RU2176482C2 - Method for performing plastic repair of nerve trunk defect - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves forming graft having neurovascular complex introduced into the cuff center. Sural nerve with lesser subcutaneous vein are included into the complex as single block. The cuff is produced from fascial cellular islet flap cut from the own crural fascia sublayer. The flap is cut so that its connections to the sural nerve and vein are retained and its length being equal to nerve trunk defect length. Then the sural nerve is transected below the distal end of the cuff. The vein transected at the level of the fifth metatarsal bone is anastomosed with the selected and transected back artery of the foot. Incision is made in the injured nerve trunk projection to remove cicatrix tissues from the ends. The selected graft is transferred to the defect. Fascial cicatricial layer and vein transformed into artery as vascular pedicle are retained on the cuff. Nerve trunk ends and the corresponding graft nerve ends are connected with sutures. Blood circulation is restored in the graft by connecting graft vein to recipient artery. EFFECT: avoided cicatrix compression of the graft. 4 dwg

Description

 The invention relates to medicine, and specifically to surgical methods, and for plastics of a defect in a nerve trunk.

 There are many different methods aimed at preventing adhesions and cicatricial compression of the graft, which is one of the main causes of adverse outcomes of plastic surgery of nerve trunks. In the famous A.S. N 515511 for the method of surgical treatment of tendons and nerves of limbs, a polyethylene tube is used in which the damaged portion of the nerve is placed. However, a plastic tube prevents scar formation only for the duration of the wound healing, after which it is removed. In accordance with the method of surgical treatment of nerve injuries of the lower third of the forearm according to A. St. N 1572560 restored the site of the nerve is placed in the newly formed muscle bed. The disadvantage of this method is the inability to use it with extensive defects of the nerve trunk.

 Closest to the proposed technical solution is the method of plastic surgery of a defect in the nerve trunk described by V. Kovachev et al. "Reconstruction of extensive stem defects using free vascularized nerve transplants", "Orthopedics and Traumatology", T. XXVII 1990, vol. 4, p. 23.

 This method is carried out by forming the neurovascular complex from the venous line along with paravasal tissues and the gastrocnemius nerve. Further, this complex is transferred to the defect of the reconstructed nerve trunk, the transplant suture with the ends of the nerve trunk is performed, the graft vein with the artery of the recipient region is anastomosed.

 The disadvantage of this method is the possibility of cicatricial compression of the graft due to scarring of the paravasal tissue, especially in conditions of a scar-modified bed.

 The task, the solution of which the proposed technical solution is directed, is the prevention of cicatricial compression of the graft.

 This problem is solved due to the fact that at the first stage a graft is formed, enclosing the neurovascular complex in the middle of the cuff formed by a fascial-cellular islet flap cut from the underlying fascia of the lower leg with preserving its connections with the calf nerve and vein and with a length equal to the length of the defect nerve trunk, the gastrocnemius nerve is crossed below the distal end of the cuff, and the vein intersected at the base of the fifth metatarsal bone is anastomosed with the isolated and crossed dorsal artery of the foot, and on T In the rum stage, an incision is made in the projection of the damaged nerve trunk with its ends liberated from the scars, and the selected transplant is transferred to the defect formed, leaving the fascial-scar layer and the vascular pedicle in the form of an arterialized vein with subsequent anastomosis of its distal end from one of the main arteries, and the proximal end with the dorsal saphenous vein of the operated area.

 The invention is illustrated by drawings, where in FIG. 1 shows the first stage of plastic surgery, the formation of fascial-cellular islet flap, the intersection of the calf nerve, in FIG. 2 - I stage of plastic surgery, the formation of a cuff from a fascial-cellular flap with the inclusion of the gastrocnemius nerve and vein, anastomosis of the central end of the vein with the dorsal artery of the foot, in FIG. 3 - II stage of plastic surgery, transplantation of the formed complex into a defect in the nerve trunk, anastomosis of the vessel and gastrocnemius nerve of the complex with the corresponding structures of the recipient region, FIG. 4 - II stage of plastic surgery, a transverse section of a complex of tissues transplanted into a defect in the nerve trunk.

 The method is as follows.

 At stage I, a graft is formed. For this, an incision is made in the skin and subcutaneous tissue in the projection of the gastrocnemius nerve along the outer surface of the lower leg and foot. The gastrocnemius nerve (1) and the small saphenous vein (2) are allocated as a single block without disturbing vascular connections. Further, this neurovascular complex is enclosed in the middle of the cuff (4), formed by a fascial-cellular islet flap cut out from the underlying fascia of the lower leg (3) while maintaining its connections with the calf nerve and vein and a length equal to the length of the defect of the nerve trunk. Cross the nerve below the distal end of the cuff, and the vein - at the base of the fifth metatarsal bone. On the front surface of the foot, a layered skin incision is performed, the dorsal artery of the foot stands out and intersects. The central end of the vein is carried out in the subcutaneous tunnel and is discharged into the wound, where it anastomoses with the peripheral end of the artery (5). The wound is sutured in layers. 3 months after the normalization of blood supply in the tissue complex, the second stage of the operation is performed - the transplant of the formed transplant itself into a nerve trunk defect on the forearm. After performing a skin incision in a postoperative scar, a graft and a vascular pedicle represented by an arterialized vein (2) are isolated from the scars, and a scar layer is left on the cuff (4). Thus, the cuff becomes three-layered, consisting of cellulose (6), fascial (3) and scar (7) layers. The gastrocnemius nerve is crossed at the level of the proximal end of the tube, the vein is distal and proximal to the tube. In the case of a defect in the main artery on the forearm, the length of the vein should be equal to the length of the missing part of the vessel. Next, a skin incision is made on the forearm in the projection of the damaged nerve trunk, its ends are extracted from the scars (8), and the graft is transferred to the resulting nerve trunk defect. The central and peripheral ends of the nerve trunk and graft are sutured together, blood flow in the graft is restored by anastomosing the distal end of the vein (2) of the graft from one of the main arteries, and its proximal end with the back saphenous vein of the hand. In the presence of a defect in the main vessel, its central end (9) anastomoses with the distal end of the vein (2), and the peripheral (10) with the proximal end of the vein (2). Sew donor and recipient wounds. The limb is immobilized with a plaster cast for 4 weeks. The proposed method operated on 8 patients.

 Clinical example.

 B-S S. Yu.S., born in 1952, was in the Nizhny Novgorod Scientific Research Institute of Nuclear Medicine because of a defect in the radial edge of the right hand, median nerve and ulnar neurovascular bundle, interruption of flexor tendons of 2-5 fingers at the level of the middle third of the forearm .

 Upon receipt, the absence of the first finger along with the metacarpal bone, loss of sensitivity of 2-5 fingers on the palmar surface, the inability to actively bend the fingers is noted. In addition, atrophy of the own muscles of the hand is determined. Previously, the patient had restored the radial edge of the hand, tendons of the flexors of the fingers and the ulnar nerve. The first stage of the plastic repair of the median nerve defect according to the developed method was performed on 2.03.94, and the second stage was performed on 05/13/94. At the second stage, the median nerve and ulnar artery were restored by plasticizing its defect with the vascular leg of the graft. The postoperative course is smooth. The wounds healed by primary intention.

 In the long term after surgery (up to 1 year), a distinct pulsation on the ulnar artery is determined. The restoration of all types of sensitivity in the innervation zone of the median nerve is also noted, which significantly improved the functionality of the hand.

 In all cases of the application of the method, adequate sensitivity was achieved in the innervation zone of the restored nerves; there were no signs of cicatricial compression of the graft.

 Thus, the use of a well-supplied arterialized cuff to isolate the graft from surrounding tissues prevents cicatricial degeneration of the graft.

 The transplant transplantation in two stages ensures the adaptation of its blood circulation to new operating conditions, which increases the viability of tissues, including cuffs. In addition, when performing the operation in 2 stages, an additional scar layer is formed on the cuff, which increases its skeleton and, accordingly, prevents the graft from being compressed by scars. At the same time, the neural transplant itself is free of scars and is surrounded by fatty tissue throughout, which preserves its extra-intraorgan blood supply.

 In addition, the proposed method simultaneously with the restoration of the nerve to restore the main artery of the forearm, which improves blood supply to the donor bed and the conditions of nerve regeneration.

 These advantages make the method most shown in conditions of cicatricial changes in the tissues of the donor region.

 The method is quite simple, effective and can be implemented in the departments of hand surgery, microsurgery and trauma, neurosurgical clinics with the appropriate equipment.

Claims (1)

 A method for plasty of a nerve trunk defect by isolating a transplant in the form of a neurovascular complex from the gastrocnemius nerve with a small saphenous vein in one block, transferring it to a nerve trunk defect with preliminary intersection of the vein and gastrocnemius at the distal and proximal levels and the suture of the ends of the nerve trunk with the corresponding the ends of the graft and vein of the transplant with the recipient artery, characterized in that at the first stage they form a graft, enclosing the neurovascular complex in the middle of the cuff, The fascial-cellular islet flap, cut from the underlying fascia of the tibia and retaining its connections with the calf nerve and vein and a length equal to the length of the defect of the nerve trunk, is crossed by the calf nerve below the distal end of the cuff, and the vein intersected at the base of the fifth metatarsal bone is anastomosed from and the crossed dorsal artery of the foot, and at the second stage, an incision is made in the projection of the damaged nerve trunk with the release of its ends from the scars, into the resulting defect they carry the selected transplant with the fascial scar layer and the vascular pedicle in the form of an arterialized vein left on its cuff and restore the blood flow in the transplant.

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