RU2254082C2 - Operative method for treating false joints of hand navicular bone - Google Patents

Abstract

FIELD: medicine, hand surgery.

SUBSTANCE: one should isolate vascular bundle out of the second dorsal metacarpal artery with two accompanying veins and underlying periosteum of the second metacarpal bone. Periosteum should be turned round the vessels by fixing it with 2-3 sutures. The obtained vascular-periosteal transplant should be applied into a canal drilled in navicular bone to prevent resorption of bony tissue in transplant's area.

EFFECT: higher efficiency of therapy.

1 dwg, 3 ex, 1 tbl

Description

The invention relates to medicine, in particular to hand surgery. There are similar methods for treating pseudoarthrosis of the scaphoid of the hand:

- bone grafting by a migrating vascularized bone graft from the distal metaphysis of the radial bone based on the radial vascular bundle;

- the use of a bone graft from the distal metaphysis of the humerus with revascularization.

The closest analogue to the prototype is a method of bone grafting of a scaphoid fracture with a migrating bone graft from the head of the II metacarpal bone based on the dorsal vascular bundle. Ashkenazi A.I. Hand Surgery // Moscow, Medicine, 1990.

But the disadvantage of this method is the absence directly in the area of the false joint of a bone-producing component, such as the periosteum, and, as a result, a longer period of fusion of the false joint and a period of restoration of the function of the wrist joint.

The objective is to improve the quality of treatment through the use of transplantation of a vascular-periosteal transplant.

The task is carried out in the following way: a vascular-periosteal graft is implanted in the scaphoid (see drawing).

Through an arcuate incision along the back of the hand, access to the scaphoid and the vascular bundle is provided. The incision begins between the bases of the II and III metacarpals, passes through the "anatomical snuff box", not reaching 6-7 mm to the tendon of the short extensor of the first finger, and then goes at a distance of 10-12 mm from the radial edge of the tendon of the long extensor of the thumb. In the "anatomical snuffbox" all the manipulations are performed atraumatically and very carefully. As a vascular bundle, a second dacal metacarpal artery with two accompanying veins is used. These vessels are located between the attachment points of the long and short radial extensors of the hand, atraumatically isolated with surrounding perivascular tissues from the arched bend of the artery when it passes to the palm of the hand to the edge of the tendon of the long radial extensor of the hand. Together with the vascular bundle, the area of the underlying periosteum of the II metacarpal bone is separated, trying not to break the connection between the periosteum and the vascular bundle. Then the tendons of the long radial extensor of the hand and the long extensor of the 1st finger are taken to the rear and elbow, the vascular bundle together with the periosteum is mobilized further, and after cutting and ligation of the distal ends of the vessels, the vascular-periosteal graft is brought to the formed gap in the “anatomical snuff box”. In the proximal direction, the vessels are secreted to the place where they depart from the radial artery and veins. The vessels do not separate from each other, small branches of vessels in the perivascular tissues coagulate. The length of such a vascular bundle is 2.5-3.5 cm, which is quite sufficient for insertion into the scaphoid without tension. After mobilization of the vascular-periosteal graft, the periosteum is wrapped around the vessels, fixing the edges of the periosteum with each other with two or three sutures. In the distal fragment of the scaphoid, the point of the inlet is determined and the axis of drilling is noted, which is preliminarily calculated from the facet image with the elbow divisions of the hand. After the bone axis is drawn, the distance from the place where it intersects the edge of the ulna to the styloid process is measured in the image. During surgery, this distance is marked with brilliant green from the ulnar side of the forearm, focusing on the styloid process of the ulnar bone. In the scaphoid, along its axis from the distal fragment to the proximal through the fracture plane, a 2 mm diameter channel is drilled with a thin drill to the required depth, determined by the picture. The correct drilling of the channel is controlled radiologically. Then the channel is drilled to a diameter of 3.5 mm. The inlet of the channel using a sweep is made conical to a diameter of 4.0-4.5 mm according to the size of the base of the vascular-periosteal graft. During channel drilling, the vascular-periosteal graft must be protected with instruments. Using a spoke conductor, a catgut thread guide is guided. One end of the thread is tied to the distal end of the graft and, when the thread is pulled over the opposite end, from the elbow side, atraumatic immersion of the vascular-periosteal graft into the scaphoid is carried out until its end stops in the bottom of the canal in the proximal fragment. To fix the vascular-periosteal graft, the same catgut thread is used, leading its end through the skin in a taut state and tying it on a gauze ball. After removing the tourniquet, good filling of the vessels and pulsation of the artery are visible, which indicates the preservation of blood flow in the graft. Parts of the scaphoid along with the graft are fixed with two knitting needles crosswise. The outer ends of the spokes bite as much as possible. After careful hemostasis, the wound is sutured in layers, an aseptic dressing and a deep palmar plaster cast are applied with the fixation of the main phalanx of the first finger in the mid-physiological position (see table).

Table Scaphoid resection of the scaphoid with autologous bone autoplasty with an enlarged bone graft Implantation of a vascular-periosteal graft into the scaphoid. False joint of the scaphoid 6 months 4 months Wrist Restoration 6-7 months 4.5-5 months Graft bone resorption + -

The advantages of the invention are shorter periods of fusion of the pseudoarthrosis of the scaphoid, the absence of bone resorption in the transplant area, a shorter period of rehabilitation treatment.

Example 1. Patient G., 35 years old. He was in the Department of Hand Microsurgery of KB # 2 from 03/12/01 to 03/30/01 with a diagnosis of pseudoarthrosis of the scaphoid of the right wrist joint. 03.16.01, the operation was performed: implantation of a vascular-periosteal transplant into the scaphoid of the right wrist joint, fixation with needles. The postoperative course is smooth. Medical therapy was carried out: analgesic, antispasmodic therapy, improving peripheral blood circulation, physiotherapy. The wound healed by primary intention. Sutures were removed on the 14th day. The patient was discharged for outpatient treatment on the 15th day. After 1.5 months, diffuse osteoporosis was observed on control radiographs. The spokes were removed, immobilization continued with a gypsum tire. A monthly x-ray control was carried out. In the dynamics, recalcination of the bones of the wrist was noted. Fusion of the pseudoarthrosis occurred at the end of 4 months. Immobilization contractures of the fingers and wrist joint were noted. Conducted rehabilitation treatment.

Example 2. Patient M., 48 years old. He was in the Department of Hand Microsurgery of KB # 2 from 02/14/01 to 02/02/01 with a diagnosis of false joints of the scaphoid bones of both wrist joints. Deforming arthrosis II Art. right wrist joint. 02/15/01, the operation was performed: implantation of a vascular-periosteal transplant into the scaphoid of the right wrist joint, fixation with needles. The postoperative period without features. Medical therapy was carried out: analgesic, symptomatic, antispasmodic therapy, improving peripheral blood circulation, physiotherapy. The wound healed by primary intention. Sutures were removed on the 14th day. The patient was discharged for outpatient treatment on the 15th day. After 1.5 months, diffuse osteoporosis was observed on control radiographs. The spokes were removed, immobilization continued with a gypsum tire. A monthly x-ray control was carried out. On the control radiographs from 06/17/01, there is fusion of the pseudoarthrosis. Fusion of the pseudoarthrosis occurred at the end of 4 months. After the termination of immobilization, rehabilitation treatment was carried out.

Example 3. B. B., 62 years. He was in the Department of Hand Microsurgery of KB # 2 from 01/01/01 to 11/21/01 with a diagnosis of pseudarthrosis of the scaphoid of the right wrist joint. November 6, 01 the operation was performed: implantation of a vascular-periosteal transplant into the scaphoid of the right wrist joint, fixation with needles. Postoperative course without features. Medical therapy was carried out: analgesic, symptomatic, antispasmodic therapy, improving peripheral blood circulation, physiotherapy. The wound healed by primary intention. Sutures were removed on the 14th day. The patient was discharged for outpatient treatment on the 15th day. After 1.5 months, diffuse osteoporosis was observed on control radiographs. The spokes were removed, immobilization continued with a gypsum tire. A monthly x-ray control was carried out. On the control radiographs from 03/10/01, there is a fusion of the pseudoarthrosis. Fusion of the pseudoarthrosis occurred at the end of 4 months. After the termination of immobilization, rehabilitation treatment was carried out.

Claims (1)

An operative method for treating false joints of the scaphoid of the hand, consisting in the implantation of a vascular bundle, characterized in that the second back metacarpal artery with two accompanying veins is used as a vascular bundle, while along with the vascular bundle, a portion of the underlying periosteum of the metacarpal bone supplied from the pool of this of the vascular bundle, then the periosteum is wrapped around the vascular bundle and its edges are fixed with each other with two or three sutures, the resulting vascular-periosteal transpl ntat immersed through reamed channel into scaphoid ends of the graft to lock in the channel bottom.