RU2269958C2 - Method for simultaneous dermato-tenoplasty at skin-tendinous defects of wrist rear surface - Google Patents

Abstract

FIELD: medicine, wrist surgery.

SUBSTANCE: in inguinal area one should cut an axial skin-fascial-aponeurotic flap upon skin-aponeurotic pedicle, ilium-rounding surface artery being a nourishing vessel. It is necessary to keep vessels that supply skin, fascia and aponeurosis with blood while cutting the flap mentioned. A tendinous transplant should be formed out aponeurosis and fascia not disturbing vascular links with the flap to be applied for substituting tendinous defect. Skin defect should be substituted with flap's skin part. One should dissect skin-aponeurotic pedicle in case of reliable healing of the stem. The innovation enables to improve functional results of tendinous plasty at minimal detriment for donor area.

EFFECT: higher efficiency.

1 ex

Description

The present invention relates to medicine, and specifically to hand surgery, and relates to methods for treating patients with skin-tendon defects of the hand and forearm.

The use of microsurgical technique allows transplantation of various blood-supplied tissue complexes into any area of the body. The main features of these operations are technical complexity, considerable complexity and duration, the availability of extensive accesses, the duration of anesthesia and the possibility of failure.

Closest to the proposed technical solution is a method for surgical restoration of the function of the tendons of the hand and fingers, described in RF patent No. 2163789 Garelikom E.I., Chichkin V.G. (see the bulletin "Inventions, utility models" No. 7 (part II) 2001, p.163). This method includes the excision of scar-modified integumentary tissues, the release of tendons from surrounding scars by dissecting them, the formation of a vascularized flap with first cutting out its skin part in accordance with the size of the defect of the integumentary tissue, and then the fascial part of a rectangular shape exceeding the transverse size of the skin part and corresponding the circumference of the tendon bundle, which covers it on all sides when replacing a defect.

However, this method is not applicable for tendon defects. The fascial component of the flap is used only to prevent re-fusion of the tendons with the surrounding tissues, and not to restore the tendon defect. In addition, the method is used to treat the effects of trauma rather than acute trauma, the operation is long, traumatic, there is a high risk of complications and necrosis of a vascularized fascial fascial graft cut from the scapular region on the vascular pedicle.

The objective of the proposed technical solution is to improve the function and reduce the treatment time for patients with skin-tendon defects of the hand.

This problem is solved due to the fact that after the initial surgical treatment of the wound, an axial skin-fascial-aponeurotic flap is cut out on the skin-aponeurotic leg with preservation of the vessels supplying the skin, fascia and aponeurosis. From fascia and aponeurosis, without breaking vascular connections with the flap, a tendon graft is formed, with the help of which tendon defect is replaced. The defect of the integumentary tissue is replaced by a full skin flap. Cutting off of the skin-aponeurotic stem is carried out with reliable engraftment of the stem at the site of transplantation after plastic surgery.

The method is as follows.

The patient in a supine position with a 90-degree arm is performing primary surgical treatment of the wound on the back of the hand and fingers. Nonviable tissues are excised, foreign inclusions are removed, hemostasis is performed. The wound is washed with antiseptics. The size of the defect of the skin and tendons is measured. Then proceed to the formation of a flap of tissue on the feeding leg, located in the blood supply to the superficial artery, enveloping the ilium, which should be moved to the defect. For this, a skin-fascial-aponeurotic flap is formed in the inguinal region with a length exceeding the largest size of the skin defect on the hand by 1.5-2 cm and a width corresponding to a smaller size of the skin defect on the hand. It includes the flap-feeding artery, the envelope of the ilium, superficial fascia and aponeurosis without crossing the aponeurotic stem included in the acute stalk. Hemostasis. The wound in the inguinal region is sutured "on itself" (tightening sutures are applied to the skin defect), leaving rubber graduates. A sharp stalk is formed from the flap, rolling up the proximal part of the flap into a tube, under which a skin triangle cut at the end of one of the incisions is brought. Fascia and aponeurosis are placed in the area of the tendon defect and sutured with nodal sutures nylon proximal to the proximal end of the damaged tendon (s), distally to the distal end of the damaged tendon (s) or to the periosteum of the nail phalanx in the area of physiological attachment of the tendon ( s) extensor (s) of finger (s). The free edge of the skin flap is modeled according to the shape and size of the recipient area, hemmed to the edge of the defect on the hand with a good adaptation of the edges of the skin. The operation is completed by the application of an aseptic dressing and a plaster thoracobrachial dressing, fixing the upper limb at the anterior abdominal wall in the position of no tension of the inflection and clamping of the stem. In this case, the stem receives sufficient nutrition through the remaining feeding leg (skin, fascia, aponeurosis). 14-15 days after removal of the surgical sutures from the skin, the inguinal end of the stem is gradually squeezed with an elastic band for 20-25 days, transferring all the food to the end, hemmed to the hand. After there is confidence that the blood circulation in the flap with a pinched end is sufficient, and therefore reliable engraftment at the site of transplantation, the flap is cut off from the mother's soil and spread onto the hands. In the postoperative period, a course of rehabilitation therapy is carried out aimed at restoring the range of movements in the joints of the hand.

Confirmation of the fact of blood supply to the fascia and aponeurosis, transferred to the tendon defect on the hand, are the results of the experiment. On the human corpse in accordance with the above method, a skin-fascial-aponeurotic flap is formed. The place where the superficial artery, the envelope of the ilium from the outer wall of the femoral artery or from the superficial epigastric artery, was allocated. A catheter introduced a 10% solution of mascara-gelatin mixture into the mouth of an artery. Tissue fragments were removed from the distal region of the flap, histological preparations were prepared. In the study of these drugs in the vessels, capillaries of the skin, subcutaneous fatty tissue of fascia and aponeurosis, a mascara-gelatin mixture was found.

Clinical example:

Patient K-s 19 l., Medical history No. 208184, was admitted to hospital in NIITO from 08/06/03 with a diagnosis of severe trauma to the right hand, soft tissue defect in the back surface of the main, middle, distal phalanx of 4 fingers, extensor tendon of 4 fingers. Injury 08/05/03 household: the brush hit the machine. In urgent care on 07.08.03, an operation was performed according to the proposed method - primary surgical treatment of wounds, plastic surgery of the skin and tendon extensor of the fourth finger with a skin-fascial-aponeurotic flap. The flap is viable. The second stage of plastic surgery - cutting off from the abdomen, flattening on the hand 09.16.03. A fragment of fascia and aponeurosis used as a tendon graft was histologically examined: fibrous tissue of a fascial nature with preserved connective tissue cells, which confirms its blood supply and vitality. The postoperative period was uneventful. A course of rehabilitation therapy. Achieved the full range of movements in the joints of the 4 fingers of the right hand.

The proposed method of simultaneous dermatotenoplasty for skin-tendon defects of the back surface of the hand is characterized by low laboriousness, efficiency (good functional result achieved), causes minimal damage to donor resources, no complications in the near (3-12 days) and long-term (3 months) observation periods, it is easy tolerated by patients.

Claims (1)

The method of simultaneous dermatotenoplasty for skin-tendon defects of the back surface of the hand, including the elimination of the defect on the back surface of the hand by grafting a flap, characterized in that an axial skin-fascial-aponeurotic flap is cut in the inguinal region on the skin-aponeurotic leg, the supply artery is the surface artery, the envelope of the ilium, when cutting the flap retain blood vessels supplying the skin, fascia and aponeurosis, from the aponeurosis and fascia, without breaking the vascular connections with the gloss that form a tendon graft, with which substitute tendon defect part of skin graft substitute of skin defect dissected dermal-aponeurotic leg at a safe engraftment of stem.