RU2791972C1 - Method for treatment of osteomyelitis of calcaneus based on lipofibrous autograft - Google Patents

Abstract

FIELD: medicine; traumatology; orthopaedics; purulent osteology; foot surgery.

SUBSTANCE: invention can be used for treatment of calcaneal osteomyelitis based on lipofibrous autograft. The volume of the resulting defect of the calcaneus is determined. Surgical access is performed in the lateral region of the abdomen. A fragment of subcutaneous fatty tissue is taken up to its own fascia, taking into account the size of the calcaneus defect. The taken fragment of subcutaneous fat is dissected in different directions and manual pressing is performed, forming a lipofibrous autograft, which is placed in the calcaneus defect so that it covers the entire surface of the defect.

EFFECT: method of filling the "dead" space after removal of the infected tissues of a purulent-necrotic focus with a lipofibrous autograft reduces the risks of soft tissue retraction, creates a condition for a complete reconstruction and restoration of the supporting function of the hindfoot due to the plastic properties of the lipofibrous autograft and the features of its preparation.

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Description

The invention relates to medicine, namely to traumatology and orthopedics, purulent osteology, foot surgery, and can be used for the treatment of calcaneal osteomyelitis based on lipofibrous autograft.

A known method for the treatment of osteomyelitis of the calcaneus (Babiak I, Pedzisz P, Kulig M, Janowicz J, Maldyk P. Comparison of Bone Preserving and Radical Surgical Treatment in 32 Cases of Calcaneal Osteomyelitis. J Bone Jt Infect. 2016;1:10-16. ) in which access to the calcaneus is carried out either through an existing skin defect, or through a posterior or lateral approach to the calcaneus. After skeletonization of the calcaneus and removal of potentially infected tissue, 6 to 9 canals 4 mm in diameter are formed in the spongy bone tissue of the calcaneus. At the next stage, "pegs" formed from one piece of collagen-gentamicin sponge containing 130 mg of gentamicin sulfate are introduced into these channels. The wound is sutured.

A known method for the treatment of osteomyelitis of the calcaneus (Drampalos E, Mohammad HR, Kosmidis C, Balal M, Wong J, Pillai A. The Foot Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate / hydroxyapatite biocomposite: The Silo technique. Foot. 2018; 34:40-4.), consisting in the fact that a longitudinal posterior incision is made with a transition to the plantar surface of the heel region, the Achilles tendon is cut off from the place of attachment to the bone. The ulcerative defect of the soft tissues is excised with an incision, removing the infected and non-viable bone tissue. A few millimeters of bone covering the hypointense and hyperintense focus of osteomyelitis are removed according to the MRI performed before the operation. For local delivery of the antibiotic and treatment of "microscopic" foci of infection in the calcaneus, several (four to five) tunnels of the "Silo" type are formed using a drill with a diameter of 3.2 mm. Drilling is performed under X-ray control in the direction of the posterior facet of the subtalar joint at a distance not closer than 0.5 cm to the articular surface. Then the surgical wound is irrigated with hydrogen peroxide and dried. The formed "Silo" tunnels are filled with 5 ml of hydroxyapatite saturated with gentamicin using dilator tips. The wound is sutured. Impose individually made orthosis for the ankle region.

The disadvantages of these methods are that they cannot be used for extensive lesions of the calcaneus and the spread of the focus of infection to the posterior facet of the subtalar joint. There is a high risk of retraction of the surrounding soft tissues with a violation of the support function of the hindfoot and the impossibility of a full reconstruction due to the fact that there is no filling of the "dead" space after removal of the infected tissues of the purulent necrotic focus.

A known method for the treatment of osteomyelitis of the calcaneus (RF patent No. 2354317 dated December 27, 2007), including sequestrectomy with excision of soft tissue scars, cutting out the medial plantar flap on the feeding leg, transposition of the medial plantar complex into the recipient bed with suturing it to the edges of the wound, followed by immobilization of the foot , the medial plantar artery and the veins accompanying it are included in the feeding pedicle and the integrity of the medial plantar nerve is preserved, and the preserved and superficially lying medial plantar nerve is covered with a muscle with a short flexor of the fingers.

The disadvantages of this method are that the method is difficult to implement due to the fact that it is necessary to cut out the medial plantar flap in such a way as to preserve and not damage the medial plantar artery, the accompanying veins and the plantar nerve in the feeding pedicle, close the donor site, which increases the duration of the operation. The risk of recurrence is high, since in the postoperative period there is a high risk of circulatory disorders of the transplanted plantar flap, which leads to impaired support function of the hindfoot.

A known method for the treatment of osteomyelitis of the calcaneus (Xu X. Y., Zhu Y., Liu J. N. Treatment of calcaneal osteomyelitis with free serratus anterior muscle flap transfer // Foot & ankle international. - 2009. - T. 30. - No. 11. - C. 1088-1093), taken as a prototype, a muscle graft of the serratus anterior muscle is taken, the focus of infection in the heel region is sanitized and the recipient bed is prepared. For autograft sampling, access is carried out in the axillary region, along the anterior edge of the latissimus dorsi muscle, about 10 centimeters long. The vascular pedicle is identified on the surface of the middle and lower parts of the serratus anterior. The vascular pedicle is isolated, the branch to the latissimus dorsi is ligated, and the muscle flap is dissected, on average, from 6.5×9 cm to 11.5×14.5 cm. Thorough debridement is performed in the heel region. The artery of the free muscle flap is anastomosed with the posterior tibial artery or dorsal artery of the foot according to preoperative angiography. The flap vein is anastomosed with the accompanying vein or saphenous vein. The muscle flap is placed into the bone cavity. In the presence of a soft tissue defect, the muscle flap is adjusted in shape and sutured to adjacent tissues under the wound edge. Drainage is placed under the muscle flap. A split skin graft is applied to the flap to close the wound. A hole is made in the bandage to observe the vascularization of the flap.

The disadvantages of this method are that the method is difficult to implement due to the fact that it is necessary to cut out the muscle graft in such a way as to preserve and not damage the feeding leg, and then sew it to the neurovascular bundle of the calcaneal region using microsurgical techniques. When taking a graft from the serratus anterior muscle, there is a high risk of developing dysfunction of the muscle. In the postoperative period, there is a high risk of circulatory disorders of the muscle graft, which requires constant monitoring, which leads to an increase in the stationary period. There is a high risk of recurrence, as a result of avascular necrosis of the muscle graft against the background of a violation of its blood supply.

The technical result of the invention is the creation of a method free from the above disadvantages.

This technical result is achieved by the fact that a method for treating osteomyelitis of the calcaneus based on a lipofibrous autograft, including surgical access, necrosequestrectomy, formation of a calcaneal defect, sampling of an autograft, installation of an autograft in a calcaneus defect, determining the volume of the formed calcaneal defect, in the lateral region of the abdomen, a surgical procedure is performed. access, a fragment of subcutaneous fatty tissue is taken up to its own fascia, taking into account the size of the calcaneus defect, the taken fragment of subcutaneous fatty tissue is dissected in different directions and manual pressing is performed forming a lipofibrous autograft, which is placed in the calcaneus defect, so that it covers the entire surface of the defect.

The invention is illustrated by the following illustrations, where in Fig. 1 - photograph, side view, image of the heel region upon admission, Fig. 2 - MSCT, axial view, heel area before surgery, fig. 3 - MSCT, frontal view, calcaneal region before surgery, fig. 4 - MSCT, sagittal projection, calcaneal region before surgery, fig. 5 - photograph showing the formed defect of the calcaneus, fig. 6 - photograph showing the installation of a lipofibrous autograft, fig. 7 - photograph, side view, image of the heel region on the 25th day after the operation, fig. 8 - MSCT, frontal projection, calcaneal region after surgery 12 months later, FIG. 9 - MSCT, axial view, heel area after surgery 12 months later, FIG. 10 - MSCT, sagittal projection, heel area after surgery 12 months later, FIG. 11 - photograph, side view, image of the heel region after surgery after 12 months.

An embodiment of the invention.

The patient is laid on their side under spinal anesthesia. A pneumatic tourniquet is placed on the middle third of the thigh. Through functioning fistulas, the affected area is stained with a dye solution, for example (brilliant green, methylene blue). Perform external extended access to the calcaneus. Next, excision of fistulas and necrosequestrectomy of the purulent focus are performed, with the formation of a calcaneus defect. Then the volume of the resulting defect of the calcaneus is determined. Next, the heel bone defect is treated with an antiseptic solution, for example (povidone iodine solution). Then, surgical access is performed in the lateral region of the abdomen. A fragment of subcutaneous fatty tissue is taken up to its own fascia, taking into account the size of the calcaneus defect. Hemostasis is performed, the wound is sutured in layers. The taken fragment of subcutaneous fatty tissue is dissected in different directions with a scalpel and manual pressing is performed through a gauze napkin, forming a lipofibrous autograft. Then the resulting lipofibrous autograft is placed in the calcaneus defect so that it covers the entire surface of the defect. The pneumatic tourniquet is removed and hemostasis is performed. A semi-tubular drainage is installed and soft tissues are sutured in layers, an aseptic bandage is applied.

Clinical example.

Patient X., born in 1956 in 2020, was admitted to the Federal State Budgetary Institution "NNIITO named after Ya.L. Tsivyan" of the Ministry of Health of Russia with complaints of a fistula in the left heel region (Fig. 1), pain in the left ankle region and fever up to 38.0 С°. From the anamnesis of the disease: in July 2018, he received a work injury, a fall from a dump truck trailer on straight legs, he felt a sharp pain in the left foot, deformity, an increase in edema in this area, he could not walk on his own. After a clinical and radiological examination in a medical institution at the place of residence, the diagnosis was made: Closed uncomplicated intra-articular fracture of the left calcaneus. Surgical treatment was carried out in the following volume: open reposition of the fracture of the left calcaneus, osteosynthesis with pins with bone grafting using the Osteomatrix bone substitute. In September 2018, a purulent fistula formed, conservative treatment at the place of residence had no effect. In December 2018, an operation was performed: excision of the fistulas of the left foot, revision of the streaks. In May 2020, I rubbed the left heel area, noted an increase in swelling and pain in this area. He did not ask for help, he was self-medicating (bandaging with an antiseptic solution). A comprehensive clinical, radiological and MSCT examination was performed (Fig. 2, Fig. 3, Fig. 4), which shows the destruction of the subtalar region of the calcaneus. According to the results of the examination, a clinical diagnosis was established: Late infection of the surgical intervention area, chronic osteomyelitis of the left calcaneal region, fistulous form. Surgical treatment was carried out according to our proposed method (Fig. 5, Fig. 6), followed by management and observation. Healing of the postoperative wound by primary intention, removal of sutures occurred on the 25th day after the operation (Fig. 7). After 12 months, a control examination of the patient was performed, a control MSCT of the left ankle region was performed (Fig. 8, Fig. 9, Fig. 10), which shows the relief of the infectious process in the heel region. A photograph of the appearance of the foot (Fig. 11), which shows well-founded postoperative scars without signs of inflammation. The patient does not complain. Notes the absence of pain syndrome, restoration of the supporting function of the hindfoot. The patient is satisfied with the results.

The advantages of the proposed method in comparison with existing ones are that the method is used for extensive lesions of the calcaneus and the spread of the focus of infection to the posterior facet of the subtalar joint. Filling the "dead" space after removal of the infected tissues of the purulent-necrotic focus with a lipofibrous autograft reduces the risk of soft tissue retraction, which creates the conditions for a complete reconstruction and restoration of the supporting function of the hindfoot. The sampling of subcutaneous fat for autograft significantly reduces the trauma and the number of complications at the donor site. To implement the method, there is no need for interventions on neurovascular structures and the use of microsurgical techniques, which significantly reduces the duration and complexity of the operation. High plastic properties of lipofibrous autograft can reduce the healing time of an infected wound and reduce the risk of osteomyelitis recurrence.

A method for treating osteomyelitis of the calcaneus based on a lipofibrous autograft is implemented using modern equipment, using modern technologies and materials.

Claims (1)

A method for treating osteomyelitis of the calcaneus based on a lipofibrous autograft, including surgical access, necrosequestrectomy, formation of a calcaneal defect, sampling of an autograft, installation of an autograft into a calcaneal defect, characterized in that the volume of the formed calcaneal defect is determined, surgical access is performed in the lateral abdomen, a fragment of subcutaneous fatty tissue is taken up to its own fascia, taking into account the size of the calcaneus defect, the taken fragment of subcutaneous fatty tissue is dissected in different directions and manual pressing is performed, forming a lipofibrous autograft, which is placed in the calcaneus defect in such a way that it covers the entire surface of the defect.

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