RU2844430C1 - Method for preventing wound infection in gunshot fractures of extremity bones - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to traumatology, and can be used in clinical hospitals for treating open gunshot fractures of extremity bones. Regardless of the presence of signs of inflammation in the region of the postoperative wound on 3rd or 4th day after the external osteosynthesis or prosthetic replacement, wound is opened and a surgical site is washed with normal saline in an amount of up to 3000 ml by means of a pulse-lavage system with further wound layer-by-layer closure.

EFFECT: method provides preventing the developing wound infection ensured by the obligatory postoperative wound sanitation on 3rd or 4th day following the internal osteosynthesis or prosthetic replacement.

2 cl, 8 dwg, 3 ex

Description

The invention relates to medicine, in particular to traumatology, and can be used in clinical hospitals for treating open gunshot fractures of limb bones. The stated objective is achieved in a method for mandatory planned sanitation of postoperative wounds on the 3rd or 4th day after performing immersion osteosynthesis or endoprosthetics for open gunshot fractures of limb bones. Wound sanitation is performed by "suturing" the postoperative wound, washing the site of the operation using a "pulse-lavage" wound surface sanitation system and repeated layer-by-layer suturing of the wound.

There are known methods for sanitizing a purulent focus in cases of already developed infectious complications of surgical interventions in traumatology and orthopedics, including the use of a system for sanitizing the wound surface “pulse lavage”.

A common disadvantage of known methods is the treatment of already developed purulent complications, which worsens the treatment results.

A method for treating gunshot wounds to the extremities is known. After the primary surgical treatment, Kotelex-ADL napkins are placed in the wound cavity, changing them every 2-3 days for 10-14 days, and then Kotelex MEX napkins are applied to the wound until full granulation has matured; after secondary surgical treatment, Kotelex anti-inflammatory napkins are applied to the wound, changing them every 1-3 days until healing (RU 2254813 C2). The disadvantages include multiple repeated surgical treatments using special dressings, which are practically impossible to perform when evacuating patients at stages of care. There is also a risk of leaving dressings behind when changing the operating doctor.

In the complex of surgical treatment, a method of primary surgical treatment of mine-explosive isolated injuries of the foot in the conditions of local military conflicts is known. In order to preserve the foot as a functioning organ, reduce disability and discharge of this contingent of wounded from the ranks of the Armed Forces, reduce the duration of treatment and material and financial costs of the treatment and rehabilitation process when providing qualified surgical care, the first stage of primary surgical treatment is performed: only clearly non-viable edges of the skin, subcutaneous tissue immobilized with blood and crushed muscles are excised, only bone crumbs are removed by jet washing of the wound with solutions of oxygen-containing antiseptics, simultaneously decompression of the vascular-nerve bundles of the foot is performed by retinaculotomy of the first osteo-fibrous canal on the dorsum of the foot and lower leg and the malleolar canal, subcutaneous fasciotomy of the osteo-fascial sheaths of the lower leg in the area of the wound localization and intermetatarsal spaces, therapeutic and transport immobilization is carried out using the G.A. compression-distraction apparatus. Ilizarov in the distraction mode, all bone fragments, including those not connected with the surrounding tissues, are placed in the maternal bed, flow-washing drainage and closure of the wound with an aseptic dressing with antibacterial ointments on a water-soluble basis are performed, the wounded are evacuated first of all according to the appointment to the microsurgical center, where, in the optimal time for a specific wounded person, the second stage of primary surgical treatment is performed using microsurgical primary reconstructive and plastic surgeries, extrafocal transosseous compression-distraction osteosynthesis according to the G.A. Ilizarov method, using a previously applied compression-distraction apparatus (RU 2173544 C2). The disadvantages include the presence of a flow-washing drainage system, the adequate functioning of which is almost impossible to ensure at the evacuation stages.

There are data on the method of wound sanitation in case of open fractures of bones of the distal part of the limbs. The set goal is achieved in the method of wound sanitation in case of open fractures of bones of the limbs against the background of anesthesia by washing through the epimetaphysis of the damaged bone, intraosseous puncture of the affected segment of the limb is carried out at two points: first, for intraosseous anesthesia, spongy tissue of the intact bone is selected, and then for transosseous lavage - the epimetaphysis of the broken bone (RU 2089119 C1). The disadvantages include limited localization of application and the presence of the lavage system itself, which requires additional care and consumables.

A method for treating chronic osteomyelitis is known. The pathological focus is surgically treated and the bone defect is subsequently filled with an implant. During treatment in the acute stage, sequester necrectomy, rinsing with antiseptics, and vacuuming are performed. Then the bone defect is filled with collapan granules. When a cavity is formed after sequester necrectomy, the filling with collapan granules is performed without tamping to the level of the edge limiting the cavity. In the case of the formation of extensive bone defects in the form of a cavity, filling with collapan granules is supplemented with muscle plastic surgery. During resection sequester necrectomy, collapan granules are placed between bone fragments and osteosynthesis is performed using a compression-distraction apparatus. During treatment in the remission stage, tunneling of the area of pathologically altered bones is performed. Then the formed channels are filled with collapan in the form of a gel through a catheter under pressure (RF No. 2155552). The disadvantages include the treatment of an already formed source of infection with the inevitable loss of bone tissue and deterioration of the final treatment result and long treatment periods.

A method for treating patients with chronic osteomyelitis of the lower extremities with bone cavities is known. For this, the following minimum parameters of sanitation are set: speed 150 ml/min; volume 20 ml; duration 0.1 minute with subsequent calculation of the coefficients of the ratio of irrigation/aspiration parameters (RF No. 2552899). The disadvantages also include the treatment of an already formed focus of infection with the inevitable loss of bone tissue and deterioration of the final result of treatment and long treatment periods.

In clinical practice, the use of pulse lavage wound sanation is known when performing osteosynthesis or prosthetics. For example, in the article "Medulloscopy in the Treatment of Complications of Intramedullary Osteosynthesis with a Pin with an Antimicrobial Coating" by I.M. Efremov et al., Surgical News, Vol. 26, No. 4, 2018, it is described that "surgical treatment was performed in the amount of osteonecrsequestrectomy of the right femur (anterior-external approach to the femur), removal of bone cement from the medullary canal, treatment of the medullary canal of the femur with flexible reamers for the purpose of additional "sterilization" of the surgical wound. Ultrasonic cavitation of the wound in a gentamicin solution was performed, as well as treatment with a pulse lavage system with active removal of the solution into the medullary canal of the femur. Two perforated drainage tubes were installed, which are connected to vacuum "bulbs". Additionally, the hernia of the quadriceps femoris muscle from the previous surgical intervention was eliminated by mobilizing and suturing the broad fascia of the thigh. In the early postoperative period, despite the performed sanitation, a relapse of the osteomyelitic process was noted as a result of incomplete removal of the cement mantle from the medullary canal of the bone. In this regard, the patient was re-hospitalized to the clinic, where on 26.01.16 we performed a repeated osteonecrsequestrectomy of the right femur (anterior-external approach to the femur), treatment of the medullary canal of the femur with flexible reamers in order to destroy and remove the remains of the cement mantle, treatment with a pulse lavage system with vacuuming."

Thus, even wound sanitation directly during osteosynthesis surgery does not guarantee the absence of infectious complications.

However, the prior art did not previously know a method for planned sanitation of postoperative wounds during immersion osteosynthesis or endoprosthetics. gunshot fractures of the bones of the extremities, which involves preventing the development of wound infection, which is proposed in the claimed invention.

The purpose of the proposed technical solution is to prevent the development of wound infection through mandatory planned sanitation of postoperative wounds on the 3rd or 4th day after performing internal osteosynthesis or endoprosthetics. in case of gunshot fractures of the limb bones. This wound sanitation can be performed, including at the next stage of providing medical care as part of another medical team. The patient does not have systems for washing or administering medications to the wound area, which require additional monitoring and care. Continuity in the provision of specialized medical care is ensured.

Thus, the technical result of the claimed invention consists in expanding the arsenal of means related to the planned sanitation of postoperative wounds during immersion osteosynthesis or endoprosthetics of gunshot fractures of the bones of the extremities, which involves preventing the development of wound infection.

The stated technical result is achieved by the fact that planned wound sanitation is performed by means of abundant washing using the system for wound surface sanitation "pulse-lavage" in case of gunshot fractures of limb bones, regardless of the presence of signs of inflammation in the area of the postoperative wound. This allows to significantly reduce the incidence of purulent complications.

The criteria for applying this method can be considered the presence of any 3 of the following factors:

- open method of fragment reposition;

- the presence of a submersible implant (pin, plate, endoprosthesis);

- duration of surgical intervention is more than 2 hours;

-blood loss of more than 1 liter, massive use of coagulation to stop bleeding from scar tissue;

- detection of non-viable tissue or foreign bodies (fragments of a wounding projectile, uniform, etc.);

- severe swelling in the postoperative period;

- hyperthermia and local inflammation in the area of the postoperative wound;

- significant difficulties in repositioning fragments associated with skeletonization of bone structures and detachment of soft tissues.

The method is carried out as follows. On the 3rd or 4th day after performing immersion osteosynthesis or endoprosthetics for gunshot fractures of the bones of the extremities, the planned sanitation of the wounds is performed by copious washing using the system for sanitation of the wound surface "pulse-lavage", regardless of the presence of signs of inflammation in the area of the postoperative wound. For washing, an isotonic solution of sodium chloride up to 3000 ml is used, it is possible to add antiseptics and antibiotics. Then repeated layer-by-layer suturing of the wound is performed. This allows to significantly reduce the incidence of purulent complications and improves wound healing.

Example 1. See Figures 1-6. Patient M. Diagnosis: MVR from 21.01.24. Gunshot shrapnel blind wounds of the right thigh, open, gunshot comminuted fracture of the lower third of the diaphysis of the right femur with displacement of bone fragments. Penetrating gunshot wound of the right shin. Surgery from 22.01.24 installation of ANF-KSVP right thigh-tibia, surgery from 06.03.24 dismantling of ANF right thigh-tibia, surgery from 12.03.24 VSHO of the wound of the right thigh, surgery from 09.04.24 open reposition, osteosynthesis of the femur with a pin with locking, surgery from 12.04.24 revision of the postoperative wound of the right thigh.

At the time of admission, the wounds had healed. On the X-ray, figure 1, in the lateral projection, significant displacement of the fragments is noted. The external fixation device was dismantled. Given the age of the injury, open reposition of the fragments with marginal resection and osteosynthesis with a universal pin were performed. During osteosynthesis, non-viable bone fragments, fragments of the injuring projectile and uniform were removed from the fracture site (see figure 3).

On the 3rd day after performing internal osteosynthesis, the following was performed as planned: the wound was opened layer by layer, the postoperative wound was sanitized by copious washing using the "pulse lavage" wound surface sanitization system, Figures 4, 5. 3000 ml of isotonic sodium chloride solution was used. Layer-by-layer wound suturing was performed. The wound healed by primary intention, the sutures were removed on the 12th day, fracture consolidation occurred after 13 weeks (Figures 2, 6).

Example 2. Figures 7, 8. Patient K., 46 years old. Admitted 2 weeks after the injury. Diagnosis: Open gunshot comminuted fracture of the head of the left femur. Along the anterior surface, a wound measuring 4x2 cm contains serous-hemorrhagic discharge. Surgical debridement of the wounds was performed, two cycles of VAC therapy were administered, the wound healed in 2 weeks. Four weeks after admission, hip replacement was performed with a cementless prosthesis. During osteosynthesis, non-viable bone fragments, fragments of the injuring projectile and uniform were removed from the fracture site. On the 4th day after the endoprosthetics, the following was performed as planned: the wound was opened layer by layer, the postoperative wound was sanitized by copious irrigation using the pulse lavage wound surface sanitization system. Isotonic sodium chloride solution 3000 ml was used. Layer-by-layer suturing of the wound was performed. The wound healed by primary intention, the stitches were removed on the 12th day.

Example 3. Wound sanitation is optionally performed, including at the next stage of providing medical care as part of another medical team. The patient does not have systems for rinsing or administering medications to the wound area, which require additional monitoring and care. Continuity in providing specialized medical care is ensured (Figure 4. External appearance of the wound after repeated suturing).

The presented figures 1-7 show the results of the rehabilitation, confirming the effectiveness of the proposed method.

Claims (2)

1. A method for preventing the occurrence of wound infection in gunshot fractures of the bones of the extremities, characterized in that, regardless of the presence of signs of inflammation in the area of the postoperative wound, on the 3rd or 4th day after performing immersion osteosynthesis, the wound is sutured and the site of the operation is washed with an isotonic sodium chloride solution in a volume of up to 3000 ml using a pulse lavage system with subsequent layer-by-layer suturing of the wound. 2. A method for preventing the occurrence of wound infection in gunshot fractures of the bones of the extremities, characterized in that, regardless of the presence of signs of inflammation in the area of the postoperative wound on the 3rd or 4th day after performing endoprosthetics, the wound is sutured and the site of the operation is washed with an isotonic sodium chloride solution in a volume of up to 3000 ml using a pulse lavage system with subsequent layer-by-layer suturing of the wound.