagnosis of Subtotal defect of the calcaneus of the left foot (Fig. 3). 07.10.19 performed the operation according to the proposed method. Reconstruction of the calcaneal region of the left foot was carried out by plasty of the calcaneus with a blood-supplied musculoskeletal graft of the iliac crest (the size of the bone part of the graft in the patient was 5.5 × 6.5 × 2.0 cm; the size of the muscle part - 7.0 × 6.0 × 2.0 cm; the length of the vascular pedicle was 5.0 cm). The graft was fixed with Kirschner wires into a pre-formed longitudinal groove in the talus, the size and shape of which corresponded to the size and shape of the bone part of the free blood supply complex of tissues. Replacement of the soft tissue defect was performed with an insular fascial-skin sural flap, followed by free skin grafting (the thickness of the split skin graft was 0.7 mm; the size of the graft was 7.0 × 6.0 cm). The limb was fixed with a plaster cast. The operation was performed under endotracheal anesthesia. The operation time was 7.0 hours. The postoperative period is smooth. The wounds healed by primary intention. The pins were removed after the formation of the bone block, which occurred 3.5 months later according to the computed tomography data, after which the load on the operated leg was allowed. Rehabilitation treatment (course of exercise therapy) was carried out. On examination after 1 year (Fig. 7), the pain syndrome was arrested, the patient walks without additional support, there is no lameness. Good aesthetic and functional results have been achieved.

Bibliography

1. Shevtsov VI, Ismailov GR .. Transosseous osteosynthesis in foot surgery. - M: Medicine, 2008 .-- p. 170

2. Pat. 2381760 RF, IPC А61В 17/56. A method for the reconstruction of the hindfoot after removal of the osteomyelitically affected calcaneus. Klyushin N.M., Zlobin A.V., Burnashov S.I .; app. 12/29/2008; publ. 20.02.2010 Bul. No. 5.

3. Pat. 2457804 RF, IPC А61В 17/56. A method for the reconstruction of the hindfoot in the absence of the heel bone. Klyushin N.M., Shlyakhov V.I., Zlobin A.V., Burnashov S.I., Bagaliev M.M .; app. 05/19/2011; publ. 10.08.2012 Bul.

4. Tsybul ES, Possibilities and results of the use of reconstructive microsurgery technologies in the treatment of patients with deformities and defects of the heel bone: Diss ... honey. sciences. - SPb., 2016 .-- 97-100 p.

5. Brenner P., Zwipp N., Rammelt S. Vascularized double barrel ribs combined with free serratus anterior muscle transfer for homologous restoration of the hindfoot after calcanectomy. J Trauma. 2000; 49 (2): 331-335.

6. Choong P.F., Qureshi A.A., Sim F.H., Unni K.K. Osteosarcoma of the foot: a review of 52 patients at the Mayo clinic. Acta Orthop.Scand. 1999; 70: 361-364.

7. Imanishi J., Choong P.F. Three-dimensional printed calcaneal prosthesis following total calcanectomy. Int J Surg Case Rep. 2015; 10: 83-87.

de serratus

propos de quatre cas. Annales de Chirurgie Plastique

2013; 58(4):321-3268. Kitsiou C., Perrot P., Duteille F. La reconstruction des pertes de substance complexes du pied par lambeau libre

de serratus

propos de quatre cas. Annales de Chirurgie Plastique

2013; 58 (4): 321-326

9. Li J., Guo Z., Pei G.X., Wang Z., Chen G.J., Wu Z.G. Limb salvage surgery for calcaneal malignancy. J. Surg. Oncol. 2010; 102: 48-53.

10. Tang M.L., Lu S.W., Ren J.W., Tang J.L., Zhou X.B., Wu S.T. Applied anatomy of the V-shaped fibular osteomyocutaneous flap in reconstruction of the hindfoot. Surg Radiol Anat. 2001; 23 (4): 215-220.

Claims (1)

A method of reconstruction of the calcaneal region with complete or partial loss of the calcaneus, including the replacement of the defect with a musculoskeletal complex of tissues from the wing of the ilium, which is isolated on the basis of the deep artery enveloping the iliac bone, and plasty of the soft tissues of the calcaneus with a sural fascial skin flap, which differs in that, that the size and shape of the bone graft is determined on preoperative planning in proportion to the height of the healthy heel bone of the contralateral limb; in the recipient zone, a longitudinal groove is preliminarily formed in the talus, which coincides in shape and size with the bone part of the transplanted graft, into which the graft is inserted, adapting it in the defect so that the cortical layer of the bone part of the iliac wing graft faces the plantar side, and its opposite edge with a cancellous substance was wedged into a pre-formed groove in the talus, and then fixed with Kirschner wires, which are passed through it into the talus block from bottom to top; the size of the muscle part of the flap along the inner side of the heel area, which is subsequently covered with a split skin graft, is chosen sufficient for suturing to the edges of the soft tissue defect; the defect formed on the posterior surface of the calcaneal region in the area of the vascular pedicle of the graft is replaced with an insular sural fascial skin flap.

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