RU2371136C1 - Plasty technique for complex shoulder defect following gunshot wounds with extensive destruction of humerus and soft tissues - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns traumatology and orthopaedics and can be applied for plasty of shoulder defects with extensive destruction of humerus and soft tissues. A linear incision is made along external surface of shin. Two osteotomies of fibular bone are made to prepare bone fragment. Axillary region is incised along anterior edge of broadest muscle of back. Broadest muscle of back is separated from its bed. Broadest muscle of back is split along muscle fibres. The prepared bone fragment of fibular bone is immerged in the formed cavity and fixed with one or two sutures. A vascularised osteomyocutaneous graft including a part of broadest muscle of back with ingrown bone fragment of fibular bone is transplanted into a shoulder defect 4-7 weeks later.

EFFECT: method allows reducing risk of graft fractures, improving functional results, reducing treatment time.

3 cl, 1 ex, 9 dwg

Description

The invention relates to medicine, namely to traumatology and orthopedics.

Known methods of bone grafting for diaphyseal defects of the humerus with non-blood transplants: parts of the ribs, diaphysis of the fibula, metaphyses of the radius and tibia, ilium, etc. (as an example, patent RU 2233638, published on 08/10/2004). A common drawback of all these methods is the insufficient volume of osteoplastic material, its sensitivity to infection, the slow implantation of the graft in the receiving bed due to the very limited participation of its cells in the recovery processes. The treatment is long due to the fact that organotypic bone restoration (complete transplant restructuring in accordance with mechanical conditions) occurs only after 2-2.5 years, and the immobilization time is 8-12 months, which, in addition to inconvenience to the patient, leads to the formation of severe joint contractures, the treatment of which in itself is a complex problem. The frequency of non-fusion of autografts with the receptive bed remains high (up to 30% or more). A significant decrease in the mechanical strength of necrovascular grafts is manifested by their frequent pathological fractures (up to 58% or more after transplantation of long grafts).

Known methods for plasticizing defects of the humerus according to Ilizarov, including various options for osteotomies with subsequent dosed movement of the selected fragment with the formation of bone regenerate (for example, see BASHIROV RS Guide for transosseous compression-distraction osteosynthesis. Tomsk, 2002, p. 193-199 )

The disadvantages of the method of replacing the defects of the humerus using compression-distraction osteosynthesis are impaired muscle and tendon function during prolonged fixation with needles, a large number of entry gates for possible infection, a decrease in the quality of life of the patient, and psychological difficulties during the recovery phase of treatment due to the cumbersomeness of the external apparatus fixation.

A common drawback of these methods is that with their help it is impossible to replace an extensive musculoskeletal defect.

As the closest analogue, one can propose a method for reconstructing complex post-traumatic shoulder defects, including excision of scar tissue, the release of fragments of the humerus, the transfer of an autograft containing the lateral edge of the scapula and a tissue complex based on the latissimus dorsi, anastomosis between the brachial and thoracic arteries (Patent RU 2266069, published December 20, 2005).

However, the bone fragment, which is the lateral edge of the scapula, is not strong enough and is not suitable for replacing extensive bone defects. When using such a bone graft, there is a risk of damage, fracture. The terms of engraftment of the autograft from the lateral edge of the scapula can be relatively long. When applying the method - the closest analogue, there are quite significant limitations on the function of the limb.

The objective of our invention is to provide the possibility of replacing extensive defects of the humerus, eliminating the risk of fractures, damage to the transplant defect, striving for the most complete restoration of limb function, shortening the treatment and rehabilitation period, and reducing the morbidity for the donor area when taking an autograft.

We propose two-stage treatment for shoulder defects with extensive destruction of the humerus and soft tissues.

According to our method, at the first stage, a linear incision is made along the outer surface of the lower leg, two osteotomies of the fibula are made, receiving a bone fragment, an incision is made in the armpit along the front edge of the latissimus dorsi, the latissimus dorsi is separated from its bed, the latissimus dorsi is folded along muscle fibers, the resulting bone fragment of the fibula is immersed in the cavity thus formed, the bone fragment is fixed with one or two sutures. At the second stage, after 4-7 weeks, they take a skin-muscle-bone flap on the vascular pedicle from the thoracodorsal artery and vein, which includes part of the latissimus dorsi with an ingrown bone fragment of the fibula, transplant this flap into a shoulder defect, impose an anastomosis between the artery and vein of the vascular pedicle of the flap and the branches of the brachial artery and vein, respectively.

Here is a more detailed description of our method for repairing shoulder defects with extensive destruction of the humerus and soft tissues.

Surgical treatment consists of two stages: at the first stage, a necrosecvestrectomy is performed in the recipient area to remove non-viable tissues in the wound and relief of inflammation, as well as pre-fabrication (preliminary preparation) of the muscle transplant by transplanting into its thickness a free nevascularized fibular bone graft for its gradual revascularization favorable conditions of aseptic wounds. At the second stage, a musculoskeletal graft on the supply vessels with an already vascularized bone fragment is transplanted into the prepared wound on the shoulder with a single block to replace the extensive gunshot musculoskeletal defect of the shoulder.

At the first stage, under endotracheal anesthesia under a tourniquet, excision of scars, necrotic soft tissues and bone fragments is performed, economical edge resection of the fragments of the humerus is performed. The resulting soft tissue defect measuring 20 by 16 cm and the bone cavity 17 by 3 by 2 cm are drained, hemostasis is performed, the edges of the bone are freshened up to blood “dew”, washed and tamped with napkins with an antiseptic.

From linear access along the external surface of the lower leg in the projection of the fibula, which is mobilized, a bone graft of the required size is taken with a chisel, which is sprinkled with a dry antibiotic. The wound on the lower leg is drained and sutured.

From an additional section 15 cm long in the axillary region in the projection along the front edge of the latissimus dorsi, the last one is exfoliated from its bed, forming a cavity measuring 15 × 6 × 5 cm, the perimizium of the latissimus muscle along the muscle fibers is stratified for 15 cm and the bone is immersed in this cavity fragment of the fibula, fixing it with one or two sutures. The wound is washed, drained and sutured.

Subsequently, antibacterial and infusion-transfusion therapy is carried out, local wounds are treated, the drains are removed 2-3 days after the operation, the wound on the shoulder is opened by using water-soluble ointments, ultrasonic cavitation of the wound with antibiotics, HBO therapy is used. After healing of the wounds on the lower leg and axillary region, stabilization of the general condition and indicators of homeostasis, complete cleansing of the wound on the shoulder no earlier than 4 weeks after the first operation (the time required for vascularization of the prepared transplant), they begin the second stage of plastic replacement of the shoulder tissue defect.

The second stage begins with a thorough toilet of the wound on the shoulder, removal of pathological (excessive) granulations, repeated washing of the wound cavity with antiseptics with a change of instruments and gloves; branches of the brachial artery are isolated by linear access into the projection of the brachial vascular bundle and taken to the holders, wounds are temporarily tamponed with napkins with an antiseptic.

Soft tissues are cut in the axillary region by a curved section, the subscapular artery and its branches are isolated. The thoracodorsal artery is mobilized to the point where it enters the latissimus muscle, in which the harvested fragment of the fibula is probed. Then, preserving the vascular supply of this muscle area, a thoracodorsal musculocutaneous flap is formed, into which a bone fragment has previously been inserted, due to which it is possible to form a musculoskeletal-bone flap on the supply vessels, corresponding in size to the soft tissue and shoulder bone defect . The thoracodorsal artery is ligated at its mouth, and the formed complex graft is fully mobilized. Hemostasis in the wound. Redon wound drainage. The flap is cut off, the stump of the thoracodorsal artery is stitched and bandaged. Layer wound closure.

The flap was transferred to the shoulder defect, the bone fragment was placed in the bone cavity and tightly embedded in the humerus, the soft tissue flap was fixed with suggestive sutures to the edges of the shoulder defect. Next, a microvascular anastomosis of the artery and vein of the graft is performed according to the type of end to end with the branches of the brachial artery and vein. The blood flow in the flap was restored, the anastomoses are tight and passable. The latissimus muscle turned pink and warmed. Hemostasis in the wound. Redon wound drainage. The wound is sutured tightly. Aseptic dressings.

Within 2-3 weeks after the operation, intensive therapy and local treatment of wounds are carried out, drainages are removed for 2-3 days. Sutures are removed 3 weeks after wound healing. The consolidation of the humerus is monitored radiologically once a month, after the fusion of the humerus the apparatus or other external immobilization is removed, rehabilitation treatment is prescribed for 3-4 weeks and the patient is discharged.

The examples confirm the implementation of the claimed method for surgical correction of extensive gunshot defects of soft tissues and the humerus with a prefabricated transplant.

A clinical example illustrating the transplantation of the peroneal graft and the transposition of the latissimus dorsi into the position of the biceps of the shoulder.

Patient D. received a gunshot perforating wound of the right shoulder, a gunshot multi-splinter fracture of the humerus in the middle third with extensive crushing of the shoulder muscles. PHO and fixation with a rod apparatus at the place of residence, upon admission to 32 CVMCG an extensive (17 cm) defect of the humerus in the middle third, the wounds healed (Figure 1). The first step is the fence nevascularized peroneal graft (Figure 2). Further, in the projection along the front edge of the latissimus dorsi (Fig. 3), the latissimus was exfoliated from the bed from an additional 15 cm long section in the axillary region, a cavity measuring 15 × 6 × 5 cm was formed, the perimizium of the latissimus muscle was opened along the muscle fibers for 15 cm and a bone fragment of the fibula fixed in two sutures is immersed in this cavity (Figure 4). 4 weeks after wound healing in the lower leg and armpit, stabilization of the general condition and indicators of homeostasis, non-free vascularized autoplasty of the defect of the humerus, soft tissues and biceps muscle of the shoulder was performed with a pre-prepared (prefabricated) thoracodorsal musculocutaneous skin graft (Figs. 5, 6, 7). The wound healed, a course of rehabilitation treatment was carried out, forearm flexion was restored (Fig. 8). No complications from the donor site were noted (Fig. 9).

Thus, the claimed method allows the surgical correction of extensive gunshot defects of soft tissues and the humerus with fewer stages of the operation, less traumatic surgical interventions, and in a shorter time completely restore the length and function of the limb.

Claims (3)

1. A method for plasticizing shoulder defects with extensive destruction of the humerus and soft tissues, including replacing the defect with a bone-soft tissue autograft, characterized in that at the first stage a linear incision is made along the external surface of the lower leg, two osteotomies of the fibula are made, receiving a bone fragment, an incision is made in the axillary region along the front edge of the latissimus dorsi muscle, the latissimus dorsi muscle is exfoliated from its bed, the latissimus dorsi muscle along the muscle fibers, in such a way formed the basal cavity is immersed in the resulting bone fragment of the fibula and fixed with one or two sutures; the second stage, after 4-7 weeks, a skin-muscle-bone-bone flap is transplanted on the vascular pedicle, which includes a part of the latissimus dorsi with a bone fragment of the fibula embedded in it into the shoulder defect, anastomosis is applied between the artery and vein of the vascular pedicle and the branches of the brachial artery and veins respectively. 2. The method according to claim 1, characterized in that the vascular leg of the musculoskeletal flap is a thoracodorsal artery and vein. 3. The method according to claim 1, characterized in that the cavity in the latissimus dorsi, where a fragment of the fibula is immersed, is formed with dimensions of 15 × 6 × 5 cm.

Images