Anastomotic ribectomy

The ribs also have an independent blood supply system, namely intercostal movements and veins. The intercostal artery originates from the dorsal side of the aorta and is divided into the anterior and posterior branches at the spine. The posterior branch supplies the paravertebral muscle, the meninges and the spinal cord, and the anterior branch is the intercostal artery [Fig. 1(1)]. The intercostal artery passes through the lower edge of the pleura and ribs and enters between the intercostal inner and innermost muscles and is divided into upper and lower branches. The upper branch is inclined to the rib angle and enters the rib groove of the upper rib; the lower limb is advanced along the upper edge of the next rib. Both the upper and lower strokes are consistent with the intercostal support of the internal thoracic artery [Fig. 1(2)]. In addition, there are many intermuscular arteries that supply the periosteum, the intercostal muscles, and the skin on them. Therefore, depending on the clinical needs, it is feasible to anastomosed rib grafts, or rib flap grafts. Treatment of diseases: bone defects Indication It is suitable for the repair of bone defects after displacement repair or filling of vertebral lesions. 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) Posterior rib resection 1. Position: lateral position, the operation side is upward. After the ribs are cut, the position is adjusted according to the needs of the surgery. 2. Incision: On the posterior side of the 8th and 9th ribs, a transverse incision is made 3 cm from the posterior median line, extending forward along the 8th or 9th rib. The length of the incision depends on the length required to graft the ribs. 3. Exposing the posterior rib vascular nerve bundle: After cutting the skin and subcutaneous tissue, the latissimus dorsi and the posterior inferior serratus muscle are cut, and the sacral spine muscle is separated and pulled to the inside. After the 8th rib or the 9th rib, the intercostal muscle and the intercostal posterior membrane are carefully cut from the upper edge of the lower rib and separated from the lower edge of the rib to be grafted, between the posterior intercostal membrane and the pleura. Find the intercostal blood vessels, nerve bundles, and separate the lengths along the blood vessels and nerve bundles forward or backward to the desired length. Care should be taken to remove the pleura during the separation to avoid injury; and some intercostal muscles should be retained to the ribs to preserve the intercostal vessels and nerve bundles. In order to increase the length of the proximal end of the intercostal blood vessel, the posterior branch of the intercostal artery can be ligated. Generally, 1 to 2 posterior branch vessels are cut off, which does not affect the blood supply to the spinal cord. 4. Cut the ribs: push the pleura on the deep side of the intercostal vessels, nerve bundles and ribs, and gradually separate from the upper edge of the ribs, cut the intercostal muscles on the upper edge of the ribs, and retain some of the intercostal muscles attached to the ribs. The pleura is then pushed forward along the deep side of the rib and back. The ribs are cut to the required length, and the front end of the flat ribs is ligated to cut the intercostal blood vessels. Such as the bone marrow cavity and intercostal muscles have active bleeding, suggesting that the rib blood supply is good. After the surgery is completed, the ribs of the intercostal blood vessels can be transferred to the pressure by ligating and cutting at the beginning as close as possible to the intercostal blood vessels. 5. Stitching: After the ribs are cut, they are sutured layer by layer. (B) rib front cutting 1. Position: supine position. 2. Incision: Starting from the lateral edge of the sternum in the fourth intercostal space, a transverse incision is made backwards, the length of which depends on the length required for the graft rib. In order to better reveal the internal thoracic artery, a longitudinal incision can be made at the lateral edge of the sternum to form a sacral incision. 3. Expose the blood vessels: After cutting the skin and subcutaneous tissue, cut and peel the 4th or 5th costal cartilage membrane, remove the costal cartilage, and then cut the costal cartilage bed, which can be in front of the sternum and the front of the transverse muscle. Find the internal thoracic veins, veins and intercostal branches, and separate the thoracic internal organs and veins from the pleura. 4. Cut the ribs: After separating the internal and inferior thoracic veins, separate the skin and subcutaneous tissue from the fascia and pull them up to reveal the ribs. Cut the outer ends of the ribs according to the required length, and then cut the ribs up and down. Muscles, note that some muscles should be retained attached to the ribs, and the lower edge should be kept more to protect the intercostal blood vessels. The ribs are cut at the flat ribs and the intercostal vessels and nerve bundles are cut. Finally, the pleura is pushed away from the ribs and intercostal vessels and the deep side of the nerve bundle, so that the transplanted ribs are completely free from the joints of the thoracic internal organs and veins. 5. Cut the rib flap: If there is skin defect in the recipient area, when the rib flap is transplanted, it can be 10%~15% according to the size of the skin defect in the receiving area, and the gentian violet is used under the skin of the rib. Draw the extent of the graft flap. Note that the width of the flap should not exceed 6 cm when the single rib-skin graft is transplanted, and the length is as long as the transplanted rib. Cut the inner edge of the flap first, and find the internal motion of the thoracic vein, vein and its intercostal branch, and protect it properly. The skin is then cut according to the range of the profiled flaps. The skin, subcutaneous tissue, fascia and muscles must be cut open, and no separation between the ribs and the skin is allowed. Carefully cut the intercostal muscles, push the pleura on the deep side of the ribs, and gradually form a rib-skin with the ribs as the axis and the pedicles in the thoracic motion. It must be noted that every time a section of skin is cut, the incision muscles, fascia and subcutaneous tissue must be sutured to protect the musculocutaneous vessels. 6. Stitching: When the rib is transplanted alone, the incision is sutured layer by layer without drainage. If the rib flap is transplanted, the donor site is deficient, and it is difficult to directly suture.