Method for surgical treatment of lower limbs ischemia at distal form of their lesion

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with surgical treatment of lower limbs ischemia at considerable lesion of distal channel and impossibility to conduct direct revascularization of vascular channel of affected limb. One should perform mechanical perforation of bony tissue up to medullary canal in epiphyses of femoral and leg bones being 4-5 cm, correspondingly, higher and lower against a knee joint, and, also, in the lower third of shin, metatarsal bones and phalanges followed by stimulation of bone marrow and tunnelization of muscular tissue of femur and shin by applying perforation foramens upon femur and punctures in additionally performed at lateral and posterior surfaces of shin by performing, moreover, per three tunnels from each foramen and puncture in. Stimulation of bone marrow and muscular tunnelization should be carried out with high-intensity laser radiation of diode laser of 10-15 W power in constant mode, with a light guide of 0.4 cm diameter, at exposure of 3-10 sec and quantity of therapy seances being, at least, two.

EFFECT: higher efficiency of therapy.

2 ex

 

The invention relates to medicine, more specifically to surgery and may find wide application in the surgical treatment of lower limb ischemia, in particular with significant distal arterial bed.

A known method of surgical treatment of obliterating diseases of lower extremities vessels in the distal type of damage, including tibial corticotomy with subsequent distraction of the cortical plate and revascularization of ischemic tissues by neoangiogenesis of bone regeneration, which leads to compensation krovoobrazhenie in the affected limb (see ed. St-in the USSR №1061803, M class. And 61 In 17/00, publ. 23.12.83 year).

In the known method the distraction of the cortical plate is produced with the 8th and 9th postoperative day during 31-36 days with daily movement of 0.5 mm, which is a rather long and laborious process.

A known method of surgical treatment of lower limb ischemia in the distal arterial lesions selected as the closest analogue, including the implementation of trephination bone size 2×2 cm, carried out on the anterior surface of the limb in the proximal and distal metatithemi areas with the removal of the cortical plate, introduction into the distal trepanation hole provodniks device and subsequent dosage mechanical injury of the bone marrow (see patent RU No. 2093085, IPC-6: 61 17/00; 17/56, publ. 20.10.1997,).

According to the authors of the famous invention, the method allows to eliminate pain, improve blood circulation and microcirculation in the extremities. The method leads to lower domestic hypertension and prolonged increase in blood flow and metabolic processes as mechanical injury, accompanied by tissue damage, leading to congestion and increase the intensity of circulation.

However, this method is not efficient as it does not attain sufficient stimulating effect on blood circulation and microcirculation. This stimulating effect is unmanaged and short-lived. When applied thin drill trepanation holes in the bone are unable to provide a complete decompression of the bone marrow, and mechanical injury of the minimum, so the period of stimulation is limited.

Thus, the technical result for the solution of which directed this invention is to increase the effectiveness of treatment for ischemia of the lower extremities with the distal form of their defeat.

This technical result is achieved by the fact that in the known method of surgical treatment of ischemia of lower extremities with the distal form of their defeat, enabling the m through the skin and soft tissue mechanical perforation of the bone tissue to bone marrow channel and subsequent irritation of the bone marrow, according to the invention the perforation of the bone tissue is performed in the epiphysis of the femur and tibia bones 4-5 cm respectively above and below the knee joint, as well as in the lower third of the tibia, metatarsal bones and the phalanges of the affected limb, in addition, are channelization of the thigh muscles, using consequently the sprocket holes previously made in the epiphysis of the femur and ukoli additionally performed on the lateral and posterior surfaces of the tibia, the number of which depending on the length and number of muscle tissue of the lower leg is 3-4 on each surface, while still in the muscles on three tunnels from each perforation the holes on the thigh and each vcol on tibia, irritation of the bone marrow and channelization muscle tissue carry out high intensity laser radiation from a diode laser with a capacity of 10-15 watts in continuous mode, using a fiber with a diameter of 0.4 cm, and the time of its impact upon stimulation of bone marrow is from 3.0 to 10.0 seconds, and the number of sessions of this surgical treatment is at least two.

The applicant has experimentally found that the implementation of perforations it in the epiphysis of the femur and tibia bones 4-5 cm respectively above and below the knee joint, as well as in sognatrice tibia, in the metatarsal bones and the phalanges of the affected limb and additional channelizate muscles of the femur and tibia using respectively perforations previously made in the epiphysis of the femur and Ukolov additionally performed on the lateral and posterior surfaces of the tibia, provides a significant increase in the efficiency of the method of surgical treatment of lower limb ischemia and with the distal form of their defeat.

This is achieved through education in locations around made perforations and channels (tunnels) in the muscle tissue of the affected limb additional network of small arteries, which compensates for the absence of distal blood flow in the affected limb.

According to the authors it is claimed the execution of punching holes and tunnels in muscle tissue, and also the number of them provide the formation of a more distal channel.

While the implementation of irritation of the bone marrow and channelizate muscle tissue exactly high-intensity laser radiation to an even greater extent contributes to the effectiveness of the proposed method.

This is ensured by the fact that irritation of the bone marrow by laser radiation reduces intraosseous hypertension and contributes to prolonged Wuxi the structure of the blood circulation and metabolic processes in his irritation, channelizate them muscle tissue provides its impact across a larger volume of tissue, which eventually leads to the formation of a more powerful network of small arteries, which provide more powerful the distal direction.

In addition, the laser radiation is characterized by a short, painless, aseptically and well tolerated by patients.

Laser radiation also increases the body's resistance, activates tissue regeneration, increases resistance to pathogenic action of various factors immunodeficiency States, activates microcirculation in tissues, normalizes permeability of blood vessels, stimulates blood flow on existing vessels due to the inclusion of reserve capillaries.

The authors also experimentally found that the implementation of irritation of the bone marrow and tunnelization muscle tissue using high intensity laser radiation with the declared modes allows you to achieve the best results of treatment method.

Finally, the authors experimentally established that the execution of data manipulation for at least 2 sessions allows you to achieve the best results in the treatment of distal forms of lesion limb.

The method is as follows.

The operation is performed under General anesthesia. Under the goal is ü the operated limb fit cushion. At scheduled points in skin and soft tissue to bone puncture by a pointed scalpel. The wound is introduced clamp the wound, pushing to the extent necessary for the introduction of a tool for applying perforations. As a tool for the application of punched holes using a drill mounted on its working end of the needle. The diameter of the spokes choose the size, few large compared to the diameter entered in the completed hole of the light guide.

The perforations do in the epiphysis of the femur at 4-5 cm above the knee joint, in the epiphyses of the tibia and fibular bones 4-5 cm below the knee joint, in the lower third of the tibia, metatarsal bones and phalanges (taking into account the anatomy of the neurovascular bundle and vascular arch feet).

In the epiphysis of the femur and tibia bones perform from 3 to 12 perforations prior to entering into the bone canal. In the lower third of the leg, the number of perforations to the entrance into the bone canal is from 3 to 9. The number of perforations in the metatarsal bones and phalanges, respectively 5.

In the perforations successively enter the light guide with a diameter of 0.4 cm and within 3-10 seconds carry out the irritation of the bone marrow of high-intensity laser radiation from a diode La the EPA with a capacity of 10-15 watts in continuous mode.

Channelization muscle tissue of the thigh exercise of perforations previously made in the epiphysis of the tibia bone at 4-5 cm above the knee joint.

Channelization muscle tissue of the lower leg are made Ukolov additionally performed on the lateral and posterior surfaces of the tibia. The number Ukolov depends on the length and number of muscle tissue of the leg and ranges from 3 to 4 on every surface.

Each perforation holes on the thigh and each vcol on the lateral and posterior surfaces of the tibia in the muscles above mentioned zones is performed by three of the tunnel.

The / tunnelling muscular tissue of the thighs are carried out either immediately after the irritation of the bone marrow, without removing the fiber from the sprocket holes, or separately after the execution of irritation of the bone marrow.

The / tunnelling muscle tissue are also taking into account the anatomy of the neurovascular bundle.

After you perform surgical treatment on the treated limb impose aseptic bandage. Designate the introduction of heparin in a dose of up to 20 units per day, or a low molecular weight garbarino (therapy, fixieren), vascular therapy, vitamins (b vitamins).

The second session is held on the same technique at 14-16 days after the first session and subsequent therapy, the third is the via the month after the first, and so on

To maintain positive effect recommend surgical treatment every 6 months in conjunction with vascular therapy.

The method is confirmed by the examples.

Example No. 1. Patient X 65. Diagnosis: obliterating atherosclerosis of the lower extremities, distal to the occlusion of the crural arteries). Chronic ischemia 2B degree Fontaine. An angiographic study has shown a significant distal bed of the affected limb, which indicates the impossibility of direct revascularization of the vessels of the extremities.

History of disease in the last 3 years, with progression in the last 6 months (decreased distance "painless" walk up to 100 m, which corresponds to stage 2B classification Fontane), a feeling of coldness and numbness of the feet. Locally: lower extremity compensated movement in full, the sensitivity is moderately reduced in the toes, the skin cool, the pulsation of the arteries of the lower extremities on the popliteal artery distal to not defined, trophic disorders no. Given the distal channel and the impossibility of carrying out reconstructive surgery with the restoration of the main flow, the patient underwent surgical treatment by the claimed method.

The perforations are made:

in the epiphysis of the femur 5 cm above the knee joint - 12 holes;

in the epiphysis of the fibula 4 cm below the knee joint 4 holes;

in the epiphysis of the tibia 4 cm below the knee joint 8 holes;

in the lower third of the leg - 9 holes;

- in metatarsal bones - 5 holes, one in each bone;

in phalanxes on 5 holes, one in each bone.

The perforations made by the needle, is inserted in the drill, before entering into the bone channel of each of the bones.

After completed the perforations in the epiphysis of the femur, tibia and fibula bones in the lower third of the tibia, metatarsal bones and phalanges of the foot using alternately put into them of a light guide made the irritation of the bone marrow using high-intensity laser radiation from a diode laser in continuous mode. For irritation of the bone marrow through the perforations in the epiphysis of the femur and tibia bones, and in the lower third of the leg was used a laser power of 10 watts. The exposure time is 10 seconds.

For irritation of the bone marrow in the metatarsal bones and the phalanges of the foot was used a laser power of 10 watts. The exposure time is 10 seconds.

Then run the / tunnelling muscle tissue of the femur and tibia, which are used respectively in the holes previously made in the area of the epiphysis bedran the th bone at its perforation and ukoli, additionally performed on the lateral and posterior surfaces of the tibia. From each hole and vcol performed on three of the tunnel.

After the operation on the operated limb imposed aseptic bandage. Patient assigned to the introduction of heparin at a dose of up to 20 units per day, vascular therapy, vitamin therapy drugs group C.

On the 5th day marked positive dynamics: regressed numbness and coldness of the feet, objectively the skin of the feet warmer sensitivity in full. 10-14 days marked increase in the distance "painless" walk up to 150 meters

The second session of the surgical treatment carried out after 15 days after the first.

The result of this operation was: increase the distance of a patent distances without pain to 500-700 m, the regression of the symptoms of numbness and coldness of the feet on a long enough period of time (up in the clinic for 1 year). To maintain the positive effect the patient was recommended to undergo this surgical treatment in combination with vascular therapy once in 6 months.

Example No. 2. Patient W. 44 years. The diagnosis of atherosclerosis. Occlusion of the femoral artery on the right. Diabetes mellitus type II. Diabetic microangiopathy. Ischemia of the lower extremities 3 degree Fontaine.

An angiographic study set is established with representation from significant distal channel.

Given the distal channel and the impossibility of carrying out reconstructive surgery with the restoration of the main flow, the patient underwent surgical treatment by the claimed method.

The sequence of the operational navigation example No. 1.

The number performed in the claimed areas of the openings in example No. 1.

The modes of the laser radiation used for the stimulation of bone marrow and / tunnelling muscle tissue:

for irritation of the bone marrow through the perforations in the epiphyses of the femur - 15 W, the exposure time is 10 seconds;

for irritation of the bone marrow through the perforations in the epiphyses of the tibia bone and also in the lower third of the leg - 15 W, the exposure time is 3 sec;

for irritation of the bone marrow in the metatarsal bones and phalanges - 15 W, the exposure time is 3 seconds.

After the operation on the operated limb imposed aseptica bandage. Patient assigned to the introduction of low molecular weight heparins (therapy), vascular therapy, vitamin therapy.

On the 7th day marked positive dynamics: regressed numbness and coldness of the feet, objectively the skin of the feet warmer sensitivity in full. On 14-15 day marked increase in the distance "painless" walk up to 160 m

The second CE is NS surgical treatment carried out after 16 days after the first. The third session is held one month after the first.

The result of this operation was: increase the distance of a patent distances without pain to 800 meters, the regression of the symptoms of numbness and coldness of the feet for a sufficiently long period (up in the clinic for 1.5 years). To maintain the positive effect the patient was recommended to undergo this surgical treatment in combination with vascular therapy once every six months.

The method of surgical treatment of ischemia of lower extremities with the distal form of their destruction, including through the skin and soft tissue mechanical perforation of the bone tissue to bone marrow channel and subsequent irritation of the bone marrow, characterized in that the perforation of the bone tissue is performed in the epiphysis of the femur and tibia bones 4-5 cm respectively above and below the knee joint, as well as in the lower third of the tibia, metatarsal bones and the phalanges of the affected limb, in addition, are channelization muscles of the femur and tibia, using respectively the perforations previously made in the epiphysis of the femur and ukoli additionally made on the lateral and posterior surfaces of the tibia, the number of which depending on the length and number of muscle mass of the lower leg extending t is 3-4 on each surface, while still in the muscles on three tunnels from each perforation holes on the thigh and from each vcol on tibia, irritation of the bone marrow and channelization muscle tissue carry out high intensity laser radiation from a diode laser with a capacity of 10-15 watts in continuous mode, using a fiber with a diameter of 0.4 cm, and the time of its impact upon stimulation of bone marrow is from 3.0 to 10.0, and the number of sessions of this surgical treatment is at least two.



 

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