RU2270627C1 - Method for surgical treatment of chronic osteomyelitis of shin bones in its inferior third - Google Patents

Abstract

FIELD: medicine, purulent septic and reconstructive surgery.

SUBSTANCE: for the purpose to liquidate soft tissue and osseous defects in inferior tibial third the suggested transplant includes median skin-osseous plantar fragment cut upon proximal nervous-vascular pedicle consisting of tibial artery and accompanying veins including size-necessary skin, fascia, subcutaneous fiber, muscles of short flexors of 1-2-3 toes all together, and, also, the fragment of proximal third of the 1^st metatarsal bone into fragment's composition, moreover, osseous fragment of the 1^st metatarsal bone should be fixed to tibial osseous defect with one or two Kirschner's needles, fragment's edges should be sutured to the edges of shin wound followed by immobilization of operated limb with Ilizarov's apparatus. The innovation enables to reconstruct mechanical strength of osteomyelitis-affected bone, prevent early postoperational complications, develop conditions for reparative osteogenesis and valuable reconstruction of osseous structure, shorten time and complexity of operative interference.

EFFECT: higher efficiency of therapy.

8 dwg, 1 ex

Description

The invention relates to medicine, in particular to purulent-septic and reconstructive surgery, specifically to methods for surgical treatment of chronic osteomyelitis of the lower leg bones, and can be used to eliminate soft tissue and bone defects of the lower third of the tibia.

There is a method of surgical treatment of chronic osteomyelitis of the lower third of the tibia, which consists in closing the defect with free blood-supplying grafts from distant parts of the human body, in particular, representing a thoracodorsal complex of tissues with fragments of ribs included in it (Belousov A.E., Tkachenko S.S., 1988 year).

The method consists in carrying out the following steps.

1. Sequestrnecrectomy of the focus of osteonecrosis.

2. Taking a thoracodorsal complex of tissues on a free feeding vascular pedicle with the inclusion of one or two rib fragments.

3. The movement of the prepared tissue complex in the recipient bed, and fragments of the ribs fit into the defect of the tibia and are fixed in one of the known ways.

4. Performing a microvascular anastomosis of the vascular pedicle of a taken tissue complex in one of the ways with the posterior tibial artery and its accompanying veins.

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

The above method has the following disadvantages.

1) A complex of tissues from distant parts of the body is used, which causes additional functional and aesthetic disorders of the upper limbs.

2) The method requires the use of microsurgical techniques, including a microscope, which lengthens the operation time required for applying a microvascular suture for 2-3 hours with free transplantation of a complex of tissues.

3) The protective function is violated - the frame stiffness of the chest, which leads to a violation of the function of external respiration.

4) A high percentage of thromboembolic complications (12-30%) during transplantation of free blood-supply tissue complexes.

A new technical problem solved by the invention is the restoration of the mechanical strength of bone affected by osteomyelitis, the prevention of early postoperative complications, the creation of conditions for reparative osteogenesis and full restoration of the bone structure, shortening the time and reducing the complexity of surgical intervention.

The problem is solved by the use of a new method for the combined surgical treatment of chronic osteomyelitis foot bones, which includes sequestronecrectomy of the osteonecrosis focus, replacing the formed bone cavity and the defect of integumentary tissues with a blood-supplying graft, which is a medial skin-bone plantar flap, which is cut out on the proximal-neurovascular consisting of the tibial artery and accompanying veins, including the size required in the flap skin, fascia, subcutaneous tissue, muscles of short flexors of 1-2-3 toes (individually or all together), as well as a fragment of the medial sphenoid bone (or a fragment of the proximal third of the 1st metatarsal bone). A bone fragment of the 1st metatarsal bone is fixed to the bone defect of the tibia with one (two) Kirschner spokes, the edges of the flap are sutured to the edges of the wound of the lower leg. The immobilization of the operated limb is carried out by the KDA of G.A. Ilizarov.

The method is as follows.

1. In figures 1, 2, sequestrnecrectomy of the focus of osteonecrosis is performed, the medial plantar flap is isolated on the proximal neurovascular leg, including the tibial artery and two veins accompanying it.

2. In figure 3, the elimination of soft tissue and bone defect is carried out by a skin-bone medial plantar flap, and a blood-supplied bone graft is placed between the muscles of the short flexor of the fingers in a bone defect of the tibia and fixed with a Kirschner spoke.

3. Therapeutic immobilization of the limb is carried out by applying the CDA of G. A. Ilizarov.

Clinical example. Patient J. was admitted to the Military Field Surgery Clinic of TVMEDI in February 12, 2004 with the diagnosis: "Chronic post-traumatic osteomyelitis of the lower third of the left tibia, fistulous form (figure 4). From the anamnesis it is known that as a result of a road injury (1964) he received an open fracture of the left tibia, which was complicated by the development of chronic osteomyelitis of the left lower leg .. Surgical interventions were performed 9 times over the above-mentioned disease in different years: opening of paraossal phlegmon; decompressive osteotrepa removal of sequestration. Upon receipt on CT-grams (Fig. 5), the destruction site 10 × 6 × 4 cm is determined in the lower third of the left tibia, the operation according to the proposed method is performed. As a result of sequestration necrectomy of the site of osteodestruction, a bone cavity measuring 12 × 6 × 5, see (Fig. 6). The next step was taken skin-bone medial plantar flap with the inclusion of a blood-supplying bone fragment of the medial sphenoid bone, size 2 × 1 × 1, see (Fig. 7). The blood supply flap on the proximal vascular pedicle is rotated 180 ° and laid in the recipient bed. Moreover, the bone graft is placed in the bone defect of the tibia and is fixed with a spoke. The soft-tissue component of the flap is hemmed with interrupted sutures to the edges of the wound of the lower leg, formed after excision of the edges of the soft-tissue defect. Immobilization of the limb KDA G.A. Ilizarov (Fig. 8).

The use of the medial plantar skin-bone blood supply flap allows the following.

1. Fill the bone cavity with a complex of tissues, including a bone graft, thereby increasing resistance to mechanical stress.

2. Eliminate the multi-stage surgical intervention and, thus, the time of surgical intervention, reduce the risk of complications and the cost of surgery and treatment in general.

3. No injury to a healthy (opposite) limb.

4. To initiate reparative bone regeneration due to stem cells of a blood-supplied bone transplant.

5. The muscles included in the flap, well supplied by the main vascular bundle, evenly fill the bone cavity without leaving “voids”, which prevents the accumulation of pathological discharge.

6. The preservation of sensitive innervation in the medial plantar flap allows to prevent subsequent neurotrophic disturbances in it.

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

Thus, the proposed method for the surgical treatment of osteomyelitis of the bones of the lower third of the leg allows eliminating bone and skin defects, restoring the mechanical strength of the leg bones, completely eliminates the site of inflammation, prevents the development of a postoperative fracture along the line of sequestrectectomy, allows you to move away from the practice of multi-stage operations, and reduces treatment time.

Literature

1. Belousov A.E., Tkachenko S.S. Microsurgery in traumatology. - L .: Medicine, 1988 .-- 224 p. (prototype).

2. Kichemasov S.Kh. Microsurgical autotransplantation of tissue complexes in reconstructive surgery / S.Kh. Kichemasov, B.C. Aminov, A.Yu. Kochish // Problems of Microsurgery. Thes. 4th All-Union. symposium on microsurgery. - Moscow, 1991. - S.154-155.

3. Milanov N.O. Modern possibilities of treatment of post-traumatic osteomyelitis using microsurgical autografts / N.O. Milanov, E.I. Trofimov, A.S. Zelenin, V.I. Simakov // Abstracts of the VII Congress of Orthopedic Traumatologists of Russia. - Novosibirsk, 2002. - Volume 1. - S.340-341.

Claims (1)

A method for the surgical treatment of chronic osteomyelitis of the foot bones in its lower third, including sequestrnecrectomy of the osteonecrosis focus, replacing the formed bone cavity and the defect of integumentary tissues with a blood supply transplant, suturing the edges of the flap to the edges of the wound of the lower leg, immobilizing the operated limb with compression-distraction A. distraction the fact that the graft includes a medial skin-bone plantar flap, which is cut out on the proximal neurovascular leg, consisting of tibial artery arteries and accompanying veins, including the flap, skin, fascia, subcutaneous tissue, muscles of short flexors of 1-2-3 toes, all necessary in size, together with a fragment of the proximal third of the 1st metatarsal bone, and the bone fragment 1st metatarsal bone is fixed to a bone defect of the tibia with one or two Kirschner spokes.

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