Anastomotic fibularectomy

The tibia has an independent blood supply system (incitement, vein). After cutting, it does not affect the blood supply of the lower limbs, and the tibia and vein can separate long pedicles. The average outer diameter of the artery is 2.0 to 2.5 mm, and the outer diameter of the accompanying vein is 2.0 to 3.0 mm, which facilitates vascular anastomosis. The length of the adult tibia is 28 ~ 30cm, except for the lower end 5 ~ 6cm is necessary for the stability of the ankle joint, the rest are available for transplantation. In addition, the cheekbones are straight and have no curvature or curvature. Therefore, the tibia is best for repairing large bone defects in the extremities of the extremities. Treatment of diseases: bone defects Indication 1. Due to congenital diseases (such as congenital sacral pseudoarthrosis), tumor segment resection or trauma caused by large bone defects in the long bones of the extremities. 2. Bloody or traumatic osteomyelitis caused by large bone defects in the long bones of the bone, and the wound completely healed for 3 to 6 months. 3. After the lower end of the humerus, the humeral head and the upper end of the tibia were used for the semi-articular graft. Preoperative preparation 1. Prevention of wound infection is an important guarantee for the success of bone grafting. The anti-infective power of the graft bone is very weak. Once infected, the bone graft is soaked in the pus, necrosis will occur, and failure will occur. The precautionary measures are: the skin should be strictly prepared for the affected area and the donor area; the storage process of the stored bone must have strict sterility requirements; those with bone and soft tissue infection must be cured after 3 to 6 months of infection. Bone graft surgery, otherwise the surgery is easy to stimulate local latent bacteria, so that the infection recurs. Such patients should use antibiotics before surgery, and should use the anti-infective cancellous bone graft or the anastomotic bone graft. 2. The soft tissue around the bone area and the blood supply to the bone should be rich, and the growth force should be strong, so as to ensure the healing process of the bone graft. If the local skin and soft tissues have extensive scars, the blood supply will not be good, and the content after bone transplantation will increase, the skin will be difficult to suture, and infection will occur easily, forming a sinus. Therefore, the scar should be removed before surgery, and the flap should be transplanted to create conditions for the healing of the bone graft. 3. Many patients who need bone grafting have undergone multiple operations or long-term external fixation, resulting in muscle atrophy of the injured limb, decalcification of the bones, varying degrees of joint activity, poor blood circulation and low anti-infectiveness. The tissue growth ability is also poor. External fixation after an indispensable period of bone grafting will result in muscle atrophy and increased joint stiffness. Therefore, a period of functional exercise and physical therapy should be performed before surgery. For patients with non-displaced lower extremity fracture non-union or bone defect, functional exercise can be performed under the protection of stent or external fixation. 4. Preoperative x-ray film to understand the condition of the diseased bone, design the operation according to the condition (including the bone grafting part, the size of the bone graft and the bone grafting method). If the bone graft is to be anastomosed, the full length of the graft bone and the lateral x-ray film should be taken before surgery to select the site and length of the bone graft. 5. Before the bone graft of the anastomotic blood vessel, the ultrasonic artery should be used to detect the presence and blood flow of the main artery in the donor and recipient limbs in order to design the operation. Generally, the branches of the main arteries of the limbs are used for anastomosis, such as the deep femoral artery of the femoral artery, the inner and outer arteries of the circumflex femoral artery. If there are 2 main arteries in the receiving area, such as the ulnar artery, radial artery, anterior and posterior iliac artery, one of the main arteries may be used for anastomosis. The prerequisite must be that another major artery is confirmed by ultrasonic flowmeter or clinical examination. The blood supply is good. The veins in the recipient area are usually treated with superficial veins, such as the cephalic vein, the venous vein, the great crypt, the small saphenous vein and its branches. Therefore, the superficial vein of the recipient area should be examined for damage or inflammation before surgery. Recently used as a puncture, the superficial vein of the infusion cannot be used as a receiving vein. Surgical procedure 1. Position: If the receiving area is the upper limb, the donor area is the contralateral humerus. The patient takes the semi-recumbent position, the upper limb is extended elbow, and the abduction is 90°, which is placed on the small table next to the operating table. If the affected area is the contralateral lower limb, the patient is lying supine, and the limb is straightened; the buttocks of the donor area are 30°45°, the limb is bent and the femoral part is closed; or the semi-recumbent position is taken first, and the humerus is completely free. And then change to a flat position. 2. Incision: starting from the posterior side of the humeral head, forward to the humeral neck, and then down the posterior aspect of the humerus to the desired length, but not more than 1/4 of the distal side of the humerus. If the humeral head needs to be cut, the incision can extend 5 to 6 cm along the posterior edge of the biceps tendon. 3. Exposure of blood vessels and nerves: After cutting the skin, subcutaneous tissue and fascia, the common peroneal nerve is found before the posterior medial edge of the biceps femoris, retracted with a rubber strip, and separated downward. The long bone of the tibia was cut under the protection of a slotted probe, and the superficial temporal and deep sacral nerves were isolated. Then, the middle part of the humerus is separated into the gap between the longissimus dorsi and the soleus muscle. Under the protection of the finger, the soleus muscle is cut at the upper end of the humerus, and the soleus muscle is pulled back, and the zygomatic arch of the iliac crest is seen. Deep in the muscles. Separate along the axillary and vein to the proximal end, taking care not to damage the branches of the tibia, muscles and skin until the spurs and veins originate from the starting point of the sacral movement and vein. 4. Cut the humerus: along the shallow surface of the iliac, vein, cut the flexor longus muscle to the required length, under the premise of protecting the common peroneal nerve from injury, cut the long and short tibia, and outside the tibia Keep 2 to 3 mm thick muscles. The distal end and the proximal end of the humerus were cut with a wire saw or a chainsaw after peeling the muscle according to the length required for the bone grafting of the recipient (the length is equal to the length of the bone defect and about 4 to 5 cm for the bone fixation). This allows the tibia to be rotated forwards or backwards for easy separation. Use the rongeur to clamp the end of the humerus, or use the curved hemostat to insert the proximal end of the humerus, rotate the humerus backward, cut the long toe, longus and interosseous membrane (be careful not to damage the posterior interosseous membrane) Blood vessels, nerve bundles). The humerus is rotated forward, and the posterior tibial muscle is cut from the bottom to the outside of the posterior tibial nerve and between the iliac and the vein, and the thickness of the muscle attached to the tibia is 0.5 to 1.0 cm. The distal end of the humerus was severed, and the distal iliac and vein were ligated and severed. At this point, the transplanted humeral segment has been freed except for the proximal iliac crest and the vein. At this point, release the gas-shaped tourniquet and observe the blood supply of the transplanted tibia. Such as periosteum, bone marrow cavity and attached muscles have active bleeding, indicating good blood supply. If the operation in the receiving area has been completed, the initial part of the iliac crest and vein can be cut and sewed separately, and the distal end of the cut blood vessel is not ligated. After cutting, the humerus with swaying and veins is transferred to the receiving area. 5. Cut the humerus with the humeral head: If the humerus with the humeral head is to be removed, the attachment of the biceps tendon and the lateral collateral ligament should be cut at the tip of the humeral head after dissociating and protecting the common peroneal nerve. Then cut the attachment of the longissimus dorsi and the soleus muscle, and retain some of the muscle fibers in the humeral head. Finally, the anterior and posterior iliac ligaments and joint capsules were cut. That is, the supracondylar joint can be inserted into the supracondylar joint with a periosteal stripper, and the humeral head can be freed, and the other steps are the same as above. 6. Stitching: The donor area completely stops bleeding and sutures layer by layer.