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32
II. ХИРУРГИЯ
LESS TRAUMATIC APPROACHES OF FLEXOR-TENDON INJURIES OF HAND FINGERS IN MICROSURGERY
Muradov M.I., Mukhamedkerim K.B., Baiguzeva A.A, Kazantayev K.E., Koshkarbaev D.Zh.
JSC "National Scientific Center of Surgery named after A.N. Syzganov", Reconstructive, plastic and aesthetic microsurgery department, Almaty, Kazakhstan
Abstract
Tendon injuries of all motor system injuries occur in 1,8%-18,8% of cases, by various authors [1,2,3]. 32% of them are flexor-tendon injuries of hand fingers [4]. High frequency of flexor-tendon injuries of hand fingers and as a result - causing or loss disability level in 40% of victims, attest to the social significance of this problem [5]. The ongoing technical difficulties in the tendons surgery require further improvement of operational tactics. Purpose of this research is improvements in treatments of patients with flexor-tendon injuries of hand fingers, using low-traumatic access. Materials and methods. In department of reconstructive microsurgery 410 of patients with flexor-tendon injuries of hand fingers were examined and operated from 2008 to 2017. The total number of flexor-tendon injures were 1005. The age of the patients ranged from 2 to 68 years. The majority of the patients are young people of working age (18-50 years old). The most of patients are 273 (66.6%) of professional workmen, 58 (14.1%) of handymen, 11 (2.7%) of students. In the seasonal distribution of flexor-tendon injuries predominate from May to July, fewer injuries accounted for winter. All surgeries were produced under conduction anesthesia using microsurgical techniques. The incisions were made along the palmar surface of the hand directly above proximal and distal ends of flexor-tendon injuries of hand fingers based on ultrasound data. Results and discussion. The complete recovery of phalanges flexor movements of fingers amplitude was obtained in 77.8% on average 1 year after the operation. Good results were obtained in 16.1% of patients, while the amplitude of the extensor movements of the fingers was associated with moderate tenogenic flexion contracture in the interphalangeal joints of the fingers. In 6,1% of the patients have satisfactory results, while active flexion movements in the metacarpophalangeal joints were restored, but the contracture of the fingers in interphalangeal joints in the position of physiological flexion developed. The part of patients with unsatisfactory results did not undergo appropriate rehabilitation therapy. Conclusions. Minimally invasive approaches combined with microsurgery techniques sufficient to undertake flexor-tendon of hand fingers reconstruction.
Кол caycaK ciœipëepimœ микpoxиpypгиялык œaparçaTbmbiœ rnafbrn eмдey-шapaлыpы
MPHTÈ 76.29.39.
ABOUT THE AUTHORS
Muradov Mismir Islamovich - head of the department of reconstructive plastic surgery.
Muhamedkerim Kanat Bazarbekovich
- microsurgeon of the department of reconstructive-plastic microsurgery.
Baiguzeva AliyaAskarbekovna -
microsurgeon of the department of reconstructive-plastic microsurgery.
Kazantayev Kymbat Yerikuly
is a junior research associate in the department of reconstructive-plastic microsurgery.
Koshkarbayev Daniyar Zhambyluly
is a junior research associate in the department of reconstructive-plastic microsurgery.
Keywords
Trauma, Reconstructive, plastic and aesthetic microsurgery, Hand
М±радов М.И., М±хамедкер1м К.Б., Байгузева A.A.,
Казантаев К.Е., Кошкарбаев Д.Ж.
«À.H. Cbi3faHOB aTbiHflafbi Улттык, FbrnbiMè хирургия орталь™» AK,,
Реконструктивт пластика жэне эстетика микрохирургия 6eëiMrneci, Алматы, Казакстан
Ацдатпа
TipeK-цимыл œyéeciHiH барлык жаракаттарыныц арасында эр rypni авторлардыц айтуы бойынша ciœipfliœ закымдануы 1,8% - 18,8% жащайларды к±райды [1,2,3]. Олардыц i0iHäe 32% саусактардыц бушш ciцipлepiнe катысты [4]. Саусактардыц бушш ciцipлepiнe закым ^л^рудЦ жорары дeцгeйi жднe нэтижeciндe зардап шeккeндepдiц 40% жумыс icreу кабmem жоралту c6e6i peтiндe элeумeттiк мацыздылырын растайды [5]. Хирургиядары тexникалык киындыктар Kß3ipri тащат eмдeу eдicтepiн dpi карай жeтiлдipудi талап eтeдi. Осы жумыстьщ максаты жаракаттык ecepi аз тэciлдepдi колдану аркылы саусакгардыц бушш ciцipлepiнe закым Keлтн наукастардыц eмдeу нэтижeлepiн жаксарту болып табылады. Мэл'/мет жэне эд '/с. Peконcтpукциялык микрохирургия бeлiмiндe 2008 жылдан бастап 2017 жылта дeйiнгi ^eme саусактардыц бушш ciцipлepiнe жаракрт алран 410 наукас тeкcepiлiп, ота жасалды. Закымдалран бушш ciцipлepiнiц жалпы саны 1005 болды. Пациeнттepдiц жасы 2^н 68 жаска дeйiн болды. Пациeнттepдiц кeпшiлiп (65,5%) жумыска кабiлeттi жастары (18-50 жас) адамдар болды. Пациeнттepдiœ кeпшiлiп 273 кэаби ^Mernep (66,6%), колeнepшiлep 58 (14,1%), cтудeнттep - 11 (2,7%). Барлык оталар микрохирургиялык эдicтepдiн колданып, eцipлiк анecтeзия бойынша eткiзiлдi. Цолдыц алакан бeтiндeгi ^скн, ультрадыбыстык мдлiмeттep нeгiзiндe журпзшщ. Нэтиже жэне талцылау. Опepациядан кeйiн 77,8% наукаста орташа 1 жылдан кeиiн бугу козралыстары амплитудасыныц толык калпына кeлуi байкалды. Жаксы нэтижeлep пациeнттepдiц 16,1% ал канараттанарлык нэтижe - 6,1% - наукастарда байкалды. К,анараттанарлыксыз нэтижeлepi бар наукастардыц бip бeлiгi тиЫ оцалту тepапияcын кабылдаран жок. Цортынды. Микрохирургиялык эдicтepмeн бipiктipiлгeн жаракаттык ocepi аз тэciлдep саусактардыц бушш ciцipлepiц peконcтpукция жолдарындары колайлы эдici болып табылады.
ABTOPËAP ТУРАЛЫ
M±paдpв Мисмил Иcлaмoвич -
peкoнcтpyêгивтi плacтикa жэнe э^ти^ микpoxиpypгия бeлiмшeciнiœ жeтeкшici
M±xaMewepiM laíar Бaзap6eкoвич -
peкoнcтpyêгивтi плacтикa жэнe эcтeтикa микpoxиpypгия бeлiмшeciнiœ микpoxиpypгi
Бaйгyзeвa ЭлияAcl&p6eкoвнa -
peкoнcтpyêгивтi плacтикa жэнe эcтeтикa микpoxиpypгия бeлiмшeciнiœ микpoxиpypгi
I|aзaнтaeв I|ым6aт Epé/c^bi -
peкoнcтpyêгивтi плacтикa жэнe эcтeтикa микpoxиpypгия бeлiмшeciнiœ к!0i гылыми кызмeткepi
I(oшlíap6aeв ÄaH^p Жaм6ыл±лы -
peкoнcтpyêгивтi плacтикa жэнe эcтeтикa микpoxиpypгия бeлiмшeciнiœ к0i гылыми кызмeткepi
Туйш ce3äep
Жapaкaт, Peкoнcтpyкгивтi, плacтикa жэне anemia mm^Û-xMpypm, Крл.
Менее травматичные доступы в микрохирургии травм сухожилий сгибателей пальцев кисти
ОБ АВТОРАХ
Мурадов Мисмип Испамович -
заведующий отделением реконструктивно-пластической микрохирургии
Мухамедкерим Канат Базарбекович
- микрохирург отделения реконструктивно-пластической микрохирургии
Байгузева Апия Аскарбековна -
микрохирург отделения реконструктивно-пластической микрохирургии
Кдзантаев Цымбат Ер1к±пы - резидент по специальности «Спортивная медицина» КазНМУ
Кошкарбаев Данияр Жамбыпупы -
младший научный сотрудник отделения реконструктивно-пластической микрохирургии
Ключевые слова
Травма, реконструктивная, пластическая и эстетическая микрохирургия, кисть.
Мурадов М.И., Мухамедкерим К.Б., Байгузева A.A., Казантаев К.Е., Кошкарбаев Д.Ж.
АО «Национальный Научный Центр Хирургии им. А.Н. Сызганова»,
Отделение реконструктивной пластической и эстетической микрохирургии, Алматы Казахстан
Аннотация
Среди всех повреждений опорно-двигательной системы травмы сухожилий, по данным различных авторов, происходят в 1,8% - 18,8% случаях [1,2,3]. Из них 32% - это травмы сухожилий сгибателей пальцев кисти [4]. Высокая частота повреждений сухожилий сгибателей пальцев кисти и как следствие - снижение или потеря трудоспособности у 40% пострадавших, свидетельствуют о социальной значимости данной проблемы [5]. Имеющие место технические сложности в хирургии сухожилий требуют дальнейшего усовершенствования оперативной тактики. Целью настоящей работы является улучшение результатов лечения больных с повреждением сухожилий сгибателей пальцев кисти, путем использования малотравматичных доступов. Материал и методы. В отделении реконструктивной микрохирургии обследовано и оперировано 410 больных с повреждениями сухожилий сгибателей пальцев кисти за период с 2008 по 2017гг. Общее количество поврежденных сухожилий сгибателей составило 1005. Возраст больных колебался от 2 до 68 лет. Большинство пациентов (65,5%) составили лица молодого трудоспособного возраста (18 - 50 лет). Основная часть пациентов составили профессиональные рабочие 273 (66.6%), разнорабочие 58 (14.1%), учащиеся - 11(2,7%). Все оперативные вмешательства производились под проводниковой анестезией с применением микрохирургической техники. Разрезы по ладонной поверхности кисти производились на основании данных УЗИ, непосредственно над проксимальным и дистальным концами поврежденного сухожилия сгибателя пальца кисти. Результаты и обсуждение. Полное восстановление амплитуды сгибательных движений фаланг пальцев получено у 77,8% в среднем через 1 год после операции. Хорошие результаты получены у 16,1% пациентов Удовлетворительные результаты у 6,1% - у пациентов. Часть пациентов с неудовлетворительными результатами не прошли соответствующей реабилитационной терапии. Выводы. Менее травматические подходы в сочетании с методами микрохирургической техникой достаточны для выполнения реконструктивных вмешательств на сухожилиях сгибателей пальцев кисти.
Introduction
Tendon injuries of all motor system injuries occur in 1,8%-18,8% of cases, by various authors [1,2,3]. 32% of them are flexor-tendon injuries of hand fingers [4]. High frequency of flexor-tendon injuries of hand fingers and as a result - causing or loss disability level in 40% of victims, attest to the social significance of this problem [5].
The ongoing technical difficulties in the tendons surgery require further improvement of operational tactics. In particular, the compact arrangement of the functionally important hand anatomical structures, developing in the postoperative period, the cicatricial process limiting the restoration of finger movements predetermine the improvement of access to injured tendons [6,7,8].
Skin incision in hand surgery should provide sufficient access and good view of the operative site without development in the subsequent disrupting function of the scars. Vessels, nerves and tendons can easily be damage in wrong skin incisions in its own field; rough cicatricial deformations and contractures develop with all its consequences [9,10].
Purpose of this research is improvements in treatments of patients with flexor-tendon injuries of hand fingers, using low-traumatic access.
Materials and methods
In department of reconstructive microsurgery 410 of patients with flexor-tendon injuries of hand fingers were examined and operated from 2008 to 2017. The total number of flexor-tendon injures were 1005.
The age of the patients ranged from 2 to 68 years. The majority of the patients are young people of working age (18-50 years old). The most of patients are 273 (66.6%) of professional workmen, 58 (14.1%) of handymen, 11 (2.7%) of students. In the seasonal distribution of flexor-tendon injuries predominate from May to July, fewer injuries accounted for winter.
There are 331(80,7%) of men and 79 (19,3%) of women. Right wrist is traumatized in 265 (64,6%) patients, left one in 145 (35,4%). Domestic wrist trauma had in 79 (19,3%) of patients, production trauma in 331 (80,7%) of patients. In 75,1% of cases cut, chopped, stab, scalp wounds were encountered. In 22% of patients are stab-smashed, press, crushed injuries. 2.9% of cases are gunshot wounds.
Time prevailed between injury and admission to the emergency hospital before 6 hours in 288 (70,3%) of patients, from 6 to 24 hours in 100 (24,3%) of patients and after 24 hours in 22 (5,4%) of patients.
At entry clinic for isolated flexor-tendon injury was identified in 108 (26,4) of patients. 302 (73,6%) of victims have asked with combined injuries of arteries, nerves, tendons, bones of the hand and fingers.
Depending on the trauma level and features of the hand topographical and anatomical structure, injuries were in the 1st zone in 9 patients (2%), in the 2nd zone - 160 (39%), III zone 61 (14.9%), IV zone 123 (30%), in the V zone 57 injured (13.9%).
396 (96,6%) of patients were done ultrasound scan of hand tissue with a view to identifying the localization ends of the flexor-tendon injuries of hand fingers. 14 (3,4%) of patients didn't do ultrasound because the severity of general health.
The research allowed objectifying trauma tendons, informed about diastasis between tendon's ends and prejudges operational access.
Displacement of Tendons ends was 5-6 cm on the average in 389 (94,9%) of patients. In 7 (1,7%) of patients with wound in I zone (5 patients of them with flexor injury of V finger) proximal ends of flexor were found at the level of carpal tunnel.
All surgeries were produced under conduction anesthesia using microsurgical techniques. The incisions were made along the palmar surface of the hand directly above proximal and distal ends of flexor-tendon injuries of hand fingers based on ultrasound data (Figure 1).
In compliance with the features of the hand anatomical structure the incisions were done under magnification of x2,5 binoculars microscope without crossing transversely, the main dermal furrows of the hand.
Obliquely transversely by the length and width of the phalange was dissecting in I, II, III of tissue. In 233
(56,8%) of patients posttraumatic wounds expanded V-shaped the length of the middle and nail phalanges for allocating distal ends of flexor. In 56 (13,6%) of the patients with trauma at the level middle phalanges the distal end of flexor was allocated through cross-section at the level of main phalange. In 28 (6,8%) of the patient was at the level of middle palmar crease and in 7 (1,7%) - at the level of carpal tunnel. In IV and V zones with injuries additional incisions were done at the level of crease of the radiocarpal joints.
The tissues were dissecting to place of wound of tendon sheath. The revision of neurovascular bundle was made. The wound of sheath was expanding in transversely direction. When the finger was bent, the distal ends of the flexors were removed into the wound. In doing so, if the length withdrawing to wound of flexor end was less than 1 cm, the wound was dilated distally.
In 340 (82,9%) of patients were done the dissecting of surface flexor after allocating of trauma tendon ends in case of wound at I, II, III, IV zones. Manipulation was done special attention at the level middle phalange, where the flexor legs under the ligament are fixed to the periosteum.
The tendon manipulation was done under magnification of x2,5 magnifying glass. Using modified suture (Figure 2).
The tendons ends were sewed on mode by Cuneo with the filament of No. 2/0 line and applied one turn on each side of the tendon end, having deviated from the edge 1-2 mm. The axial load was evenly distributed throughout the tendon end, which prevented the stratification and corrugation of the tendons ends during further manipulation. The tendons ends were brought
Figure 1.
Less traumatic incisions on the hand taking into account anatomical features
Figure 2.
Modified ligaments suture
«to each other» under the ligaments in the osteo-fibrous canal with the help of the Rozov's tendon conductor. This method of tendon suture allows the sewn tendons ends to pass through the bone-fibrous canal into the main wound of two incisions, without crossing the skin and the synovial sheaths during the diastase between the tendons ends. The strength of the modified suture allows avoiding fixing the injured segments with a gypsum langette and starting an early postoperative development of the cross-linked tendons.
The suture of arteries and nerves was done under magnification of x 10 microscope with filaments 8/0 - 9/0.
In 12 patients with extensive skin defects of the hand and fingers, full-layer skin plastic was produced. In 9 patients, the skin defect was eliminated by plastic surgery with local tissues. In 3 victims on the area of the restored tendons, a superficial palmar arterial arch and branches of the median and ulnar nerves, the radial flap was moved. The hand was fixed in a functional position.
Therefore, in 87 (21,2%) of patients one of the tendon end managed to extract from the main wound (proximal tendon end is in 52 (12,6%) of the patients and distal tendon end is in 35 (8,5%) of the patients) and for recovering of the tendon one incision or increase of the main wound was performed. In other patients were done 2 additional incisions.
Results and discussion
Remote results of surgical treatment of flexor-tendon injuries of hand fingers using minimally invasive approaches, modified tendon suture and appropriate rehabilitation therapy were observed in 162 (39,5%) of patients in place within a year to 3 years. In the long-term period from five to seven weeks were recorded 4 ruptures of the tendon suture, which occurred during development.
Evaluation of the results of treatment was performed under patient's examination 1 year after surgery based on scheme proposed by the American Association of Surgeons of the hand (AAHS), in the modification of I.N. Kurinnii. Phalanges flexion recovery of injured fingers was assessed as excellent from 75 to 100%, good from 50 to 74%, satisfactory from 25 to 49% and poor from 0 to 24%.
The complete recovery of phalanges flexor movements of fingers amplitude was obtained in 77.8% on average 1 year after the operation. Good results were obtained in 16.1% of patients, while the amplitude of the extensor movements of the fingers was associated with moderate tenogenic flexion contracture in the interphalangeal joints of the fingers. In 6,1% of the patients have satisfactory results, while active flexion movements in the metacarpophalangeal joints were restored, but the contracture of the fingers in interphalangeal joints in the position of physiological flexion developed. The part of patients with unsatisfactory results did not undergo appropriate rehabilitation therapy.
Conclusions
1. Minimally invasive approaches combined with microsurgery techniques sufficient to undertake flexor-tendon of hand fingers reconstruction.
2. Determination of the localization of the injured tendons ends with ultrasound scanning and small incisions on the hand allow us to observe the basic principles of low-injury technique and not to break the anatomical features of the hand structure, thereby improving the outcome of treatment of this category of patients.
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