Angina

After subcutaneous. Subcutaneous injection - self-injection

Human skin consists of the epidermis, dermis and a third layer - consisting of fat cells. It acts as a thermostat and protects internal organs from shock. Inflammation of the subcutaneous tissue is a phenomenon that occurs quite often and brings a lot of trouble to the sick person.

Inflammatory processes with the accumulation of pus in the subcutaneous tissue are presented in several forms. In all pathologies, the most common pathogen is staphylococcus. The infection develops when the integrity of the skin and the overall immune resistance of the entire body decreases. The accumulation of a large number of bacteria also leads to the onset of the disease.

Boils and furunculosis

Inflammation of the hair follicle and the tissues located next to it, accompanied by a purulent process, is called furunculosis. The disease develops as a result of trauma to the skin - the appearance of cracks and abrasions, and also as a complication of diabetes mellitus, after severe hypothermia, and with vitamin deficiency.

At the beginning of the disease, an inflammatory infiltrate forms under the skin in the area of the hair follicle, which to the touch resembles a small nodule. The area above it hurts and swells, acquiring a red tint. As the infiltrate matures, tissue necrosis begins. After 3–5 days, the necrotic skin becomes so thin that the contents of the boil come out with fragments of hair. The wound is cleared of pus and gradually heals. A light scar remains in its place.

Depending on the location, a boil (or several at once in case of furunculosis) can cause a serious deterioration in the general condition. For example, purulent infiltrates that appear on the face in the area of the nasolabial triangle, near the eyes, often cause inflammation of the meninges. These diseases occur with high fever (up to 40 degrees), severe swelling, and hypertonicity of the occipital muscles.

Phlegmon

Cellulitis is a diffuse inflammation of the subcutaneous tissue caused by pyogenic microorganisms that enter through wounds (streptococci, staphylococci, E. coli and others). The disease manifests itself in the form of suppuration that does not have a capsule. Because of this, the process spreads very quickly.

The main complaints of people with phlegmon are a sharp increase in temperature to 39–40 degrees, chills, and growing swelling in the affected area. During palpation, pain is felt. At first, the infiltrate is felt under the fingers, but later it “spreads.”

Experts distinguish three types of phlegmon:

serous;
purulent;
putrid.

Surgical methods are used to treat purulent and putrefactive phlegmon. If the process occurs in a serous form, then conservative methods of therapy are most effective.

Carbuncle

Carbuncle is an inflammation of the subcutaneous fat, in which several hair follicles located nearby are simultaneously affected by infection. The cause of suppuration is streptococcal or staphylococcal infection.

A large infiltrate formed in the thickness of the skin makes itself felt with the following symptoms:

feeling as if the pain is bursting from the inside;
the skin becomes tense;
the inflamed area is painful to touch.

Most often, carbuncles appear on the face and back of the body - buttocks, lower back, shoulder blades and neck. In the place where the inflammatory process develops, the skin acquires a bluish tint, becomes hot and very painful. Symptoms of general intoxication appear - high fever, vomiting, dizziness, sometimes leading to loss of consciousness.

After ripening and necrotization of the tissue, the carbuncle is cleared of pus. The surface of the skin in the inflamed area becomes covered with funnels with holes, and later with wounds with loose edges.

Treatment of a carbuncle is carried out by opening and draining the abscess. After the operation, dressings are done twice a day, while sanitizing the wound. A course of antibiotic therapy and drugs to relieve intoxication and pain are prescribed. General strengthening drugs are mandatory.

Abscess

An abscess is also called an abscess of the subcutaneous tissue, in which the tissue becomes necrotic, and in its place a cavity filled with pus is formed. A process develops under the skin due to infection - streptococci, staphylococci, E. coli and other pathogenic microorganisms that cause an atypical course of the disease. An abscess has a membrane that separates the infected tissue from the healthy tissue.

A purulent accumulation that develops in adipose tissue or other tissue can have many manifestations. If it is localized under the skin, the symptoms are usually as follows;

redness of the inflamed area;
pain during palpation;
increase in body temperature up to 41 degrees;
lack of appetite.

An abscess is a disease that can be treated with surgical methods - open and closed. In the first case, the doctor makes a small incision in the skin, through which a tube is inserted to drain the pus and wash the inflamed area of subcutaneous fat. In the second, the abscess is completely opened, drains are inserted, then dressings and sanitation of the operated area are performed daily. In severe cases, when the abscess threatens to develop into sepsis, antibiotics and detoxification agents are used.

Erysipelas

Erysipelas is a skin disease caused by beta-hemolytic streptococci. The development of infection is promoted by:

skin injury;
diabetes mellitus and other diseases that cause vascular fragility;
prolonged exposure to dust, soot, and chemicals on the skin;
decreased immune defense of the body;
chronic diseases;
vitamin deficiency.

Erysipelas appears within a day after infection. Itching and burning of the skin begins in the affected areas, and inflammation quickly spreads throughout the body. Other symptoms appear during the day:

the temperature reaches 40 degrees;
muscle aches and headache appear;
severe fever accompanied by nausea and vomiting;
the skin becomes extremely painful and turns red.

Areas of inflammation become covered with blisters filled with ichor or pus, which then turn into pustules. The edges of the affected area have a characteristic shape resembling tongues of fire.

Treatment is carried out on an outpatient basis. Antibiotics are used and must be taken for 7 to 10 days. The therapist or surgeon also prescribes anti-inflammatory and antipyretic drugs. To relieve intoxication, it is recommended to drink large amounts of liquid.

Inflammation of subcutaneous fat tissue

Inflammatory processes developing in adipose tissue are called panniculitis by experts. The pathology is associated with changes in the structure of the partitions between cells or affecting the lobules of subcutaneous tissue.

Gynoid lipodystrophy, better known as cellulite, is associated with structural changes in adipose tissue, which lead to a significant deterioration in blood microcirculation and lymph stagnation. Not all doctors consider cellulite a disease, but insist on calling it a cosmetic defect.

Cellulite most often appears in women due to hormonal imbalances that occur at different stages of life - in adolescence, during pregnancy. Sometimes it can be triggered by taking hormonal contraceptives. Hereditary factors and dietary habits play a major role.

Depending on the stage, cellulite manifests itself in different ways:

fluid stagnates in adipose tissue;
blood and lymph circulation deteriorates, collagen fibers between cells harden;
small nodules form that give the skin the appearance of an orange peel;
The number of nodules increases, and they become painful when touched.

At the third and fourth stages, cellulite begins not only to spoil the appearance, but also causes physical discomfort. The skin takes on a bluish tint, depressions form on it, and the temperature changes. Muscle tissue is also weakened and nerve endings suffer. Due to compression, large vessels (especially the veins in the legs) are compressed, which leads to the appearance of varicose veins, and smaller ones located under the skin - a mesh of capillaries appears on its surface.

Subcutaneous inflammation - lipodystrophy of adipose tissue is treated comprehensively. To achieve success, you need to eat right, take multivitamins, and antioxidants. An important component of therapy is active movement and sports.

Experts recommend a course of procedures that improve lymph and blood circulation - massage, bioresonance stimulation, magnetic and pressure therapy, special wraps. The size of fat cells decreases after the use of ultraphonophoresis, electrolipolysis, ultrasound and mesotherapy. Special anti-cellulite creams are used.

There is no survival rate in the normodose and low-dose irradiation groups.

2. The technique of low-dose irradiation of the chest at a dose of 40 Gy in 20 daily fractions seems justified, since it allows you to reduce the cumulative dose to critical organs while maintaining the level of local control achieved with the traditional 50 Gy SOD.

LITERATURE

1. Baysogolov G.D., Kiryushkin V.I. // Bulletin. radiation honey. - 1961. - No. 4. - P. 143-150.

2. Baysogolov G.D. // Med. radiol. - 1987. - No. 3. - P. 3-6.

3. Baysogolov G.D., Kiryushkin V.I. // Radiation and risk. - Obninsk, 2000. - P. 43-47.

4. Korytova L. I., Khazova T. V., Zhabina R. M. // Pract. he-col. - 2000. - No. 2. - P. 46-56.

5. Complications of radiation therapy in cancer patients / Ivanitskaya V.I., Kislichenko V.A., Gerinshtein I.G., etc. - Kyiv: Health, 1989. - P. 181.

6. Sergomanova N. N. Post-radiation changes in the cardiovascular system in the complex treatment of breast cancer: Dis. ...cand. honey. Sci. - M., 2005.

7. Khmelevsky E. V. Modern radiation therapy in the treatment of locally advanced and recurrent breast cancer: Dis. ...Dr. med. Sci. - M., 1997.

8. Khmelevsky E.V., Dobrenky M.N., Sergomanova N.N. et al. // Vestn. Ross. scientific X-ray Radiology Center Ministry of Health of the Russian Federation. - 2005. - No. 5.

9. Khmelevsky E.V. // Mammology: National Guide. - M., 2009. - P. 251-269.

10. Chang D. T., Feigenberg S. J., Indelicato D. J. et al. //Int. J. Radiat. Oncol. Biol. Phys. - 2007. - Vol. 67, N 4. - P. 1043-1051.

11. Clarke M., Collins R., Darby S. et al. Early Breast Cancer Tri-alists" Collaborative Group // Lancet. - 2005. - Vol. 366. N 9503. - P. 2087-2106.

12. Cuzick J., Steward H., Rutqvist L. et al. // J. Clin. Oncol. - 1994. - Vol. 12. - P. 447-453.

13. Dunst J., Steil B., Furch S. et al. // Strahlenther. Onkol. - 2001. - Bd 177, N 10. - S. 504-510.

14. Early Breast Cancer Trialists" Collaborative Group // N. Engl. J. Med. -1995. - Vol. 333. - P. 1444-1455.

15. Fodor J., Polgar C., Major T., Nemeth G. // Strahlenther. Onkol. - 2003. - Bd 179, N 3. - P. 197-202.

16. Gagliardi G., Ingmar Lax, Gabor G. // Radiother. Oncol. - 1998. - Vol. 46. N 1. - P. 63-71.

17. Gebski V., Lagleva M., Keech A. et al. // J. Natl. Cancer Inst. - 2006. - Vol. 98. N 1. - P. 26-38.

18. Giordano S. H., Kuo Y. F., Freeman J. L. et al. // J. Natl. Cancer Inst. - 2005. - Vol. 97. N 6. - P. 419-424.

19. Hehr T., Classen J., Huth M. et al. // Strahlenther. Onkol. - 2004. - Bd 180, N 10. - S. 629-636.

20. Huang E. H., Tucker S. L., Strom E. A. et al. // J. Clin. Oncol. - 2004. - Vol. 22, N 23. - P. 4691-4699.

21. Overgaard M., Hansen P. S., Overgaard J. et al. // N. Engl. J. Med. - 1997. - Vol. 337, N 14. - P. 949-955.

22. Wang S. L., Li Y. X., Song Y. W. et al. // Zhonghua Zhong Liu Za Zhi. - 2009. - Vol. 31, N 11. - P. 863-866.

23. Yadav B. S., Sharma S. C., Singh R. et al. // J. Cancer Res. Ther. - 2007. - Vol. 3, N 4. - P. 218-224.

24. Zhang Y. J., Sun G. Q., Chen J. et al. // Ai Zheng. - 2009. - Vol. 28, N 4. - 28, N 4. - P. 395-401.

D. D. Pak1, E. A. Troshenkov1, D. A. Petrovsky2

USE OF MESH IMPLANT IN COMBINATION WITH SILICONE ENDOPROSTHESIS FOR SIMULTANEOUS BREAST RECONSTRUCTION AFTER SUBCUTENARY MASTECTOMY

"FGBU Moscow Research Oncological Institute named after P. A. Herzen (dir. - Academician of the Russian Academy of Medical Sciences V. I. Chissov) Ministry of Health and Social Development of the Russian Federation, 2BGUZ Yaroslavl Regional Clinical Oncology Hospital

The experience of 35 primary reconstructive operations in patients with breast cancer after subcutaneous mastectomy using mesh implants and silicone endoprostheses is presented. The authors proposed an original option for forming a combined pocket for a silicone endoprosthesis, consisting of the pectoralis major muscle and a composite mesh - a mesh implant. The pocket volume allows the placement of an endoprosthesis of up to 335 cm3, which is sufficient for the reconstruction of small and medium-sized breasts. The proposed technique provides good cosmetic and functional results.

Key words: subcutaneous mastectomy, mesh implants, primary reconstructive surgery, breast cancer

USE OF A MESH IMPLANT IN COMBINATION WITH A SILICONE ENDOPROSTHESIS DURING ONE-STAGE BREAST RECONSTRUCTION AFTER SUBCUTANEOUS MASTECTOMY D. D. Pak1, E. A. Troshenkov1, D. A. Petrovsky2

Herzen Moscow Oncology Research Institute, Ministry of Health and Social Development of the Russian Federation, 2Yaroslavl Regional Clinical Oncological Hospital

The paper describes experience with 35 primary reconstructive operations using mesh implants and silicone endoprostheses in patients with breast cancer after subcutaneous mastectomy. The authors propose an original option for forming a combined pocket for the silicone endoprosthesis consisting of the pectoralis major and a composite

mesh - a mesh implant. The pocket volume allows one to place an endoprosthesis up to 335 cm3, which is sufficient to repair small-to-medium-sized breasts. The proposed procedure ensures good cosmetic and functional results.

Key words: subcutaneous mastectomy, mesh implants, primary reconstructive operations, breast cancer

Malignant breast tumors are the leading oncological pathology in women. According to WHO experts, from 800 thousand to 1 million new cases of breast cancer (BC) are detected annually in the world.

In Russia in 2010, breast cancer accounted for 18.1% of all malignant diseases. At the same time, the proportion of patients with stage I-II breast cancer among patients diagnosed for the first time in their lives was 64.2%, stage III - 25.8%, stage IV - 10%. Over the past 10 years, the proportion of patients with stage I-II breast cancer has increased by 3.2%. Treatment of patients with breast cancer, despite the progress of modern medicine, remains a completely unresolved problem.

The main treatment method for breast cancer is surgery, which in combination with chemohormonotherapy and radiation therapy provides high 5-year survival rates. Improvement of the surgical method led to the expansion of indications for economical operations on the mammary gland, but due to the large percentage of unsatisfactory cosmetic effect, the search for methods for correcting the resulting defect continued, which led to the development of the plastic component. Currently, the task of breast restoration is included in the general program of radical treatment of cancer. Reconstructive operations provide complete psychological, social and labor rehabilitation of patients, which allows most of them to start working in the near future and lead a normal lifestyle.

Primary reconstructive plastic surgery for breast cancer involves two successive stages of surgical intervention. The first stage is oncological, the second is reconstructive and plastic.

Radical subcutaneous mastectomy with simultaneous breast reconstruction for cancer combines the principles of oncological radicalism and improves the quality of life of patients. Currently, there is no consensus among plastic surgeons about the most promising method of breast reconstruction after radical oncological interventions.

The use of silicone implants allows you to achieve good cosmetic results with breast size 0-1 in bra cups, since the space between the pectoral muscles allows you to place an implant up to 180 cm3. To reconstruct a larger mammary gland, they resort to forming a pocket for an endoprosthesis. The existing method of forming a pocket using the pectoralis major muscle (PMM) and the latissimus dorsi muscle (LMS) has a number of disadvantages: the technical difficulty of isolating the vascular pedicle of the latissimus dorsi muscle fragment, the significant duration of the operation, large blood loss, and scoliotic deformity of the back.

Based on literature data and our own experience in treating patients with breast cancer at the Moscow Oncology Research Institute named after. P. A. Ger -

For correspondence: Pak D. D. - Dr. med. sciences, prof., supervisor Department of General Oncology; 125284, Moscow, 2nd Botkinsky pr., 3, e-mail: [email protected]

price A new technique for primary reconstructive plastic surgery using mesh implants, which is an adequate alternative to the SMS flap, has been developed and introduced.

Mesh implants have been used in breast reconstruction relatively recently, but we believe that this is a promising direction in mammoplasty in patients with breast cancer. The most high-tech synthetic implants currently used are double-sided meshes with a non-adhesive coating. In our work, we used the Proceed mesh implant from Johnson & Johnson.

PROCEED surgical mesh is a sterile, thin, flexible, laminate mesh designed for repair of fascial defects (Fig. 1). The implant consists of a woven material made of oxidized regenerated cellulose (ORC) and a soft non-absorbable polypropylene mesh made of PROLENE material, encapsulated with polydioxanone (Fig. 2). The polypropylene mesh portion of the implant promotes tissue ingrowth, and the oxidized regenerated cellulose portion serves as a self-absorbable layer that physically separates the polypropylene mesh from adjacent tissues and organ surfaces during wound healing to minimize the likelihood of fusion with the mesh. The ORC layer at the site of material implantation is absorbed within 4 weeks. The remaining large-porous mesh structure is filled with a three-dimensional network of collagen fibers. The polypropylene mesh does not interfere with the course of this process, so the formation of connective tissue is moderate and the development of scar changes does not occur. Since the implant contains ORC, careful hemostasis should be carried out in the surgical field to prevent the formation of fibrinous exudate, which can increase the likelihood of adhesions.

The essence of the breast plastic surgery option we propose is to form an interpectoral pocket for a silicone endoprosthesis using the pectoralis major, serratus anterior muscles and a mesh implant. The mammary gland is removed in a single block with the fascia of the mammary gland, subcutaneous fatty tissue and lymph nodes of the subclavian, axillary and subscapular areas.

The silicone endoprosthesis should correspond as closely as possible to the volume of glandular breast tissue being removed. Of the variety of silicone endoprostheses, we used anatomically shaped prostheses from Mentor and McGhan, since they best meet the requirements for implanted materials: chemical neutrality, absence of irritating and allergenic effects, constancy of physical and absence of oncogenic properties, ability to withstand radiation exposure during therapy up to 100 Gr.

The oncological stage of the operation involves performing a subcutaneous mastectomy using the classical method. The second stage involves breast reconstruction. Depending on the size of the milk

Rice. 1. Macroscopic view of the PROCEED mesh implant.

Rice. 2. Microscopic view of the PROCEED mesh implant.

glands, we have developed two options for forming a pocket for an endoprosthesis.

A technique for forming a pocket for an endoprosthesis using a mesh implant and the pectoralis major muscle with cutting off its abdominal part. This technique is appropriate for patients with breast size 2-3 in bra cups.

After removing the breast tissue, the outer edge of the breast tissue is isolated. The pectoralis major and minor muscles are separated and intermuscular tissue is removed. The pectoralis major muscle is transected at the site of attachment to the anterior wall of the rectus abdominis muscle vagina. A silicone endoprosthesis is installed under the formed flap, the size of which is determined individually based on calculations and data from a clinical and anatomical study. Then a fragment of the mesh implant of the required size is cut out. The mesh implant with its proximal edge is fixed to the distal part of the muscle using separate interrupted sutures made of non-absorbable threads (pro1pe(g) 2/0-3/0), at a distance of at least 1.5-2 cm from the edge of the muscle; at the same time, being its continuation, it compensates for the deficiency of muscle tissue. The other edge of the mesh implant fragment is fixed to the anterior wall of the rectus sheath, which corresponds to the level of the submammary fold. In the formed pocket, the anterior-inferior wall is represented by a mesh implant that covers the lower pole of the endoprosthesis (Fig. 3).

The lateral wall of the endoprosthesis is fixed to the lateral edge of the femoral bone and the separated fragment of the serratus anterior muscle.

A technique for forming a pocket for an endoprosthesis using a mesh implant and the pectoralis major muscle without cutting off its abdominal part. This option is used in patients with breast size 0-1 in bra cups.

After subcutaneous mastectomy, intermuscular tissue is removed. Maximum isolation of the pelvic floor is carried out to the place of its attachment to the sternum, cartilages of the II-VII ribs and the upper parts of the anterior wall of the rectus abdominis sheath. A silicone endoprosthesis is installed in the formed space. Parallel to the outer edge of the femoral bone, the serratus anterior muscle is dissected at the level of the middle third of the length of the femoral bone. The mesh implant becomes the lateral wall of the pocket. It is fixed first to the outer edge of the pectoralis major muscle and then to the distal part of the dissected serratus anterior muscle. Thus, in the formed pocket, the outer wall is represented by a mesh implant that covers the lateral pole of the endoprosthesis.

In the Department of General Oncology, Moscow Research Institute of Oriology. P. A. Ger-tsen in the period from 2009 to 2011, 35 patients aged from 21 to 60 years underwent radical subcutaneous mastectomy with primary reconstruction according to the method we proposed, depending on the size of the mammary glands (from 0 to 3 bra cups).

In 25 (71.4%) patients, initial breast cancer was diagnosed (stage 0, I, PA); in 10 (28.6%) it was locally advanced (PB stage) (Fig. 4).

Surgical intervention was the only treatment method in 12 (34.3%) patients. The remaining patients, 23 (65.8%), underwent postoperative radiation therapy and chemohormonotherapy. 22 (62.9%) patients were of reproductive age.

Rice. 3. Placement of a silicone endoprosthesis into a pocket formed by a mesh implant, cutting off the abdominal part.

50 -| 45 -40 -35 -30 -25 -20 -15 -10 -5 -

1---1---1---g

TisNOMO T1N0M0 T1N1M0 T2N0M0 T2N1M0

Rice. 4. Distribution of patients by stage of the tumor process.

90 -80 -70 -60 -50 -40 -30 -20 -10 -O -

Rice. 5. Cosmetic effect after subcutaneous mastectomy with simultaneous reconstruction of the mammary glands with a mesh implant and silicone endoprosthesis.

1 - satisfactory, II - good, III - excellent.

All 35 patients underwent radical subcutaneous mastectomy with preservation of the nipple-areolar complex and simultaneous reconstruction of the gland. The reconstructive plastic stage varied depending on the size of the patients' mammary glands. In 9 (26%) patients, primary reconstruction of the mammary gland was performed with a breast implant without cutting off its abdominal part, using a silicone endoprosthesis and a mesh implant. In 26 (74%) patients, reconstruction was performed with a femoral bone marrow with abdomen cutoff, a silicone endoprosthesis and a mesh implant.

All patients were followed up for 1-3 years after surgery. When assessing oncological results, it should be noted that in our study, no local relapses or distant metastases were detected in the main group.

Early postoperative complications occurred in 5 (17.1%) patients: marginal necrosis of the breast skin was noted in 1 (2.85%), dehiscence of the wound edges - in

2 (5.7%), diffuse bleeding - in 1 (2.8%), suppuration of the postoperative wound - in 1 (2.85%).

Among the late postoperative complications, 2 (5.7%) patients developed capsular contracture of the mammary gland of the 2nd degree, and 1 (2.8%) patient developed edema of the upper limb of the 2nd degree.

It should be noted that capsular contracture developed only in patients who underwent postoperative radiation therapy, and therefore capsular contracture was considered a complication of radiation therapy.

The cosmetic result after radical subcutaneous mastectomy with simultaneous breast reconstruction was assessed after 6 months by the volume, shape, symmetry of the breast, position of the nipple-areolar complex, and the condition of the postoperative scar. The majority (85.7%) of patients had excellent cosmetic results (Fig. 5, 6,7).

3-4 months after treatment, 80% of patients were able to return to normal work activities and daily life.

The use of the technique we developed for simultaneous breast reconstruction allows us to significantly reduce both the operation time and the volume of intraoperative blood loss, which, compared with subcutaneous mastectomy with plastic surgery with a fragment of the BMS and a silicone endoprosthesis, affects the course of the postoperative period, the condition of patients and the duration of hospitalization (Fig. 8, 9, 10). The reduction in intraoperative blood loss when using our technique is due to the fact that there is no need to isolate the BMS on the feeding vascular pedicle.

The technique we propose using a breast implant, a silicone endoprosthesis and a mesh implant can become the operation of choice in stage 0-II breast cancer patients with small and medium-sized mammary glands.

1. For breast sizes 0-1 in patients, the optimal restoration technique is using the pectoralis major muscle without cutting off its abdominal part, a silicone endoprosthesis and a mesh implant.

2. Cutting off the abdominal part of the breastbone and fixing the mesh implant to its cut edge and the anterior chest wall to create additional volume of the endoprosthesis pocket is effective for breast sizes 2-3 in bra cups, when use

Fig. 6. 10th day after subcutaneous mastectomy with simultaneous reconstruction of the gland using the pectoralis major muscle without cutting off its abdominal part, a silicone endoprosthesis and a mesh implant.

Rice. 7. 1 year after radical subcutaneous mastectomy on the left with simultaneous reconstruction of the gland using the pectoralis major muscle with its abdominal part cut off, a silicone endoprosthesis and a mesh implant.

80 -■ 70 -60 -50 -40 -30 -20 -10 -O -Fig.8

30 25 -20 -15 -10 5 N O

450 400 350 300 250 200 150 100 50 O

Rice. 8. Duration of the operation depending on the method of breast reconstruction.

I - classic operation: subcutaneous mastectomy with plastic surgery; II - subcutaneous mastectomy with plastic surgery with a silicone endoprosthesis and a mesh implant with cutting off the hip bone; III - subcutaneous mastectomy with plastic surgery with a silicone endoprosthesis and a mesh implant without cutting off the femoral bone. Rice. 9. Duration of hospitalization depending on the method of breast reconstruction.

I - subcutaneous mastectomy with plastic surgery; II - subcutaneous mastectomy with plastic surgery with a silicone endoprosthesis and a mesh implant. Rice. 10. The volume of intraoperative blood loss depending on the method of breast reconstruction

I - classic operation: subcutaneous mastectomy with plastic surgery; II - subcutaneous mastectomy with plastic surgery with a silicone endoprosthesis and a mesh implant with cutting off the femoral bone; III - subcutaneous mastectomy with plastic surgery with a silicone endoprosthesis and a mesh implant without cutting off the femoral bone.

techniques without cutting off the femoral bone are impossible due to the excess of the required volume of interpectoral space over the physiologically possible one.

3. The technique of radical subcutaneous mastectomy with simultaneous reconstruction with a silicone endoprosthesis and mesh implant is easily reproducible, reduces operation time, intraoperative blood loss, and is accompanied by a low incidence of early and late postoperative complications.

LITERATURE

1. Adamyan A. A. Atlas of plastic surgeries on the chest wall using endoprostheses. - M., 1994.

2. Bratik A.V. Long-term results and complications after reconstructive plastic surgery on the mammary gland using silicone endoprostheses in cancer patients: Abstract of thesis. dis. ...cand. honey. Sci. - M., 1997.

3. Vasiliev Yu. S. Optimization of planning and performance of plastic surgeries in patients with breast cancer: Abstract of thesis. dis. ...cand. honey. Sci. - Chelyabinsk, 2004.

4. Demidov V.P., Pak D.D. // Mammology. - 1993. - No. 4. - P. 45-51.

5. Zakharkov L. I. Subcutaneous radical mastectomies with primary reconstruction in the treatment of patients with breast cancer: Dis. ...cand. honey. Sci. - M., 2006.

6. Lee A.G. // Annals of plastics, reconstruction, esthetics. hir. - 2004. - No. 3-4. - P. 101.

7. Pak D. D. Organ-preserving, functional-sparing and reconstructive plastic surgeries in the combined treatment of breast cancer: Dis. . Dr. med. Sci. - M., 1998.

8. Pak D. D., Saribekyan E. K. Method of breast reconstruction. - Pat. No. 2208394 dated July 20, 2003.

9. Pak D. D., Troshenkov E. A., Rasskazova E. A. Method of primary breast reconstruction with the pectoralis major muscle, mesh implant and silicone endoprosthesis after radical subcutaneous mastectomy for cancer. - 2009. - P. 5-6.

10. Pak D. D., Rasskazova E. A., Ermoshenkova M. V. Breast cancer. - M.: Triada-X, 2010.

11. Rasskazova E. A. Primary reconstructive plastic surgery in patients with breast cancer using the pectoralis major and latissimus dorsi muscles: Dis. ...cand. honey. Sci. - M., 2004. - P. 34-61.

12. Surkov N. A. et al. // Annals of plastics, reconstruction, aesthetics. hir. - 2004. - No. 2. - P. 54-59.

13. Troshenkov E. A. Subcutaneous mastectomy with simultaneous reconstruction with a silicone endoprosthesis and mesh implant in patients with breast cancer: Dis. ...cand. honey. Sci. - M., 2011.

14. Chissov V.I., Starinsky V.V., Petrova G.V. The state of oncological care to the population of Russia in 2010 - M., 2011.

15. Amanti C. et al. // G. Chir. - 2002. - Vol. 23, N 10. - P. 391-393.

16. Loustau H. D. et al. // J. Plast. Reconstr. Aesthet. Surg. - 2007. - Vol. 60, N 11. - P. 1233-1238.

17. Loustau H. D. et al. // J. Plast. Reconstr. Aesthet. Surg. - 2009. - Vol. 62, N 5. - P. 626-632.

18. RoetjensM. et al. //Ann. Chir. Plast. Esthet. - 1997. - Vol. 42. N 2. - P. 177-182.

19. Rietjens M. et al. //Ann. Plast. Surg. - 2005. - Vol. 54, N 5. - P. 467-470.

Complications may occur after any type of injection. The cause may be an incorrectly placed injection, poor hygiene during the procedure, or individual intolerance of the body. How to prevent complications after an injection? We will describe in detail what should be done at the first signs of injection complications in this article.

Complications with intramuscular injection

Complications with an intramuscular injection are more common than after a subcutaneous injection. The main complications include the following:

An abscess is an accumulation of pus in muscle tissue.
Infiltrate - formation of compaction.
Redness, burning and other skin reactions.

The patient may develop a fever and general malaise. These may be signs of sepsis.

Possible reasons why complications arise after intramuscular injection are identified:

The injection was made with a needle that was too short and the medication got under the skin and not intramuscularly.
The syringe or hands were not sterile enough, and bacteria got into the muscle.
The medicine was administered too quickly.
The medicine was made for a long time. As a result, a compaction appeared.
An allergic reaction of the body to a medication.

If a patient develops a lump after an intramuscular injection and the muscle hurts, you can try to alleviate the condition with ointments: Traxevasin, Traxerutin. At night, you can make a mesh with iodine or lotions with alcohol. Traditional medicine recommends applying cakes made from honey and flour. To do this, honey is mixed with flour and a small cake is made. It is applied to the sore muscle and covered with film overnight.

An abscess can be cured using compresses with ointments: Vishnevsky or Heparin. But if there is an increase in temperature, it is better to consult a doctor. The fact is that an abscess can rupture inside the muscle and infection will occur. In difficult cases, surgery may be necessary.

If redness appears, you should consult an allergist or your doctor. The drug that is being administered most likely causes an allergy. It is necessary to change the medication to a less allergenic analogue.

Complications after a subcutaneous injection

Subcutaneous injection rarely causes complications. The fact is that mistakes are made less often during subcutaneous administration.

Possible complications include:

Allergic reactions at the injection site.
Formation of ulcers.
Air embolism is when air gets under the skin.
Formation of a hematoma at the site of needle insertion.
Lipodystrophy is the formation of pits under the skin. Associated with the breakdown of fat due to frequent administration of a drug, for example, insulin.

Complications may have the following causes:

Misadministration of the wrong drug.
Air getting into the syringe along with the medicine.
Getting bacteria under the skin.
Using a blunt needle to prick.

If any of the complications arise, you need to contact a specialist. You may need surgical intervention or a change in medication.

When an abscess forms, you should not lubricate the lesion with iodine or brilliant green. It will be difficult for the doctor to examine the sore spot and determine the cause.

Complications after an injection into a vein

Intravenous injections are given in the hospital; they are rarely given at home. Complications with a well-placed intravenous injection occur sporadically.

Possible ones include:

Thrombophlebitis - damage to the vessel and inflammation of the vein, the formation of a blood clot.
Oil embolism - an oil-based composition was accidentally injected into a vein. Together with the blood, it enters the vessels of the lungs and the patient suffocates. In 90% it ends in death.

First aid can only be provided within the walls of the hospital, since mistakes when injecting into a vein are dangerous.

It's easier to prevent than to cure

You can prevent complications after intramuscular or subcutaneous injection in simple ways:

You can give an intramuscular injection only with a needle from a syringe with 5 or more cc. The needle from a two-cc syringe is suitable for subcutaneous administration of the drug.
All injections are made with a sharp needle. If it is necessary to draw the drug into a syringe from a vial with a rubber cap, then the puncture is carried out with a separate needle.
Before injection, shake the syringe and release any air bubbles. Release some of the medication through the needle; there may also be air there.
The procedure is performed only under sterile conditions. The needle insertion site is pre-treated with spit.
For injections, it is better to use disposable syringes.
Before any injections, the doctor must do a test for the prescribed drug.

Among the most terrible complications are infections with HIV, hepatitis or sepsis. The video explains which medications and where to administer them correctly to avoid mistakes.

Hello.

The publication will be about post-injection abscesses and infiltrates. If this topic is interesting to you, then be sure to read to the end. The article is long, please be patient.

Have you had any injections? Yes, yes, injections in the buttock, in the shoulder, under the shoulder blade, intravenous. I think everyone did. Did you have any complications after these injections in the form of “bumps”, lumps, ulcers?

I suppose they did. Not everyone, of course, but this has happened to some.

And how did you fight this illness? Yes, who knows, I guess. Isn't it true? Whoever advised what, did it.

If you don't mind, then let's talk about this topic. We will take specific complications after an injection (injection) and analyze them from a practical point of view.

Let's talk about how to try to prevent these complications, and if they arise, how to treat them correctly.

How to give an injection correctly

As a rule, injections are carried out in clinics, hospitals, and at home. The main ones are intradermal, subcutaneous, intramuscular, intravenous.

Intradermal injections are usually carried out to test the tolerance (or intolerance) of a certain drug (for example, an antibiotic, a vaccine, etc.). I have not encountered any complications after them (although they probably happen). Therefore, I won’t talk about it.

Here, one should not confuse the true complication after an injection from various reactions of the body, which manifest themselves in the form of all kinds of allergic reactions - redness, the formation of blisters, skin itching, increased temperature and even the formation of infiltration at the injection site within 24 hours after the injection. These reactions are stopped (pass) after taking antihistamines such as diphenhydramine, suprastin, tavegil, etc.

Subcutaneous injections (injections) are usually given in the middle and upper third of the shoulder, under the shoulder blade, and under the skin of the abdomen.

The drug is injected directly into the subcutaneous fat. The injection is made with a sterile syringe; the length of the needle ranges from 1.5 to 4-5 cm.

Not all drugs can be administered subcutaneously, but only those that are permitted by the instructions for use of this medicine. Therefore, read it (the instructions) carefully.

Places for intramuscular injections are: the upper outer quadrants of the gluteal regions, the shoulder - the deltoid muscle area, the anterior outer surface of the thighs (usually in the upper and middle third). The needle for injection (injection) must be at least 5 cm long. This is especially true for overweight people. It is advisable to administer the drug slowly.

Intravenous medications are given that are permitted by the instructions. The medicine must be administered slowly unless circumstances require it.

Injection sites

The injection sites are the area of the elbow fossa, sometimes the dorsum of the hand, and even – don’t be surprised – the dorsum of the feet.

In cases where they cannot find a vein, the doctor performs catheterization of the subclavian vein under local anesthesia. The catheter is sutured to the skin.

In some patients, especially those with deformities of the chest and spine, the doctor is unable to place a catheter in the subclavian vein. What to do then?

There is another way, this is venesection. What is it? This is a mini operation that is performed in the cubital fossa. In this area, a skin incision is made and a vein is identified in the subcutaneous fat layer, incised, and a polyvinyl chloride catheter is inserted into its lumen. The skin is sutured.

Recently, the method of placing a peripheral catheter has become “fashionable,” i.e., a soft catheter is inserted into a vein and fixed to the skin with an adhesive tape. The advantage of this method is that you do not need to make injections into a vein multiple times each time; they are given into a catheter. Another advantage of this method is that the patient can bend his arm at the elbow without fear that something wrong will happen.

Frequent trauma to a vein with a needle can cause complications, which we will discuss below.

Preparing for the injection

So, you have been prescribed injections. Many people believe that anyone can get an injection, especially into a muscle. In principle, yes, but it will still be better if a medical professional (preferably with experience) gives the injection.

What is needed for this? The skin at the injection site should be treated with sterile material with 70% alcohol (from 96% you will get a skin burn). Nowadays special skin antiseptics are often used.

The person giving the injection should preferably wear sterile gloves; the syringe is disposable. If there are no gloves, then hands should be thoroughly washed with soap and water and treated with alcohol or other approved disinfectant.

Before opening, treat the ampoule with the drug (after filing) with alcohol (the very place of the sawing on the neck of the ampoule). Currently, almost all ampoules do not need to be filed. At the top of the ampoule there is a dot drawn with paint. Turn the ampoule point towards you and break the ampoule away from you. That's all. (Well done, they finally came up with something useful).

Complications after injections (shots)

Well, now let's talk about what complications can arise at the injection site.

Well, this is just an infiltration for now. Although it is already necessary to punctuate

Immediately after an intramuscular injection, pain may occur (this depends on the composition of the drug itself and the speed of its administration), which disappears after a short time. Immediately after the injection, it is advisable to apply a warm heating pad or other dry heat to this area, which helps to dilate the blood vessels and enhance the penetration of the drug into the bloodstream.

Sometimes, over the next few days (4-7-10 days), compaction and tissue infiltration may occur at the injection site. Patients sometimes call this formation “bumps.”

At this stage, a person should definitely see a doctor, preferably a surgeon, who can correctly assess the situation.

The doctor, to exclude abscess formation, may refer the patient to an ultrasound of the infiltrate or perform a puncture. If pus is detected, opening the abscess under local anesthesia or general anesthesia is indicated.

After opening such an abscess there was 200 ml of pus

If the infiltrate does not suppurate, then the use of antibiotics (in tablets or intravenously) and physical treatment for the infiltrate are indicated. Many patients benefit from compresses made from rye bread with honey, vodka compresses or compresses with Vishnevsky ointment.

Sometimes, after an intravenous injection, the drug does not enter the vein, but under the skin. This manifests itself as pain under the needle, a burning sensation, and swelling under the skin. As a rule, this situation is noticed immediately and does not require any help (the drug will then “dissolve on its own”). A semi-alcohol or vodka compress can be applied to the site of such an injection.

If calcium chloride gets under the skin, then you should immediately inject the area with a 0.25% novocaine solution (this will reduce the concentration of calcium chloride in the surrounding tissues) and apply one of the above compresses.

Such necrosis occurred when the medicine did not enter a vein, but under the skin

If a lot of the drug gets under the skin, tissue necrosis occurs. I have had to treat such patients. I’ll say right away that this is not easy, both for the patient and for the doctor. Black skin necrosis is usually deep; it has to be excised, sometimes more than once. Wounds heal slowly with the formation of a rough scar.

Sometimes after intravenous administration of certain drugs, hyperemia and thickening along the vein and pain in it appear almost immediately or within several days. This is the so-called phlebitis or inflammation of the vein walls. Thrombophlebitis can even occur when blood clots form in the lumen of the inflamed vessel.

In such cases, I usually use compresses with Vishnevsky ointment, heparin ointment, drugs that improve microcirculation, antibiotics, and low molecular weight heparins.

There are cases when patients come in about “bumps” on the buttocks, which persist after injections for several months or even years.

What can be advised in this situation? It is necessary to conduct an examination and study of these formations and conduct a differential diagnosis for benign or malignant tumors.

In most of these cases, conservative treatment of “bumps” does not have a positive effect and these formations have to be excised, although very rarely.

What can lead to the development of post-injection complications and what are their causes?

The conclusions below are my subjective opinion based on many years of experience as a surgeon.

In most cases, this is a violation of the rules of asepsis and antisepsis, i.e. the infection enters the tissue through poorly treated skin, hands, an infected syringe, etc.

There are a number of drugs, such as analgin, diclofenac, ketorol, magnesium sulfate (magnesia), etc., which themselves can cause aseptic inflammation, which can turn into suppuration if a secondary infection occurs.
If a drug intended for intramuscular injection enters the subcutaneous fatty tissue, where the “absorption” of the drug into the blood occurs more slowly. As a result, a secondary infection may occur again.
Weakened immunity in cancer patients suffering from diabetes, etc.
When a needle enters a sufficiently large vessel, a hematoma is formed (in muscles or fatty tissue), which may not have time to “resolve” and as a result it suppurates.

Well, I think I’ve said the main thing. Some readers may think, what does injections and a surgeon have to do with it?

But the fact is that surgeons deal with the treatment of complications associated with injections. And we want there to be fewer complications, which is what we wish for you too.

Take care of yourself. A. S. Podlipaev

And also do not forget about comments, ask your questions. But first I advise you to read the pages "" and "".

Based on the recommendations received, please consult a doctor, including to identify possible contraindications! Taking recommended medications is possible ONLY IF THEY ARE GOOD TOLERATED BY PATIENTS, TAKEN INTO ACCOUNT OF THEIR SIDE EFFECTS AND CONTRAINDICATIONS!

The paper presents the results of an examination of 50 children (77 feet) with congenital clubfoot of III-IV degree, who underwent subcutaneous transverse achillotomy at the final stage of treatment using the Ponseti method. Analysis of the echostructure of the tendon in 36 patients on 56 feet, in whom subfascial transverse tenotomy was performed without damaging the vessels of its mesentery, showed that the processes of reparative regeneration of tendon tissue occur under favorable conditions. Data from an ultrasonographic examination of 14 patients on 21 feet confirm that when the synovial vagina and mesentery are completely transected, as happens during a traumatic intervention, the processes of its reparative regeneration occur under unfavorable conditions. An ultrasound study showed that after achillotomy performed in the treatment of clubfoot using the Ponseti method, in all cases there is a complete restoration of the anatomical integrity of the Achilles tendon by 30 days.

ultrasonography

Ponseti method

congenital clubfoot

Achilles tendon

regeneration

1. Alexandrov V.V. [and others] Features of Achilles tendon regeneration after subcutaneous tenotomy in different age groups in the treatment of congenital clubfoot using the Ponseti method // Proceedings of the 3rd International Conference “Treatment of Congenital Foot Deformities in Children”. – Yaroslavl, 2009. – P. 1.

2. Zubarev A.R. Diagnostic ultrasound. Musculoskeletal system. – M.: Strom, 2002. – 136 p.

3. Zubarev A.R. Ultrasound examination of the musculoskeletal system in adults and children: a manual for doctors / A.R. Zubarev, N.A. Nemenova. - M.: Vidar-M, 2006. - 136 p.

4. Kholin A.V. [and others] Possibilities of ultrasound diagnostics of pathology of the foot and ankle joint // Traumatology and Orthopedics of Russia. – 2009. – 4 (54). – pp. 65-72.

5. Ericson S.J. High-resolution imaging of the musculoskeletal system // Radiology. – 1997. – 205. – S. 593-618.

6. Herzenberg J.E., Radler C., Born N. Ponseti versus traditional methods of casting for idiopathic clubfoot // J. Pediatr. Orthop. – 2002. – V. 22, N 4. – P. 517-521.

7. Martinoli C., Derchi L.E., Pastorino C., Bertolotto M., Silvestri E. Analysis of echotexture of tendons with US. // Radiology. – 1993. – 186. – S. 839-843.

8. Morrissy R.T., Weinstein S.L. Atlas of pediatric orthopedic surgery. – Fourth edition. – 2006. – R. 710.

9. Ponseti I.V. Treatment of congenital clubfoot // J. Bone Jt. Surg. – 1992. – V. 74-A, N 3. – P. 448-454.

Introduction

The method of correcting elements of foot deformity in the treatment of congenital clubfoot with staged plaster casts according to Ponseti, based on a detailed study of the functional anatomy of the foot, is ideal. In case of persistent equinus position of the foot, it involves performing a subcutaneous transverse achillotomy. It should be noted that this intervention, despite its simplicity, requires high precision from the surgeon, since the conditions under which regeneration of the transected Achilles tendon will occur depend on how extensively the peritendinous tissue is damaged. Damage to tendon structures that are actively involved in its blood supply leads to a significant decrease in the reparative capabilities of tendon tissue. Work is emerging indicating a direct connection between the technique of tenotomy, the age of the child and the regenerative ability of the Achilles tendon.

The issue of tendon tissue regeneration remains not fully understood to this day. Most researchers believe that tendon tissue does not undergo true regeneration, and the tendon defect is replaced by scar tissue.

One of the accessible and non-invasive methods for studying the phases of reparative regeneration of tendons is ultrasonography. The increasingly widespread use of this technique is facilitated by the high resolution of modern ultrasonic devices. The use of high-bandwidth, high-frequency, high-density transducers provides the highest precision resolution in sonographic images of connective tissue and accurately depicts the structure of collagen fibers, which are the basic basis of tendons. In fact, the sonographic picture of tendons currently corresponds to their histological structure.

The purpose of this work was to study the processes of regeneration of the Achilles tendon after subcutaneous transverse tenotomy using ultrasonography.

Materials and methods

When performing a subcutaneous achillotomy, special attention was paid to the process of transection of the Achilles tendon. In the projection of the Achilles tendon, 1 cm above the place of its attachment to the heel bone, a skin was punctured with a scalpel, the lateral border of the tendon was clearly defined, and then, with one movement of the scalpel, the tendon was crossed transversely in the direction from bottom to top. It should be noted that, ideally, tenotomy should be performed simultaneously, in one pass of the scalpel. Repeated attempts to cut the Achilles tendon cause additional trauma to the tendon and peritendinous tissues.

Despite the desire of surgeons to perform subcutaneous transverse achillotomy as accurately as possible, this was not achieved in all patients. In this regard, we identified two groups of patients. The first group included 36 patients (56 feet), in whom tenotomy was performed simultaneously, in one pass of the scalpel, with the characteristic sound effect of tendon intersection. The second group included 14 patients (21 feet), in whom a convincing transection of the Achilles tendon was not immediately obtained, which required a repeated, “control” transection of the surviving parts of the tendon tissue.

All patients underwent ultrasound examination of the Achilles tendons using an Acuson X 300 device (Siemens, Germany), with 13-5 MHz linear sensors with a small working surface for ease of scanning. The tendon was examined in two mutually perpendicular planes, with the ultrasound beam forming a right angle with the tendon. Strict adherence to this condition during the examination made it possible to exclude the occurrence of the anisotropy effect, according to which the echogenicity of the structure under study changes. This reduced the likelihood of obtaining an incorrect conclusion about the state of the reparative process in the Achilles tendon. The tendon was examined from the place of attachment to the calcaneus to the place of transition to the gastrocnemius and soleus muscles, and its thickness in the proximal and distal parts and the severity of paratonon were determined. The distance between the ends of the tendon after its transverse intersection was measured, the structure of the tendon, the condition of its ends and paratenial tissues, and the formation of the regenerate (fusion) were assessed. Ultrasonography of the Achilles tendon was performed before surgery, as well as on days 7, 15, 30, 48 and one year after it.

Echo image of the Achilles tendon before tenotomy

All patients underwent a sonographic examination of the Achilles tendon before surgery. With longitudinal ultrasound scanning, it had a tubular structure with parallel hyperechoic lines (Fig. 1), which were reflections of the ultrasound beam from collagen and endothelial septa. The Achilles tendon was traced throughout its entire length, well differentiated from the surrounding soft tissues, and its contours and fibrous structure were clearly defined. During ultrasound scanning, hyperechoic lines were visualized along the edges of the Achilles tendon - the paratenon, the thickness of which was 0.27 ± 0.04 mm. The anteroposterior size of the proximal end of the tendon was 2.7±0.22 mm, and the distal end was 2.9±0.17 mm.

Rice. 1. Image of the Achilles tendon before subcutaneous tenotomy.

During transverse scanning, the Achilles tendon was located as an oval-shaped formation with clear contours and bright hyperechoic dots.

Echo picture of the Achilles tendon on the 7th day after subcutaneous transverse Achilles tendon

In patients of the first group, on the 7th day after tenotomy, longitudinal scanning revealed an interruption of the continuous contour of the tendon, and a hypoechoic zone of the defect appeared (p<0,001). Концы сухожилия обнаруживались дистальнее и проксимальнее места тенотомии (рис. 2), диастаз между ними составил 17,35±1,5 мм. Выявлялось снижение эхогенности концов сухожилия и неоднородность их структуры за счет утолщения, разрыхления и набухания соединительнотканной основы. Концы сухожилия имели нечеткий и неровный контур с утратой упорядоченной эхоструктуры. Передне-задний размер проксимального конца сухожилия составил 3,1±0,25 мм, а дистального - 3,3±0,28 мм.

Rice. 2. Image of the Achilles tendon on the 7th day after tenotomy. The first group of patients.

Between the ends of the tendon, a low-echoic zone of irregular shape with fuzzy, uneven contours and a complete absence of echo signals was found, which corresponded to the formed area of the hematoma. Compared with the study of the tendon before surgery, an interruption of the paratenon contour appeared above the hypoechoic zone of the defect. The subcutaneous tissue was thickened, its echogenicity was reduced, which indicated the development of its edema. Increased vascularization was observed with the use of EDC.

On the 7th day after subcutaneous tenotomy in patients of the second group, longitudinal scanning also revealed an interruption of the continuous contour of the tendon and the appearance of a hypoechoic zone of the defect with the formation of a diastase between its ends up to 21.13 ± 1.86 mm (Fig. 3). The echogenicity of the ends of the tendon was reduced, their structure was heterogeneous due to swelling of the connective tissue base, the contours were unclear and uneven. The anteroposterior size of the proximal end of the tendon was 3.2±0.27 mm, and the distal end was 3.5±0.31 mm.

Rice. 3. Image of the Achilles tendon on the 7th day after tenotomy. The second group of patients.

Between the ends of the tendon, similarly to the first group, a low-echoic zone of irregular shape with unclear, uneven contours was found, corresponding to the formed area of the hematoma. Compared to the picture before surgery, there was an interruption of the paratenon contour above the hypoechoic zone of the defect. In this group, thickening of the subcutaneous tissue with a decrease in its echogenicity due to edema was also noted. Increased vascularization was observed with the use of EDC.

On the 7th day after tenotomy, there were no obvious differences in the process of reparative regeneration of the Achilles tendon in patients of the first and second groups. Ultrasonographic examination showed the uniformity of the course of the wound process: filling of the diastasis between the crossed parts of the tendon with a hematoma, swelling and thickening of the ends of the tendon, as well as the development of lymphostasis and edema in the adjacent tissues. The only difference concerned the size of the diastasis between the ends of the tendon. In the first group, diastasis was 17.35±1.5 mm, in the second group - 21.13±1.86 mm (p<0,001).

Echo picture of the Achilles tendon on the 15th day after subcutaneous transverse Achilles tendon

In patients of the first group, longitudinal scanning showed the proximal and distal ends of the tendon (Fig. 4). Compared to the study on the seventh day, the indicators of the anteroposterior dimensions of the proximal and distal ends remained at the same values. The anteroposterior size of the proximal end of the tendon was 3.0±0.25 mm, and the distal end was 3.1±0.26 mm. Signs of moderately reduced echogenicity of tendon fragments and the heterogeneity of their structure remained; the proximal and distal ends were not clearly visualized, their contours were blurred, and between them there was a clearly defined zone that had a heterogeneous structure (mostly hypoechoic) and an unclear contour.

Rice. 4. Image of the Achilles tendon 15 days after tenotomy. The first group of patients.

The heterogeneity of the echostructure of this zone is due to the replacement of the lysed hematoma with newly formed tissue - regenerate. Compared to the seventh day of the study, a decrease in the diastasis between the proximal and distal ends of the tendon to 14.8±1.21 mm was clearly visible (p<0,001). Над гипоэхогенной зоной лоцировались единичные участки соединительнотканной оболочки ахиллова сухожилия. Подкожная клетчатка незначительно сниженной эхогенности, что свидетельствовало об уменьшении отёка. При использовании ЭДК отмечалось небольшое усиление васкуляризации.

On the 15th day after subcutaneous tenotomy in patients of the second group, longitudinal scanning revealed the proximal and distal ends of the tendon (Fig. 5). Compared to the 7th day of the study, there was a decrease in the diastasis between the ends of the tendons to 19.68±1.67 mm (p<0,001), увеличение передне-заднего размера проксимального конца сухожилия до 3,3±0,25 мм, а дистального - до 3,6±0,29 мм (p>0.05). Persistent swelling of the connective tissue base of the tendon was determined by moderately reduced echogenicity of tendon fragments, heterogeneity and indistinctness of their structure with blurred contours. As in the first group, the lysed hematoma was replaced by a newly formed regenerate, as evidenced by the presence between the proximal and distal ends of the tendon of a zone with a heterogeneous structure, predominantly hypoechoic, and an unclear contour.

Rice. 5. Image of the Achilles tendon 15 days after tenotomy. The second group of patients.

Compared to day 7, isolated areas of the connective tissue membrane of the Achilles tendon appeared above the hypoechoic zone. The subcutaneous tissue was thickened, its echogenicity was reduced, which indicated the persistence of edema of the subcutaneous tissue. When using EDC, perifocal blood flow is located.

Thus, on the 15th day after tenotomy, in patients from both groups, the processes of reparative regeneration of the Achilles tendon became intensified: there was a decrease in the diastasis between the ends of the tendon due to the newly formed regenerate. In patients from the first group, the diastasis between the ends of the Achilles tendon decreased due to the formation of the regenerate to 14.8 ± 1.21 mm (on average 14.7% from the previous value), and in patients from the second group - to 19.68 ± 1 .67 mm (on average 6.9% from the previous value) (p<0,001). Кроме того, у пациентов из второй группы было выявлено увеличение передне-заднего размера проксимального конца сухожилия до 3,3±0,25 мм, а дистального - до 3,6±0,29 мм, что указывало на нарастание отека соединительнотканной основы сухожилия. Данный факт свидетельствовал о том, что у пациентов из второй группы имелось снижение репаративной регенерации ахиллова сухожилия по сравнению с первой группой.

Echo picture of the Achilles tendon on the 30th day after subcutaneous transverse Achilles tendon.

In patients of the first group, ultrasound examination of the Achilles tendon revealed a complete restoration of its anatomical integrity. Longitudinal scanning revealed the proximal and distal ends of the tendon (Fig. 6) with uneven and unclear contours, reduced echogenicity and an ordered echostructure.

Rice. 7. Image of the Achilles tendon 30 days after tenotomy. The first group of patients.

Compared to the 15th day of the study, there was a decrease in the anteroposterior size of the proximal end to 2.6±0.18 mm, and the distal one to 3.0±0.25 mm (p<0,05). Между концами сухожилия отчетливо определялся новообразованный регенерат, который имел неоднородную структуру (преимущественно гипоэхогенную) и нечеткий контур. По сравнению с 15 сутками после тенотомии протяженность гипоэхогенной зоны регенерата уменьшилась и составила 12,37±0,98 мм (p<0,001). Соединительнотканная оболочка ахиллова сухожилия (паратенон) прослеживалась на всем его протяжении. Над зоной регенерата ахиллова сухожилия толщина паратенона составила 0,39±0,02 мм. Прилежащие к ахилловому сухожилию ткани (подкожная клетчатка) были обычной эхогенности. При использовании ЭДК лоцировались единичные очаги васкуляризации.

In patients of the second group, complete restoration of the anatomical integrity of the Achilles tendon was also noted. Longitudinal scanning identified the proximal and distal ends of the tendon (Fig. 7).

Rice. 7. Image of the Achilles tendon 30 days after tenotomy. The second group of patients.

Compared with the study on day 15, there was a decrease in the anteroposterior size of the proximal end of the tendon to 2.9±0.24 mm, and the distal end to 3.3±0.28 mm (p<0,05), что свидетельствует об уменьшении разрыхления и набухания соединительнотканной основы сухожильной ткани. Проксимальный и дистальный концы имели упорядоченную эхоструктуру, контуры их четкие, неровные, с умеренно сниженной эхогенностью. Между концами сухожилия отчетливо определялся регенерат с неоднородной структурой (преимущественно гипоэхогенной) и нечетким контуром. Протяженность гипоэхогенной зоны регенерата уменьшилась по сравнению с 15 сутками и составила 17,46±1,48 мм (p<0,001). Соединительнотканная оболочка ахиллова сухожилия (паратенон) прослеживалась на всем его протяжении. Над зоной регенерата ахиллова сухожилия отмечается увеличение толщины паратенона до 0,4±0,03 мм. Прилежащие ткани к ахилловому сухожилию (подкожная клетчатка) принимают картину нормальной эхогенности. При использовании ЭДК лоцировались единичные очаги васкуляризации.

Conclusion. On the 30th day after tenotomy, an ultrasound examination of the Achilles tendon in patients from the first group, the diastasis between the ends of the Achilles tendon decreased to 12.37±0.98 mm (on average by 16.5% of the previous value), and in patients from the second group the diastasis decreased to 17.46±1.48 mm (on average by 11.3% from the previous value) (p<0,001). Данный факт указывает на то, что у пациентов из второй группы сохранялось снижение темпов репаративной регенерации ахиллова сухожилия за счет медленного формирования регенерата по сравнению с первой группой.

Echo picture of the Achilles tendon on the 48th day after subcutaneous transverse Achilles tendon

In patients from the first group, ultrasound examination showed complete restoration of the anatomical integrity of the Achilles tendon, and processes of maturation of the tendon regenerate were observed (Fig. 8).

Rice. 8. Image of the Achilles tendon 48 days after tenotomy. The first group of patients.

The ends of the Achilles tendon were not differentiated, the defect area was completely filled with regenerate. Compared to 30 days, after tenotomy, there was a decrease in the anteroposterior size of the proximal part of the Achilles tendon to 2.8±0.2 mm, the distal part - to 3.1±0.27 mm, and the regenerate zone - to 2.9±0. 26 mm (p<0,05). Проксимальная и дистальная часть сухожилия обычной эхогенности, с упорядоченной эхоструктурой, с четкими ровными контурами. Эхоструктура регенерата имела сниженную эхогенность, четкие и ровные контуры. Толщина паратенона определялась на всем протяжении ахиллова сухожилия и составила 0,4±0,01 мм. При ЭДК лоцировались единичные очаги васкуляризации. Подкожная клетчатка обычной эхогенности.

On the 48th day after surgery, in patients of the second group, as well as in the first group, processes of maturation of the tendon regenerate were observed with complete restoration of the anatomical integrity of the Achilles tendon (Fig. 9). In this case, the ends of the Achilles tendon did not differentiate, and the defect area was completely filled with regenerate.

Rice. 9. Image of the Achilles tendon 48 days after tenotomy. The second group of patients.

Compared to 30 days, after tenotomy there was a decrease in the anteroposterior size of the proximal and distal parts of the Achilles tendon to 2.9 ± 0.26 mm, distal - 3.1 ± 0.29 mm against the background of an increase in the anteroposterior size in the regenerate area up to 3.3±0.31 mm (p>0.05). The proximal and distal parts of the Achilles tendon had clear, even contours, normal echogenicity with an ordered echostructure. The echostructure of the regenerate had reduced echogenicity, clear and even contours. The well-defined connective tissue sheath of the Achilles tendon (paratenon) was clearly visible along its entire length and amounted to 0.42±0.03 mm. During EDC, single foci of vascularization were located. The tissue adjacent to the Achilles tendon (subcutaneous tissue) had a picture of normal echogenicity.

Conclusion. On the 48th day after tenotomy, in both groups there was a complete restoration of the anatomical integrity of the Achilles tendon, the processes of maturation of the tendon regenerate were observed, its echostructure had reduced echogenicity, clear and even contours. However, differences were identified in the process of tendon regenerate formation. In patients from the first group, during the maturation of the regenerate, there was a uniform decrease in the anteroposterior size of the proximal part of the Achilles tendon to 2.8±0.2 mm, the distal part - 3.1±0.27 mm, and the regenerate zone itself to 2.9±0 .26 mm. In patients from the second group, during the maturation of the regenerate, its anteroposterior size increased to 3.3 ± 0.31 mm against the background of a decrease in its anteroposterior size in the proximal part to 2.9 ± 0.26 mm and in the distal part - 3.1 ±0.29 mm.

Echo image of the Achilles tendon 1 year after subcutaneous transverse Achilles tendon

1 year after tenotomy, in patients of the first group, longitudinal scanning of the tendon showed a linear structure with clear, even contours, echogenic boundaries, continuous throughout from the muscular part to the attachment to the calcaneus (Fig. 10).

Rice. 10. Image of the Achilles tendon 1 year after tenotomy. The first group of patients.

The Achilles tendon had a uniform change in thickness in the direction from the calcaneal tubercle to the tendon-muscular junction. The thickness in the proximal part of the tendon was 3.3±0.29 mm, and in the distal part - 3.9±0.35 mm. The anteroposterior dimension in the middle part of the Achilles tendon (tendon regenerate zone) was 3.7±0.32 mm. The echogenicity of the tendon is normal, the echostructure is ordered. The connective tissue membrane of the Achilles tendon (paratenon) was uniform throughout its entire length and amounted to 0.29 ± 0.01 mm. No increased vascularization was detected when using EDC. The surrounding soft tissues are unremarkable.

1 year after tenotomy, in patients of the second group, ultrasonograms of the Achilles tendon during longitudinal scanning showed a heterogeneous structure with echogenic continuous boundaries along the entire length from the muscular part to the attachment to the calcaneus (Fig. 11).

Rice. 11. The same b-th. Image of the Achilles tendon 1 year after tenotomy. The second group of patients.

The fusiform shape of the Achilles tendon was preserved. The thickness in the proximal part of the tendon was 3.7±0.36 mm, and in the distal part - 4.1±0.39 mm. The maximum value of the anteroposterior size was determined in the middle part of the Achilles tendon (tendon regenerate zone) and amounted to 4.5 ± 0.44 mm. This indicated a relatively incomplete restoration of the Achilles tendon structure in the regenerated area. The thickness of the connective tissue sheath was determined along the entire length of the tendon and amounted to 0.33±0.03 mm. No increased vascularization was detected when using EDC. The surrounding soft tissues are unremarkable.

Conclusion. The results of an ultrasonographic examination of the Achilles tendon showed that the final reconstruction of the tendon in the area of its transverse intersection takes quite a long time. A year later, in patients from the first group, the Achilles tendon had normal echogenicity with an ordered echostructure, a uniform change in thickness in the direction from the calcaneal tubercle to the tendon-muscular junction, which indicated a relatively complete restoration of its structure in the regenerate zone. In patients from the second group, a year after achillotomy, the tendon had a heterogeneous structure, a fusiform shape with an increase in anteroposterior size in its middle part, which indicated relatively incomplete maturation of the regenerate.

Thus, the study showed that in children in the first months of life after transverse achillotomy performed in the treatment of clubfoot using the Ponseti method, in all cases there is a complete restoration of the anatomical integrity of the Achilles tendon by 30 days.

At the same time, in the zone of diastasis formed between the ends of the transected tendon, a gradual formation of a regenerate occurs, which, a year after surgery performed by simultaneously transecting the tendon, is sonographically practically indistinguishable from the distal and proximal parts of the tendon. In the case of a more traumatic intervention, that is, with repeated intersection of the tendon, a spindle-shaped regenerate with a heterogeneous structure is formed.

The results obtained make it possible to assume that with subfascial intersection of the tendon, damage to the vessels of its mesentery is eliminated, normal blood supply to parts of the tendon is maintained, as a result of which regeneration occurs under more favorable conditions than with complete intersection of the synovial sheath and mesentery, as is the case with traumatic intervention.

The data obtained can be used by pediatric orthopedists when drawing up individual rehabilitation programs for children with congenital clubfoot when treating them using the Ponseti method, depending on the traumatic nature of the achillotomy.

Reviewers:

Korolev Svyatoslav Borisovich, Doctor of Medical Sciences, Professor, Head of the Department of Traumatology, Orthopedics and Military Surgery of the State Budgetary Educational Institution of Higher Professional Education "Nizhny Novgorod State Medical Academy" of the Ministry of Health of Russia, Nizhny Novgorod.

Malyshev Evgeniy Stepanovich, MD, PhD, Professor of the Department of Surgery (course of traumatology and orthopedics) of the State Budgetary Educational Institution of Higher Professional Education "Nizhny Novgorod State Medical Academy" of the Ministry of Health of Russia, Nizhny Novgorod.

Bibliographic link

Vlasov M.V., Bogosyan A.B., Musikhina I.V., Kuznetsova I.V. REPARTIVE REGENERATION OF THE ACHILLES TENDON AFTER SUBcutaneous TENOTOMY IN THE TREATMENT OF CONGENITAL CLUBFOOT IN CHILDREN USING THE PONSETI METHOD (BASED ON ULTROSONOGRAPHIC STUDY) // Modern problems of science and education. – 2013. – No. 1.;
URL: http://science-education.ru/ru/article/view?id=8514 (access date: 02/01/2020). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"