Сохранение опороспособности стопы при посттравматических дефектах методами микрохирургической аутотрансплантации тканей

Background. Severe open injuries of the lower extremities in most cases are the result of high-energy trauma, because the foot and ankle are damaged as a result of automobile accidents almost in every fourth victim. According to the literature, the percentage of infectious complications after surgical debridement of open injuries of the foot is 43–67.9% and shows no tendency to decrease.Material and methods. We performed 32 operations with the use of free revascularized grafts in patients aged from 16 to 70 years with extensive posttraumatic defects of the foot between 2010 and 2018.Results. As a result, 30 (93.7%) out of 32 grafts provided foot support ability provided during the post-operative period. When replacing large defects (more than 80 cm2) of soft tissues supporting surface of the foot we used free musculocutaneous flap of the latissimus dorsi, fasciocutaneous flaps were used for defects of the dorsum of the foot (less than 80 cm2). Long-term results were assessed using the Foot and ankle ability Measure (FAAM) questionnaire.Conclusion. Primary early replacement of tissue defects on the foot with free revascularized autografts is the method of choice for solving this problem, as it allows you to maintain the supporting function of the foot and is often alternative method to amputation.Актуальность. Тяжелые открытые повреждения нижних конечностей в большинстве случаев являются следствием высокоэнергетической травмы; так, стопа и голеностопный сустав повреждаются в результате автомобильных аварий почти у каждого четвертого пострадавшего. По данным литературы, доля инфекционных осложнений после хирургической обработки открытых повреждений стопы составляет 43–67,9% и не проявляет тенденции к снижению.Материал и методы. В отделении неотложной пластической и реконструктивной хирургии НИИ СП им. Н.В. Склифосовского за период с 2010 по 2018 год было выполнено 32 операции с применением свободных реваскуляризированных лоскутов у пациентов в возрасте от 16 до 70 лет с обширными посттравматическими дефектами стопы.Результаты. В результате проведенных операций 30 из 32 пересаженных лоскутов (93,7%) обеспечили опороспособность стопы в послеоперационном периоде. При замещении обширных дефектов мягких тканей опорной поверхности стопы (более 80 см2) использовали свободный кожно-мышечный лоскут широчайшей мышцы спины, при дефектах на тыльной поверхности стопы (менее 80 см2) применяли кожно-фасциальные лоскуты. Отдаленные результаты оценивали по опроснику функциональных возможностей стопы и голеностопного сустава Foot and Ankle Ability Measure (FAAM).Заключение. Первичное раннее замещение дефектов тканей на стопе свободными реваскуляризированными аутотрансплантатами является методом выбора для решения проблемы подобных травм, так как позволяет сохранить опорную функцию стопы и часто является альтернативой ампутации

АУТОТРАНСПЛАНТАЦИЯ АНТЕРОЛАТЕРАЛЬНОГО БЕДРЕННОГО ЛОСКУТА — МЕТОД ВЫБОРА В НЕОТЛОЖНОЙ РЕКОНСТРУКТИВНОЙ ХИРУРГИИ НИЖНЕЙ КОНЕЧНОСТИ (АНАЛИЗ КЛИНИЧЕСКИХ НАБЛЮДЕНИЙ)

BACKGROUND. Requirements for the graft used in microsurgery are simple retrieval, minimal anatomic variability, the possibility to operate on one surgical area, great length and diameter of flap vessels.PURPOSE OF STUDY. Evaluation of the results and advantages of revascularized free anterolateral muscle flap usage in emergency surgery.MATERIALS AND METHODS. Free muscle flap of the lateral vastus muscle on a vascular pedicle of the descending branch of the lateral femoral circumflex artery (anterolateral flap) was used to replace the defect in 2 patients. In one case, a patient had open fractures of the lower leg, complicated with primary defects of soft tissue, and in the other case a patient had incomplete traumatic amputation of the left foot. All the victims underwent soft tissue defects restoration within the first hours after the injury, next to fixation of the fracture.RESULTS. All grafts have completely healed, total necrosis of muscle flaps hasn’t been observed. All patients had primary wound healing after the transfer. Cases of deep purulent infection after the surgery haven’t been noted.CONCLUSION. The transfer of a free anterolateral muscle flap is the best method for emergency plastic and reconstructive surgery of the lower limbs. The advantages are simple and prompt retreival, no need to turn the patient to the lateral position, large amount of the flap, great length and caliber of vessels. АКТУАЛЬНОСТЬ. Требования, предъявляемые к трансплантату, используемому в экстренной микрохирургии — это простота забора, минимальная вариабельность анатомии, возможность работы на одном операционном поле, большие длина и диаметр сосудов.ЦЕЛЬ ИССЛЕДОВАНИЯ. Оценить результаты использования и преимущества свободного реваскуляризированного мышечного антеролатерального бедренного трансплантата в экстренной микрохирургии.МАТЕРИАЛ И МЕТОДЫ. Свободный мышечный лоскут из латеральной широкой мышцы бедра на сосудистой ножке из нисходящей ветви латеральной артерии, огибающей бедренную кость (антеролатеральный лоскут), был применен для замещения дефекта 2 пострадавшим. В одном случае это был пациент с открытым переломом костей голени, осложненным первичными дефектами мягких тканей, в другом — неполная травматическая ампутация левой стопы. Всем пострадавшим замещение дефекта мягких тканей выполнено в первые часы после травмы, после фиксации перелома.РЕЗУЛЬТАТЫ. Все трансплантаты прижились полностью, тотальных некрозов мышечных лоскутов не установлено. У всех пациентов наблюдалось первичное заживление ран после пересадки лоскута. Случаев глубокой гнойной инфекции после закрытия дефекта лоскутом не отмечено.ВЫВОДЫ. Пересадка свободного антеролатерального бедренного мышечного лоскута — это оптимальный метод для экстренной пластической и реконструктивной хирургии нижних конечностей. Его преимуществами являются простота и быстрота забора, отсутствие необходимости поворота пострадавшего на бок, большой объем лоскута, большие длина и калибр сосудов.

ТАКТИКА ЛЕЧЕНИЯ ПОСТТРАВМАТИЧЕСКИХ ДЕФЕКТОВ МЯГКИХ ТКАНЕЙ КОНЕЧНОСТЕЙ

Background Due to the non-decreasing incidence of such injuries, prolonged treatment and high incidence of complications, treatment of posttraumatic soft tissue defects of extremities is an actual problem within traumatology and plastic and reconstructive surgery. Aim of study Development of tactics for the treatment of posttraumatic soft tissue defects of extremities with the use of vascularized tissues (flaps) and evaluation of its results. Materials and methods: 118 patients with posttraumatic soft tissue defects of extremities were included into the study. Patients were divided into 2 groups. In the comparison group (49 patients), the traditional management for posttraumatic defects was performed: local treatment of the wound followed by autodermoplasty. In the second group (study group), the developed procedure of cover tissues restoration using vascularized tissue complexes (69 patients) was applied. Results The developed treatment reduced the incidence of deep wound infection by 13.6%, necrosis of naked functional structures by 36.3%, chronic osteomyelitis by 17% and contraction of adjacent joints by 18.2%. At the same time, we noted a decrease in the duration of inpatient treatment by 14.7 days in patients with posttraumatic soft tissue defects of extremities. Conclusion The developed tactics of cover tissues restoration using vascularized tissue complexes reduced the incidence of complications and improved the functional results of treatment in patients with posttraumatic soft tissue defects of extremities.АКТУАЛЬНОСТЬ Лечение посттравматических дефектов мягких тканей конечностей является актуальной проблемой на стыке травматологии и пластической и реконструктивной хирургии в связи с неубывающей частотой подобных повреждений, продолжительным лечением и высокой частотой осложнений.ЦЕЛЬ ИССЛЕДОВАНИЯ Разработка тактики лечения посттравматических дефектов мягких тканей конечностей с использованием васкуляризированных комплексов тканей (лоскутов) и оценка результатов ее применения. Материал и методы В исследование включены 118 пациентов с посттравматическими дефектами мягких тканей конечностей. Пациенты разделены на 2 группы. В группе сравнения (49 пострадавших) применена традиционная тактика лечения посттравматических дефектов, заключающаяся в местном лечении раны с последующей аутодермопластикой. Во второй группе (исследуемой) применена разработанная тактика восстановления покровных тканей с использованием васкуляризированных комплексов тканей (69 пострадавших).РЕЗУЛЬТАТЫ При применении разработанной тактики лечения удалось снизить частоту развития глубокой раневой инфекции на 13,6%, некроза обнаженных функциональных структур — на 36,3%, хронического остеомиелита — на 17%, контрактур смежных суставов — на 18,2%. В то же время отмечено уменьшение длительности стационарного лечения в среднем на 14,7 койкодня у пострадавших с посттравматическими дефектами мягких тканей конечностей. Вывод Использование разработанной тактики восстановления покровных тканей конечностей с помощью васкуляризированных комплексов тканей позволяет уменьшить частоту осложнений и улучшить функциональные результаты лечения пациентов с посттравматическими дефектами мягких тканей конечностей

FREE ANTEROLATERAL FEMORAL FLAP IS THE FIRST CHOICE IN EMERGENCY RECONSTRUCTIVE SURGERY OF THE LOWER LIMB (ANALYSIS OF CLINICAL CASES)

BACKGROUND. Requirements for the graft used in microsurgery are simple retrieval, minimal anatomic variability, the possibility to operate on one surgical area, great length and diameter of flap vessels.PURPOSE OF STUDY. Evaluation of the results and advantages of revascularized free anterolateral muscle flap usage in emergency surgery.MATERIALS AND METHODS. Free muscle flap of the lateral vastus muscle on a vascular pedicle of the descending branch of the lateral femoral circumflex artery (anterolateral flap) was used to replace the defect in 2 patients. In one case, a patient had open fractures of the lower leg, complicated with primary defects of soft tissue, and in the other case a patient had incomplete traumatic amputation of the left foot. All the victims underwent soft tissue defects restoration within the first hours after the injury, next to fixation of the fracture.RESULTS. All grafts have completely healed, total necrosis of muscle flaps hasn’t been observed. All patients had primary wound healing after the transfer. Cases of deep purulent infection after the surgery haven’t been noted.CONCLUSION. The transfer of a free anterolateral muscle flap is the best method for emergency plastic and reconstructive surgery of the lower limbs. The advantages are simple and prompt retreival, no need to turn the patient to the lateral position, large amount of the flap, great length and caliber of vessels

Saving of Foot Support Ability in Post-traumatic Defects Using Microsurgical Tissue Autotransplantation

Background. Severe open injuries of the lower extremities in most cases are the result of high-energy trauma, because the foot and ankle are damaged as a result of automobile accidents almost in every fourth victim. According to the literature, the percentage of infectious complications after surgical debridement of open injuries of the foot is 43–67.9% and shows no tendency to decrease.Material and methods. We performed 32 operations with the use of free revascularized grafts in patients aged from 16 to 70 years with extensive posttraumatic defects of the foot between 2010 and 2018.Results. As a result, 30 (93.7%) out of 32 grafts provided foot support ability provided during the post-operative period. When replacing large defects (more than 80 cm2) of soft tissues supporting surface of the foot we used free musculocutaneous flap of the latissimus dorsi, fasciocutaneous flaps were used for defects of the dorsum of the foot (less than 80 cm2). Long-term results were assessed using the Foot and ankle ability Measure (FAAM) questionnaire.Conclusion. Primary early replacement of tissue defects on the foot with free revascularized autografts is the method of choice for solving this problem, as it allows you to maintain the supporting function of the foot and is often alternative method to amputation

TACTICS OF TREATMENT FOR POSTTRAUMATIC SOFT TISSUE DEFECTS OF EXTREMITIES

Background Due to the non-decreasing incidence of such injuries, prolonged treatment and high incidence of complications, treatment of posttraumatic soft tissue defects of extremities is an actual problem within traumatology and plastic and reconstructive surgery. Aim of study Development of tactics for the treatment of posttraumatic soft tissue defects of extremities with the use of vascularized tissues (flaps) and evaluation of its results. Materials and methods: 118 patients with posttraumatic soft tissue defects of extremities were included into the study. Patients were divided into 2 groups. In the comparison group (49 patients), the traditional management for posttraumatic defects was performed: local treatment of the wound followed by autodermoplasty. In the second group (study group), the developed procedure of cover tissues restoration using vascularized tissue complexes (69 patients) was applied. Results The developed treatment reduced the incidence of deep wound infection by 13.6%, necrosis of naked functional structures by 36.3%, chronic osteomyelitis by 17% and contraction of adjacent joints by 18.2%. At the same time, we noted a decrease in the duration of inpatient treatment by 14.7 days in patients with posttraumatic soft tissue defects of extremities. Conclusion The developed tactics of cover tissues restoration using vascularized tissue complexes reduced the incidence of complications and improved the functional results of treatment in patients with posttraumatic soft tissue defects of extremities

Experience of using vascularized bone grafts to treat nonunion fractures and limb bone defects

Background. Vascular bone graft transposition is the one of most effective method of nonunion fracture and bone defect treatment. However, the use of this technique is associated with some difficulties. One is the adjustment of recipient bed size and the graft. The other is the difficulty to reconstruct the alignment and length of bone. A promising method of preparing for the vascular bone graft transposition is virtual three-dimensional planning based on computed tomography data and three-dimensional printing templates.The aim was to summarize our experience in the treatment of bone nonunion and defects with vascular bone autografts using tree-dimensional virtual planning and printing.Material and methods. We analyzed the treatment process and outcomes of 4 patients with limb bone nonunion and 6 patients with bone defects. In all cases, we used vascular bone grafts. Internal fixation of grafts was used in 7 cases, external fixation was used in 3 cases. At preparation stage in 4 cases, we used tree-dimensional virtual surgery planning and printing templates.Results. One case was diagnosed with bone graft necrosis caused by venous thrombosis. Consolidation was achieved in all patients; a late consolidation was observed in 2 cases. Hematoma in donor area was seen in 2 patients. When using three-dimensional virtual planning and tree-dimensional printing templates, the operation time was decreased by 1 hour 5 minutes. We identified two cases of poor reposition in the group without virtual planning. No poor reposition was observed in the cases where tree-dimensional planning was used.Conclusion. Vascularized bone grafts provide an effective method to treat bone defects and nonunion. But the planning of graft and recipient site sizes is associated with certain difficulties. Our preliminary results have shown that virtual three-dimensional planning and printing allow improving the precision of the surgical procedure and decreasing operative time