RU2240743C1 - Method for surgical treating osteomyelitis of plantar bones - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: as an autotissue one should apply medial plantar cutaneous-fascial-muscular-osseous fragment cut at damaged limb either upon proximal and/or distal nervous-vascular pedicle, including necessary cutaneous-fascial fragment of short flexors' muscle of 1-2-3 toes either separately or all together into the composition of tissue complex, and, also, the fragment of medial wedge bone and/or that of proximal third of the 2^nd metatarsal bone at sizes being 2 x 1 x 1 cm, moreover, after turning the fragment one should fix osseous one to osseous defect with one or two Kirschner's needles, fragment's edges should be sutured up to wound's edges, and subsequent immobilization of affected limb should be performed with compression-distraction apparatus at decompression of vascular bundle's area that prevents platypodia, fractures along the line of sequestrnecrectomy, restores mechanic tissue resistance at supporting surface.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, surgery, specifically to methods for surgical treatment of osteomyelitis of the bones of the foot.

There is a method of surgical treatment of osteomyelitis of the foot bones, which consists in closing the defect with free blood-supplying grafts from distant parts of the human body in combination with local myoplasty with the tibial muscles on the distal tendon leg, which is the main stage in the treatment of osteomyelitis defects of this department [1].

The method consists in carrying out the following steps:

1. Sequestrnecrectomy of the focus of osteonecrosis.

2. Substitution of the leg cavity formed after sequestrinecrectomy of the bone cavity with calf muscles (gastrocnemius or soleus) on the distal tendon leg.

3. Closure of the defect of integumentary tissues by transplantation from distant parts of the body of blood-supplied tissue complexes (radiation, ulnar and others).

4. Fixation of the limb compression and distraction apparatus G. A. Ilizarov.

This method has the following disadvantages:

1) The method requires the use of an operating microscope, which lengthens the operation time required for applying a microvascular suture for 2-3 hours with free transplantation.

2) The composition of the skin of the transferred tissue complex does not correspond to the texture of the plantar area of the foot, the flaps are mostly insensitive, unstable to mechanical stress.

3) Muscle flaps when moving on the distal vascular pedicle are unstable to hypoxia and are prone to the development of necrotic changes.

4) Muscle transplants when filling the bone cavity with them reduce the strength of the latter and can cause the development of pathological fractures and the development of post-traumatic flatfoot.

A new technical problem solved by the invention is to reduce intra- and postoperative complications, reducing the time and complexity of surgery.

The problem is solved by the use of a new method for the surgical treatment of osteomyelitis defects of the foot bones, including sequestrnecrectomy of the osteonecrosis focus, replacement of the formed bone cavity and soft tissue defect with autotissue, and the medial plantar fascial-muscular-muscular-bone flap is used as autotissue, which is cut into and / or distal neurovascular leg, including tissue size-necessary fascial flap and m the short flexor cords of 1-2-3 toes separately and / or together, a fragment of the medial sphenoid bone and / or a fragment of the proximal third of the second metatarsal bone about 2 × 1 × 1 cm in size, and after the flap is rotated, the bone fragment is fixed to the bone defect of one or with two Kirschner spokes, the edges of the flap are sutured to the edges of the wound, and the subsequent immobilization of the injured limb is carried out by a compression-distraction apparatus with decompression of the zone of passage of the vascular bundle.

The method is carried out in the following way.

A diagram illustrating the phased implementation of the method shown in figures 1-3.

1. In figure 1, a sequestrnecrectomy of the osteonecrosis focus is performed, a medial plantar flap is isolated on the distal neurovascular leg (1a) in the presence of defects in the middle and hindfoot.

2. On figa fill the formed bone cavity in the anterior and middle part of the foot with a medial plantar flap.

3. In FIG. 2b, the resulting bone cavity in the middle and hindfoot is filled with a medial plantar flap: the flap is cut out on the distal neurovascular leg, including, in addition to the skin and fascia of the above flap, short flexor muscles of 1-2-3 fingers (in individually or together), as well as a fragment of the medial sphenoid bone (or the proximal third of the first metatarsal bone) 2 × 1 × 1 cm in size.

4. In figure 3, the bone fragment after turning the flap is fixed with one (two) spokes with a diameter of 1 mm To the resulting defect after sequestrnecrectomy, the flap is sutured to the edges of the wound.

5. Therapeutic immobilization of the limb is carried out by applying a compression-distraction apparatus, with decompression of the zone of passage of the vascular bundle.

Clinical example

Patient G., 48 years old, was admitted to the TVMED clinic for chronic post-traumatic calcaneus osteomyelitis on the left with trophic osteomyelitis ulcer of the plantar surface of the foot after a 3-4 degree burn.

Conservative treatment for 2 months is ineffective.

An operation was performed under epidural anesthesia: sequestration necrectomy of the purulent foci of the right calcaneus, after which a bone cavity 3 × 2 × 1 cm in size was formed, and the integumentary tissue defect was 6 × 5 cm.

The defect in the calcaneal region was filled with a medial plantar flap cut on the proximal neurovascular leg: a 6 × 5 cm flap including skin with subcutaneous tissue, fascia, short flexor muscles was cut from the access on the medial surface of the affected tibia in the projection of the posterior tibial bundle 1-2 fingers, as well as a fragment of the medial sphenoid bone measuring 2 × 1 × 1 cm. The flap was rotated by 120 °. Then the aforementioned tissue complex without tension, freely laid in the formed bone cavity with fixation of the bone fragment of the flap with a needle with a diameter of 1 mm in the bone cavity. The defect in the donor area on the foot is closed with a free split graft from the hip.

Immobilization of the foot and lower leg with a compression-distraction apparatus with an angle of 90 ° in the ankle joint was performed.

Immobilization was carried out for 20 days. No complications were noted.

Thus, the proposed method, which consists in using a skin-fascial-musculoskeletal blood-supplied flap as an autotissue, allows:

to exclude prolonged immobilization and related complications;

to exclude multi-stage surgical intervention;

Do not injure a healthy (opposite) limb.

Blood-supplied flaps are resistant to infection, trophic disorders in a closed wound, provide resorption of the remaining foci of necrosis, protecting the deeper located anatomical structures.

The muscles included in the flap are well supplied with blood due to the main vascular bundle, evenly fill the bone cavity, do not leave “voids”. They prevent the accumulation of pathological discharge, and the bone blood supply fragment is the source of osteogenesis initiation in the area affected by the osteomyelitis process in the bone.

The blood-supplying bone fragment moved to the bone cavity fuses with the bed for one month, which prevents fractures in the area of sequestrnecrectomy when walking, after removing the compression-distraction apparatus, as well as the development of post-traumatic flatfoot.

The medial plantar flap has a skin texture as close as possible to the supporting surface, as well as sensitive innervation, which makes it indispensable in the elimination of osteomyelitis defects on the plantar surface of the foot.

The use of a compression-distraction apparatus in the early postoperative period helps to prevent circulatory disorders in the blood supply flap (decompression) of the vascular bundle passage zone), greatly facilitates maintenance and patient care.

Thus, the proposed method for the surgical treatment of osteomyelitis of the foot bones allows to eliminate the bone and skin defect, restore the mechanical stability of the tissues on the supporting plantar surface, move away from the practice of multi-stage operations, shorten the treatment time (up to 3 weeks), completely eliminate the focus of inflammation, and prevent the development of post-traumatic flatfoot , as well as fractures along the line of sequestrnecrectomy.

Sources of information

1. Patent No. 2195217, BI No. 36, 12/27/02 (prototype).

Claims (1)

A method for the surgical treatment of osteomyelitis defects of the foot bones, including sequestechnectomy of the osteonecrosis focus, replacing the formed bone cavity and soft tissue defect with autotissue, characterized in that the medial plantar fascial-muscular-muscular-bone flap is used as an autotissue, which is cut on the damaged and limb extremity and or distal neurovascular leg, including in the composition of the tissue complex the required size of the skin-fascial flap and muscles of short flexors 1-2-3 toes separately or all together, as well as a fragment of the medial sphenoid bone and / or a fragment of the proximal third of the second metatarsal bone about 2 × 1 × 1 cm in size, and after turning the flap, the bone fragment is fixed to the bone defect with one or two Kirschner’s spokes, the edges of the flap are sutured to the edges of the wound, and the subsequent immobilization of the injured limb is carried out by a compression-distraction apparatus with decompression of the vascular bundle passage zone.

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