RU2217074C1 - Method for performing ii,iii and iv toes amputation in the cases of purulent necrotic complications of diabetic foot syndrome - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves closing wedge-like wound defect by applying parametatarsal suture without affecting soft tissues. The thread is drawn around metatarsal bones located laterally and medially with respect to metatarsal bone to be excised together with toe. The threads are tied in bringing the bones close. Free ends of the thread are brought outside via the wound slit. EFFECT: reduced risk of traumatic complications. 3 dwg

Description

 The present invention relates to medicine, namely to surgery, and can be used to treat complications of the syndrome of diabetic foot (CDS), such as dry gangrene and purulent pandactylitis II, III, IV toes.

 If purulent-inflammatory and destructive processes occur on the toes, the latter are amputated according to Farabef or S.F. Godunov (S.F. Godunov "Methods and techniques of amputation". Medicine, 1967). According to Farabef, a racket-shaped incision is performed, covering the removed finger, with the continuation of this incision after its transition to linear on the back of the foot in the projection of the metatarsal bone with resection of its head. According to Godunov, a racket-shaped incision is also performed with a transition from linear to the rear of the foot, but unlike the previous method, a distal third of the metatarsal bone is resected together with the removed finger. The resulting wound defect is closed with interrupted sutures applied to the soft tissue edges of the wound. We have taken this method as a prototype.

 The method of closing the wound according to Godunov is dangerous to use in patients with complicated diabetic foot syndrome. they often have occlusal stenotic lesions of the main arteries, and there is always microangiopathy with an outcome in tissue ischemia. The use of conventional nodal sutures causes compression of soft tissues, which ischemia is aggravated. As a result of this, postoperative paravular necrosis often occurs with an outcome in post-necrotic suppuration of the wound with a high probability of amputation of the lower limb.

Tasks:
- reduction in cases of postoperative paravulnar necrosis and suppuration of the surgical wound;
- elimination of compression of the edges of the operative wound with sutures, providing drainage of the slit-like wound cavity.

Technical result:
A parametarsal suture is proposed that brings the edges of the wedge-shaped wound closer to a fairly tight mutual contact. Such a comparison of the edges of the wound provides healing by primary intention without imposing additional sutures on the soft tissues.

 The parametarsal suture only exerts pressure on the adjacent metatarsal bones, without compressing, and consequently, ischeming the soft tissues. Such a distinctive feature of the parametarsal suture avoids postoperative paravular necrosis.

 The free ends of the threads of the parametarsal suture after tying the knot out through the wound gap on the back of the foot out. This creates the possibility of the outflow of wound serous exudate. The drainage function of the free threads of the parametarsal suture is activated during dressings by moving these threads along the wound. Such activation prevents premature bonding of the edges of the wound, provides free outflow and thereby prevents suppuration.

 The essence of the method of amputation of II, III or IV toes in diabetic foot syndrome complicated by purulent pandactylitis or dry necrosis is the closure of a wedge-shaped wound defect by applying a parametarsal suture without seizing soft tissues. The method is as follows. A racket-shaped incision is made at the base of the removed II, III, or IV toe. Then the incision is continued to the rear of the foot in the projection of the metatarsal bone corresponding to the removed finger (see Fig. 1). After dissection of the soft tissues, the metatarsal bone is isolated with a raspator and resected over the distal 2/3 of its length. For resection, you can use a Jigley saw or nippers. Resected 2/3 of the metatarsal bone is excised in a single block together with the amputee II, III, or IV foot of the foot. The resulting wedge-shaped wound is closed with one parametarsal suture. Its essence consists in holding a thick strong surgical thread around the metatarsal bones located laterally and medially with respect to the metatarsal bone resected with the finger (see figure 2). When tying the ends of this thread in a wound on the dorsum of the foot, the parametarsal bones captured in the suture bring together. As a result of this, the edges of the wound also come closer to their tight contact (see figure 3). In this case, there is no compression of soft tissues, including the skin, since the pressure from the seam extends only to the bone tissue. The need for additional sutures on the skin, as a rule, does not arise. The free ends of the threads after tying the knot are not cut and removed through the wound gap on the back of the foot to the outside (see figure 3). These free ends of the threads contribute to the outflow of serous exudate from the wound and thereby prevent postoperative suppuration. The parametarsal suture is removed on day 18-24. For this, the free ends of the threads are pulled with a certain force until a knot appears from the remaining point wound. After that, one part of the thread forming a parametarsal loop is crossed directly below the node. Continuing traction for the free ends of the thread, the entire seam is easily removed.

 Technically, the holding of threads around the adjacent contralateral metatarsal bones in order to form a parametarsal suture can be carried out as follows.

 Take a cool and durable medium-sized surgical needle. A sufficiently thick and strong thread is inserted into the needle, for example, dacron 8-10. The needle is injected from the side of the wound cavity and groped with the tip of the needle one of the metatarsal bones adjacent to the resected. Then, this metatarsal bone is enveloped with a needle from its plantar side and this needle is punctured again into the wound cavity, but already along the back surface of the bone. The end of the thread carried out in the wound. Then, the other end of the thread is inserted into the needle and also precisely drawn around the other metatarsal bone adjacent to the resected one. As a result, both ends of the filament of the parametarsal suture turn out to leave the wound on the dorsum of the foot and are ready for tying.

 Sometimes, especially if you have to bend the metatarsal bone with a thread I, it is not possible to bring the needle into the wound in one stage. In such cases, after the needle is bent around the metatarsal bone from its plantar surface, the puncture is carried out through the skin of the rear of the foot. Then the needle is inserted into the puncture hole and brought out into the wound cavity immediately above the dorsal surface of the metatarsal bone. After pulling the ends of the thread, its loop on the rear of the foot is immersed under the skin through the injection-puncture hole.

 The proposed method for closing a wound defect using a parametarsal suture avoids compression ischemia of soft tissues, which necessarily occurs when conventional nodular sutures are applied, and also promotes drainage of the sutured wound and therefore prevents the development of postoperative complications in the form of necrosis and suppuration.

 The proposed method, when used, reduces the average patient's stay in the hospital, reduces the number of postoperative complications, allows you to accelerate social rehabilitation and quickly begin the patient to work and self-care.

 The method was tested on 12 patients for 6 months.

 Example 1. Patient F., 76 years old, medical history 20799, was admitted to the General Surgery Clinic on 12.10.01 with a diagnosis of diabetic foot, mixed form, chronic osteomyelitis of the fourth metatarsal bone of the left foot, dactylitis of the fourth toe of the left foot, tenor vaginitis of the flexor of the fourth finger. After resection of the distal 2/3 of the IV metatarsal bone (10/13/01), along with the amputation of the fourth finger, the edges of the wound were reduced using a parametarsal suture covering the III and V metatarsal bones. The postoperative period was uneventful. The seam was removed on the 18th day. The patient with recovery was discharged home.

Remote results
After the operation of metatarsal amputation of the II, III and IV toes of the feet with the closure of the wound with a parametarsal suture, 12 patients were operated on. Long-term results were studied in 6 patients. There is no deformation of the arch of the feet. Feet are supportive. Postoperative scars are linear, mobile. Radiologically in the structure of the metatarsal bones, in the place of pressure on them parametarsal sutures, there are no changes in the form of resorption or pathological rearrangement.

Claims (1)

The method of amputation of the second, third or fourth toe, in case of diabetic foot syndrome complicated by purulent pandactylitis or dry necrosis, including a racket-shaped incision at the base of the removed toe with a continuation of the incision on the dorsum of the foot in the projection of the metatarsal bone of the same name, with a resection of at least 2/3 of it distal and metatarsal amputation of the affected finger, characterized in that the wedge-shaped surgical wound formed after metatarsal amputation of the finger is closed by holding the thread around the metatarsal s bone disposed laterally and medially from resected with finger metatarsal bone, for tying the ends of the bone thread pull together the free ends of the filament after tying assembly withdrawn through the wound gap on the rear of the foot outwards.

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