Surgical method for treating patients for hematogenous tibial osteomyelitis

FIELD: medicine.

SUBSTANCE: method involves making longitudinal incision in tibia projection. Pathologically changed tissues are withdrawn. Two cutaneofascioperiosteal flaps produced by separating longitudinal surgical wound edges from bone are used for filling. Threads are conducted through bone. The cutaneofascioperiosteal flap ends are sutured and drawn close with the frontal thread ends. The rear thread ends are brought to posteroexterior shank surface and fixed on support members. Filling tissues are adapted to bone wound walls by progressively increasing tension in threads conducted through bone.

EFFECT: reliable fixation and controlled tension of filling tissues; reduced risk of suppuration and skin necrosis.

2 cl, 1 tbl

 

The present invention relates to medicine, namely to surgery, and is intended for the treatment of chronic hematogenous osteomyelitis of the tibia.

Osteomyelitis of the tibia is one of the most difficult from a surgical point of view of localization of infectious and destructive process. This is due to the anatomical features of this area: the presence of a significant surface of the tibia, covered only by skin and fascia and muscle of the array. Modern methods of surgical treatment of chronic osteomyelitis require primary closure of the bone cavity muscle tissue that region of the tibia is a considerable challenge. The lack of effective and non-traumatic method of treatment of chronic hematogenous osteomyelitis of the tibia determine the relevance of the task and causes the development of the present invention.

There is a method of surgical treatment of chronic osteomyelitis of the tibia by means of surgical treatment of osteomyelitis focus with the subsequent closure of bone defects skin fasciale-periosteal flaps with pressing them to the bone tightly twisted in the form of a roller with a cloth. This roller is fixed varneville U-shaped seams imposed on the ankle do is to s at a distance of 3-4 cm from the cut line. (Akihito GN. "Osteomyelitis". - M.: Medicine, 1986)

This method has several disadvantages.

1. The pressure roller gauze on the skin fasciale-periosteal flaps in combination with the tension of the skin on the posterior surface of the tibia between the attachment threads significantly impair blood supply in tissues, which leads to impaired wound healing and possible necrosis.

2. The contraction of the fibres leads to uncontrolled approximation of skin edges-fasciale-periosteal flaps with possible vmorajivaniem.

3. Threads, providing pressure, is fixed to the skin, which is due to the elastic stretches and weakens the pressing flap.

4. Long pressing flaps hygroscopic material not adequately aseptically, and the change violates the fixation of tissues.

There is a method of skin-fasciale-periosteal plastics osteomyelitis ulcers of the extremities by means of surgical treatment of osteomyelitis focus with the subsequent closure of bone defects skin fasciale-periosteal flaps and fixation of their gauze balls, tied at the ends of the Mylar threads drawn through two cross-channel at an angle of 50-70° together with an exit on the opposite side. (Nikitin GD "Surgical treatment of osteomyelitis". - Saint-Petersburg: Russian graphics, 2000).

This method has a number the drawbacks:

1. Unacceptable for the treatment of osteomyelitis of the tibia, as when conducting filaments at an angle of 50-70° together with an exit on the opposite side of one of the filaments can be carried out in the projection of the neurovascular bundle of the tibia.

2. Final fixation does not provide progressively increasing dermatophytes, and simultaneously forced pressure is fraught with the onset of ischemic necrosis.

3. Long-lasting hold gauze balls are not adequately aseptically.

4. This method is intended for the treatment of osteomyelitis ulcers.

Objectives of the invention.

1. Reliable fixation of viable tissue sealing to the walls and bottom of the bone cavity without disturbing the blood flow.

2. The possibility of progressively increasing controlled the tensions sealing tissue.

3. Improving treatment outcomes by reducing the number of postoperative complications.

4. The decrease in the number of bed-days spent sick in the hospital.

5. Eligibility for the treatment of chronic hematogenous osteomyelitis of the tibia taking into account topographic-anatomical features of the tibia.

The essence of the invention lies in the fact that after rehabilitation osteomyelitic lesion filling is formed on the reaction is carried out using two skin-fasciale-periosteal flaps, formed by separating the longitudinal edges of the wound from the bone with laying under them, if possible, proprietary krovosnabjaemah bone graft, with the adaptation and sealing tissue to the walls of the bone wound perform progressively increasing tension transosseous held seams-threads, the front ends of which are stitch and bring the edges of soft tissue wounds, and hold back on the posterolateral surface of the tibia and fixed stops.

The method is as follows. Perform a longitudinal section in the projection of the tibia. Widely prepare the chin from the bone along the line of the incision prepreparatory monolithic layer of soft tissue in the form of two skin-fasciale-periosteal flaps. Produce longitudinal resection of osteomyelitis focus: remove the sequestrum and other diseased tissue, including available sites scleratinian walls sequestrating capsules. Bone wound flattened give scaphoid shape. The filling is prepared bone wounds produce two pre-formed soft tissue skin fasciale-periosteal flaps. In the presence of preserved outer cortical wall of the bone wounds of the tibia, it is also used for filling. For this purpose from it using an oscillating saw blades or drill bits which form the bone graft, associated with the periosteum and anterolateral muscle group. This graft is placed on the bottom of the bone wound, and the top cover his two pre-prepared skin fasciale-periosteal flaps. If proprietary bone graft to form fails, the soft tissue flaps are placed directly on the bottom of the bone wound. Using a drill with a diameter of about 2 mm at the bottom of the bore through bone wound from two to four through holes, which are located one after the other in clinico bones. If you are using bone graft, it also bore through holes corresponding to the holes done at the bottom of the bone wound. Through each hole in the bone long straight needle from front to back and transosseous through the rear array of soft tissue on the skin of the posterolateral surface of the tibia is conducted twice in a strong thread, such as a monolith or braided Dacron No. 3-4. The front ends of the threads from the inside to the outside is carried out through the corresponding holes in the bone graft, stitch the edges of the skin-fasciale-periosteal flaps and form protivosvertyvayuschih element seam on Donate. Fasten the front ends of the threads of the first surgical site, allowing converge and are mapped to edges of soft tissue wounds. The second node is formed in the form of a loop of ribbon-like Shoe laces. Then p is otvorenie, the rear ends of the threads pull. When the tension in the strings, tied over the skin of the wound, the bone graft is pressed to the bottom of the bone wounds and soft tissue flaps are pressed against the bone graft. Since then, the two strands bind on the rear surface of the tibia emphasises two nodes with the formation of the loops of the bows. After two or three days after surgery bows joints loose and by pulling the first node on the threads of the front and back to achieve a more intimate mutual contact soft tissue grafts, bone graft (if it was used) and the bottom bone wounds. This procedure is dosed stretching of soft tissues using end-to-end external threads usually repeated at intervals of 2-3 days. For permanently tight mutual contact all items are sewn wound requires from two to five sessions tissue tensions. Dosed stretching the soft tissues of the external threads not only allows you to achieve the end result of the operation, but also renders prophylactic action of complications such as ischemic tissue necrosis.

The results of the observations are summarized in table.

The methodology usedThe number of patients treatedThe next postoperative complications, %Relapse OST is Amalita in the later stages, %The average number of bed-days
The pressing roller14503559.4
Transosseous fixation threads with metered tension358.516.535.6

Example. Patient P., 41, case history No. 8292, was admitted to the hospital 29.02.04 diagnosed with "Chronic hematogenous osteomyelitis of the upper third of the right tibia". Suffering from this disease for 25 years, has repeatedly operated. Radiographically in the upper third of the right tibia during 16 cm multiple areas of destruction with indistinct contours. Expressed sekventalnaya capsule with sclerotiorum thickened walls. Determined by the sequester 1,5×6 see Operation No. 548 from 02.03.04. Made a longitudinal incision in the projection of the tibia length 27 see widely debonded from the bone along the line of the incision prepreparatory monolithic layer of soft tissue in the form of two skin-fasciale-periosteal flaps. Made the bone trepanation. Removed diseased tissue, including available Sclerotinia part sequestrating capsules. Formed bone wound boat-shaped processed pulsating stream of an aqueous solution of chlorhexidine. In the bottom of the bone RA is s drill drilled three holes in the anteroposterior direction clinico bone at a distance of 5 cm from each other. From the outer cortical wall of the bone wounds of the tibia using an oscillating saw is formed bone grafts sizes 10×2 cm and 4×2 cm associated with the periosteum and anterolateral muscle group. Sealing is formed bone wounds made two skin-fasciale-periosteal flaps with laying under them proprietary krovosnabjaemah bone graft. Through each hole in the bone long straight needle from front to back and transosseous through the rear array of soft tissue on the skin of the posterolateral surface of the tibia is held twice in a solid thread. The front ends of the threads are held through three holes drilled in the bone graft, then they are from the inside outwards flashed edge skin fasciale-periosteal flaps and formed protivosvertyvayuschih element seam on Donate. Tied the front ends of the threads of the first surgical site, which has brought together and juxtaposed edges of soft tissue wounds. The second node formed in the form of a loop of ribbon-like Shoe laces. Then opposite the rear ends of the threads are pulled so that the soft tissue flap and bone graft prilepi close to the bottom and the walls of the bone wound. Then both threads tied on the back surface of the tibia emphasises two nodes with the formation of loops-bow the Cove. Two days after surgery bows seams unleashed and by pulling the first node on the threads of the front and back have achieved more intimate mutual contact soft tissue grafts, bone graft and bottom of the bone wound. This procedure is dosed stretching of soft tissues using end-to-end external threads repeated with an interval of 3 days twice.

The postoperative course without complications, the wound healed by first intention. Issued on the 29th day. Within six months of recurrence was not detected.

When applying this method provides the following medical and social effect.

1. Improving treatment outcomes by reducing the rate of postoperative complications (suppuration, necrosis of the skin).

2. The decrease in the number of bed-days spent by patients in hospital.

3. Improvement of remote results of treatment, reducing the number of relapses.

1. The method of surgical treatment of chronic hematogenous osteomyelitis of the tibia, including the implementation of a longitudinal slit in the projection of the tibia, peeling skin fasciale-periosteal flap, removal of pathologically changed tissues, including available sclerotioides part sequestrating capsules, filling the formed defect biological tissue, wherein plom the licensing realized with two skin-fasciale-periosteal flaps, formed by separating the longitudinal edges of the wound from the bone, conduct external threads, the front ends of the thread stitch and bring the edges of the skin-fasciale-periosteal flaps, the rear ends of the threads is performed on the posterolateral surface of the tibia and fixed stops, adjust sealing tissue to the walls of the bone wound progressively increasing tension transosseous conducted threads.

2. The method according to claim 1, characterized in that under the skin and fascial flaps stack proprietary krovosnabjaemah bone graft, through the holes which hold the threads of transosseous sutures.



 

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