The method of treatment of chronic osteomyelitis of long bones

 

The invention relates to medicine, namely to traumatology in the surgical treatment of osteomyelitis focus located nutricote. Essence: cut out the bone flap for soft tissue supply legs in the projection of the pathological focus, throw back flap rotation around its own axis, sanitize pathological focus through a window formed within healthy tissue, from the inside, from the bone-marrow channel, perform osteoperforative to the periosteum throughout the access and on the flap with a distance from each other 1.5 cm, osteoperforative have a conical shape with the base facing medially medullar channel, the flap is fixed in the "mother Lodge" spoke with thrust pad and the operated segment stabilize long bone external fixation device, what stimulates regeneration by increasing blood circulation in the area of the hearth. 7 Il.

The present invention relates to medicine, namely to traumatology and can be used in the surgical treatment of pathological lesion located nutricote.

A known method of treatment of osteomyelitis, using muscle plasty substitution is on fire. Scars and fistulous course excised. Naked muscles and push them stupidly in hand before the exposure of the surface of the bone. Access to pathological lesion perform throughout the pathological focus. Produce cortical resection and necrsequestrectomy cavity. Near the postoperative cavity choose muscle as possible free from scars, and calculate the length, width and thickness of the flap in accordance with the size of the cavity. Muscle flap should be thick, especially at the base, through which occurs the supply of the flap arterial and venous blood. After the muscle for plastic surgery is scheduled, dissect its fascial sheath. Incision, parallel lengthwise, netscout the surface of the muscle and then a blunt instrument to separate one or the other edge of the muscle intended for education of the flap. Previously, this region of the muscle should be separated from the deeper anatomical structures and raise it, to avoid damage to vessels and nerves. Separated thus in the longitudinal direction of the stretch muscles cross at the distal end transversely, and then produce hemostasis of the graft and its bed. At the end of the flap impose hemostatic clip Kocher or CT this tightly. Hold the drain tube. Immobilization with a plaster bandage.

However, this method has significant drawbacks:

1. Remove only the primary pathological focus is not given to the provision of sepsis, which can lead to relapse.

2. Reduce the mechanical strength of the operated limb segment.

3. Off of the muscle component of motor function.

Closest to the present invention is a method of treatment of osteomyelitis of the long bones by accessing the pathological lesion through the skin and musculo-periosteal bone flap for soft tissue supply legs, which is cut in the projection of a pathologic focus throughout the affected branches intraosseous artery. This cut through the skin, subcutaneous tissue and superficial fascia in one block so that the cut out on the edge of the muscle, scheduled for cutting out the flap. Stupidly stretched muscles, go to the bone, cut through the periosteum on the edge of the muscle attachment. Using, for example, reciprocating saws cut through the anterior cortical layer with rounded upper and lower angle of the wound in the side wickramagamage flap. The opposite cortical wall netscout using on the Lenna in several techniques, stretching soft tissue supply the legs of the flap so as not to damage them. Shift convex adjacent to the cut edge of the flap rotation around the axis that runs along the opposite edge of the posterior cortical wall. Thus, provide wide access to the pathological focus throughout the affected branches intraosseous artery with preservation of optimal blood supply of the flap due to the soft tissue of the supply legs of the attached muscles. The pathologic lesion remove a single block using bits, bent on the plane, and globewatch bits, bent stylobate. Then the formed bone cavity is treated with electromechani to complete smoothing of walls and washed with antiseptics. The flap is placed on the bone cavity, locking 2-3 seams for a soft tissue. Impose layered sutures in the wound with a sterile dressing. Fix the limb in a plaster splint [2].

However, the known method has significant drawbacks:

1. When using the known method the period of inpatient treatment are 77 days [3].

2. Fixation of the bone flap for soft tissue supply legs by applying 2-3 joints for soft tissue leads to instability of the flap is th bus leads to contractures of the adjacent joints.

4. Processing the cortical layer of the bone from the inside to the point of bleeding leads to coagulation of amputated vessels of the cortical layer of the bone, revascularization which requires considerable time.

Based on the existing level of technology of treatment of chronic osteomyelitis of the long bones, the task was: to reduce the treatment time by increasing blood circulation in the area of the pathological lesion and provide early load on the damaged limb.

The set task is solved as follows:

Treatment of chronic osteomyelitis of long bones is carried out by cutting out the bone flap for soft tissue supply legs in the projection of the nidus, the pivoting flap rotation around its own axis, rehabilitation of the nidus through a window formed within healthy tissues and return flap in the "mother Lodge". New treatment technologies is that after the reorganization of the nidus inside from bone marrow channel are osteoperforative to the periosteum throughout the access and on the flap with a distance from one another 1.5 to see If this osteoperforative have a conical shape with the base facing medially KOs is hydrated segment stabilize long bone external fixation device.

Explain any significant distinguishing features of the proposed method.

Execution after recovery of the nidus of osteopetrosis to the periosteum throughout the access and on the flap with a distance from each other 1.5 cm from the side of the bone-marrow channel provides the optimal distance for the growth of the regenerate and full overlay regenerate formed bone cavity all over.

The conical shape of osteoperforative with the base facing medially of bone-marrow channel of the flap needed to guide the growth of the regenerate and eliminate the formation of avascular necrosis areas sharp ends, which arise, for example, in cylindrical form osteopetrosis [4].

Fixation of the graft in the "mother Lodge" spoke with thrust pad, as well as stabilization of the operated segment long bone external fixation device enables stable to hold the bone graft in the "mother Lodge" and provides full mechanical strength of the operated segment and functionality of the adjacent joints.

Conducted latent research And subclasses 61 In 17/56 and analysis of scientific and medical information that reflects the existing level of treatment creamy "Method of treatment of chronic osteomyelitis of long bones" is new.

The relationship and interaction of the essential techniques of the proposed method achieve new technological and medical results in solving the task, namely, to reduce the treatment time (from 77 to 25 days) by increasing the blood supply in the area of the pathological lesion and provide early load on the damaged limb.

Thus, the proposed solution involves an inventive step.

The proposed method for the treatment of chronic osteomyelitis of long bones is industrially applicable in the field of practical health care, as it can be reproduced repeatedly, does not require exceptional resources to implement.

The essence of the proposed method of treatment is as follows:

Access to pathological lesion carry out through the window formed in the cortical bone by cutting out a bone graft for soft tissue supply legs throughout the pathological focus. This cut through the skin, subcutaneous tissue and superficial fascia as a single unit with access to the periosteum. The periosteum is dissected throughout the pathological focus. Using a reciprocating saw cut the front one flap for soft tissue supply legs. The opposite cortical bone layer netscout bits inserted through a groove formed from the saw. Formed bone flap for soft tissue supply stalked away in the direction they screw with the point of rotation around the axis passing through nadrejene the cortical layer of the bone.

Thus, provide wide access to the pathological focus throughout the affected branches nutrient intraosseous artery with preservation of blood supply to a bone graft due to the soft tissue of the legs. The pathologic lesion is removed as a single unit within healthy tissue using globewatch bits, bent in the longitudinal plane. Wall formed bone cavity and the bone flap for soft tissue supply legs milling process to the point of bleeding and washed with antiseptics. Then from bone marrow channel are osteoperforative to the periosteum throughout the access and on the flap with a distance from one another 1.5 to see If this osteoperforative have a conical shape with the base facing medially bone marrow channel (see the Appendix for the description of Fig.1 and Fig.1A). Bone cavity repeatedly washed with antiseptics, set dreano which rotate in the "mother Lodge" and fix transcutaneous needle with thrust pad with side flap. The stitches on the wound. Through the proximal and distal metaphysi of the operated segment long bone is carried out on two intersecting spokes that capture and pull in the rings of the external fixation device. Rings connecting rods. Spoke with thrust pad is stretched and fixed in distraction clamp mounted on the ring external fixation device. Aseptic bandage.

The essence of the proposed method is illustrated by a clinical example:

Patient M., 55 years. Did 17.10.2001, Diagnosis: Fused comminuted fracture of the upper third of metadiabase right tibia. Malunion of the fibula in the upper third of the diaphysis. Chronic traumatic osteomyelitis of the proximal metadiaphysis right tibia, active form in the stage of incomplete remission.

From the anamnesis: 03.03.1990, in the home was injured. Diagnosis: Open comminuted fracture of the upper third of the right tibia II B Art. with displacement of fragments. Outdoor oblique fracture of the upper third of the right fibula with displacement of fragments. Was treated at the place of residence method of skeletal traction for 25 days, then superimposed circular plaster splint to the upper third of the right thigh, the period - 2 months the scrap in the upper third of the right tibia.

10.07.1990, the operation of transosseous osteosynthesis with the imposition of external fixation device in right ankle.

On radiographs from 05.02.1991, a fracture in the upper third of the right tibia fused, dismantle the apparatus.

10.10.2000, After hypothermia appeared pain in the upper third of the right tibia, edema, hyperemia followed by the opening of the fistula. Treated on an outpatient basis.

17.10.2001, was admitted to the hospital NC RVH wsns WITH the RAMS.

Diagnosis at admission: Fused comminuted fracture of the upper third of metadiabase right tibia. Malunion of the fibula in the upper third of the diaphysis. Chronic traumatic osteomyelitis of the proximal metadiaphysis right tibia, active form in the stage of incomplete remission (see the Appendix for the description of Fig.2).

During the inspection: the axis of the limb is correct, the swelling is not significant (+2 cm), the skin in the upper third of the leg on the front-inner surface of the scar changed and partially fused with the underlying tibia at the site of 4.51.5 cm On the front-inner surface of the right tibia at the junction of the upper and middle third has a fistula with moderate purulent discharge. Movement in the knee and Golnik vessels are the same on both sides.

18.10.2001, Made tense fistulography through a fistulous passage. On radiographs: the axis of the tibia saved, the outer cortical plate on the inner and outer surfaces has a periosteal layers with distinct outlines of a thickness of 2-3 mm, 6-7 cm, medullar channel with areas of osteosclerosis and osteoporosis. Introduced contrast agent passes through the medullar channel in the form of narrow strips from the border of the middle third of the diaphysis of the proximal direction to the epiphyseal region (see the Appendix for the description of Fig.3).

On computer tomogram from 26.10.2001,:

The structure of the bone of the tibia heterogeneous: a background of dense sections 651 unit N. determined less dense inclusions (-67% N.) (see the Appendix for the description of Fig.4).

Conclusion: chronic osteomyelitis of the proximal tibia and the upper third of the diaphysis to the right.

30.10.2001, the operation of the proposed method.

Accessed tibia.

Front interior section, departing from the tibial tuberosity distal 2 cm, the cut is made to the border of the middle and upper thirds with rounded upper and lower ends of the incision in the medial side.

On the of ECEN anterior cortical layer of bone with a rounded top and bottom corners of the wound towards the base wickramagamage bone graft for soft tissue supply legs. The opposite cortical bone layer dadsetan bits inserted through a groove formed from the saw. Formed bone flap for soft tissue supply legs aside they screw with the point of rotation around the axis passing through nadrejene the cortical layer of the bone.

The pathologic lesion is removed as a single unit within healthy tissue using globewatch bits, bent in the longitudinal plane. Wall formed bone cavity and the bone flap for soft tissue supply legs processed by the mills to the point of bleeding. The resulting cavity is washed with antiseptics.

Then from bone marrow channel is made of osteoperforative to the periosteum throughout the access and on the flap with a distance from one another 1.5 to see If this osteoperforative have a conical shape with the base facing medially bone marrow channel. Bone cavity repeatedly washed with antiseptics, installed drain pipe for the inflow and the outflow drainage throughout the formed cavity.

The bone flap is returned to the "mother Lodge" and fixed transcutaneous needle with thrust pad with side flap. The stitches on the wound. Through the proximal tight in the rings of the external fixation device. Rings connected by rods. Spoke with thrust pad is stretched and fixed in distraction clamp mounted on the ring external fixation device. Aseptic bandage.

The postoperative period is smooth. Sutures were removed on day 10, the wound healed by primary intention. The patient walks with the aid of a cane with the load on the limb. On radiographs from 06.11.2001 was made with the introduction of a contrast agent is determined by contrasting the tube throughout with beyond the proximal metaphase up to 1 cm in the diaphyseal area up to 3 cm along the medullar canal (see the Appendix for the description of Fig.5).

On radiographs from 14.11.2001 was made with the introduction of a contrast agent is determined by contrasting the tube throughout with beyond 1 mm throughout. Saakov not identified (see the Appendix for the description of Fig.6).

15.11.2001, the Drainage tube is removed in the region of its distal exit entered Polustrovo. The patient's condition is satisfactory. No complaints. Temperature is normal. In the ligation: normal skin color, edema, signs of inflammation there.

24.11.2001, on the x-ray axis of the limb is correct. In the proximal right tibia bone flap lies in "m the flap and the "mother Lodge" has a bridge periosteal regenerate. The edges of the bone wounds and ecoperformance holes blurred, filled regenerate (see the Appendix for the description of Fig.7).

Given the presence of primary bone spur between the bone flap and "mother's couch", decided to make the dismantling of the device.

26.11.2001, the patient was discharged to outpatient treatment at the place of residence.

Thus the Method of treatment of chronic osteomyelitis of long bones" allows, in comparison with known technology to achieve better results of treatment, to reduce the treatment time up to 25 days due to improve blood flow in the area of the pathological lesion and early activation of the patient, as well as sufficient fixation of the injured limb.

Sources of information

1. Nikitin, D., Cancer A. C., Linnik S. A., Saldun, P., Kravtsov A. G., I. Agafonov A., Fakhrutdinov R. H., Haimin centuries Surgical treatment of osteomyelitis", S. - Petersburg, 2000, S. 98-134.

2. SPEAKER OF THE USSR №952229, MCI AND 61 IN 17/00,1982, IB NO. 31.

3. Vinogradov Century, Resection of bone from the inside in the complex treatment of chronic osteomyelitis of the bones of the limbs. Ed. Irkutsk University, 2000, S. 106.

4. Vinogradov Century, Resection of bone from the inside in the complex treatment of chronic osteomyelitis of the bones of the limbs, Ed. Irkutsk University, 2000, S. 92.


 

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