RU2791412C1 - Method for replacing combined posttraumatic extensive shin tissue defect - Google Patents

Abstract

FIELD: medicine; traumatology; orthopaedics; plastic surgery.

SUBSTANCE: invention relates to treatment of congenital hip dislocation. The incision line is marked to isolate the flap along the outer surface of the intact leg. A wavy incision is made above the pedicle of the flap, an arcuate incision is made along the anterior edge of the fibular flap to the muscle tissue, the fascia covering the muscles is sutured to the flap. Feeding perforating arteries passing in the intermuscular septum are found. The peroneal muscle is separated from the fibula. The peroneal vascular bundle is isolated, the incision is continued to a circular one, an osteotomy of the fibula is performed with the release of a bone fragment, and the pedicle of the fibular flap is isolated. A full-thickness skin graft is taken from the iliac region to cover the flap stem, and the flap stem is wrapped. Re-osteosynthesis is performed with an apparatus for external fixation of the damaged lower leg and foot, and of the intact lower leg and foot. Devices are installed on both legs. In the wound of the injured leg, hypergranulations are removed, the ends of the tibia are isolated, and the bone endplates are removed from the ends of the fragments of the tibia. Osteotomy is performed through the area of the false joint of the fibula. A bed is formed for a fragment of a complex non-free vascularized flap with a fragment of the fibula, external fixation devices are interconnected using hinged nodes. A non-free vascularized flap with a fragment of the fibula taken from the intact leg is placed in the defect of the tibia, the fragment of the fibula is fixed with an intramedullary pin. Stitches, bandages are applied and drainage is established.

EFFECT: possibility of simultaneous replacement of a complex defect in the tissues of the lower extremities, including bone tissue, integumentary tissues, muscles through the use of a complex non-free flap based on peroneal vessels from the opposite leg.

1 cl, 10 dwg, 1 ex

Description

The field of technology.

The invention relates to medicine, and can be used in traumatology and orthopedics, plastic surgery for the treatment of patients with post-traumatic combined extensive defects in leg tissues, including the main vessels.

The level of technology.

A known method of replacing the tissues of the lower limb using an Italian flap with a loose type of blood supply from the opposite leg. (Aristov A.M., Afaunov A.A., Blazhenko A.N., Kurinny S.N., Shevchenko A.V. Experience of using a non-free blood-supplied gastrocnemius muscle flap for plastic replacement of defects in the integumentary tissues of the lower extremities // Innovative Medicine of Kuban 2016. No. 4. URL: https://cyberleninka.ru/article/n/opyt-ispolzovaniya-nesvobodnogo-krovosnabzhaemogo-loskuta-ikronozhnoy-myshtsy-dlya-plasticheskogo-zamescheniya-defektov-pokrovnyh (date of access: 06/21/2022 ).In this method, the flap, which includes the skin and subcutaneous fat, is cut out according to the size of the existing defect on the posterior and / or lateral surfaces of the lower leg. After the flap is isolated, it is fixed on the feeding leg on the recipient wound. After 30-40 days, the flap is cut off (General surgery: textbook / Gostishchev V.K. - 4th ed., Revised and added - 2010. - S. 552-553).

The disadvantages of using this method in this case is that the problem of replacing a bone tissue defect is not solved, and therefore in the future the patient will be forced to operate additionally.

In the middle of the 20th century, the outstanding domestic traumatologist-orthopedist G.A. Ilizarov proposed a method of bilocal combined compression-distraction osteosynthesis to replace defects in the bone diaphysis, which consists in the formation of a distraction regenerate when an osteotomized fragment of one of the fragments is moved through the defect zone (Ilizarov G.A., Gracheva V.I. Bloodless treatment of congenital pseudoarthrosis of the lower leg with simultaneous elimination shortening by the method of dosed distraction // orthopedic, traumatol. 1971. - No. 2. - P. 42-46).

This method is carried out as follows. A pair of intersecting wires is passed through the metaphyseal sections of the tibia and one more wire is passed through the metadiaphyses of both fragments, which are fixed in a tense state in the external supports of the Ilizarov apparatus, interconnected by threaded rods. Then an intermediate bone fragment is formed; for this, two intersecting wires are passed through the middle third of the fragment planned for osteotomy, which should not pass near the main neurovascular formations. These spokes are attached in a taut state in an annular support connected by rods to the proximal and distal supports of the apparatus. From the incision (0.5-0.7 cm), a partial corticotomy of the metadiaphyseal part of this fragment is performed. 1-2 nodal sutures are applied to the wound. On the 6th day after the operation, the formed fragment is moved to the opposite one by uniform and simultaneous screwing of the outer nuts of both traction rods 0.25 mm × 4-6 times a day, which is necessary for the gradual formation of a full-fledged regenerate in the resulting diastasis. Upon reaching the contact of the ends of the movable and opposing fragments, compression is started at the junction. Supportive compression at the junction of the fragments is performed once every 3 days at a rate of 1 mm for 4 twists within 1-1.5 months, depending on the congruence of the ends of the fragments. Fixation is continued until the integrity of the bone is achieved.

The disadvantage of this method is that it does not solve the problem of replacing a large soft tissue defect on the lower leg. On the other hand, if the patient had circular scars on the lower leg with no subcutaneous fat during distraction, these scars would be cut through with pins and inflammation of the soft tissues.

Closest to the claimed technical solution is the method of one-stage replacement of a complex defect in the tissues of the lower leg with a free peroneal flap from the opposite lower leg (Kochish A. Yu. Anatomical and clinical rationale for plastics with axial complex flaps on the lower limbs: Dis. Doctor of Medical Sciences. - St. Petersburg. , 1998. 558 p.;

Pshenisnov K.P. Principles of reconstruction of the lower limb// Selected issues of plastic surgery. 2003. - V. 1, No. 3. - S. 3 - 45; Serafm D. Atlas of microsurgical composite tissue transplantation. Philadelphia: W. B. Sannders company, 1996. - 813 p.). The method includes the isolation of a free peroneal flap on a healthy limb and the use of microsurgical techniques for suturing donor and recipient vessels on the affected limb (Fig. 1 is a scheme for isolating a complex of tissues based on peroneal vessels).

In case of high damage to the anterior tibial and peroneal vascular bundles of the leg, compromised posterior neurovascular bundle, microsurgical sutures of vessels can be performed only with the use of vascular plasty of the artery and veins, which is risky. It is also risky to connect donor vessels to the preserved vascular bundle, because in case of failure, you can get necrosis of not only the transplanted tissue complex, but also cause trophic disorders on the foot.

The disadvantages of these technical solutions is the following. In the case of using only a soft tissue flap, the problem of replacing a bone tissue defect is not solved. When using a distraction-compression apparatus for external fixation, the problem of eliminating an extensive wound defect is not solved. Performing microsurgical transplantation of a complex complex of tissues is very risky in the presence of compromised vessels in the recipient area.

Thus, there is a problem of replacing lost tissues; in practice, it is required to ensure the possibility of simultaneous replacement of a complex defect in the tissues of the lower extremities, including bone tissue, integumentary tissues, and muscles.

The essence of the invention.

The task to be solved by the method is to provide simultaneous replacement of complex complex post-traumatic defects of the tissues of the lower leg in the conditions of chronic defects and compromised main vessels of the affected lower leg with the creation of conditions for the resolution of post-traumatic lymphedema.

The technical result consists in the simultaneous replacement of a complex defect in the tissues of the lower extremities, including bone tissue, integumentary tissues, muscles, with the creation of conditions for the resolution of post-traumatic lymphedema.

The technical result is achieved by the fact that in the method of replacing a post-traumatic combined defect of the tissues of the lower leg using a non-free soft tissue flap, osteosynthesis is performed with an external fixation apparatus of the damaged lower leg, distraction between fragments of the tibia is performed, interposition of the soft tissues of the lower leg is eliminated, the defect of the tibia of the damaged lower leg is replaced with a non-free vascularized fibula with a complex flap from an intact tibia: for this, the incision line is marked to isolate the flap along the outer surface of the intact tibia, a wavy incision is made above the leg of the flap, an arcuate incision is made along the anterior edge of the fibular flap to the muscle tissue, the fascia covering the muscles is sutured to the flap, the supply perforating arteries passing in the intermuscular septum separate the peroneal muscle from the fibula, secrete the peroneal vascular bundle, continue the incision to a circular one, produce steotomy of the fibula with the release of the bone fragment, the leg of the fibular flap is isolated, a full-thickness skin graft is taken from the iliac region to cover the leg of the flap, the leg of the flap is wrapped; perform repeated osteosynthesis with an apparatus for external fixation of the damaged lower leg and foot, and an intact lower leg and foot, connect the apparatuses of both lower legs with their fixation in a single module: for this, the apparatuses are installed on both lower legs, hypergranulations are removed in the wound of the damaged lower leg, the ends of the tibia are isolated, bone endplates from the ends of the fragments of the tibia, perform osteotomy through the area of the false joint of the fibula; a bed is formed for a fragment of a complex non-free vascularized flap with a fragment of the fibula, external fixation devices using hinged nodes are interconnected; a non-free vascularized flap with a fragment of the fibula taken from the intact leg is placed in the defect of the tibia, the fragment of the fibula is fixed with an intramedullary pin, sutures, bandages are applied and drainage is established.

The method provides the possibility of simultaneous replacement of a complex defect in the tissues of the lower extremities, including bone tissue, integumentary tissues, muscles, using a complex non-free flap based on peroneal vessels from the opposite leg. The method is not only capable of solving the problem of replacing lost tissues, but also helps to reduce the severity of post-traumatic foot lymphedema.

EFFECT: method allows to simultaneously replace a deep complex wound defect of the lower leg, including a defect in the main vessels, to significantly reduce the risk associated with necrosis of donor tissues, trophic disorders on the foot of the affected lower limb.

The invention is illustrated by images:

fig. 1 - Scheme for isolating a complex of tissues based on the fibular vessels, a method for one-stage replacement of a complex defect in the tissues of the lower leg with a free peroneal flap from the opposite lower leg;

Fig. 2 - Photographs of the lower extremities of the patient U.

Fig. 3 - Radiographs of the lower extremities of patient U.

Fig. 4 - CT with vascular contrast in 3D modeling of the right lower leg and foot.

Fig. 5 - Photographs of the lower extremities of patient U. in the external fixation apparatus, at the stage of eliminating the interposition of the soft tissues of the right leg.

Fig. 6 - X-ray of the right foot and lower third of the lower leg in the lateral projection of patient U. at the stage of eliminating the interposition of the soft tissues of the right lower leg.

Fig. 7 - Photograph of the lower extremities of patient Y with preoperative planning of incisions on the left leg.

Fig. 8 - Photograph of the lower extremities of patient Y with fixation of both legs after plasty with a non-free fibular flap.

Fig. 9 - Photographs of the lower extremities of patient U. 3 years after the end of treatment.

Fig. 10 - X-ray of the lower extremities of patient U. 3 years after the end of treatment.

Implementation of the invention.

In this method, it is proposed to use a non-free fibula flap on the injured tibia with included fragments of the fibula from the opposite tibia. Fixation of both legs in the postoperative period is performed using the Ilizarov apparatus. Microsurgical suture of recipient vessels with donor vessels is not required. 4-5 weeks after the operation, the vascular pedicle is cut off, the Ilizarov apparatus is dismantled from the donor tibia.

A method for replacing a post-traumatic combined extensive defect in the tissues of the lower leg using a non-free soft tissue flap, characterized in that osteosynthesis is performed with an external fixation apparatus of the damaged lower leg, dosed distraction between fragments of the tibia is performed, interposition of the soft tissues of the lower leg is eliminated, the defect of the tibia of the damaged lower leg is replaced with a non-free vascularized peroneal complex flap from the intact tibia: for this, the incision line is marked to isolate the flap along the outer surface of the intact tibia, a wavy incision is made above the leg of the flap, an arcuate incision is made along the anterior edge of the fibular flap to the muscle tissue, the fascia covering the muscles is sutured to the flap, feeding perforators are found arteries passing in the intermuscular septum separate the peroneal muscle from the fibula, secrete the peroneal vascular bundle, continue the incision to a circular one, produce osteotomy of the fibula with the release of a bone fragment, the leg of the fibular flap is isolated, a full-thickness skin graft is taken from the left iliac region to cover the leg of the flap, the leg of the flap is wrapped;

perform repeated osteosynthesis with an apparatus for external fixation of the damaged lower leg and foot, and an intact lower leg and foot, connect the apparatuses of both lower legs with their fixation in a single module with the optimal position of the leg of the non-free fibular flap: for this, the apparatus is installed on both lower legs, hypergranulations are removed in the wound of the damaged lower leg, the ends of the tibia are isolated, the bone endplates are removed from the ends of the fragments of the tibia, osteotomy is performed through the area of the false joint of the fibula; a bed is formed for a fragment of a complex non-free vascularized flap with a fibula, external fixation devices are interconnected using hinged nodes; a non-free vascularized flap with a fibula from an intact tibia is placed in the defect of the tibia, the fibula isolated from the intact tibia is fixed with an intramedullary pin, sutures, bandages are applied and drainage is established.

The method is used for simultaneous replacement of a complex complex of soft tissues and a bone tissue defect, elimination of an extensive wound post-traumatic defect in the tissues of the lower leg in conditions of chronic defects and compromise of the main vessels of the affected lower leg with the creation of conditions for the resolution of post-traumatic lymphedema.

The possibility of simultaneous replacement of a complex defect in the tissues of the lower extremities, including bone tissue, integumentary tissues, muscles, using a complex non-free flap based on peroneal vessels from the opposite leg is provided. This method is not only able to solve the problem of replacing lost tissues, but also helps to reduce the severity of post-traumatic lymphedema.

Clinical example (FIGS. 2 to 10).

We present the experience of treating patient U., 17 years old. There was a combined injury of the right shin: the shin in the upper third was swept by a cable, the skin with subcutaneous fat was pulled off by a “stocking” to the border of the middle and lower thirds, and a loader fell on the same place. As a result of a severe injury, an open comminuted fracture of the bones of the right tibia (according to the Gustilo-Anderson classification III B type) occurred with a total detachment of the skin of the tibia, a defect in the muscles of the anterior and external muscle groups, a defect in the anterior neurovascular bundle (classification of open fractures by AO and E. Muller et all., (1990, 1996) IO-5, MT - 4, NV - 4. According to the J.W. May classification, this fracture belongs to type 4: a tibial defect > 6 cm with a lesion of the fibula.

Primary surgical treatment of the wound, osteosynthesis of the lower leg with an external fixation device were performed at the place of residence. Subsequently, 13 operations were performed, including necrectomy, plasty with split skin autografts. Within one year of treatment at the place of residence, bone fusion and wound healing were not achieved. With an extensive purulent wound, a defect in the tibia, an old injury to the anterior neurovascular bundle, tendons and muscles of the anterior and lateral groups of the lower leg, post-traumatic severe lymphedema of the right foot, the patient was admitted to the Ilizarov Center for a year. Upon admission, the patient walked with support on 2 crutches, without stepping on the right lower limb. Locally, circular hypotrophic scars were noted around the entire circumference of the lower leg (from the knee joint to the fracture site) with the absence of subcutaneous fat, in this area split skin autografts were transplanted onto the superficial fascia (Fig. 2; 3). Distal to the border of the middle third and up to the line of the ankle joint, there was a sluggish granulating wound on 3/4 of the circumference of the lower leg 13 by 20 cm with serous-purulent scanty discharge. The wound is uneven, there is a depression along the anterior surface of the lower leg between the ends of the tibia. The preserved bridge of soft tissues along the posterior surface of the lower leg was "invaginated" into the space between the ends of the tibia with a rigid skin fold without the possibility of immediate expansion. Sowing from the wound upon admission to the clinic showed the presence of Pseudomonas aeruginosa - confluent growth, methicillin-resistant Staphylococcus aureus 105. The only objective argument for the preservation of the right foot was the complete preservation of the sensitivity of the entire sole and the possibility of rocking active flexion movements with the fingers.

For the purpose of diagnosis, X-ray contrast angiography of the vessels of the right lower extremity was performed. After CT scan with vascular contrast in 3D modeling, it turned out that there was no anterior tibial artery, the posterior tibial artery was sharply narrowed at the level of the ankle joint. The viability of the right foot is ensured by the dilated superficial arteries of the subcutaneous fat (Fig. 4). The consequence of such internal ischemia of the foot and the lack of load during the year was almost complete demineralization of the bodies of the bones of the foot, which is also clearly visible on the CT picture. In addition, trauma and the long existence of a subcircular extensive wound in the fracture zone, cicatricial constriction of this wound led to an almost complete blockage of the lymphatic outflow from the right foot and sharply reduced the venous outflow. In fact, at the time of transfer to the Clinic of Reconstructive Plastic Surgery and Surgery of the Hand, the lymph outflow of the right foot was carried out into the wounds of the lower third of the lower leg in bandages, which also aggravated the situation.

Diagnosis: “Acquired recurvation deformity of the lower third of the right tibia, pseudoarthrosis, diastasis defect of 7 cm of the lower third of the right tibia, improperly consolidated fracture of the fibula. Chronic osteomyelitis of the right leg, foot (remission). Chronic damage to the anterior and posterior tibial arteries, peroneal nerve, extensor tendons of the foot and fingers. Osteoporosis of the bones of the foot. Post-traumatic lymphedema of the right foot.

It is ineffective to perform classical osteosynthesis of the lower leg bones using the Ilizarov method in conditions of an extensive wound. By applying compression between the ends of the tibia, we would increase the corrugation of the tissues of the isthmus with compression of the great vessels, which would first entail an increase in lymphedema, and then trophic disorders in the tissues of the foot. On the other hand, performing a microsurgical replacement of a complex tissue defect in the lower third of the leg with a precision suture of donor and recipient vessels is also very risky due to the presence of only actually acting superficial loose-type arteries on the affected limb. It was practically impossible to find a vein worthy of a vascular suture under conditions of circular scars. However, the aim of the treatment was to reconstruct the right limb of the young patient, for this.

At the first stage, osteosynthesis was performed with an external fixation device (Ilizarov TM) of the right leg and foot. In the postoperative period, dosed distraction between tibial fragments was performed with an external fixation device. The result of this stage was the elimination of the interposition of the soft tissues of the lower leg, which clinically resulted in a slight decrease in the severity of foot lymphedema (Fig. 5, 6).

In order to rehabilitate the victim, a treatment method was implemented using a non-free complex peroneal flap from the opposite limb, which included the following:

• Replacement of the defect of the tibia of the right tibia with a non-free vascularized peroneal complex flap from the opposite tibia;

• Reosteosynthesis with an external fixation apparatus of the right leg and foot;

• Osteosynthesis with external fixation apparatus of the left leg and foot.

• Mounting of the devices of both legs with their fixation in a single module with the optimal position of the stem of the non-free fibular flap.

Operation progress. First brigade. Under ETN and after 3-fold treatment of the left lower limb with an antiseptic solution , an incision was made on the left leg . Inflated hemostatic cuff (60 min) in the lower third of the thigh.

On the outer surface of the intact lower leg, a 15*6 cm flap was marked (Fig. 7). A wavy incision was made over the leg of the flap. An arcuate incision along the anterior edge of the fibular flap to the muscle tissue. The fascia covering the muscles was serrated and sutured to the flap. Feeding perforating arteries passing through the intermuscular septum were found by tissue sampling. Separated peroneal muscle from the fibula. Selected peroneal vascular bundle (distal portion). The incision is continued to a circular. The skin flap is fully exposed. Produced osteotomy of the fibula with the allocation of a bone fragment of 9 cm . Hemostasis. The peroneal bundle was tied twice at the level of the border of the lower and middle thirds. The artery and veins are crossed. The tourniquet was removed, the blood supply to the flap was satisfactory.

Next, the pedicle of the fibular flap was dissected over a length of 18 cm. Hemostasis. Two drains have been installed. The wounds on the leg are sutured. After a possible suturing, a skin defect of 18 * 6 cm and 10 * 5 cm remained.

A split skin graft was taken along the outer surface of the left thigh to close the wound. On the thigh wound - dry gauze bandages. Split skin grafts are placed on the wounds of the left leg, stitches around the circumference of the wound.

To cover the leg of the flap, a full-thickness skin graft 8 * 5 cm was taken from the left iliac region . The wound on the abdomen is sutured. Drainages. Asep. Bandages.

The graft was processed according to Krasovitov. They wrapped the leg of the flap. Stitches on the skin.

The second brigade - on the right lower leg and foot.

After three standard processing of the surgical field , osteosynthesis was performed with an external fixation apparatus of the right leg and foot . Marked osteoporosis of the foot bones, distal tibia is noted. The apparatus was mounted with the elimination of recurvation at the level of the tibial defect. X-ray control.

In the wound on the right leg, hypergranulations were removed, the ends of the tibia were exposed. Removed bone endplates from the ends of the fragments of the tibia. Produced osteotomy through the area of the false joint of the fibula.

A bed was formed for a fragment of a complex non-free vascularized flap with a fibula . To immobilize the right tibia relative to the left tibia, the pre-assembled external fixation devices are interconnected using hinged assemblies. A non-free vascularized flap with the fibula from the left tibia was placed in the defect of the right tibia (Fig. 8). The bone graft was fixed with an intramedullary pin. Soft tissues are adapted to each other. Stitches on the skin. Drainages. aseptic bandages.

In the postoperative period, no trophic disorders were found in the transplanted flap. Healing of all wounds by primary intention. After a period of fixation of both lower extremities for 7 weeks, taking into account additional reinsurance, the leg of the flap (arterial and venous vessels wrapped in a full-thickness skin graft) was transected, and the device from the left lower extremity was dismantled. The patient began an active lifestyle.

The patient was verticalized after 4 days, the patient began to walk with the help of two crutches. Gradually, over the course of three months, the patient began to lean on the right foot with full load. X-ray control showed not only the presence of processes of consolidation of bone fragments of the tibia, but also a gradual decrease in the phenomena of local osteoporosis of the bones of the right foot. Throughout the period of fixation of the right leg, we noted a gradual decrease in foot lymphedema.

The device was dismantled after 6 months of fixation in the device. Then the patient underwent a course of rehabilitation at the place of residence.

One year after the removal of the device to restore the length of the right lower limb, the right femur was lengthened by 5 cm. Currently, the patient walks independently, without additional support.

The result of treatment (Fig. 9, 10). The foot is saved. Chronic osteomyelitis stopped. Bone and soft tissue defects were replaced. Consolidation achieved. Significantly reduced swelling on the foot. Serious complications were avoided during the course of treatment.

Claims (1)

A method for replacing a post-traumatic combined defect of lower leg tissues using a non-free soft tissue flap, characterized in that osteosynthesis is performed with an external fixation device of the damaged lower leg, distraction is performed between fragments of the tibia, interposition of the soft tissues of the lower leg is eliminated, the defect of the tibia of the damaged lower leg is replaced with a non-free vascularized peroneal complex flap from an intact tibia: for this, the incision line is marked to isolate the flap along the outer surface of the intact tibia, a wavy incision is made above the leg of the flap, an arcuate incision is made along the anterior edge of the fibular flap to the muscle tissue, the fascia covering the muscles is sutured to the flap, the supplying perforant arteries are found passing in the intermuscular septum, separate the peroneal muscle from the fibula, allocate the peroneal vascular bundle, continue the incision to a circular one, produce an osteotomy of the peroneal th bone with the allocation of the bone fragment, allocate the leg of the fibular flap, take a full-thickness skin graft from the iliac region to cover the leg of the flap, wrap the leg of the flap; perform repeated osteosynthesis with an apparatus for external fixation of the damaged lower leg and foot, and an intact lower leg and foot, connect the apparatuses of both lower legs with their fixation in a single module: for this, the apparatuses are installed on both lower legs, hypergranulations are removed in the wound of the damaged lower leg, the ends of the tibia are isolated, bone endplates from the ends of the fragments of the tibia, perform osteotomy through the area of the false joint of the fibula; a bed is formed for a fragment of a complex non-free vascularized flap with a fragment of the fibula, external fixation devices using hinged nodes are interconnected; a non-free vascularized flap with a fragment of the fibula, taken from the intact leg, is placed in the defect of the tibia, the fragment of the fibula is fixed with an intramedullary pin, sutures, bandages are applied and drainage is established.

Images