CC BY
18
I. ХИРУРГИЯ
UDC 616.833-001-036.14-08
THE USE OF EPI-PERINEURAL SUTURE OF PERIPHERAL NERVE IN EXTREMITY REPLANTATION
ABOUT THE AUTHORS
Mismil I. Muradov - head of the Department of reconstructive, plastic and aesthetic microsurgery of the NSCS n/a Syzganov, cand. med., a high level certificate physician; Timur A. Sadykov - microsurgeon, e-mail: sadikov.t@mail.ru.
MuradovM.I., SadykovT.A.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Republic of Kazakhstan Department of reconstructive, plastic and aesthetic microsurgery.
Keywords:
traumatic amputation, extremity replantation, epi-perineural suture, peripheral nerve, postoperative period
АВТОРЛАРТУРАЛЫ
Мурадов Мисмил Исламулы - Сызганов атын. YFXO Реконструктивп, пластикалык, жене эстетика микрохирургия бел/мшес/н/ц MeHrepyrnici, м.г.к, жогаргы санатты дер/гер; Садык,ов Тимур Эш1мулы. -дэркер-микрохирург, e-mail: sadikov.t@mail.ru.
Abstract
Currently there are developed many different ways to peripheral nerve suture. However, significant progress in the prevention of nerve neuromas weld area has not been achieved. There is no single treatment algorithm in the early and late postoperative period in patients with large replanted limb segments. In this regard, many therapeutic complexes are not sufficiently effective, and there is a need for improvement.
Аяк -колдарын кайта кондыру кезшдеп периферияльщ нервтердщ эпи-периневральды TiricTi колдану
Мурадов М.И., Садыков Т.А.
А.Н. Сызганов атында?ы Улттык^ыльш хирургия орталь™, Алматы к,., К,азак,стан, Реконструктивп, пластикалык,жэне эстетика микрохирургия бел1мшеЫ
Туйш сездер
жаракаттык отау, аяк-колды кайта кондыру, эпипериневрал-ды riric, перифериялык нерв, операциядан кейшп мерзм.
Ацдатпа
K,a3ipri тацда периферияльщ нервке riric салудыц квптеген v/pni тэалдер1 эз1рленген. Дегенмен нерв т1пс1ндеп жагында невромныц дамуын алдын алуда айтарлыкгай жетЫктер болмаган. Ауруларга ipi кайта цондырылган аяк,- цолдарыныц сегменттер1мен операция жасалганнан кей1нп ерте жэне кщ1рткен мерз1м1нде емдеудщ б1рде 6ip алгоритмы жо^. OcbifaH байланысты квптеген емдеу кешендерщ ти1мдш1п жеткшшз болады, сонды^ан оларды жетшд1руд1ц цажеттш1п туындайды.
ОБ АВТОРАХ
Мурадов Мисмил Исламович - заведующий Отделением реконструктивной, пластической и эстетической микрохирургии ННЦХ им. Сызганова, к.м.н., врач высшей категории;
Садыков Тимур Ашимович -врач -микрохирург, e-mail: sadikov.t@mail.ru.
Использование эпи-периневрального шва периферических нервов при реплантации конечности
Мурадов М.И., Садыков Т.А.
Национальный научный центрхирургии им. А.Н. Сызганова, г. Алматы, Казахстан Отделение реконструктивной, пластической и эстетической микрохирургии
Ключевые слова:
травматическая ампутация, реплантация конечности, эпи-периневральный шов, периферический нерв, послео-
Аннотация
В настоящее время разработано множество различных способов наложения шва периферического нерва. Однако заметных успехов, в профилактике развития невром области шва нерва, не разработано. Нет единого алгоритма лечения в раннем и позднем послеоперационном периоде больных с крупными реплантированными сегментами конечностей . В связи с этим многие лечебные комплексы оказываются недостаточно эффективными, и возникает необхо-
перационный период. димость в их усовершенствовании.
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Hypothesis
Traumatic amputation of large segments of extremities is severe trauma with an ambiguous outcome after replantation, caused not only by the quality of the sewed vascular anastomoses, but also a choice of suturing technique of peripheral nerves [1,6,7]. Devoid of innervation tissue subjected to atrophy and degeneration with the development of neurogenic muscle contractures and neurotrophic ulcers. The most important are the changes in the muscles that become unrecoverable and fibrosing in a year after nerve injury [2,4]. At present time there are many different ways to suture peripheral nerve. However, notable successes in the prevention of neuroma nerve in suture area are not developed. No single treatment algorithm in the early and late postoperative period in patients with replanted large segments of extremities [3,5,8,9]. In this regard, many treatment complexes are not sufficiently effective and need to be improved.
Aim of study: improve treatment of patients with traumatic amputations of extremities by applying during the replantation epi-perineural suture of nerve.
Material and methods
In Reconstructive, Plastic and Aesthetic Microsurgery department of National Scientific Center of Surgery named after A.N. Syzganov for the period from 2011 to 2015 there were treated 62 patients with traumatic amputation of extremity segments in age from 25 to 68 years. Surveyed were divided into main group of 30 and a comparison group of 32 patients. Most of the patients were of working age - 61.3%, among them prevailed men - 85.5%. On character of injuries, patients were distributed as follows: guillotine amputation - 18 patients, amputation of an electric saw - at 44. All patients were delivered in time for 1-3 hours from the time of injury. By the level of damage, the patients were selected with injuries of forearm and lower third of the arm.
All operations were performed under optical magnification (from 2.5 to 16-fold) using microsurgical instruments and atraumatic suture material (11/0 to 3/0).
Replantation of traumatically amputated segment was as follows: primary debridement, al-
location and marking of arteries, veins, nerves, bone repositioning, metal osteosynthesis, suture of tendons, restoration of blood flow in the main amputated segment after applying microvascular anastomoses of the veins and arteries, nerves suture. In comparison group of patients nerve was recovered by epineural suture. In contrast to the comparison group, to patients from the main group was performed epi-peri-neural suture of nerve with atraumatic needles with thread 8/0. Table 1 presents the results of extremities replantation during the period from 2011 to 2013.
To assess the results after 6 months of treatment was performed a full clinical examination considering the topography of the innervated tissue of recovered nerve and extremity function, vascular ultrasonography, radiography, measurement of electric potential of the surface tissue (Gerasimov
A.A. 1986), stimulatory electromyography (Hecht
B.M. and coauthors).
Results and Discussion
In the comparison group postoperative complications were noted in 10 (31.25%) cases. In 3 patients (9.4%) came thrombosis of vascular anastomoses. 6 months after replantation of extremity in 7 (21.9%) patients revealed unsatisfactory recovery of peripheral nerves with the absence of sensitive and vegetative-trophic function of the extremity. Of them in 5 (15.63%) cases are diagnosed the complete absence of extremity motor function, in 4 (12.5%) patients were formed neurotrophic ulcers, and therefore, to the patient was performed second surgery neuroma excision with imposing epi-perineural nerve suture.
In the main group postoperative complications were noted in 4 (13.33%) cases. In 1 patient occurred venous thrombosis of vascular anastomoses. In 3 (10%) patients, 6 months after the replantation of extremity revealed unsatisfactory recovery of peripheral nerves with incomplete restoration of the sensitivity. Extremity motor function was determined, but with decreased muscle strength. Trophic ulcers was not.
Full restoration of all clinical manifestations of nerve trunks injury not a single patient in both groups was not observed.
Level of Replanted extremities Satisfactory results after 6 months Unsatisfactory results
amputation The main group (n=30) Comparison group (n=32) The main group (n=30) Comparison group (n=32) The main group (n=30) Comparison group (n=32)
Forearm 27 30 24 21 3 9
Arm 3 2 2 1 1 1
Table 1.
Results of extremities replantation
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Thus, the use of epi-perineural nerve suture in the main group of patients contributed to the reduction of unsatisfactory results with the development of violations of sensitivity, motor function from 21.9% to 10% (p <0.05), and reduction of vegetative-trophic function of the extremity with the development trophic ulcers from 12.5% to their total absence.
The use of epi-perineural nerve suture in the main group of patients allowed to restore motor function of extremity in all cases and improve the results of replantation of extremity segments.
References
1. Belousov A.E. Microsurgery in traumatology /A.E. Belousov, S.S. Tkachenko.-L.: Medicine, 1988224 p.
2. Belousov A.E., Makarov F.N., Danilenkova L.V., et al. Microsurgical suture of peripheral nerves in the experiment // Quest, neurosurg.- 1983,- № 5,- P. 53-54.
3. Bogomolov M.S., Sedov V.M. Microsurgical replantation of fragments of the hand. - St. Petersburg.: «St. Petersburg medical publishing» - «Albee - St. Petersburg». - 2003. - 236 p.
4. Volkova A.V. Reconstructive hand surgery with combined injuries of tendons and nerves (at the level of the distal third of the forearm, wrist joint and carpal tunnel): Author, dis. Dr. med. sciences.- M., 1978- 25 p.
5. Datiashvili R.O. Extremities replantation / M., - Medicine, 1991. -240 p.
Conclusion
1. The use of epi-perineural suture during replantation reduces the number of unsatisfactory results of nerve recovery by 11.9% (p <0.05).
2. Replantation of extremity, including epi-peri-neural nerve suture allows to restore motor function and to do without repeated reconstructive surgery on peripheral nerves.
3. The use of epi-perineural suture of peripheral nerve during replantation reduces the risk of forming neurotrophic ulcers of replanted ex-tremityfrom 12.5% to their total absence.
6. KrylovV.S., MilanovN.O., Borovikov A.M., et al. Five years experience in microsurgical autotransplantation tissue / Problems of microsurgery.- M., 1985. -P. 9-11.
7. Podgayskiy V.N. Organizational and tactical aspects of microsurgical replantation of extremities and their segments: Dis. Doctor, med. Sciences: 14.00.27/ BGIUV. - Minsk., 1997. - 338 p.
8. Kaplan I. et al. Free flaps reconstruction in hand and orthopaedic surgery /1. Kaplan, S. Ada, F. Ozerkan et al. // 6th Congress of the International Federation of Societies for Surgery of the Hand (IFSSH). July 3-7. - Helsinki, 1995. - P. 207-211.
9. Weaver F.A. Difficult peripheral vascular injuries / F.A. Weaver, G. Papanicolaou, A.E. Yellin // Surg. Clin. NorthAmer.- 1996.-Vol.76.-P.4-9.
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