zemo kidurebis grZeli Zvlebis segmentaluri da rbilqsovilovani

defeqtebis kompleqsuri mkurnaloba.

l.TavberiZe, e. gocaZe, n. TavberiZe

travmatologiisa da orTopediis centri, sefsisis sawinaaRmdego centri,

Tbilisi, saqarTvelo

zemo kidurebis grZeli Zvlebis, posttravmuli Zvlovani da rbilqsovilovani defeqtebis mkurnaloba, qronikuli Cirqovani infeqciisa da sisxlis mimoqcevis limfo-venuri ukmarisobis fonze, soliduri problem [1,2], romlis gadawyveta rekonstruqciuli qirurgiis Tval-sazrisiT moiTxovs qirurgisagan umaRles kvalifikacias. am SemTxvevaSi qirurgiuli taqtikis efeqturoba bevrad aris damokidebuli imaze, Tu ramdenad srulfasovnad xdeba rbilqsovilovani safarvelis aRdgena da Seqmnili sareceli ramdenad aris vaskularizebuli Zvlovani autotransplantantebis implantaciisaTvis [1-.3]. arsebuli qronikuli infeqcia xSirad gamoirCeva maRali medegobiT antibiotikebis mimarT, romelTa keraSi mitana, sisxlis mimoqcevis deficitis fonze, TavisTavad SezRudulia [1, 5 ].

70-ian wlebSi sabWoTa mecnierebis: oTar RuduSaurisa da gavrila ilizarovis mier mowodebulma da danergilma kompresiul-distraqciulma osteosinTezma samarTlianad moipova aRiareba mTel msoflioSi da unda iTqvas, rom aRmosavleT evropaSi farTed gavrcelebuli meTodia, Tumca es ukanaskneli asocirdeba mraval garTulebasTan [ 8 ].

mcire wvivis vaskularizebuli Zval-kan-kunTovani autotrans-plantanti, aRwerili 1983 wels Cenisa da ianis mier da SemdgomSi oisimuras mier, gaxda erT-erTi daxvewili meTodika zemo kidurebis da kerZod, winamxris grZeli Zvlebis rbilqsovilovani defeqtebis rekonstruqciaSi [1,7,9,10 ixil, sur1].

sur. 1

alternatiuli variantia, idayvis Zvlis defeqtis rekonstruqcia Zval-rbilqsovilovani implantiT mkvebav fexze, romelic formirebulia TeZos frTidan[ 8 ].

Sromis mizans warmoadgens, zemokidurebis grZeli Zvlebis Zval-rbilqsovilovani inficirebuli segmentaluri defeqtebiskompleqsuri mkurnaloba kompresiul-distraqciuli osteosinTezisa da Zvlis Tavisufa

li kortikaluri da spongiozuri autotransplantantebis gamoyenebiT.

masala da meTodebi:

Cveni Setyobineba bazirebulia saq. Sromis, socialuri da janmr-Telobis dacvis saministros o. RuduSauris saxelobis travmatologii-sa da orTopediis da sefsisis sawinaaRmdego centrebis 1986-2002 wlebis klinikur masalaze, sadac mkurnaloba Cautarda 762 pacients grZeli Zvlebis inficirebuli defeqtebiT. maT Soris iyo 76 qali da

686 mamakaci. pacientTa saSualo asaki varirebda 14-dan 50 wlamde.

59 %-s osteomieliti ganuviTarda Ria motexilobis fonze, xolo 41 %-s - gegmiuri operaciebis Semdgom. pacientTa 93 %-s mote-

xiloba Sexorcebuli hqonda, Cirqovan garTulebaTa xangrZlivoba ki 1

Tvidan 1 wlamde. am periodSi pacientTa did nawils CvenTan moxvedramde

warmoebuli hqonda minimum 2-3 operaciuli Careva, rasac Sedegi ar mohyva.

saintertesoa Cirqovan garTulebaTa struqtura. Tu 1981_86 wleb-Si arsebuli antibiotikebis gamoyenebis fonze stafilokokuri infeqci-is xvedriTi wona Seadgenda 68%-s, xolo gramuaryofiTi flora - 32 %-s, amJamad sefsisis centris mikrobiologiuri laboratoriis monace-mebiT stafilokokuri floris xvedriTi wona 64 %-ia, xolo gramuar-yofiTi mikrobebisa 36%. Arac Seexeba mikrobTa mgrZnobelobas, beta-laqtamaza maproducirebel mikrobTa rezistentobas iseT farTed xmarebuli antibiotikis mimarT, rogoric aris ciprofloqsacilini, is 37%-ia, xolo penicilinis mimarT - 84%, amoqsacilinis mimarT - 88%.AMA kidurebis grZeli Zvlebis segmentaluri da rbilqsovilovani defeqte- bis ganviTarebis wamyvan faqtorad Cveni masalis analizis safuZvelze ZiriTadSi gvevlineba e.w. maRali energiis mqone travma. Tumca aranakleb

serozul mizezad SeiZleba CaiTvalos mZime da gaumarTleblad travma- tiuli operaciebi, rasac SeiZleba mohyves Zvlis vrceli nekrozi da Wri-

lobis daCirqeba. rac Seexeba pacientTa maRalmedegi baqt. floris warmomavlobas, es SeiZleba aixsnas im naklebefeqturi da araradikaluri

qirurgiuli CarevebiT, rasac mimarTaven dabali kvalifikaciis qirurgebi

warmoqmnili postoperaciuli garTulebebis SemTxvevaSi. qirurgiuli taqtika WrilobaTa damuSavebisa da reviziebis dros aris radikaluri da amave dros faqizi rbili qsovilebis mimarT. Cveni gamocdilebiT Cirqo-

vani procesis fonze warmoebuli rekonstruqciuli Careva moiTxovs gaaz-

rebuli dizainis garda, sisxlis mimoqcevis posttravmuli kompensaciis pi

robebis realur Sefasebas. am mxriv gansakuTrebiT faqizia rbilqsovilo

vani safarveli. maRali energetikuli travma ZiriTadi mizezia rbilqsovi-

lovani safarvelis daJeJvisa da moWyletis. mas xSirad axlavs e.w. “kompa-

ktment” sindromi. KkanqveSa SemaerTebel qsovilovan areSi iqceva sisxli,

viTardeba anTebiTi procesi SeSupebiT, aweuli wneva arRvevs kanqveSa cximovani qsovilis trofikas, viTardeba nekrozuli areebi da iqmneba xelsayreli pirobebi anaerobuli infeqciis ganviTarebisaTvis. am meqaniz-

mebis codna aucilebelia swori samkurnalo strategiis asarCevad. Cveni

azriT maRali energetikuli travma iseve, rogorc sarevizio–rekonstruq-

ciuli operaciebi, moiTxovs qirurgisagan umaRles profesionalizms, me-

tadre rTulia travmiT dazianebuli zemo kiduris SenarCuneba, mZime tra- vmisa da TandarTuli infeqciis fonze. im dros, rodesac qvemo kiduri

sayrdenia, zemo kiduri Sromis iaraRia. mas gaaCnia multifunqcia. aseTi tipis travmebis dros srulyofili funqcia znelad misaRwevia da xangr- Zlivia droSi. zemo kidurebis grZeli Zvlebis inficirebuli defeqtebis mkurnaloba kompleqsuria, romlis mizansac Seadgens travmiTa da Tandar-

Tuli infeqciiT gamowveuli cvlilebebis adeqvaturi koreqcia. aq gasa-Tvaliswinebelia winamxris Zvlebis sigrZivi Tanafardoba, kerZod 2 sm-de

arsebuli segmentaluri defeqtis mkurnaloba kompresiuli osteosinTe- ziT damoklebis gamo, an iZleva deformacias, an warmoqmnis konfliqts idayvis saxsarSi, rodesac idayvis damoklebis gamo warmoiqmneba sxivis Tavis zewola mxris Zvlis sasaxsre zedapirze. rac Seexeba mxris Zvals, aq SedarebiT naklebi problemaa, radganac erT ZvalTan gvaqvs saqme, kom-presiuli osteosinTezi SeasaZlebelia da meti plastiurobiT. Zvlis seg- mentaluri defeqtebis dros winamxris Zvlebis zonaSi Cven mivmarTavT autoplastikas kortikaluri da spongiozuri transplantantebis gamo yenebiT. es meTodika SeiZleba iyos warmatebuli maSin, Tu gvaqvs gadasa nerg zonaSi Sesaferisi sareceli, rbilqsovilovani safarvelis defeq tis gareSe. Tuki saqme gveqneba safarvelis defeqtTan, maSin aucilebelia am safarvelis xelovnurad Seqmna. am mizniT Cven masalaSi viyenebdiT oTx sxvadasxva meTodikas: kanis plastikas italiuri meTodiT mkvebav fexze, kanis plastikas filatovis wesiT, kanis meorad plastikas gaxleCili naf- leTiT, bilokaluri osteosinTezs ilizarovis meTodiT. Zvlis autopla- stika aucilebelia yvela SemTxvevaSi, rom ar warmoiqmnas Zvlis Sexorce- bis problema. bunebrivia, rom aseTi tipis travmebis mkurnalobisas nebis- mieri operaciis warmoebisas Cven unda gaviTvaliswinoT infeqciis faq- tori. plastikis win gadasanergi kanis zedapiri unda iyos mzad am opera- ciisaTvis. es imas niSnavs, rom zedapiri unda iyos dafaruli cocxali granulaciiT, nekrozuli qsovilebis gareSe. operaciis dros, misi mocu- lobis gaTvaliswinebiT, Cven bunebrivia mivmarTavT antibiotikoTerapias mikrobuli floris mgrZnobelobis mixedviT.

1986-2002 wlebSi travmatologiisa da orTopediis da sefsisis sawi- naaRmdego centrebis bazebze 762 avamyofidan, romelTac hqondaT grZeli Zvlebis travmuli osteomieliti, 152 SemTxvevaSi Cvens mier gakeTda autoplastika kortikaluri da spongiozuri autotransplantantebis gamo- yenebiT. Zvlis segmentaluri defeqti aRemateboda 3 sm-s. aqedan 26 SemTx- vevaSi operacia warmoebul iqna zemo kidurze, mxari iyo _ 12, xolo wina mxari _ 14. rbilqsovtlovani defeqtiT iyo 6 pacienti. 2 pacients didi zomis rbilqsovilovani defeqtis gamo gaukeTda kanis plastika italiuri meTodiT mkvebav fexze kiduris fiqsaciiT mucelze. am pacientebs erT- droulad gaukeTdaT operacia Zvalze kideebis ganaxlebiT, Zvlis auto- plastika da garegani fiqsacia Rerovan aparatze calmxrivi mdebareobiT aragamWoli ReroebiT. avamyofTa 95 %-s gaaCnda met-naklebad gamoxatuli limfo-venuri ukmarisoba, romlis simZime damokidebuli iyo paTologiuri procesis xangrZlivobaze. analizebSi yuradRebas ipyrobda gamoxatuli koagulopaTia sisxlis siblantis momatebiT. yovelive zemoTxsenebulis gamo postoperaciul periodSi pacientebs utardebodaT TerapiaHhepariniT, gadasxmebiT (reopoliglukini, trentali, aktovegini), detraleqsiT. es ukanaskneli eniSnebodaT 2 Tvis ganmavlobaSi, TiTo kapsula 2-jer dReSi.

paralelurad sisxlZarRvovani Terapiisa, pacientebs utardebodaT baro-

Terapiis 5_ 6 seansi. am fonze limfo–venuri SeSupeba cxreboda, kidurSi

arsebuli hipoqsia ixsneboda. Terapiis efeqturobas vamowmebdiT kiduris

diametris gazomvis meTodiT. aseTi saxis kontroli xorcieldeboda uSua-

lod postoperaciuli intensiuri Terapiidan 1 kviraSi da SemdgomSi det raleqsiT Terapiis me-2 Tvis bolos. gverdiTi movlenebi Cven ar SegvimC- nevia. aseTi Terapia Cautarda 15 avadmyofs detraleqsis gamoyenebiT.

Sedegebi: Sedegebis Sefaseba xdeboda Semdegi kriteriumebis gaT- valiswinebiT: 1]. Cirqovani procesis kupireba Catarebuli Ooperaciuli

Carevis Semdgom; 2]. Zvlovani defeqtis adeqvaturi Canacvleba Zvlis kotikaluri da spongiozuri autotransplantantebis gamoyenebiT. 3] rbilqso- vilovani defeqtis adeqvaturi dafarva; 4] limfedemis dacxroma, sisxlis mimoqcevis mowesrigeba.

kargi Sedegi miRebuli iqna 24 SemTxvevaSi, 1 SemTxvevaSi mxris

dabali cecxlnasroli motexilobis mkurnalobis Semdgom motexiloba ar Sexorcda, Tumca Cirqovani procesi kupirebul iqna. 1 SemTxvevaSi adgili

hqonda transplantantis liziss.

gansja: amrigad, zemo kidurebis grZeli Zvlebis segmentaluri da rbilqsovilovani defeqtebis mkurnaloba aris kompleksuri da moicavs: 1] adeqvatur antibiotikoTerapias mikrobTa mgrZnobelobis gaTvaliswine- biT ahtibiotikebisa da Wrilobis baqterifagebis mimarT; 2] segmentaluri defeqtis odenobisda mixedviT ganisazRvreba rekonstruqciuli operaciis tipi da autoplastikis moculoba; 3] rbilqsovilovani defeqtis mdebare- obisa da farTis mixedviT xdeba kanis plastikis saxeobis gansazRvra: zerele defeqtis SemTxvevaSi kanis plastika gaxleCili nafleTiT an tirSis wesiT; Rrma da vrceli defeqtisas - kanis plastika italiuri meTodiT an Tavisufali nafleTiT mkvebav fexze.

4]. srulfasovani sisxlZarRvovani Terapia sisxlis koloiduri Tvisebebis gaTvaliswinebuT.

literatura:

1. Calkins,M.S.; Burrkhalter ;W.: and Reyes,F.: Traumatic segmental bone defects in the upper extremity. Treatment with exposed grafts of corticocancellous bone. J. Bone and Joint Surg., 69-A: 19-27, Jan. 1987
2. Scaglietti,O.; Stringa,G.; and Mizzau, M.: Bone grafting in nonunion of the forearm. Clin. Orthop., 43: 65-76, 1965
3. Castle,M. E.: One bone forearm. J. Bone and Joint Surg., 56-A: 1223 – 1227, Sept. 1974
4. Dabezies, E.J.; St ewart, W.E.; Goodman, F.G.; and Deffer, P.A.: Management of segmental defects of the radius and ulna. J.Trauma, 11: 778-788, 1971
5. Weiland, A.J.; Kleinert, H.E.; Kutz, J.E.; and Daniel, R.K.: Free vascularized bone grafts in surgery of the upper extremity. J. Hand Surg., 4: 129-144, 1979
6. Harrison, D.H.: The osteocutaneus free fibular graft. J. Bone and Joint Surg., 68-B[5]: 804-807,1986
7. Koshima, I.; Higaki, H.; and Soeda, S.: Combined vascularized fibula and peroneal

composite-flap transfer for severe heat-pres injury of the forearm .Plast. and Reconst. Surg.,88: 334-341, 1991

8. Tonkin, M.A.; Hanel, D.P.; and Scheker, L.R.: Vascularized fibular osteocutaneus

graft. Surgucal technique and clinical study. Australian and New Zelaland J. Surg.,

60: 51-57 1990

9. Grishin,I.G.; Golubev,V.G.: Goncharenko,I.V.; et all. Transfer of free vascularized bone and skin-bone autografts. Experiences in the application of external fixation apparatus. J.Reconstr. Microsurg., 6:1-11,1990

10. Yoshimura,M;Shimamura,K.;Yamauchi,S.; and Ueno,T.: Free vascularized fibular transplant. A new method for monitoring circulation of the grafted fibula. J.Bone and Joint Surg., 65-A: 1295-1301, Dec. 1983

Summary

Complex Treatment of Long Bones Segmental and Soft Tissue Septical Defects of

Upper Limb.

L . Tavberidze , E . Gotsadze, N .Tavberidze

O. Gudushauri’s Centre of Orthopedic and Traumatology, Sepsis Centre, Tbilisi, Georgia

The study cohort comprised 26 patients, who were treated in O.Gudushauri Centre of Orthopedic and Traumatology and Sepsis centre of Georgia from 1986 to 2002 years, with

long bones segmental and soft tissues septical defects of upper limb. Average age 40 years . From 26 patients, .23 was male and 3 female. 59% of patients were with nonunion fractures, after high energy open trauma. 41 % of patients had complications after combine fractures by non stabile osteosinthesis. All patients before our treatment, spend in other clinics from 1 month to 1 year. Some of them had from 1 to 3 operations without result. In 1981-86 years

in 68 % cases grew up staphylococci microbes, the gram-negative infection was 32%. In present we had another information from microbiology laboratory of sepsis centre, staphylococci flora grew in 64%, gram-negative microbes - in 36 %, effectiveness of popular antibiotic ciprofloxsacilline - in 63 %, penicciline – in 16%,amoxicilline – in 12%. Before operations we used antibiotics after test with pathogenic microbes from the wound. From 152 cases of grafting long bones septical defects with cortical cancellous and spongioza auto grafts upper limb was in 26 cases (17%). In 6 cases there was skin and soft tissue defects of arm and forearm. To covered soft tissue defects in 2 cases with big area of skin defect, we use free vascularized abdominal flap, in other cases we use free flap of skin. In 5 cases bone grafting used before skin plastic. The positive result after our treatment we watch in 24 cases, in 1 patient after gunshot trauma of arm the bone was nonunion, without infection, in 1 case was recidive of osteomielit.