The way to determine the length of the graft for reconstructive microsurgical operations on the nerves, blood vessels and tendon-muscle complex

 

(57) Abstract:

The invention relates to medicine, in particular to surgery, and can be used when conducting post-traumatic reconstructive operations on the nerves, blood vessels and tendon-muscle complex. When reconstructive microsurgical operations on the nerves, blood vessels and tendon-muscle complex measure the tension force of the distal and proximal ends of the restored structure, the cross-sectional area recovered and transplanted structures, determine the tension force of the recovered patterns that occur when stretching at 1 cm, determine the value of this power, referred to the unit cross-sectional area of the recovered structure to measure the longitudinal tension force transplanted patterns and determine its relation to the unit cross-sectional area transplanted patterns. Determine the length of the graft llawsuitfrom the relation where d is the magnitude of the diastasis; Fs- longitudinal tension force transplanted patterns, referred to the unit area of the cross section of this structure; Fcs- the tension related to the square of pop is the INIC length. The method provides the possibility of determining the optimal length of the graft.

The invention relates to medicine, in particular to surgery, and can be used when conducting post-traumatic reconstructive operations on the nerves, blood vessels and tendon-muscle complex (hereinafter referred to as the elastic structure).

It is known that when performing operations on the damaged elastic structures, the question arises about the application of the graft, and in the case of a positive answer - about the size (I. A. Grigorovich. Surgery of the nerves. - L.: Medicine. - 1969. - S. 154-155; P. O., Datiashvili. The reconstructive limb. - M.: Medicine. - 1991. - S. 118). In practice, both these questions are addressed empirically. Typically, the solution to these two questions depends on the skill of the surgeon.

It is known that injuries major branches of the brachial plexus may be Troubleshooting using the tension of the nerves of the defect length 2-4 cm (Lurie A. S. Surgery of the brachial plexus. - M.: Medicine, 1968).

Perineurally seam can be applied only if the diastasis not exceed 2-3 cm (Millesi, G. Meissl, A. Berger. The interfascicular nerve grafting of the median and ulnar nerves // J. Bone and Joint Surg. - 1972. - Vol. 54a. - P. 727-750; Gourgey. - 1980. No. 9. - S. 68-70; K. J. Opennew and R. A. Atakhanov. Diagnosis and microsurgical treatment of traumatic peripheral nerve injuries // microsurgery traumatic injuries of peripheral nerves. - M., 1983. - S. 29-46).

There is a method of determining the size of the skin graft brushes, including the modeling of the defect of the skin of the hand and fingers, measure the distance from the edges of the scar along the Palmar creases for directions to the edges of the brush and interphalangeal folds, the transfer of the coordinates of the points on the symmetric parts of the contralateral hand, and by connecting the transferred points outline a contour, which is mirroring the true defect. (RF application No. 98118603, And 61 In 5/107).

However, this method is only applicable for modeling defects of the skin brush.

The known method of forming neurovascular transplant, which emit venous line and sural nerve in one block, put the Central end of the nerve in the form of duplicatory so that the length of the dual part of the nerve corresponded to the size of the alleged defect nerve in the recipient area cut out in the area of duplicatory of his own duplicator nerve Vienna, which is crossed at the ankle, there are the back of the artery of the foot and anastomosing its "end-to-end with the proximal end of the vein conducted in a subcutaneous tunnel on the back surface of the foot (RF application No. 97107268, IPC And 61 In 17/56).

Here, however, is not determined by the length of the graft.

The closest is the way plastics defect of the nerve trunk by allocation of transplant in the form of neurovascular complex of the sural nerve with the small saphenous vein in one unit and transferring it to the defect of the nerve trunk with preliminary intersection of the vein and sural nerve at the distal and proximal levels and weld the ends of the nerve trunk with the corresponding ends of the graft and the vein graft to the recipient artery. At the first stage to form the graft through the neurovascular complex in the middle of the cuff formed by a cut of the subject of the fascia own leg fasciale-islet cellular tissue flap with preservation of its relations with sural nerve and vein and the length equal to the length of the defect in the nerve trunk, cross sural nerve below the distal end of the cuff, and rugged at the level of the base of the fifth metatarsal vein anastomosis military nerve trunk with the release of scars of its ends and a defect in the transfer dedicated transplant, leaving on his cuff fasciale-scar layer and the vascular pedicle as arteriovenous vein with subsequent rastamozhivanie its distal end with one of the main arteries, and proximal - dorsal subcutaneous vein of the operated area (RF application No. 98119248, IPC And 61 In 17/00).

The disadvantage of this method is that when determining the length of the graft is not fully take into account the tension force arising in the restored structure. It is not possible to find the optimal length of the graft.

The objective of the proposed solutions is the ability to determine the optimal length of the graft.

The problem is solved in that in the method of determining the length of the graft for reconstructive microsurgical operations on the nerves, blood vessels and tendon-muscle complex, including the measurement of the length of the diastasis, according to the invention to measure the tension of the distal and proximal ends of the restored structure, the cross-sectional area recovered and transplanted structures, determine the tension force of the recovered patterns that occur when stretching at 1 cm, determine the value of this power, referred to the unit cross-sectional area of the recovered structure to measure the longitudinal tension force transplanted patterns and determine its respect to the claim ratio

where d is the magnitude of the diastasis;

Fs- longitudinal tension force transplanted patterns, referred to the unit area of the cross section of this structure;

Fcs- the strength of the restored structure, referred to the cross-sectional area of the recovered structure.

Determining the length of the graft recoverable elastic structures (nerve, blood vessel, tendon-muscle complex) is carried out in the following sequence.

Mobilize the distal and proximal ends of the recovered structure and measure the amount of diastasis d.

Pulling the distal and proximal ends of the recovered structure at 0.5 cm each towards each other and measured values resulting tension forces Fdand Fp.

Determine the value of the tension force Fcthe recovered patterns that occur when stretching at 1 cm, according to the formula

Determine the cross-sectional area of the recovered structure according to the formula where a and b are major and minor axis of the elliptical cross section of the restored structure.

Determine the value of the tension force is splinterware structure and measure the amount of longitudinal tension force tension force transplanted patterns F by the formula

Previously rigidly fix two points a and b of the elastic structure, between which performs the measurements in order to eliminate possible bias in places anchor fastening structure. Measure the distance between points a and B. At the midpoint With a perpendicular structure exert a force which moves it to the value of d1and measure the magnitude of this force is F1. The experiment is repeated. To the middle point C perpendicular to the structure exert a force which moves it to the value of d2relative to the initial position, and measure the magnitude of this force is F2. Tension force acting between the fixed points a and B at point C, is determined according to the above formula, where x is half the distance between points a and B.

Determine the cross-sectional area of transplantable structure according to the formula , where a and b are major and minor axis of the elliptical cross-section transplanted patterns.

Determine the value of the tension force Fsrelated to the cross-sectional area transplanted patterns:

Determine the magnitude of the graft (insert) by the formula where units DL. indicates that the last quotient is measured in using the material in the following sense. A mathematical relationship to determine the length of the graft is the first approximation of the infinite iterative process converging to the exact solution. However, according to the clinical testing of this method, this first approximation is sufficient for obtaining good results. The method used two tension force: recovered and transplanted institutions. In fact, the strength of the recovered structure is unknown, but since the most difficult part of the recovered structure after recovery of the transplanted graft, the tension of the graft is taken as a model. On the other hand, the transition to the forces, referred to the unit area, aligns their value. Note also that this method can be used when restoring a nerve with special tubes for the sprouting of nerve cells. For this purpose the ends of the nerve should be close in direction to each other by a distance equal to the length llawsuit.

It should be noted that the length of the graft, obtained from this ratio may be equal to or less than 0. In the case of zero length, this means that the graft is not needed and m is wearing suggests, that the distal and proximal ends should be trimmed by an amount equal to the absolute value of the obtained length, and the ends are then sewn directly. Such situations arise when the shortening of the bone.

In performing the process of determining the optimal length of the graft is automated through the use of computers with appropriate software.

An example of application of the method of determining the length of the graft.

The patient was admitted in a planned manner on the 3rd month after the injury. The injury was received by the glass of the window frame. Appealed to the Central district hospital where the initial surgical treatment, stopped the bleeding, superimposed primary seams.

Diagnosed with damage to the ulnar nerve, but the nerve was not restored.

Upon admission to the Department of microsurgery, the patient had symptoms of damage to the ulnar nerve: loss of sensation in the Autonomous zone of innervation of the ulnar nerve, some atrophy of the worm-like muscles, some atrophy of the hands. On electromyography complete injury of the ulnar nerve. Under endotracheal anesthesia, the patient was operated. The selected ends of the damaged nerve n the start-UPS amounted to: d=4.5 cm, parameters nerve: a=6 mm, b=4,4 mm Produced defining distal and proximal longitudinal forces of tension that occurs when pulling the distal and proximal ends of the restoring nerve 0.5, see Fd=120 g, Fp=130, Defined by Fc=of 124.8,

Decided to take autonorny graft from the tibia. Produced access to the nervus suralis. Parameters are defined graft: a=2.25 mm, b=2.5 mm Nerve was recorded on microclima special device and produced two offset nerve in the transverse direction at a fixed distance by measuring the resulting tension forces F1=20 g, d1=0.5 cm, F2=85 g, d2=1,0 Then see the results of the measurement are defined longitudinal tension force F=29,035 was Then determined cross-sectional area of the graft and restore nerve. The results are substituted into the formula, the resulting value of llawsuit=3,41 see

The way to determine the length of the graft for reconstructive microsurgical operations on the nerves, blood vessels and tendon-muscle complex, including the measurement of the length of the diastasis, characterized in that the measured tension force of the distal and proximal ends of the recovered structure is restored structure, encountered in its stretching at 1 cm, determine the value of this power, referred to the unit cross-sectional area of the recovered structure to measure the longitudinal tension force transplanted patterns and determine its relation to the unit cross-sectional area transplanted patterns, determine the length of the graft llawsuitratio

where d is the magnitude of the diastasis;

Fs- the power of longitudinal tension transplanted patterns related to the cross-sectional area of transplantable structure;

Fcs- the tension related to the cross-sectional area of restored structures

when this quotient has the dimension selected for measurement units of length.



 

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