Contraindications for wounds. Primary surgical treatment of a wound - what is it, algorithm and principles
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a) Definition, stages
PRIMARY WOUND TREATMENT is the first surgical operation performed on a patient with a wound under aseptic conditions, with anesthesia, and consists in the sequential execution of the following steps:
- Dissection of the wound.
- Revision of the wound channel.
- Excision of the edges, walls and bottom of the wound.
- Hemostasis.
- Restoration of the integrity of damaged organs and structures
- Suturing the wound, leaving drainage (if indicated).
Dissection of the wound is necessary for a complete revision of the zone of distribution of the wound channel and the nature of the damage under the control of the eye.
Excision of the edges, walls and bottom of the wound is performed to remove necrotic tissue, foreign bodies, as well as the entire wound surface infected with injury. After completing this stage, the wound becomes cut and sterile. Further manipulations should be carried out only after changing instruments and processing or changing gloves. It is usually recommended to dissect the edges, walls and bottom of the wound in a single block approximately 0.5-2.0 cm (Fig. 4.3). In this case, it is necessary to take into account the localization of the wound, its depth and the type of damaged tissue. For dirty, crushed wounds, wounds on the lower extremities, the excision should be wide enough. With wounds on the face, only necrotic tissues are removed, and with a cut wound, excision of the edges is not performed at all. Viable walls and the bottom of the wound cannot be excised if they are represented by tissues of internal organs (brain, heart, intestines, etc.).
After excision, a thorough hemostasis is performed to prevent hematoma and possible infectious complications.
The recovery stage (suture of nerves, tendons, blood vessels, connection of bones, etc.) is desirable to be performed immediately at PST, if the qualification of the surgeon allows. If not, you can subsequently perform a second operation with a delayed suture of the tendon or nerve, and perform a delayed osteosynthesis. Restoration measures in full should not be carried out at the PWO in wartime.
Suturing the wound is the final stage of the PHO. The following options are available for completing this operation.
- Layer-by-layer wound closure
- Suturing a wound leaving drainage (s)
but it is very small, or the wound is localized on the foot or lower leg, or the area of \u200b\u200bdamage is large, or the PHO is performed 6-12 hours after the moment of injury, or the patient has a concomitant pathology that adversely affects wound process, etc.
- The wound is not sewn up
- late PHO,
- abundant contamination of the wound with earth,
- massive tissue damage (crushed, bruised wound),
- concomitant diseases (anemia, immunodeficiency, diabetes mellitus),
- localization on the foot or lower leg,
- old age of the patient.
Suturing a wound tightly in the presence of unfavorable factors is a completely unjustified risk and an obvious tactical mistake of a surgeon!
b) Main types
The earlier from the moment of injury the wound PST is performed, the lower the risk of infectious complications.
Depending on the age of the wound, three types of PHO are used: early, delayed and late.
The early PHO is performed within 24 hours from the moment of wounding, includes all the main stages and usually ends with the imposition of primary sutures. With extensive damage to the subcutaneous tissue, the inability to completely stop capillary bleeding in the wound, drainage is left for 1-2 days. In the future, the treatment is carried out as in a "clean" postoperative wound.
Delayed PCO is performed from 24 to 48 hours after wounding. During this period, inflammation develops, edema, exudate appears. The difference from early PCO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving the wound open (not sutured) with the subsequent imposition of delayed primary sutures.
Late PCO is performed later than 48 hours, when the inflammation is close to maximum and the development of the infectious process begins. Even after PHO, the likelihood of suppuration remains high. In this situation, it is necessary to leave the wound open (do not suture) and conduct a course of antibiotic therapy. It is possible to apply early secondary sutures on days 7-20, when the wound is completely covered with granulations and acquires relative resistance to the development of infection.
c) Indications
An indication for performing a PHO wound is the presence of any deep accidental wound within 48-72 hours from the moment of application.
PHO are not subject to the following types of wounds:
- superficial wounds, scratches and abrasions,
- small wounds with a divergence of the edges less than 1 cm,
- multiple small wounds without damage to deeper tissues (shot wound, for example),
- puncture wounds without damage to internal organs, blood vessels and nerves,
- in some cases, through bullet wounds of soft tissues.
There are only two contraindications for performing a PHO wound:
- Signs of development in the wound of a purulent process.
- Patient's critical condition (terminal condition, shock
- degree).
- TYPES OF SEAMS
Benefits of suturing:
- acceleration of healing,
- reduction of losses through the wound surface,
- reducing the likelihood of recurrence suppuration wounds,
- increasing the functional and cosmetic effect,
- facilitating wound treatment.
a) Primary seams
Primary sutures are applied to the wound before the development of granulations, while the wound heals by primary intention.
Most often, primary sutures are applied immediately after the completion of the operation or PCO of the wound in the absence of a high risk of developing purulent complications. Primary sutures are inappropriate to use for late PHO, PHO in wartime, PHO of a gunshot wound.
Removal of sutures is carried out after the formation of dense connective tissue adhesions and epithelialization at a certain time.
Delayed primary sutures are also placed on the wound before the development of granulation tissue (the wound heals by primary tension). They are used in cases where there is a certain risk of infection.
Technique: the wound after surgery (PHO) is not sutured, controlled inflammatory process and when it subsides for 1-5 days, delayed primary stitches are applied.
A variety of primary delayed sutures are provisional ones: at the end of the operation, sutures are applied, but the threads are not tied, the edges of the wound are not brought together in this way. The threads are tied for 1-5 days when the inflammatory process subsides. The difference from conventional delayed primary sutures is that there is no need for repeated anesthesia and stitching of the wound edges.
b) Secondary seams
Secondary sutures are placed on granulating wounds that heal secondary tension... The point of using secondary sutures is to reduce (or eliminate) the wound cavity. A decrease in the volume of a wound defect leads to a decrease in the number of granulations required to fill it. As a result, the healing time is reduced, and the content connective tissue in a healed wound, in comparison with wounds that were conducted in an open way, much less. This has a beneficial effect on the appearance and functional features of the scar, on its size, strength and elasticity. The convergence of the wound edges reduces the potential gateway for infection.
The indication for the imposition of secondary sutures is a granulating wound after elimination of the inflammatory process, without purulent streaks and purulent discharge, without areas of necrotic tissue. To objectify the subsiding of inflammation, sowing of wound discharge can be used - in the absence of growth of pathological microflora, secondary sutures can be applied.
Allocate early secondary sutures (they are applied on days 6-21) and late secondary sutures (applied after 21 days). The fundamental difference between them is that by 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the approach of the edges and the process of their fusion. Therefore, when applying early secondary sutures (before scarring the edges), it is enough to simply stitch the edges of the wound and bring them together by tying threads. When applying late secondary sutures, it is necessary to excise the scar edges of the wound under aseptic conditions ("refresh the edges"), and only after that, suture and tie the threads.
To accelerate the healing of a granulating wound, in addition to suturing, you can use the tightening of the edges of the wound with strips of adhesive plaster. The method does not completely and reliably eliminate the wound cavity, but it can be used even before the inflammation completely subsides. Pulling the edges of the wound with adhesive plaster is widely used to accelerate the healing of purulent wounds.
Surgical debridement can be primary or secondary.
The purpose of the primary surgical treatment of the wound is to prevent the development of suppuration, create favorable conditions to heal the wound and restore the function of the damaged part of the body in the shortest possible time.
Secondary surgical treatment of the wound is performed in order to treat infectious complications that have developed in it.
Primary surgical debridement
During the initial surgical treatment of a wound, five or more surgical techniques are performed in total.
Dissection of the wound.
Excision of dead tissue and tissue of dubious vitality.
Detection and removal of small bone fragments from the wound, devoid of the periosteum, foreign bodies, blood clots.
The final stop of bleeding, i.e. ligation of bleeding vessels, vascular suture or prosthetics of large wounded vessels.
In the presence of conditions - various options for osteosynthesis, suture of tendons and nerve trunks.
Primary skin suture or wound tamponade.
Detection during the surgical treatment of the wound of its penetration into the pleural, abdominal or other natural cavity of the body serves as an indication for changing the plan of surgical intervention. Suturing is performed depending on the specific clinical situation open pneumothorax, closed drainage of the pleural cavity, wide, joint capsule suture and other surgical interventions.
The provisions outlined above convince that the surgical debridement of the wound is largely diagnostic. Complete and accurate diagnostics of injuries, foreign bodies is one of the most important conditions for the successful operation and uncomplicated course of the postoperative period.
Dissection of the fascia is necessary for full-fledged manipulation in the depth of the wound. Undisclosed fascia prevents the spreading of the edges and examination of the bottom of the wound channel.
If you suspect that the wound has penetrated into the serous cavity, the lumen of a hollow organ and it is impossible to reliably establish this by inspection, vulneography is shown. A catheter is inserted into the wound channel without effort. The patient on the operating table is given such a position in which the contrasting area is below the wound. From 10 to 40 ml of a water-soluble contrast agent is injected through the catheter and X-ray is performed in one or two projections. Vulneography greatly facilitates the diagnosis of deep, tortuous wound canals that penetrate into the cavity.
In the case of multiple, especially shot wounds in the projection of large vessels, there is an indication for performing intraoperative angiography. Failure to follow this rule can have dire consequences. Here is a clinical observation.
F., 26 years old, wounded from a distance of 30 meters with a buckshot charge. Delivered to the Central District Hospital in 4 hours in a state of hemorrhagic shock III degree. There were 30 shot wounds on the anterior wall of the abdomen, the anterointernal surface of the left thigh. There was no pulse in the arteries of the left leg. There were symptoms of generalized peritonitis and intra-abdominal bleeding. After carrying out anti-shock measures, an emergency laparotomy was performed, 6 shot wounds of the ileum were sutured. Blood clots were removed from the retroperitoneal space, the marginal defect in the wall of the left external iliac artery was sutured. Femoral artery pulsation appeared. However, the pulse was not detected on the arteries of the left foot. not carried out. The absence of a pulse in the arteries of the foot was explained by arterial spasm. The patient was transferred to 3 days after the operation in an extremely serious condition with ischemia of the left leg 3A stage. and anuria. The operation revealed a wound of the left femoral artery measuring 1.5 × 0.5 cm, thrombosis of the femoral artery and vein. It was not possible to restore the main blood flow in the limb. Performed at the level of the upper third of the thigh. The patient died of acute renal failure.
Thus, during the first operation, the injury of a large artery outside the intervention zone was not recognized. Arteriography after suturing the wound of the external iliac artery would diagnose a femoral artery injury.
Stab wounds of the chest wall, located on the front surface below 4 ribs, on the side - below 6 ribs and on the back - below 7 ribs, are subject to pedantic research. In these cases, there is a high probability of injury to the diaphragm. If the penetration of the wound into the pleural cavity is established during the PCO, the defect in the intercostal space should be expanded by dissecting the tissues to 8-10 cm to inspect the adjacent part of the diaphragm. The elastic diaphragm can be easily displaced with tupffers in different directions and viewed over a large area. Rare doubts about the integrity of the diaphragm can be resolved with diagnostic laparoscopy.
Excision of nonviable tissue is the most important stage in the surgical treatment of a wound. Non-removed necrotic tissue causes a prolonged course of suppuration in the wound with a possible outcome in wound exhaustion and sepsis. During treatment in the first hours after injury, devitalized tissues are less noticeable, which makes it difficult to perform a full necrectomy. Unreasonable radicalism leads to the loss of viable tissue. Necrosis is recognized by the loss of anatomical connection with the body, macroscopic destruction of the structure, absence of bleeding from the incision. Primary skin necrosis in bruised, gunshot wounds usually does not extend further than 0.5-1.5 cm from the edge of the defect. Subcutaneous adipose tissue imbibed by blood, contaminated with foreign particles, and deprived of a reliable blood supply should be excised. Unviable fascia lose their characteristic color and shine, become dull. An unviable muscle loses its natural bright pink color and elasticity, does not respond to intersection. The incision line does not bleed. Small, free-lying, often numerous bone fragments are to be removed. A sparing version of the primary operation often entails the need to re-treat a gunshot, crushed wound after 2-3 days in conditions of more clearly defined boundaries between living and dead structures.
Secondary surgical debridement
With the development of suppuration, except common symptoms purulent infection, skin hyperemia, local fever, edema and tissue infiltration, purulent discharge, lymphangitis and regional lymphadenitis are observed. In the wound, areas of tissue necrosis and fibrin deposition are determined.
Anaerobic non-spore-forming infection complicates the course of a wound in the neck, abdominal walls, pelvis when contaminated with contents oral cavity, pharynx, esophagus, colon. This infectious process usually occurs in the form of phlegmon: cellulitis, fasciitis, myositis. Fields of necrosis of subcutaneous adipose tissue and fascia have a gray-dirty color. The fabrics are saturated with brown exudate with a pungent unpleasant odor. Due to thrombosis of the blood vessels, the affected tissues hardly bleed during excision.
With Clostridial infection, a significant overgrowth of tissues is noted. The fabrics look lifeless. Swollen skeletal muscles are dull in color, lacking firmness, elasticity and natural pattern. When seized with instruments, muscle bundles break and do not bleed. There is no unpleasant odor, unlike a non-spore-forming infection.
An operation to remove the suppuration substrate and ensure the complete outflow of purulent exudate from the wound is a secondary surgical treatment, regardless of whether the primary was preceded or not. surgical debridement wounds. The direction of the incision is determined by inspection and palpation of the damaged area. Diagnostic information about the localization and size of purulent streaks is given by radiography, fistulography, CT, etc.
The article was prepared and edited by: surgeonOf the whole variety of surgical operations, to-rymi in us, operative surgery currently has, two operations have a pronounced and great state and social significance. These are the operations:
Primary surgical treatment of a wound;
Amputation operation
The state and social significance of the noted operations is based on two principles:
Reducing the time of treatment and disability;
Prevention of deep disability of the wounded.
Primary surgical debridement is a complex surgical operation performed in the first 24-48 hours from the moment of injury (before the development of infection) in order to prevent infectious complications in the wound and prevent severe complications associated with damage to vital organs and tissues. The operation solves the following tasks :
Remove non-viable tissue from the wound, which is a good breeding ground for microflora;
Remove foreign bodies;
Stop the bleeding;
Find damage to vital organs, large vessels and, if possible, eliminate these damage.
Classification of the operation of primary surgical debridement :
Early - up to 24 hours; --- deferred - up to 48 hours; --- late - over 48 hours.
Based on the tasks set, the operation consists of strictly defined stages, developed over several centuries of wars, and which are currently mandatory for implementation. Neglect of these rules leads to severe complications of the course of the wound process and disability of the victim.
When it comes to wounds, first of all always referring to gunshot woundssince the complexity of their structure, expressed in morphological and functional changes, to-rye spread far beyond the wound channel, I make their treatment very difficult.
The stages of the surgical treatment are associated with the features of the morphology of gunshot wounds. It is necessary to pay attention to the fact that in case of gunshot wounds, a wounding projectile-bullet, a fragment, flying at high speed, have high kinetic energy. This is their distinctive feature from edged weapons, a cut does not have such destructive power.
At the moment of contact with the body, the kinetic energy of the wounding projectile is transferred to the tissues. Pieces of clothing are torn out, then skin, subcutaneous tissue, the destruction of fascia, muscles, bones. Part of the kinetic energy is transferred to these particles, and they begin to behave like a hurting projectile. A stream of destroyed tissue particles is formed around the bullet. This flow is carried in tissues at the speed of a bullet, but the direction of its movement is both parallel to the trajectory of the bullet and in the radial direction. At the same time, air enters the wound channel, on which the kinetic energy of the bullet acts, and gas bubbles form from the destruction of tissues. In the process of injury, a temporary pulsating cavity is formed, which collapses as the projectile passes. Then it is re-formed in a smaller volume. Both factors described, acting at the time of injury (the flow of particles, destroyed tissues and a temporary pulsating cavity), contribute to extensive tissue destruction, deep penetration of foreign bodies and the development of infection in tissues.
As a result of a gunshot wound, a wound channel is formed, filled with blood clots, wound detritus, foreign bodies, to which the zone of primary necrosis is directly presented. These are dead tissues destroyed at the time of injury (direct impact zone). They are adjacent to tissues, changes in to-rykh are less pronounced (the zone of lateral impact and the zone of molecular concussion and vasomotor disorders). Changes in this zone are reversible, but if the operation is not performed, this extensive zone of lateral impact becomes a zone of secondary necrosis due to compression of edematous muscles in the fascial sheaths and disruption of their blood supply due to prolonged arterial spasm (up to 24 hours), contributing to the development of anaerobic infection ... Thus, feature of gunshot wounds consists in a combination of the following points:
Formation of tissue defect along the wound channel;
The presence of a zone of dead tissue around the wound channel;
The development of circulatory and nutritional disorders in the tissues bordering the injured area;
Contamination of the wound with various microorganisms and foreign bodies.
All of the above determines the course of the primary surgical treatment of the wound.
Stages of primary surgical treatment of a wound:
Dissection of the wound.Begin by dissecting the skin, subcutaneous fatty tissue. The fascia and muscles are then dissected. On the limbs, the dissection is performed along the axis of the limb, that is, along the neurovascular bundles. For the correct execution of the wound dissection, it is necessary to know the projections of the neurovascular bundles. At the first stage, the surgeon solves the problem of creating an optimal wide operative access in order to qualitatively solve the main tasks of the operation, that is, to perform a qualitatively operative technique. During primary surgical treatment (PCO) of wounds on the face, this stage of the operation is usually not done, or if done, then in the presence of deep local wounds and large pockets, usually in the submandibular region.
Excision of non-viable tissue... The excision begins from the skin. The wound edges are excised sparingly within a few millimeters (2-3 mm). The exfoliated but viable skin remains. The skin is protected to close the wound as much as possible at the end of the operation. The subcutaneous fatty tissue is excised more widely. Fatty tissue can be removed more - all subcutaneous fatty tissue, contaminated and saturated with blood, is excised, since this is a good environment for pyogenic and putrefactive infection. The intrinsic fascia rarely has to be excised widely; only fragments are excised from the fascia. It should be noted that fascia wounds are usually perforated, and muscle destruction is significant (large lateral impact zone). The developing traumatic edema leads to compression of the damaged muscles in the fascial cases and a sharp deterioration in the blood supply to the tissues in the lateral impact zone - secondary necrosis quickly sets in. Therefore, when treating wounds of the extremities, the intrinsic fascia is dissected with a wide longitudinal incision and supplemented with transverse notches in the shape of the letter Z. This surgical technique is called decompressive fasciotomy.
Further, the muscles are widely excised. At the same time, they seek to excise all non-viable muscles. Damaged and non-viable muscles have a dark crimson color, are saturated with blood, and do not contract. Crushed muscles are an excellent environment for anaerobic microflora, especially well developed in closed fascial cases on the limbs. The stage of muscle excision is especially important for gunshot wounds of the extremities, which is associated with the morphological features of the gunshot wound listed above, and the sheath structure of the fascial system on the extremities.
Next, the muscles are carefully excised. Thus, in the second stage, the surgeon must excise all non-viable tissues and partially the tissues of the lateral impact zone, preferably within healthy tissues. Excision is performed to the full depth of the wound channel. In summary, it should be noted that excision and dissection create favorable conditions for healing.
In parallel with excision, the surgeon conducts a revision of the wound, determines the depth of penetration of the wounding projectile, the nature of the wound (blind, through), the direction of the wound channel, the severity of damage to organs and tissues. If large vessels are damaged, then the bleeding is stopped. In case of injury to the great vessels, the issue of vascular suture, vascular prosthetics or vessel ligation is resolved. The stage of wound revision is especially important for wounds localized in the projection of the head, chest, abdomen. In these areas, wounds can be penetrating with damage to internal organs and the development of life-threatening complications. With head injuries, complications can be associated with hemorrhages in the cranial cavity and the formation of hematomas, damage to the brain substance. With penetrating chest wounds, pneumothorax, hemothorax, damage to internal organs, lungs, and heart develop. With penetrating wounds of the abdomen, injuries to the hollow organs of the abdomen cause peritonitis; with injuries of the liver, spleen, hemoperitoneum is formed. If the penetrating nature of the wound is revealed during the PHO, a wide surgical access is made, the damaged organ is found and its suture or resection is performed, the recovery stage of the operation.
The final stage of the operation. The closure of the surgical wound in PHO is carried out strictly individually. When deciding on the closure of the wound, one should take into account the nature of the wound, its location, the timing and quality of the PHO. Taking into account the conditions in which further treatment will take place after the PHO. For cut and chopped wounds in conditions of constant observation of the patient, a primary suture can be applied to the wound.
With gunshot wounds, the wound remains open. Tampons moistened with antiseptic fluids, tubes for wound irrigation and drainage are introduced into the wound. In the absence of purulent-inflammatory complications between 4 and 7 days after treatment, a primary delayed suture is applied.
Classification of seams after PHO:
Primary seam;
Primary delayed suture (application period 5-7 days);
Secondary early suture (application period 8-15th day);
Secondary late suture (application period 20-30th day).
Lecture 15. TOPOGRAPHIC ANATOMY OF LARGE JOINTS OF THE LIMBS, PRINCIPLES OF OPERATIONS ON THE JOINTS.
Lecture plan:
General design of joints, importance in pathology;
The structure of large joints upper limb (shoulder, elbow);
Features of the joints lower limbs, the structure of the knee and hip joints;
Principles and types of operations on joints (puncture, arthrotomy, arthrodesis, arthroresis, joint resection, joint plastic).
Diseases and injuries of the large joints of the limbs are very common. Therefore, knowledge of the topographic anatomy of large joints is of great interest for doctors of various specialties. First of all, of course, for traumatologists-orthopedists, therapists-specialists in joint diseases, as well as pediatricians, infectious disease specialists, dermatovenerologists. Knowledge of the topographic anatomy of the joints allows for the correct diagnosis, differential diagnosis of articular and periarticular lesions, and for an orthopedist, it makes it possible to perform corrective operations on the joints. In the lecture, we will touch on the topographic anatomy of the large joints: shoulder, elbow, hip, knee. This is due to the fact that they are most often affected by injuries and various diseases, sometimes leading to deep disability of the patient.
General structure of the joints of the limbs includes the following elements:
The articular surfaces of the bones that define the shape of the joint and are covered with articular cartilage
Joint capsule, consisting of the fibrous layer and synovium;
Ligamentous apparatus that strengthens the joint capsule;
Involutions of the synovium;
Silky bags;
Intra-articular formations.
SHOULDER JOINT
The shoulder joint refers to the joints with a large range of motion, formed by the head and articular surface of the scapula. The joint belongs to weakly congruent joints, since the head of the shoulder is immersed in the gentle articular surface of the scapula only by 1/3. Thus, the articular surface of the scapula is 3 times smaller than the articular surface of the shoulder head. The joint has the largest joint cavity. To some extent, this discrepancy between the articular surfaces is compensated by the cartilaginous lip along the edge of the articular surface of the scapula. Above, in front and partially behind, the joint is protected by the bony protrusions of the scapula, shoulder (acromion) and coracoid processes (processus coracoideus) and the coracohumeral ligament (lig.coracoacromiale) connecting them, forming the arch of the shoulder. The arch of the shoulder protects the joint from above and inhibits shoulder abduction and raising the arm above shoulder level. The joint capsule is the largest and most spacious. It is loosely stretched, which helps to carry out a large range of movements in accordance with the charter. Greater mobility leads to loss of joint stability. Stability depends mainly on the muscles and ligaments of the rotator cuff. The capsule is almost devoid of strengthening ligaments.
Shoulder ligaments:
Lig. glenohumerale superior, medius (front), inferior;
Lig. coracohumerale;
Lig. coracoacromeale.
The last ligament and processes of the scapula form the arch of the joint, which inhibits raising the arm up and abducting the shoulder above the level of the shoulder. Movements above are due to the entire shoulder girdle.
The capsule of the joint is well strengthened by the tendons of the muscles that form the rotator cuff of the shoulder and ensure the stability of the shoulder joint. The rotator cuff consists of the supraspinatus muscle, the infraspinatus muscle and the small round muscle, which attach to the large tubercle of the humerus. The subscapularis muscle attaches to the lesser tubercle of the humerus. Bottom part the capsule of the shoulder joint from the axillary fossa is not strengthened by the muscles. It is a weak point - capsule ruptures easily occur here.
The inner surface of the joint is lined with a synovial membrane, the edges go beyond the attachment of the fibrous capsule of the joint, forming twists or inversions of the synovial membrane. These are peculiar pockets that ensure the redistribution of intra-articular fluid during movements in the joint in different directions. With arthritis, there is a breakthrough of infection in neighboring areas.
Turns of the synovial membrane of the shoulder joint:
Intertubular volvulus (recessus intertubercularis or vagina sinovialis caput longum m. Biceps);
Subscapular volvulus (recessus subscapularis);
Axillary volvulus (recessus axillaries).
The direction of flow in purulent arthritis of the shoulder joint is determined by the position of the turns.
The presence of a wide capsule at the shoulder joint with the formation of a large axillary volvulus causes a high frequency of traumatic dislocations in the shoulder joint (41.6% of traumatic dislocations, according to Sinillo MI, 1979). This is also facilitated by the weak congruence of the articular surfaces, a thin capsule devoid of strong ligaments, and a large range of motion in the joint. In traumatic dislocations, the displaced shoulder head quite easily breaks the capsule in the lower part and slides out of the articular surface of the scapula.
Projection relationships in the area of \u200b\u200bthe shoulder joint. The head of the humerus is projected from the front 1-1.5 cm outward from the inner edge of the deltoid muscle; behind - a line drawn from the acromial end of the clavicle down; from below - by 6-7 cm of the acromioclavicular joint.
In accordance with this, the operative access to the joint cavity - arthrotomy, is: anterior, external and posterior. When puncture of the joint, the puncture sites are selected in the same way: in front, outside or behind.
Dislocation of the shoulder may be accompanied by damage to the elements of the neurovascular bundle lying in the axillary fossa. More often than others, between the displaced articular surfaces, the axillary nerve (n. Axillaries) is pinched, which threatens with paralysis and atrophy of the deltoid muscle, since the nerve bends around the surgical neck of the shoulder and innervates the deltoid region. Less commonly, the radial nerve (n. Radialis) and other nerves of the brachial plexus are impaired. Therefore, after reduction, it is necessary to check the sensitivity of the skin in the areas of innervation of the main nerves.
ELBOW JOINT
Another large joint of the upper limb, which ranks second in the frequency of traumatic dislocations, is the elbow joint (traumatic dislocations of the forearm are 13.4%). The elbow joint is an example of a complex joint. In contrast to the shoulder joint, this joint is more complex, since it consists of 3 joints in one fibrous capsule and has a common articular cavity.
It consists of:
Shoulder joint; --- brachioradial joint; --- radioulnar joint
Recall that the articular surface of the distal epiphysis of the shoulder has a complex configuration and is represented by a block for articulation with the ulna and the capitate eminence for the ray, i.e., the articular surfaces are highly congruent. Due to the articular surfaces, the shape of the joint has the form of a block, in which the brachio-ulnar and brachioradial (spherical) joints are included. The radial joint is cylindrical in shape. The fibrous capsule of the joint is thin and rather loosely stretched. The anterior and posterior parts of the capsule are devoid of ligaments. On the lateral surfaces of the capsule there are strong ligaments - the lateral ligaments, around the head of the radius - the annular ligament ((lig.annulare radii). Due to the presence of strong lateral ligaments, high congruence of the articular surfaces, the main movement in the joint is flexion, and The anatomical complexity of the elbow joint explains the variety of dislocations in the area of \u200b\u200bthe elbow joint.Forward dislocations of the forearm are more common, less often posterior and isolated dislocations of the radial head in children.
Elements of orientational anatomy help diagnose dislocations and fractures. The bony protrusions in the region of the elbow joint, the epicondyle of the humerus and the olecranon form a regular equilateral triangle with the apex down (Gunther's triangle). If the forearm is unbent, then the epicondyles and the olecranon (olecranon) will be located on the same line - the Tiglio line.
With dislocations of the forearm, there is a danger of pinching the nerves, since the radial nerve that bends around the head of the ray and the ulnar nerve in the region of the ulnar groove lie on the joint capsule. This determines the puncture points of the elbow joint and surgical approaches. Puncture of the joint is performed from two points. First, from the outer, between the outer epicondyle and the head of the radius. Second, from the posterior point above the apex of the olecranon.
LOWER LIMB JOINTS
The joints of the lower limb have their own anatomical features, to-rye are associated with the functional features of the lower limb - support and amortization. A person's legs support the entire body weight. Therefore, the joints of the lower extremities experience great physical stress along the axis. Because of this, the joints of the lower limb are more massive and have a number of common adaptive mechanisms that provide high physical activity on the legs.
These include:
A powerful ligamentous apparatus that strengthens the fibrous capsule of the joints;
High congruence of articular surfaces and special auxiliary devices - intra-articular cartilage;
Intra-articular ligamentous apparatus;
Intra-articular fat bodies (shock absorbers);
Due to this, the joints of the lower limb are characterized by high stability.
HIP JOINT
It is one of the largest joints in the human body. In shape, it is a kind of spherical joint - nutty. The joint is formed by the articular surface of the femoral head and the acetabulum. On the lower inner surface of the acetabulum, there is no cartilage; here lies a fatty body - a pillow.
The hip joint is enclosed in a very dense fibrous capsule on all sides. The fibrous capsule starts from the edge of the acetabulum and attaches to the distal end of the femoral neck, which is very important. In front, the capsule is attached to the intertrochanteric line. And thus, the entire femoral neck is in the joint cavity. The articular cavity is divided into cervical and acetabular. Therefore, hip fractures, which are quite common in clinical practice in old and senile age, are intra-articular fractures. The fibrous capsule tightly covers the neck and, in addition, the high congruence of the articular surfaces determines the small capacity of the joint, only 15-20 cubic meters. see and explains severe bursting pains even with minor hemorrhage into the joint cavity or the formation of exudate during inflammation. The density of the fibrous capsule is complemented by the ligaments:
Lig. Iliofemorale (Y-shaped) - Bertini's ligament; 1cm it can withstand stretching up to 350kg;
Lig. Pubofemorale;
Lig. Ishiofemorale;
Lig. Transversum;
Zona orbicularis Weberi;
Lig. Capitis femoris, an intra-articular ligament with a length of 2 to 4 cm, a thickness of up to 5 mm, can withstand a tear of up to 14 kg. It is of great retention value.
However, the fibrous capsule of the hip joint has weak points due to the nature of the course of the fibers of the ligaments. Weak points are located between the ligaments in:
The anterior-internal section of the capsule, between the Bertini ligament and the pubo-femoral ligament;
The lower part of the capsule, between the pubo-femoral and ischio-femoral ligaments;
Posteriorly between the ilio-femoral ligament and the ischio-femoral ligament.
In these places, the fibrous capsule ruptures during traumatic dislocations of the hip, to-rye are less common than dislocations in the upper limb, but in comparison with dislocations of other segments of the lower limb, quite often (from 5 to 20% according to different authors). Hip dislocations can depend on the direction of displacement of the femoral head: posterior, anterior and iliac. Since the hip joint is surrounded on all sides by powerful muscles, it is well protected from traumatic influences, therefore, significant forces are required to dislocate the femoral head. Usually it is a serious injury, road or motorcycle, falling out of the train carriage on the move and in other situations.
However, the hip joint is characterized by a large range of motion with marked stability. Joint stability is provided by:
Strong muscles;
Strong fibrous capsule, well reinforced with ligaments;
Deep position of the femoral head in the glenoid cavity, deepened cartilaginous lip.
Between m.iliopsoas and eminentis iliopectinea of \u200b\u200bthe ilium there is a mucous bag (bursa iliopectinea). In addition, the trochanteric bursa and the ischio-gluteal bursa are available.
Close to the anterior surface of the hip joint is presented femoral artery... Therefore, one of the symptoms in case of damage to the hip joint is a symptom of increased pulsation of the femoral artery (Girgolava symptom), for example, with anterior dislocations and fractures of the femoral neck. Conversely, with posterior hip dislocations, the pulsation disappears. It should be noted that the head of the femur is projected approximately 1 cm outward from the point of pulsation of the artery.
The sciatic nerve lies on the posterior surface of the capsule of the hip joint. Dislocations of the joint are sometimes accompanied by injury to the sciatic nerve.
The correctness of the anatomical relationships in the area of \u200b\u200bthe hip joint during the examination of patients is confirmed by a number of reference lines:
--- roser-Nelaton line - this is a straight line connecting three points: the anterior iliac spine (spina iliaca anterior superior), the greater trochanter and the ischial tubercle; when flexing the hip in the hip joint at 35 degrees;
--- shemaker's line - this is a straight line connecting three points: the greater trochanter, the anterior iliac spine and the navel;
--- briand's triangle , the sides to-rogo are: the axis of the thigh, going through the greater trochanter, and the line drawn from the anterior superior spine posteriorly; joining, they form a right-angled triangle, the legs of which are approximately equal.
With hip dislocations, fractures and other pathology in the hip joint, these anatomical landmarks are violated.
The joint gap is projected outward from the point of pulsation of the femoral artery. Joint punctureproduced from two points. First, from the anterior point, the edge is in the middle of the line between the middle of the inguinal ligament and the greater trochanter. Second, from the lateral point above the greater trochanter.
KNEE-JOINT
The knee joint is the largest human joint. Functionally and in shape, this joint is rotational-blocky.
It is formed by the articular surfaces of the thigh, the condyles of the femur, the patella and the condyles of the tibia.
The congruence of the articular surfaces of the tibia is enhanced by the inter-articular cartilages - menisci, which are located on the condyles of the tibia with their anterior and posterior ends attached to the intercondylar eminence. In front, the menisci are connected by a transverse ligament. The outer edge of the menisci is fused with the articular capsule. With sharp flexion in the joint with simultaneous rotation of the lower leg, tears of the menisci, more often of the internal one, can occur, since it has a free edge and a posterior horn. In this case, the menisci find themselves between the two condyles as in a millstone.
The knee joint has a thick fibrous capsule, the edges are reinforced with numerous ligaments. The lateral ligaments, the patellar ligament of the patella, the patella retainer, the transverse ligament are distinguished, in addition, on the posterior surface of the joint - oblique and arcuate.
Lateral ligaments impede lateral movements, therefore, if these ligaments are damaged, rocking movements occur; the joint space on radiographs becomes uneven.
A distinctive feature of the joint is the presence of intra-articular cruciate ligaments, anterior and posterior (lig.cruciatumanteriusetposterius). The main role of the cruciate ligaments is to limit the forward-backward movement of the lower leg. Damage to the cruciate ligaments leads to gross instability of the joint. In case of damage, a movement of the lower leg relative to the thigh appears back and forth, the so-called drawer symptom.
The synovium in the front of the joint protrudes into the cavity in the form of two pterygoid folds, which contain a layer of fat, these are the so-called plicaalarae or fatty bodies.
Cruciate ligaments, menisci, fatty bodies form a kind of amortization system of the knee joint, a buffer-brake system, edges are of great importance in the functioning of the joint.
The volume of the joint cavity is increased due to the turns of the synovial membrane. There are 9 of them. The largest volvulus - anterior superior, is formed due to the transition of the synovium from the femur to its own ligament of the patella. The rest are located around the cartilaginous cover of the femoral condyles and tibia. Serve as a place of accumulation of exudate and blood. Joint punctureproduced from lateral points, retreating posterior to the patella and the upper pole.
In the area of \u200b\u200bthe joint there are mucous bags. The most important are the bags in front of the patella (prepatellar). Here prepatellar bursitis can form.
JOINT OPERATIONS
Principles of joint surgery:
Anatomical approach to the joint cavity, i.e. to go into the joint cavity through the places where the articular membranes are closest to the skin surface; make incisions away from important ligaments or parallel to their fibers and away from the neurovascular bundles;
Physiology of accesses; not to damage the ligaments and muscles at the site of attachment without special need;
Atraumatic; spare the synovium and articular cartilage, do not leave coarse drainages in the cavity; restore the joint capsule strictly layer by layer;
Thorough hemostasis; residual blood in the joint cavity causes arthrosis, the occurrence of ossificates;
Technical equipment; the presence of an orthopedic table, special orthopedic instruments, a mobile X-ray machine, a plaster room with special equipment, the skill of joint operations.
Types of joint surgery:
Puncture of a joint is a surgical manipulation used for diagnostic or therapeutic purposes, when a cut is made a puncture of the joint capsule;
Arthrotomy is a surgical operation of opening the joint and exposing the articular surfaces for the purpose of prompt access to the joint cavity;
Joint resection - surgical removal of articular surfaces and joint closure;
Joint plastic surgery, arthrolysis - an operation to restore joint mobility by restoring congruent articular surfaces (arthroplasty);
Arthrodesis - an operation to create an artificial joint ankylosis;
Arthrorisis is an operation that creates a bone brake to limit the range of motion in a joint;
Endoscopic joint surgery.
Arthrotomy, autopsy operationor exposure of the joint, is carried out according to the following indications:
Access to the joint cavity for the purpose of removing foreign bodies in case of injuries, for removal of menisci, reduction of old dislocations, for injuries and wounds, etc., for tumors of the articular surfaces;
In the treatment of purulent arthritis for the evacuation of pus.
Types of arthrotomy.
For arthrotomy, a place is chosen where the joint capsule is closer to the skin in order to less disturb the ligamentous apparatus, and taking into account the position of large vessels and nerves located near the joint. At the same time, the access should be wide enough to thoroughly examine the joint cavity.
Arthrotomy according to Langenbeck is more often done on the shoulder joint. Skin incision from the scapular process downward or along the inner edge of the deltoid muscle. Exfoliate muscle fibers and open the capsule. Access can also be rear and external. The posterior method of arthrotomy is less convenient, since there is a risk of damage to the axillary nerve.
For arthrotomy of the elbow joint, vertical incisions are used along the lateral surface of the joint, parallel to the ligaments, but it should be borne in mind that the ulnar nerve runs along the inner surface of the joint, and the branches of the radial nerve along the outer surface.
The hip joint can be approached by an anterolateral approach or a lateral approach with muscle dissection.
To access knee-jointFor example, for resection of a torn meniscus, lateral and posterior approaches are used: parapatellar, transverse, oblique. But in order to perform a large operation in the cavity of the knee joint, the joint is opened wide along the Textor with an arcuate incision under the patella. In this case, the ligaments have to be restored.
Joint resection- operation, with a cut, the articular surfaces are removed. It can be economical when only the cartilage and part of the epiphysis are removed, complete resection with the removal of the epimetaphysis with the joint capsule. The indications are joint damage in tuberculosis, osteomyelitis with the transition to the joint. Joint resection, as a rule, ends with artificial joint ankylosis, joint closure, arthrodesis.
Indications for arthrodesis(operation of artificial ankylosis of the joint) are paralytic joint laxity with impaired limb function. The operation is carried out for tuberculosis, osteomyelitis. The joint is fixed in a functionally advantageous position and intra-articular or extra-articular arthrodesis is performed.
Arthrorisis- surgery to limit the range of motion in the joint (bone brake). Produced with paralytic joint laxity in infantile cerebral palsy, poliomyelitis, nerve injury in order to increase the support ability of the limb. Arthrorisis is done more often on the knee or ankle joint.
Arthroplasty- restoration of joint mobility by recreating congruent articular surfaces. It is used for ankylosis of inflammatory or other etiology, after joint resection. Types of arthroplasty:
Using autoplastic materials; refreshing the articular surfaces and covering them with their own tissues, for example, fascia lata of the thigh; the disadvantage of this method is the formation of adhesions and the occurrence of contractures;
Using alloplastic materials (ceramics, metal prostheses); for example, the use of acrylic prostheses, endoprostheses according to Tsivyan, metal coatings from vitalium, ceramics.
Joint transplantation;
Complete prosthetics with artificial joint replacement.
The principle of atraumatic joint operations forced the development of a completely new technology of joint operations using endoscopic techniques, when a surgeon-traumatologist-orthopedist enters the joint cavity by puncturing the capsule with a special operating endoscope and performs an operation through the endoscope, for example, removal of a torn meniscus , intra-articular foreign bodies, etc.
Lecture 16. OPERATIONS ON VESSELS. TOPOGRAPHIC JUSTIFICATION OF OPERATIONS ON VESSELS. PRINCIPLES OF THE VASCULAR SEAM. TYPES OF OPERATIONS ON VESSELS.
Lecture plan:
Anatomical foundations of vascular surgery; --- views operations on vessels;
Principles and types of vascular suture; --- types of operations using a vascular suture;
Vascular plastic; --- modern trends in the development of vascular surgery.
Diseases of the cardiovascular system are one of the leading problems of modern medicine. Prevention and treatment of diseases of blood vessels is in the focus of doctors of various profiles: therapists, surgeons. In the last 20-30 years, vascular surgery has been rapidly developing in connection with the introduction of new methods of diagnosis and surgical treatment into clinical practice. However, it should be recalled that the basis of vascular operative surgery is knowledge of the topographic anatomy of the vascular system. Perhaps, it is in vascular pathology and in vascular surgery that the fundamental importance of anatomy for the therapist and surgeon is more acutely manifested! Three fundamental questions of the topographic anatomy of the vascular system are of great importance to the practitioner:
The doctrine of the laws governing the construction of the fascial sheaths of the neurovascular bundles, or, in other words, the doctrine of the paravasal connective tissue structures;
The doctrine of the individual constitutional variability of the structure of the vascular system;
Collateral circulation theory.
One of the important prerequisites for the development of surgery of blood vessels was the doctrine of Pirogov's Research Institute on the patterns of the location of the vessels of the extremities in relation to the surrounding tissues, a cut outlined in the clinical work "Surgical Anatomy of Arterial Trunks and Fascia", published in 1837. The greatest merit of Pirogov lies in the fact that he was the first to formulate the most important laws for the construction of vascular sheaths. These laws remain a guide to action in operations on the great vessels of the extremities.
Today, the complex of connective tissue formations around the vessel is united by a common name - paravasal structures. They include:
Common fibrous sheath of the neurovascular bundle;
Own fibrous sheaths of the artery, vein and nerve;
Paravasal cleft filled with loose fiber;
Connective tissue spurs;
Paravasal nerves and vascular tracts.
All of these elements are of great importance for the normal functioning of blood vessels, and their violation in pathology is accompanied by a violation of vascular function.
The second fundamental question of topographic anatomy is the doctrine of the individual variability of the vascular-nervous system, the main position of which is the dependence of the structure of the vascular-nervous system on the type of physique. There are two extreme types - dolichomorphic and brachymorphic body type. They correspond to two types of the structure of the vascular-nervous system - loose and main. This has a certain value in pathology and should be taken into account during operations.
The third fundamental question of topographic anatomy is that the theory of collateral circulation makes it possible to understand the compensatory capabilities of the vascular system in case of impaired blood flow through the main vessels (with thrombosis, embolism, compression). In addition, taking into account the collateral circulation, a forced vascular ligation is performed in case of injuries, plastic surgery. So, we already know that it is better to ligate the axillary artery below the discharge of the subscapularis artery in order to maintain roundabout blood flow along the scapular arterial circle, and to prevent gangrene of the lower limb, ligation of the femoral artery is done below the discharge of the deep artery of the thigh. Let us pay attention to the fact that collaterals can be intrasystemic - these are branches of the same artery and the paravasal vascular bed, and intersystemic - anastomoses between vessels of different regions. If natural collaterals are insufficient, they can be formed artificially. An oil seal can be used for this. It is also possible to stimulate collateral opening by dissecting the sympathetic nerves running in the paravasal tissue - periarterial sympathectomy.
Thus, operations on vessels are performed taking into account the noted fundamental provisions.
All operational techniques used in operations on vessels can be divided into the following types:
Vascular ligation; --- operations on the sympathetic nervous system;
Operations using a vascular suture.
The most historically ancient type of vascular surgery - dressing was considered in practical classes.
Consider operations on vessels using a vascular suture. The modern principles and technique of the vascular suture were laid down by Alexis Carrel. He was born in France in 1873. He is an outstanding experimental surgeon who worked in the USA and was involved in kidney transplantation. For the development of the technique of vascular suture and work on kidney transplantation in animals, he was awarded the Nobel Prize in 1912. The seam technique he used is as follows. After temporary clamping of the vessel with clamps, the ends of the vessel are brought together by three sutures-holders, imposed along the perimeter of the vessel at the same distance from each other through all layers of the vessel wall. The vessel is stretched by these holders, after which the vessel lumen takes the shape of an equilateral triangle. After that, all three sides of the vessel are sewn together with a continuous twisted seam. Today there are many modifications of the vascular suture.
They can be divided into two groups:
Wound seams - Karrel, Morozova; --- eversion seams.
The second group of vascular sutures allows you to more closely match the inner surfaces of the vessels. The most widespread are Gorsley's seam, Polyantsev's seam (1945), Braitsev's seam.
Regardless of the type of vascular suture, it must meet the following principles:
The ends of the vessel to be stitched should touch along the seam line with their inner sheath - intima to intima;
Atraumatic - gentle handling of intima;
The suture material should not protrude into the lumen of the vessel to avoid thrombosis;
Tightness;
The seam should not narrow the vessel lumen;
Types of operations with the use of a vascular suture:
Suture of the vessel in case of injury;
Reconstructive and plastic surgery on vessels for vascular diseases;
Reconstructive vascular surgery for organ diseases (heart, liver, lungs5);
Organ transplant.
With the improvement of the vascular suture technique, it became possible to restore traumatic vascular injury, which made it possible in a number of cases to avoid limb amputation, and in recent years, a technique for attaching a completely severed limb has been developed.
But most operations with the use of a vascular suture are performed not for injuries, but for diseases with impaired vessel patency due to narrowing or occlusion of its lumen by a pathological process (for example, atherosclerosis, nonspecific aortoarteritis). Such diseases are highlighted in special group - occlusive vascular disease.
Reconstructive and plastic surgery on vessels using a vascular suture:
Embolectomy; --- intimendarterectomy; --- bypass shunting; - replacement of the vessel section.
One of the formidable complications of cardiovascular diseases is thromboembolism of the great vessels, when a large wandering embolus wedges into one or another part of the vessel and disrupts its patency. In this case, an operation is used - embolectomy using a Fogarty balloon probe (indirect embolectomy). Direct embolectomy is used in easily accessible anatomical areas.
Often, in atherosclerosis, an overgrown atherosclerotic plaque narrows the lumen of a blood vessel and disrupts blood flow, as in nonspecific aortoarteritis. Then the operation of thrombointimectomy and endarterectomy is used. Muscle layer and adventitia remains in these operations.
If the vessel is affected over a significant extent, then prosthetics (replacement of the vessel) or bypass grafting with the help of a prosthesis are used. The patient's own vessels (for example, autovein) or synthetic prostheses can be used as a prosthesis.
Types of vascular prostheses:
1.Biological:
Autovena;
Homoprostheses - lyophilized cadaveric vessels, umbilical cord;
Heteroprostheses (xeno-) - treated vessels of animals [aortografts (USA, sleepy
arteries of cattle), Solkograft (1986, Switzerland, carotid arteries calves)]
2.Synthetic:
Materials are used from lavsan, nylon, teflon, fluorlon, etc.
Dentures with velor inner surface;
Silver-framed dentures;
Antithrombogenic prostheses.
Materials for plastic vessels:
Autovena (Carrel) - v. saphena magna; --- homografts (retained);
Heterografts (retained); --- synthetic woven prostheses - dacron, lavsan, fluorlon.
The possibilities of creating prostheses with an antithrombogenic surface, the introduction of anticoagulants are being studied. Giving an electronegative potential to the prosthesis - to prevent thrombus formation. Prostheses with a silver frame have been created. Antimicrobial prostheses have been created.
Requirements for prostheses:
Must not be pathogenic; --- must not be allergenic;
Should not destroy tissue; --- must not be thrombogenic;
Must not be carcinogenic; --- strength;
Flexibility elasticity; --- ease of sterilization;
Durability (modern prostheses lose up to 60-80% of their strength in 5 years).
Unfortunately, prostheses that fully meet all these criteria have not yet been created.
EXAMPLES OF OPERATIONS USING PROSTHETICS
Along with operations for vascular diseases, with the development of a vascular suture technique, it became possible to treat a number of diseases of internal organs using vascular operations. For example, with complex congenital heart defects, when a one-stage radical operation is dangerous. In patients with tetrad of Fallot, an anastomosis can be made between the pulmonary artery and the branches of the aortic arch, or the connection of the aorta with the pulmonary artery using a vascular prosthesis.
With cirrhosis of the liver, a syndrome of portal hypertension (increased pressure in the portal vein) develops, to-ry it is dangerous by bleeding from varicose veins of the esophagus. To reduce the pressure in the portal vein and prevent bleeding, operations are used to create portocaval anastomoses using a vascular suture - the portal vein is sewn into the vena cava.
The progress of vascular surgery continues to this day. A new direction in vascular surgery has appeared - X-ray endovascular methods of treatment of vascular diseases. A number of promising operations have already been developed and introduced into clinical practice, the main principle of which is a more sparing mode of operation with minimal trauma for the patient and blood vessels.
Here are some of them:
X-ray endovascular filling of cerebral aneurysms.If earlier, with aneurysms of the cerebral vessels, craniotomy was performed with the shutdown of the vessel with the aneurysm or its plastic, nowadays, the probing of the cerebral vessels is performed through the common carotid artery or the femoral artery and the filling of the aneurysmal sac with plastic.
X-ray endovascular vascular dilation.An example is the coronary arteries, the iliac arteries. The technique is as follows. Under local anesthesia, the Seldinger femoral artery is probed. A probe with a balloon is inserted into the desired segment of the vascular system and a contrast agent is injected into the balloon under pressure until the vessel expands to the desired diameter. After completing the procedure, the can is emptied. The procedure is carried out several times until the effect of dilation is achieved.
X-ray endovascular vascular prosthetics.After a simple balloon dilatation of the vessel, a relapse may occur. Therefore, to prevent it, a folded spiral or a stent made of a special alloy - nitinol (nickel-titanium alloy) - an alloy with "memory", is inserted into the enlarged area (after dilatation). In the vessel, under the influence of body temperature, the spiral of this alloy straightens to the planned width and this section of the vessel is maintained in a dilated state, which improves blood flow in this segment of the vessel.
Using a laser.This is the very cutting edge of vascular surgery. In the All-Union Scientific Center of Chemistry (Moscow), in an experiment, a laser was successfully used to evaporate atherosclerotic plaques in the coronary, renal and other arteries. In this case, a light guide is introduced into the lumen of the vessel, which is supplied to the plaque, and a laser pulse is applied to evaporate the plaque.
Summarizing what has been said, it should be noted that vascular surgery is the most rapidly developing area of \u200b\u200bmodern surgery - the surgery of the future.
Lecture 17. THE TEACHING ABOUT AMPUTATIONS. REPLANTATION OF LIMBS.
Lecture plan:
Definition and indications for surgery;
Types of amputation by timing and technique;
The main stages of the operation;
Features of amputations in children;
Limb replantation.
Amputation is an operation, when a cut is performed the removal of the peripheral part of the limb along the bone. A type of amputation is exarticulation - removal at the level of the joint.
Information about amputation dates back to ancient times. Probably, the indications for amputation at that time were mainly injuries during hunting or military operations. Despite its long history, the operation retains its practical significance to the present day, and its technique continues to be improved.
The operation is of great state and social importance. First, because of its crippling nature, as a rule, it leads to profound disability of the patient. Therefore, according to the decree of the 27th All-Union Congress of Surgeons (1965), the decision on amputation is made by a council of three doctors, and the patient is informed about the nature of the operation. Secondly, the operation has a restorative nature, its purpose is to return the patient to an active life. Therefore, the quality of the operation contributes to early prosthetics and the return of the patient, at least partially, to work.
Modern indications for amputation can be divided into 5 groups:
The first group of indications - traumatic lesions of the extremities (42% in peacetime):
Traumatic separation of the limb;
Extensive crushing of limb tissues with rupture of the main neurovascular bundles and loss of soft tissues by more than 2/3 of the volume;
Damage to the neurovascular bundles, if it is impossible to impose a vascular suture;
Thermal burns of the 4th degree (charring);
Electrical injury;
Frostbite of the extremities, but not earlier than 12-14 days from the moment of frostbite - after the formation of the demarcation line.
The first group of indications for amputation can be called primary. Amputations with them are performed in the first hours after the injury, before the development of clinical signs of infection in the wound, and is, as a rule, in the nature of the primary surgical treatment of the wound. This group increases markedly during hostilities. According to the WWII experience, amputation was performed in 26% of the wounded.
The second group of indications is severe purulent-septic complications of wounds of the extremities and infectious diseases of the tissues of the extremities.
Progressive anaerobic gas infection, not amenable to intensive antibacterial therapy, the so-called fulminant form; according to the experience of WWII, amputation for gas infection was 14.4% of the total number of amputations, and was performed in 43.2% of patients with gas gangrene;
Progressive purulent infection of wounds, not amenable to intensive antibiotic therapy and threatening sepsis;
(These two indications can be attributed to secondary indications; the operation is preceded by conservative therapy, and surgical treatment is performed to save the limb and the patient's life)
Purulent osteomyelitis, threatening with amyloidosis of internal organs;
Osteoarticular tuberculosis with the threat of generalization of infection and amyloidosis of internal organs;
(The last two indications can be called late, since the disease can be chronic
for a long time).
The third group of indications is vascular diseases of the extremities with deep trophic disorders in the tissues (47.6% in peacetime):
Thrombosis and embolism of the main arteries with tissue necrosis, usually 5-6 hours after embolism;
Obliterating atherosclerosis of the vessels;
Obliterating endarteritis;
Diabetic gangrene;
Long-term trophic ulcers with degeneration into cancer.
Fourth group - malignant tumors limb tissues.
Fifth group - orthopedic amputations and reamputations:
Congenital malformations of the limbs;
Large bone defects due to injuries when plastic surgery and prosthetics are impossible;
Reoperations for vicious stumps.
According to indications for amputation and time of operation from the moment of illnessNN Burdenko divided amputations into:
Early: a) primary, b) secondary.
Late;
Repeated.
According to the technical method of performing amputations, they are subdivided into:
Circular; --- patchwork; --- osteoplastic.
Circular amputation methodsbelong to the oldest methods of amputation and therefore, to a large extent, are no longer used due to imperfection. With circular methods of amputation, limb tissue is truncated strictly perpendicular to the axis of the limb. Depending on the level of tissue truncation, circular methods are subdivided into guillotine method, one-, two-, three-moment methods. The guillotine method retains its practical significance, with which the fabrics are cut off at the same level, as they are chopped off by the guillotine (Guillotin is a French doctor who became famous for having invented the guillotine, 18th century). The only indication for this method is gas anaerobic infection at the stages of evacuation, where there is no specialized surgical care and continuous monitoring of the wounded. The purpose of the method is to stop the progression of the infection.
Great distribution got patchwork methods of amputation, allowing you to close the wound with primary sutures, and start early prosthetics of the amputee. Patchwork methods are divided into one- and two-piece. According to the composition of the tissues included in the flaps, the fascioplastic method and the myoplastic method are distinguished.
Osteoplastic methods of amputationoriginate from the osteoplastic amputation of the lower leg, developed by NI Pirogov in 1852. In osteoplastic amputations, in order to increase the supporting ability of the stump, the sawdust is closed with a bone graft. For the first time, this kind of bone grafting during the operation was performed by NI Pirogov. He proposed to close the stump of the tibia with sawdust of the calcaneus during the amputation of the tibia. Thus, after the operation, the tissues of the heel region, intended by nature for support, were preserved. In addition, the length of the limb decreased slightly, which allowed the amputee to do without a prosthesis. Later, Pirogov's idea was further developed with amputations in other areas. Methods were developed for amputation of the femur with the closure of the stump of the femur with sawdust of the patella (method of Gritti-Shimanovsky - 1857-1863, amputation of the lower leg according to Beer - 1892) During the Second World War, amputation of the femur according to Dzhanelidze was used, with a cut for the prevention of osteophytes sawdust of the femur closed with a ring from the removed segment of the thigh.
Regardless of the method of amputation, the operation consists of three stages:
Cutting out a skin-fascial flap; --- dissection of the periosteum and sawing of the bone;
Stump wound toilet.
Technique of individual stages of the operation:
After the introduction of the patient into anesthesia, a hemostatic tourniquet or elastic bandage is applied to the root of the limb. The surgeon plans 1-2 flaps, to-rye should close the stump. At the same time, the reserve of skin for contractility is added - on the thigh it is 3-4 cm. Further, the flaps are separated and pulled to the root of the limb and the muscles are truncated with an amputation knife. The latter are pulled back with a retractor. The periosteum is truncated in a circular motion with a scalpel, shifted with a raspatory to the distal side. The bone is sawn through with a frame saw.
The third stage of amputation is the most important - the toilet of the stump wound. It consists of three points:
Stopping bleeding; we begin with the seizure of hemostatic clamps and bandaging of large arteries and veins in the wound of the stump, to-rye we see on the transverse section of the limb; small vessels that have contracted in the tissue are stitched with Z-shaped seams; after which we remove the tourniquet and additionally sew the bleeding places;
The second point is the truncation of the nerve; we produce anesthesia of the nerve by introducing 1% novocaine solution perineurally, pulling the nerve into the wound by 3-4 cm and cutting it off with a safety razor blade (Albrecht's method); truncation of the nerve prevents the ingrowth of its stump into the scar of soft tissues and the development of causalgia;
The final stage of the operation is suturing the fascial skin flap with the installation of rubber drains under the flap to drain residual blood and serous transudate from the wound. After suturing the wound to prevent flexion contractures, the stump is immobilized with a longitudinal plaster cast.
FEATURES OF AMPUTATION IN CHILDREN
(for the pediatric faculty)
Strict saving of the length of the removed segment;
The use of skin grafting in amputations for injuries;
Sparing the epiphyseal growth zones, preserving the joints;
For vicious stumps, the use of plastic surgery, not re-amputation;
When the lower leg is amputated to prevent the formation of a conical stump, a shorter truncation of the fibula is due to its advanced growth.
LIMB REPLANTATION
No matter how economically the amputation was performed, and no matter how convenient the prosthesis was, the operation leads to disability, and therefore surgeons developed ways to restore the severed limb. With the development of anesthesiology and vascular suture technique, it became possible to restore a lost limb, and since the late 70s, the operation has been widely used in clinical practice.
Replacement of a limb is an operation to anatomically restore a limb with its complete or incomplete detachment.
The success of the operation depends on the quality and timeliness at the prehospital stage, effective anti-shock measures at the site of injury, correct transportation of the severed limb to an institution where there are conditions for replanting. During transportation, the limb is preserved by external cooling using ice packs. Small segments are transported in a double ice bag. It is believed that if the limb was immediately cooled, it can be replanted in the following terms: fingers - within 18-24 hours; hand and foot - 10-12 hours; larger segments - 5-6 hours.
The success of replantation depends on:
The general condition of the patient (shock, blood loss);
Local tissue condition of the detached segment; a crushed, crushed limb with heavy contamination is not suitable for replantation;
Technical support of the operation (the presence of an anesthetic team, two specially trained teams of surgeons, instrumental support and suture material, the possibility of qualified postoperative management).
The replantation operation consists of the following stages, provided that two teams of surgeons are working simultaneously:
Primary surgical treatment of the wound of the stump and the wound of the detached segment with the marking of the anatomical structures;
Restoration of the bone skeleton of the limb using osteometallosynthesis;
Restoration of the main blood circulation in the limb, restoration of veins and arteries, as a rule, using microsurgical techniques;
Recovery of muscles and tendons;
Nerve repair, usually a secondary nerve suture;
Restoration of the skin using skin grafting.
According to statistics, about 30% of the replanted limbs do not take root, since it is difficult to fulfill all the conditions that ensure engraftment of the detached limb segment. Therefore, in these conditions, an operation is required to remove the unhealed segment.
Lecture 18. PLASTIC AND RESTORATION OPERATIONS.
Lecture plan:
Definition; classification and types of plastic;
Skin plastics; morphological foundations and principles;
Types, indications and technique plastic;
Reconstructive and plastic surgery on bones (osteosynthesis, bone grafting).
Plastic and reconstructive operations are surgical operations aimed at restoring the normal form and function of various parts and organs of the human body, completely or partially lost due to injuries, diseases, surgical removal, or absent due to congenital deformities.
The whole variety of plastic and restorative operations on various tissues and organs constitutes a separate branch of surgery - plastic surgery. A number of plastic surgeries on individual systems that require a highly specialized approach are included in the respective branches of surgery: vascular surgery, urology, gynecology, endocrine surgery, dentistry, etc.
Depending on the indications for plastic surgery plastic surgery decidethe following tasks:
Cosmetic operations aimed at restoring and changing external forms: plastic surgery of the nose, lips, ears, mammary glands, elimination of wrinkles on the face, neck, removal of skin and fat folds, liposuction;
Operations aimed at restoring lost functions, plastic surgery on internal organs (plastic surgery of the esophagus, plastic surgery of the heart valves), endocrine system, bone marrow transplant;
Operations that restore the shape and function of lost organs (skin grafting, bone grafting, keratoplasty);
It should be especially noted that one of the tasks that plastic and reconstructive surgery solves is the restoration of the psychological balance of the personality and the return of a full-fledged social status to a person.
Plastic surgery solves the presented tasks using various plastic materials and plastic methods.
Depending on the plastic material used, the following types of plastic are distinguished:
--- autoplasty;during autoplasty, a person's own tissues are used, to-Roma plastic surgery is performed; these tissues either move completely, separating from the mother or donor surface - free plastic, or the connection with the donor surface is maintained through the feeding stem; during autoplasty, depending on the indications, all body tissues can be used: skin, adipose tissue, muscles, tendons, bones, cartilage, blood vessels, nerves;
--- homoplasty; in homoplasty, tissue taken from another donor is used as a plastic material. These are commonly referred to as grafts. Donors can serve as living people or corpses, in the first 6 hours after death. Due to tissue incompatibility, such tissues sometimes do not take root, but their transplantation allows you to get a temporary improvement in the patient's condition and prepare for another type of plastic surgery. If it is required to achieve engraftment, then methods of immunosuppression are used, i.e., suppression of the immune system of both the host and the plastic material – homograft. Homoplasty is widely used in clinical practice. The skin, the cornea of \u200b\u200bthe eye (keratoplasty), bones, joints, blood vessels, heart valves, cellular material of individual organs (for example, bone marrow) are used;
--- heteroplasty; in heteroplasty, tissues taken from animals serve as plastic material; such tissues have complete biological incompatibility with the human body, therefore, they require special processing; as a rule, heterotissues transplanted into the human body are gradually absorbed and replaced by the connective tissue of the recipient; nevertheless, heteroplasty is useful in that it fills in tissue defects and serves as a stimulant for the regeneration of a person's own tissues; with heteroplasty, specially treated skin, bones, blood vessels, heart valves (more often the aortic valve of a pig) can be used;
--- alloplasty (xenoplasty);for alloplasty, implantation of artificial materials is used; the materials are plastics (AKR, polystyrene, nylon, lavsan), silicone rubber, metals (titanium, tantalum, their alloys - vitalium), ceramics; plastics allow you to correct the external forms of the surface of the human body when they are lost, or, if the patient wishes, to improve their external data, for example, breast plastic; plastics and metals replace parts of the bone skeleton after trauma and surgical removal, for example, plastics of a skull defect after resection trepanation, restoration of the upper jaw after resection for a tumor; the lens of the eye, heart valves, vessels (woven synthetic prostheses), ligaments and joints are made from artificial materials.
When it comes to plastic surgery, we first of all think about skin plastic surgery. This is probably due to the fact that the integuments of the human body give it a certain appearance, and its defects are noticeable and attract attention. And, probably, for the same reason, skin grafting is the oldest type of plastic surgery. In addition, skin grafting is one of the most common types of plastic surgery.
In order to understand why it is necessary to do skin grafting and the technical differences between different plastic methods, it is necessary to briefly recall the anatomy of the skin and its function.
The skin is a complex organ that covers the outside of the body and consists of the epidermis, dermis and subcutaneous tissue (hypodermis). Besides protection human body from external harmful influences, the skin performs the functions of touch, metabolism, in particular, water-electrolyte metabolism, skin respiration, thermoregulation, etc. histological structure the skin has an outer layer, represented by the epidermis, to-ry refers to stratified squamous epithelium. The lowest layer of the epidermis is the basal layer, it is also called the germ layer. Cell division takes place in this layer. Above it lie sequentially: a prickly layer, granular, vitreous. The outer layer of the epidermis is the stratum corneum. The epidermis thickness ranges from 0.07 to 1.5 mm (on the palms and soles). The dermis consists of dense connective tissue, its thickness is from 0.5 to 4 mm. The vessels and nerves of the skin pass through the dermis. The dermis contains the sebaceous and sweat glands. The average skin thickness over most of the human body surface is 1mm.
Skin grafting operations:
Skin grafting (or skin grafting, skin transplantation) is a surgical operation undertaken to close skin defects after wounds, burns, frostbite, extensive operations for oncological diseases, trophic ulcers, congenital malformations.
The classification of the methods of skin grafting operations corresponds to the general principle of plastic surgery, depending on the choice of the donor and the plastic material. Distinguish between autoplasty (skin is taken from the patient himself), homoplasty (from another person), heteroplasty (use of animal skin preparations).
Autoplastic skin grafting methods are divided into free skin grafting and non-free skin grafting. With free skin grafting, the transplanted skin area - the graft is completely separated from the maternal or donor surface. The main indications for free skin grafting are extensive thermal burns of the 3rd and 4th degree, as well as large granulating wounds. For free skin grafting, any healthy areas of the human skin are used, but most often the skin of the thigh, buttocks, chest and abdomen is used (Ariev TYa, 1971). It is now generally accepted that a prerequisite for engraftment is the inclusion of the surface layers of the dermis in the flap, in addition to the epidermis.
The most widespread are the following free skin grafting methods:
Reverden's method (1869) - transplantation of pieces of the epidermis with a thickness of 0.3-0.4 mm and an area of \u200b\u200b0.4 sq. Cm. The method was improved in 1869 by the Russian surgeon S. Yanovich-Chainsky, and, later, 44 years later, by the American D. Davis. They recommended taking thicker pieces by grasping the superficial layers of the dermis (epidermal-dermal plastics). The skin of the donor site is lifted with a needle or tweezers and cut with a razor or sharp scalpel and these pieces are placed on the granulating surface.
The Tirsch method (1874) - transplantation of large skin flaps (20-25 x 5-6 cm).
Krause's method - full thickness skin grafting without subcutaneous tissue. When a large surface is closed, the flap is perforated. VK Krasovitov suggested using skin flaps torn off during trauma for autoplasty.
Split-graft dermatomal skin grafting became possible after Paget and Hood invented the mechanical dermatome in 1939, a tool for collecting skin grafts. In 1946, M. Kolokoltsev developed an adhesive dermatome in Russia. Later, electrodermatomes were constructed. A dermatome is a complex surgical instrument, which allows cutting off skin flaps of a given thickness from 0.3 to 0.6 mm. In addition, the dermatome allows you to cut flaps up to 20-25 cm wide and up to 50-60 cm long, depending on the donor surface. The collection of epidermal - dermal flaps with partial preservation of the growth layer promotes spontaneous, rapid epithelialization of the donor site, which makes it possible to re-harvest skin grafts from the used donor site after about 2-3 weeks.
To solve the problem of tissue deficiency, have also been proposed placement methodsskin grafts on the wound and burn surface:
The method of "postage stamps" (Gabarro P., 1943). Using this method, you can restore skin on an area much larger than the size of the skin graft. The idea of \u200b\u200bthe method is that epithelialization occurs from the edges of the graft, therefore, rather significant gaps (1: 1.5 to 1: 5) can be left between individual pieces of skin. The postage stamp method is one of the most effective methods restoration of the skin over large areas.
--- the "intermittent tape method", the "zebra" method (Mowle and Jackson, 1952). With this method, skin grafts are arranged in the form of ribbons. Alternation of auto- and homografts of skin is possible.
Widely perforated skin autologous graft transplant. To increase the area of \u200b\u200bthe surface to be closed, the dermatome flap is perforated in a special device in a checkerboard pattern. In this case, the flap takes the form of a mesh, a cut cover the burn surface.
The method of using cell cultures. Covering the burn surface with cultured human skin cells and grafts from cultured human fibroblasts. The latter method is used in combination with perforated flaps, since fibroblasts stimulate regeneration.
Skin homoplastyit is used for extensive thermal burns to close the burn surface in order to combat burn shock and disorders of water-electrolyte metabolism in burn patients, since water, proteins, electrolytes are lost through the burn surface (plasmorrhea). After 2-3 weeks, less often up to 2 months, the homograft is absorbed or rejected, and the patient undergoes autoplasty of the skin.
Skin Heteroplastyis used to treat burns for the same indications as homoplasty. Xeno skin is widely used - it is specially processed (lyophilized) pig skin.
Non-free skin plastic... With this method, the donor flap retains its connection with the mother's surface. This type of plasty is subdivided into plasty with local tissues and plasty with leg flaps. Local tissue repair is used to close small tissue defects. The method is carried out by displacement of the skin areas closest to the defect. At the same time, the edges of the skin are separated and laxative incisions are made.
To close large skin defects on the face with the restoration of the shape of individual areas of the face, it is necessary to move skin flaps of full thickness and with subcutaneous tissue. Such movements are possible only if the feeding pedicle is kept at the skin flap. The most ancient method of plastics is the Indian method. In this method, the skin flap is moved from the forehead to the nose. In Italy, at the beginning of the 16th century, a method was developed for plastic nose surgery from shoulder skin. Especially famous for these operations, Professor of the University of Bologna Gaspar Tagliacozzi. The method was called Italian plastics and was used for plastics of skin defects in other areas of the human body. The method allows the transfer of a full-thickness skin flap from areas that are distant from each other. Both methods retain their significance to this day and are used in clinical practice.
The development of technology, including military technology, has led to the appearance of traumatic injuries of a significant volume, with complete loss of organs and deep maxillofacial injuries, which require large-volume full-thickness flaps during the restoration of multi-stage plastics. This method was developed in 1916 by the famous Russian ophthalmologist surgeon VP Filatov. The method has established itself in world surgery under the name - plastic round migrating stem according to Filatov.
It should be recalled that another plastic operation is associated with the name of Filatov, which has also received worldwide recognition - this is a keratoplasty operation - a cornea transplant from a corpse. This is one of the methods of restoring vision in patients with thorns.
The operation of plastic surgery with a round migrating stem according to Filatov is performed in several stages.
First step.Two parallel incisions cut out the skin tape and separate it from the fascia. The tape can be cut wherever the leather is gathered into a fold. The size of the flap varies depending on the needs, but to ensure its viability, it is necessary that the length of the flap does not exceed its width by more than three times. The edges of the tape are sewn together so that a round stem is formed. The wound of the donor site is sutured tightly. After removing the sutures, they begin to train the stem, achieving the development of a good blood supply from one end of the stem. To do this, the stem is pulled with a rubber cord from one end, which is planned to be crossed in the future. The clamping time is at first 5 minutes, then daily the time of the stem overlap increases by 5-10 minutes. Ultimately, the flap is kept warm and has a normal coloration for 1 hour. After that, proceed to the second stage.
Second phase... The flap is cut off and sewn into the defect if it is located nearby. If the stem is located far from the defect, then the flap is transferred to an intermediate platform, for example, on the hand or forearm, and the stem training is repeated. After training, the stem is cut off again and transferred to the defect. Depending on the needs, the training is repeated and after 10-15 days the flap is cut off and the plastic use of the stem is started. On the face of the stem, you can model the nose, lips, cheek. The plasticity of the flap allows you to restore many organs, for example, the mammary gland, penis, close large defects in any part of the body. However, the multistage plasty with a migrating stem makes it long-lasting, the operation can take several months.
In recent years, in connection with the development of microsurgical techniques, free transplantation of a full-thickness skin flap with subcutaneous tissue with the isolation and intersection of the feeding neurovascular bundle has begun. This flap can be cut out in the groin area. The flap is transferred to the area of \u200b\u200bthe defect, and its vascular pedicle is connected to the nearby neurovascular bundle. If the plastic is performed on the face, then with the facial artery or carotid artery. Plastic surgery using microsurgical techniques significantly shortens the plastic surgery time.
BONE SURGERY (osteosynthesis, bone grafting)
Reconstructive and plastic surgery of the human skeleton is usually performed by a traumatologist-orthopedist. These operations are extremely common because in the 20th century, man-made traumatism significantly increased, to-ry took on a massive character. All this required the development and widespread use of surgical methods for treating bone fractures.
A surgical operation performed for bone fractures with the aim of open reduction and fixation of bone fragments is called osteosynthesis.
Osteosynthesis allows you to get a good result only with the maximum observance of all principles of fracture treatment:
Careful reduction of the fracture with the elimination of tissue interposition;
Dense contact of fragments with compression;
Gentle handling and preservation of the periosteum;
Preservation of blood supply to bone fragments.
Diverse methods of fixation of bone fragmentstoday can be divided into several groups:
--- percutaneous fixationfragments with a bone suture, knitting needles, screws; this method of fixation is used to fix small bone fragments, for example, fractures of the olecranon, patella, fractures of the ankles, femoral and tibial condyles, clavicle, etc.
--- extramedullary osteosynthesisis the oldest method of fixing bone fragments and is the binding of fragments with wire or metal bands; another extramedullary fixation method is fixation with extramedullary plates; extramedullary osteosynthesis using extramedullary plates is widespread in clinical practice for fractures of long tubular bones.
--- intramedullary osteosynthesis- fixation with intraosseous rods, pins; intramedullary osteosynthesis with the help of rods inserted into the bone marrow canal was widely developed on the eve of World War II and is associated with the name of the German surgeon Kuntscher (1940); currently there are a large number of different designs of metal posts for osteosynthesis;
--- extrafocal compression osteosynthesis using Ilizarov apparatus, Gudushauri and others; in the mid-50s, the Kurgan traumatologist GA Ilizarov developed an original apparatus for extrafocal compression fixation of fractures; fixation of fragments outside the fracture zone and creation of their compression allows accelerating the process of bone tissue regeneration; the apparatus proved to be especially useful in the treatment of false joints and for bone grafting.
However, the treatment of fractures with conservative methods or surgical methods often ends in unsatisfactory outcomes. In these cases, bone deformities may occur with impaired support function and cosmetic defects. Bone skeletal defects can sometimes occur as a result of extensive trauma. Violation of the bone regeneration process can lead to the appearance of a false joint, when only a fragile connective tissue fusion is formed at the fracture site without restoring the full structure of the bone tissue. Unsatisfactory outcomes require repeated surgery, the edges are already called bone grafting.
Bone graftingcalled a bone graft surgery for anatomical reconstruction bone structures, as well as to stimulate regenerative processes and bone formation.
As with skin grafting, they distinguish the following types of bone grafting:
Autoplasty; --- homoplasty; --- heteroplasty; --- alloplasty.
With autoplastythe bone tissue of the patient himself is used. In this case, bone grafting can be free when the bone graft loses its connections with the donor site. Bone grafting can also be non-free when the pedicle is preserved. An example of non-free bone grafting can be the operation of osteoplastic amputation of the lower leg according to Pirogov, when a cut of the tibial sawdust is closed with sawdust of the calcaneus, which is kept on a soft tissue flap of the calcaneal region (1852). Another example of non-free bone grafting can be the closure of a skull defect during osteoplastic trepanation according to Olivecron, which was described in the last lecture. For resection craniotomy, as a rule, use alloplastic plastic AKR.
Usually bone grafting is combined with osteosynthesis, with the help of which both a bone graft and bone fragments are fixed.
In bone autoplasty, bone grafts are taken from the wing of the ilium. The fibula, ribs, cortical plate of the tibia can also serve as plastic material.
In the treatment of pseudoarthrosis using the method of bone graft placement bone platemay be:
Extra bone parietal plastic;
Sliding graft according to Olbi-Khakhutov;
Combined extra-bone plasty with intraosseous fixation with a rod;
Combined intra-extramedullary plastic surgery according to Chaklin.
For large bone defects, for example, the tibia, they use the movement of the fibula to the tibial position. In recent years, plastic methods have been developed using microsurgical techniques. In this case, the bone-periosteal flap is transferred to a new bed and its vascular pedicle is connected to the nearby large artery. Thus, the blood supply to the bone tissue is restored and the regeneration processes are improved.
In the treatment of false joints and congenital or traumatic shortening of the limbs, good results have been obtained using compression-distraction osteosynthesis using the Ilizirov apparatus and others.
Bone homoplasty with material obtained from human corpses is used to stimulate the process of osteogenesis with delayed consolidation or surgical treatment of false joints. The homograft is lyophilized (dried in vacuum), or frozen, or preserved in formalin. A homograft is used for extra-bone parietal grafting. The graft is fixed to its own bone, as a rule, with catgut. The transplanted homograft gradually dissolves, stimulating the growth of its own bone.
The use of heterobony from animals has not yet become widespread in clinical practice due to high immune activity.
As for the use of plastics for bone grafting, they are widely used to restore the articular surfaces of bones damaged as a result of trauma or after economical joint resection.
Bolshakov OP and others. Lectures on operative surgery and topographic anatomy. St. Petersburg, 2000.
Bolshakov OP and others. Operative surgery and topographic anatomy.-Saint Petersburg, 2001.
Brown MP. General foundations of the technology of surgical operations.-Moscow, Rostov-on-Don, 1999.
Voilenko VN et al. Atlas of operations on abdominal wall and organs of the abdominal cavity. (Edited by Ostroverkhov GE.-Moscow, 1965)
Voino-Yasenetsky VF. Essays on purulent surgery. Medgiz, 1965.
Godunov SF. Methods and technique of amputation.-Leningrad, 1967.
Zolotareva TV et al. Surgical anatomy of the head. - Moscow, 1968.
Zolotko YL. Atlas of Topographic Human Anatomy. In three volumes. - Moscow, 1976.
Clinical anatomy and operative surgery (tasks and questions) (Edited by VK Tatyanchenko. - Rostov-on-Don, 2000.
Kovanov VV et al. Surgical anatomy of human extremities. - Moscow, 1983.
Kukudzhanov NI. Inguinal hernia... - Moscow, 1969.
Lopukhin YM. Lectures on topographic anatomy and operative surgery. - Moscow, 1994.
Lubotsky DN. Fundamentals of Topographic Anatomy. - Moscow, 1953.
Mirsky MB Surgery from antiquity to the present. - Moscow, "Science". 2000.
Nikitina TD et al. Topographic anatomy of human fascia and cellular tissue. - Novosibirsk, 2001.
Operative urology (Glukharev AG et al. - Moscow, 1986).
Operative surgery for children. (Edited by EM Margorin. -Leningrad, 1967.
Operative surgery with topographic anatomy of children. (Edited by Isakov YF et al. - Moscow, 1989
Operative surgery and topographic anatomy. (Edited by VV Kovanov. - Moscow, 1985.
Ostroverkhov GE. Lectures on operative surgery. - Leningrad, 1976
Ostroverkhov GE et al. Course of operative surgery and topographic anatomy. Moscow, 1963.
Semyonov GM and others. Surgical suture. - St. Petersburg, 2001
Sleptsov IV et al. Nodes in surgery. - St. Petersburg, 2000.
Cardiovascular surgery. (Ed.VI Burakovsky), - Moscow, 1989
Topographic and anatomical features of a newborn (Ed. By EM Margorin), Leningrad. 1977
Surgical anatomy of the breast. (Edited by AN Maksimenkov), Leningrad, 1955
Surgical anatomy of the abdomen. (Edited by AN Maksimenkov), Leningrad, 1972
PHO is the first surgical operation performed on a patient with a wound under aseptic conditions, with anesthesia, and consists in the sequential execution of the following steps:
1) dissection;
2) audit;
3) excision of the edges of the wound within the apparently healthy tissues, walls and bottom of the wound;
4) removal of hematomas and foreign bodies;
5) restoration of damaged structures;
6) suturing if possible.
The following options for suturing wounds are possible:
1) layer-by-layer suturing of the wound tightly (for small wounds, slightly contaminated, with localization on the face, neck, trunk, with a short period from the moment of injury);
2) suturing the wound, leaving drainage;
3) the wound is not sutured (this is done with a high risk of infectious complications: late PCO, abundant contamination, massive tissue damage, concomitant diseases, old age, localization on the foot or lower leg).
Types of PHO:
1) Early (up to 24 hours from the moment of wounding) includes all stages and usually ends with the imposition of primary sutures.
2) Delayed (from 24-48 hours). During this period, inflammation develops, edema, exudate appears. The difference from early PCO is the implementation of the operation against the background of the introduction of antibiotics and the completion of the intervention by leaving it open (not sutured), followed by the imposition of delayed primary sutures.
3) Late (later than 48 hours). The inflammation is close to maximum and the development of the infectious process begins. In this situation, the wound is left open and antibiotic therapy is given. Perhaps the imposition of early secondary sutures for 7-20 days.
PHO are not subject to the following types of wounds:
1) superficial, scratches;
2) small wounds with a divergence of the edges of less than 1 cm;
3) multiple small wounds without damage to deeper tissues;
4) puncture wounds without damage to organs;
5) in some cases, through bullet wounds of soft tissues.
Contraindications to the implementation of the PHO:
1) signs of development of a purulent process in the wound;
2) the critical condition of the patient.
Types of seams:
Primary surgical.Apply to the wound before the development of granulations. Impose immediately after the completion of the operation or PHO wound. It is inappropriate to use in case of late PHO, PHO in wartime, PHO of a gunshot wound.
Primary delayed.Apply until granulations develop. Technique: the wound after the operation is not sutured, the inflammatory process is controlled and when it subsides for 1-5 days, this suture is applied.
Secondary early.Apply to granulating wounds, healing by secondary intention. The imposition is made on days 6-21. By 3 weeks after the operation, scar tissue forms at the edges of the wound, which prevents both the approach of the edges and the process of fusion. Therefore, when applying early secondary sutures (before scarring the edges), it is enough to simply stitch the edges of the wound and bring them together by tying threads.
Secondary late.Apply after 21 days. When applying, it is necessary to excise the scar edges of the wound under aseptic conditions, and only then suture.
Toilet wounds. Secondary surgical treatment of wounds.
1) removal of purulent exudate;
2) removal of clots and hematomas;
3) cleaning the wound surface and skin.
Indications for VHO are the presence purulent focus, lack of adequate drainage from the wound, the formation of extensive zones of necrosis and purulent streaks.
1) excision of non-viable tissues;
2) removal of foreign ones and hematomas;
3) opening pockets and streaks;
4) drainage of the wound.
Differences between PHO and WMO:
| Signs | PHO | WMO |
| Deadlines | In the first 48-74 hours | After 3 days or more |
| The main purpose of the operation | Suppuration prevention | Treating an infection |
| Wound condition | Does not granulate or contain pus | Granulates and contains pus |
| Condition of the excised tissue | With indirect signs of necrosis | With clear signs of necrosis |
| Cause of bleeding | Self-injury and tissue dissection during surgery | Arrosion of a vessel in a purulent process and damage during tissue dissection |
| The nature of the seam | Closure with a primary suture | Subsequently, it is possible to apply secondary sutures |
| Drainage | According to indications | Required |
Classification by the type of damaging agent: mechanical, chemical, thermal, radiation, fire, combined.
Types of mechanical injuries:
1 - Closed (skin and mucous membranes are not damaged),
2 - Open (damage to mucous membranes and skin; risk of infection).
3 - Complicated; Immediate complications that arise at the time of injury or in the first hours after it: Bleeding, traumatic shock, violation of vital functions of organs.
Early complications develop in the first days after injury: Infectious complications (wound suppuration, pleurisy, peritonitis, sepsis, etc.), traumatic toxicosis.
Late complications are detected at a time remote from damage: chronic purulent infection; violation of tissue trophism (trophic ulcers, contracture, etc.); anatomical and functional defects of damaged organs and tissues.
4 - Uncomplicated.