RU2235522C1 - Surgical method for treating the cases of bony and osteo-articular panaritium - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making osteoperforations in the bone destruction zone in two mutually perpendicular planes 0.5 cm far one from another once. Infrared diode laser radiation of 10-20 W power is applied for 3-10 s using light of 0.4 mm diameter. Fistula being found, thermotherapy is additionally carried out in continuous mode with power of 3 W during 15 s.

EFFECT: enhanced effectiveness of treatment; reduced risk of traumatic complications.

2 cl

Description

The invention relates to medicine, in particular to purulent-septic surgery and purulent hand surgery, and can be used in the treatment of bone and bone-articular panaritium.

There are traditional methods of treating bone and osteoarticular panaritium, including adequate surgical treatment of purulent foci with radical sequestrectomy, the use of gypsum immobilization, and the use of antibiotics. The main differences of the previously proposed methods are in the methods of completion of the operation, as well as in the methods of using antibiotics (V.A. Popov. V.V. Vorobyov. “Panaritius”, Medicine, Moscow, 1986). Of the methods for ending the operation, the main ones are wound management in an open or closed way. When conducting wounds in an open way, wound drainage is applied with a strip of glove rubber, gauze turunda with an antiseptic solution until self-healing or the application of secondary sutures. With this method of wound management, it is also proposed to carry out delayed re-surgical treatment of the wound 3 days after the initial treatment (RF patent No. 2055524 of 1996.03.10). When conducting a wound in a closed manner, it is proposed that the wound be closed tightly using an antibiotic “filling”, as well as various options for draining the wound: the introduction of a microirrigator, strips of glove rubber, the use of a device for evacuating pathological contents (RF patent No. 2051693 of 1996.01.10), the use of vacuum drainage (V.A. Popov. V.V. Vorobiev, “Panaricium”, Medicine, Moscow, 1986) or continuous long-term washing of the wound with antiseptic solutions (V.I. Yukhtin et al. Surgery No. 9, 1997).

To improve the results of treatment and reduce the frequency of suppuration of wounds, irradiation of the wound with ultraviolet rays was proposed (V. Struchkov, L. M. Nadvetskaya 1978). Complex methods of closing a wound are also proposed, for example, the use of a skin-fat flap on a neurovascular leg (RF patent No. 2144384 dated 2000.12.10) or skin plasty on a feeding leg. Conducting antibiotic therapy differs in the method of administration of antibiotics. Intramuscular, intravenous, retrograde intravenous, intraosseous administration of antibiotics is used.

With all of the above methods of surgical treatment of bone and osteoarticular panaritium, daily dressings, rinsing of existing fistulas with antiseptic solutions, staged necrectomy, and the introduction of antibiotics are necessary.

Moreover. all these methods do not fully restore the anatomical structure of the finger, quickly stop the purulent-inflammatory process, prevent its spread, preserve the finger segment and, accordingly, the function of the brush. In addition, almost all of them lead to the formation of rough scars.

In recent years, a search and development of new technologies has been carried out using various physical factors that affect inflammatory processes in the endosteum, periosteum and paraossal tissues. These factors include the emission of high-energy lasers.

A known method of surgical treatment of inflammation in the tooth and bone tissues, selected by the applicant as a prototype (The mechanism for drilling tooth and bone tissue by radiation of a repetitively pulsed laser on AIG: Nd. S.A. Naumovich, G.A. Berlov, S.A. Batitsche . "Modern dentistry" 1997., No. 1, p.15-18). A method of surgical treatment of inflammation of the tooth and bone tissue involves applying osteoperforations in the lesion by a laser in a pulse-periodic mode. Treatment is carried out with a preliminary opening of soft tissues. For the treatment of teeth and jaw bones, an AIG-niode laser is used with the following modes: frequency 1-50 Hz, average power 150 W, pulse duration 100-120 μs, the optical fiber used is 0.6 mm in diameter.

This method of treatment used in dentistry has its own characteristics inherent only for this disease. The treatment uses a powerful laser (power 150 W), which has large overall dimensions and requires the use of cooling. The article describes a method for the treatment of osteomyelitis of the cancellous bone tissue, which is a complex biological structure consisting of organic and inorganic compounds with a high water content. In this case, the jaw bones are medium-sized bones. The spread of infection in this case goes from the tooth to the bone and then goes to the soft tissues. Moreover, laser osteoperforation used in dentistry is performed on bone tissue with preliminary opening of soft tissues located on the face, and the fiber is in direct contact with the bone.

The objective of the proposed method is to improve the quality and effectiveness of surgical treatment of bone and osteoarticular panaritium due to exposure to laser radiation without dissection of soft tissues.

A method for surgical treatment of bone and bone-articular panaritium, including applying osteoperforations in the lesion in a pulse-periodic mode with a laser equipped with a fiber, according to the invention, osteoperforation is performed once in two mutually perpendicular planes with a diode infrared laser when a fiber with a diameter of 0.4 mm is brought to the bone without preliminary puncture with a needle of soft tissues, while in the presence of a fistula, laser thermotherapy is performed.

For laser thermotherapy, the same diode laser with a light guide is used, and the treatment is carried out continuously for 15 seconds.

Bone and osteoarticular panaritium requires other modes of laser osteoperforation and a slightly different sequence of operations than osteomyelitis of the maxillofacial region. With the advent of yttrium aluminum garnet lasers with neodymium (YAG: Nd), erbium (AIG: Er), semiconductor (gallium arsenide AsG), or they are also called infrared diode, it became possible to transmit high-energy radiation through fiberglass. For the treatment of panaritium, a portable, compact, small-sized diode infrared laser is used. During the pilot tests, many laser systems were used. However, only the use of the characteristics of a diode infrared laser provides an effective treatment for panaritium. Laser radiation due to its physical properties has a powerful sanitizing effect. The biostimulating effect of laser radiation on bones and soft tissues is based on the phenomenon of the resonant response of a system that perceives the effect of laser radiation. Moreover, the duration of preservation of acquired properties depends on the dose and wavelength of the radiation: the shorter the wavelength, the less pronounced the biostimulating effect of this radiation on the biological fluid.

Panaritium affects the small bones of the hand. Moreover, the infection, as a rule, spreads from the soft tissues to the bones. The proposed surgical treatment of panaritium consists in a single osteoperforation with a diode laser. When processing the affected areas with a laser, deep thermal lesions of soft tissues and bones do not occur, the formation of bone fragments that are present during ordinary mechanical osteoperforation is excluded. In addition, laser radiation, due to its physical properties, has a powerful sanitizing effect. This action is enhanced by osteoperforation in two mutually perpendicular planes. The effect is achieved due to the crossing of the laser radiation fields. The applied fiber diameter of 0.4 mm provides a reduction in the diameter of the laser beam, which eliminates extensive thermal damage to tissues and leads to an improvement in the quality of processing of the affected areas.

The positive effect of laser osteoperforation is due to the death of microorganisms as a result of thermal exposure, vaporization of necrotic tissues and stimulation of reparative processes in the bone. After exposure to laser radiation, the number of microbial cells decreases below a critical level on the second day.

Patent studies have not revealed methods for surgical treatment of bone and osteoarticular panaritium characterized by the claimed combination of features, therefore, we can assume that this method meets the criterion of "novelty."

The use of a combination of distinctive features is also unknown, which indicates compliance with the criterion of "inventive step".

The inventive method can be carried out in any specialized medical institution, therefore, it meets the criterion of "industrial applicability".

The essence of the method is as follows.

For treatment, diode infrared lasers are used: medical laser device SRG3-30-980 (P-20 W, λ-980 nm). ALTO 300000 (P-25 W, λ-860 nm), medical laser scalpel LS-0.97-IRE POLYUS (P-30 W, λ-970 nm). Energy is delivered to the affected bone without preliminary puncture with a soft tissue needle by contact through a monofilament quartz fiber with a diameter of 0.4 mm. Osteoperforation is carried out in a pulse-periodic mode. The parameters of laser radiation were previously worked out on isolated bones and on animal bones. It was found that under laser radiation with a power of 10-20 watts for a period of time from 3 to 10 seconds in the pulse-periodic mode, osteoperforation of all layers of the bone occurs. Under these conditions, there is no deep thermal damage to the soft tissues and bones. In addition, laser radiation has a powerful sanitizing effect on bones and surrounding tissues.

With bony and osteoarticular panaritiums, a single overlay of 2-4 osteoperforations on the entire affected phalanx of the finger is sufficient.

We are currently conducting this treatment on an outpatient basis. The technique consists in applying laser osteoperforations in the area of radiologically determined bone destruction once in two mutually perpendicular planes in a pulse-periodic mode at a distance of 0.5 cm from each other. In this case, a diode infrared laser with a fiber guide of 0.4 mm diameter is applied, which is fed to the bone without preliminary puncture with a soft tissue needle. If there is a fistula, laser thermotherapy is performed with the same laser with a light guide, but in a constant mode for 15 seconds. Conducting treatment under intravenous anesthesia or conduction anesthesia.

All patients showed good tolerability of this treatment method, which was expressed in the relief of pain on the second day after surgery. Swelling and tissue tension decreased after a few hours. Existing fistulas were closed for 2-3 days. The use of antibiotics is not required. In the control group of patients, the onset of clinical improvement was 2-3 times longer during antibiotic treatment.

The method developed by us was applied in 44 people. Of these, 35 patients had a bone form of felon and 9 bone-articular form. In the comparison group of 45 patients, traditional methods of treatment were used (necrectomy, antibiotic administration, physiotherapeutic measures).

The following are clinical observations of treatment in the main group of the proposed method in comparison with the control group with the traditional method of treatment.

All patients noted a decrease in pain from the second day after laser osteoperforation. Clinically, improvement is accompanied by a decrease in tension and swelling of the soft tissues, a decrease in discharge from the fistula. In some cases, with the traditional method of treatment, amputations of the phalanges of the fingers are still performed. In the proposed method of treatment, one session of laser osteoperforation and an aseptic dressing for 1-2 days was enough. Bacteriological examination revealed that in the main group of patients, sanation of the pathological lesion occurred 2-3 days after surgery. In the control group, the reorganization of the outbreak occurred on the 6-7th day. When cytological examination of smears of fingerprints from wounds, it was found that the transition of the inflammatory type of reaction into a regenerative one in the main group of patients occurred 2-3 days after surgery. In the comparison group, even with a favorable course of the wound process, similar changes were manifested on day 6-8. Relapse of the disease was not observed in both groups of patients, but in the comparison group in 2 out of 45 patients the treatment ended with amputation of the distal phalanges of the affected fingers. In 6 patients in this group, persistent interphalangeal ankylosis occurred, which affected working capacity. Of the 44 patients of the main group, interphalangeal ankylosis was noted in 2. With ultrasound osteodensitometry, it was noted that in the main group of patients, the speed of ultrasonic wave transmission through the affected bone is restored on day 10-12, in the comparison group on day 28-29. An X-ray examination that we carry out 10, 20, 30 and 60 days after the operation showed that the beginning of the restoration of bone structure in the main group was observed from 10 days, and in the control from 20 days. Complete recovery was noted in the main group by day 40, in the control group by day 60 after surgical treatment.

The total duration of disability in the main group was 3.2 ± 1.4 days, in the control group 29.1 ± 1.8 days.

We present the clinical observations of three patients, in the treatment of which laser osteoperforation was used with a diode laser according to the proposed method.

Example No. 1. Patient Ch., 15 years old, was admitted to the department 2 weeks after the onset of the disease with a clinic of bone panaritium of the distal phalanx of 1 finger of the left hand. At admission, there was a fistula with purulent discharge, swelling of the finger, pain, radiographs determined the destruction of the distal phalanx. On the day of admission under iv anesthesia with a diode laser with a wavelength of 980 nm, a power of 10 watts, 4 osteoperforations were applied in a pulse-periodic mode, laser-induced thermotherapy of purulent fistula was performed in a constant mode with a power of 3 watts for 15 s. The purulent fistula closed on the 3rd day, the pain syndrome and finger edema stopped, the patient was discharged from the department. Examined after 1, 3, 6 months, no complaints, finger function does not suffer, there are no phalanges on radiographs of destruction, there is moderate cortical osteosclerosis. Engaged in martial arts.

Example No. 2. Patient P., 49 years old, was admitted to the department 1 month after the onset of the disease with a clinic of osteoarticular panaritium of 1 finger of the right hand. On admission, there was swelling, deformation in the projection of the interphalangeal joint, pain on palpation and movements in the joint. On the back of the finger there was a fistula with purulent discharge, communicating with the joint cavity. On radiographs, there was deformation of the joint space and marginal destruction of articulating articular surfaces. On the day of admission under the on / in anesthesia with a diode laser with a wavelength of 980 nm, a power of 10 watts, 6 osteoperforations were applied in a pulse-periodic mode, laser-induced thermal therapy was performed in a constant mode with a power of 3 watts for 15 s. On the 2nd day, the purulent fistula was closed, the pain syndrome was stopped, the patient was discharged home. Examined after 1, 3, 6 months. No complaints, there is a slight rigidity in the joint, not limiting the ability to work, on radiographs without pathology.

Example No. 3. Patient S., 58 years old with concomitant type 2 diabetes mellitus, was admitted to the department 3 weeks after the onset of the disease with a clinic of osteoarticular panaritium 3 fingers of the right hand, which developed after a dog bite. At admission, there was severe pain, swelling, finger deformation, in the projection of the distal interphalangeal joint there were 2 wounds up to 1 cm with moist necrosis, purulent discharge, pathological mobility, crepitus in the joint were determined. During radiography, there was a destruction of the distal interphalangeal joint. A patient under intravenous anesthesia with a diode laser with a wavelength of 980 nm and a power of 10 watts was applied 6 osteoperforations in a pulse-periodic mode, laser-induced thermotherapy was applied in a constant mode with a power of 3 watts for 15 seconds, and soft tissue necrosis was excised. After 2 days, the purulent discharge from the wounds stopped, the swelling of the finger stopped, after 7 days the wounds were closed, the patient was discharged to work. The patient was examined after 1, 3, 6, 12 months, does not show complaints, there is no deformation of the finger, there is a moderate restriction of mobility in the joint, not limiting the ability to work. On radiographs, there is no destruction. There is minor cortical sclerosis.

Thus, the clinical experience of laser osteoperforation in the treatment of bone and osteoarticular panaritium indicates the effectiveness of this method of surgical treatment. This method of surgical treatment of bone and osteoarticular panaritium avoids amputation of the phalanx and restores the function of the hand, does not leave rough scars on the skin and can significantly reduce treatment time and provide quick labor rehabilitation of patients.

Claims (2)

1. A method of surgical treatment of bone and osteoarticular panaritium, characterized in that osteoperforations are applied once in the bone destruction zone in two mutually perpendicular planes at a distance of 0.5 cm from each other in a pulse-periodic mode by radiation of a 10-20 diode infrared laser W for 3-10 with a light guide with a diameter of 0.4 mm. 2. The method according to claim 1, characterized in that in the presence of a fistula, thermotherapy is additionally carried out by radiation of a diode infrared laser in a continuous mode with a power of 3 W for 15 s.