TROPHIC ULCERS (Greek trophe food, food) — big group of the ulcers of a neurogenic and trophic origin differing in a torpid current, tendency to recuring and resistance to conservative treatment.
Majority of T. I. is a complication of the acquired or inborn diseases and damages of vessels, nerves, soft tissues and bones. T. I. are followed by considerable disturbances of food of fabrics. Food of fabrics can be broken under the influence of the various reasons (see the Trophicity) in this connection also origins of T are various. I. Most often T. I. develop as a result of diseases of veins — a posttrombofle-bitichesky syndrome (see Thrombophlebitis), a varicosity (see); diseases of arteries — an obliterating endarteritis (see Obliterirtsyushchy defeats of vessels of extremities), atherosclerosis (see), an idiopathic hypertensia (see); inborn malformations of vessels — hemangiomas (with - m); Parks Weber's diseases (see Parks Weber a syndrome); damages of large vessels (effect of bandaging of arteries, aneurisms and arteriovenous fistulas); damages or diseases of c. N of page and peripheral nervous trunks; injuries of soft tissues and bones, including burns (see), freezing injuries (see), and also decubituses (see); nek-ry general diseases and diseases of a metabolism — a diabetes mellitus (see a diabetes mellitus), a scurvy (see), collagenic diseases (see), and also beam damages (see).
To the T conducting in a pathogeny. I. falloff of a blood-groove in microvessels of the struck part of a body is (see Mikrotsirkulyation) that leads to ischemia (see), hypoxias (see) and to a necrosis (see) fabrics. At a posttromboflebitichesky syndrome and a varicosity these changes are caused by increase (more than on 30 mm of mercury.) pressure in venules owing to difficulty of outflow of blood, a spasm of small arteries, disclosure of an arteriovenous anastomosis (see), falloff of a blood-groove in capillaries. Prp obliterating diseases of arteries (see Obliterirtsyushchy defeats of vessels of extremities) disturbances of microcirculation in fabrics are connected with sharp reduction of inflow of an arterial blood, disclosure of an arteriolovenulyarny anastomosis, decrease in a blood-groove in capillaries. At injuries and diseases of of N of page and peripheral nerves formation of T. I. it is caused by the disturbances of an innervation and trophicity of fabrics which are expressed, in particular, that fabrics do not acquire nutrients from the inflowing blood. After extensive burns and other types of injuries of disturbance of microcirculation are caused by thrombosis of the main veins or extensive hems. At a diabetes mellitus and collagenic diseases microcirculation is broken owing to a vasculitis (see) and disclosures of an arteriolovenulyarny anastomosis at the different levels.
In fabrics with the broken microcirculation activity of oxidizing enzymes goes down. Oxidation-reduction processes are slowed down, there is fabric a metabolic acidosis. The anaerobic type of exchange prevails, the catabolism prevails over anabolism (see the Metabolism and energy). Stocks of a glycogen are exhausted, contents increases it membranotoksi-is new. There is a disintegration of lysosomes (see) with release of the hydrolases (see) lyseing cells and fabrics. Content of potassium in a cell decreases, it is replaced with sodium. Raises gidrofiljnost (see) fabrics, their hypostasis amplifies. In pe-rikapillyarny spaces the finely divided proteins promoting further deterioration in microcirculation accumulate. In response to alteration of fabrics and implementation of disease-producing microflora there is an infectious and allergic process (see the Allergy, the Infectious allergy). In an organism of the patient autoimmune reactions and an autoaggression develop (see Autoantigens).
At all variety of T. I. morfol. the picture has them many general signs. Defect of skin more deeply - the located fabrics at T. I. it is partially filled with the granulations covered with the detritis containing pathogenic microorganisms, leukocytes. Under a layer of granulations dense fibrous fabric with the centers of inflammatory infiltration is located. In a zone of deep T. I. shins are quite often observed a periostitis (see), a subperiosteal resorption and sequestration of a bone (see the Sequester). Sometimes at the bottom of T. I. muscles, sinews, joints are found. At microscopic examination of vessels in a zone T. I., as a rule, reveal a vasculitis, for to-rogo the fibrinoid necrosis, a hyalinosis are characteristic (see). By means of a submicroscopy (see) find the capillaries narrowed almost twice with the basal membrane thickened by 6 — 7 times, existence of blood clots in them.
On a surface and in the depth of T. I. microflora develops pathogenic (more often polymorphic) (staphylococcus, enterokokk, colibacillus, proteas, a pyocyanic stick, a streptococcus, anaerobic bacteria, to-rinebakterii, fungi, Vincent's spirochetes).
For T. I. the chronic, usually progressing current with frequent aggravations, a recurrence and small tendency to healing is characteristic. T. I. arise preferential on a shin and foot, in rather typical sites for ulcers of this or that etiology. Most often T. I. are localized: at a varicosity and post-tromboflebiticheskom a syndrome — on an inner surface of the lower third of a shin (tsvetn. tab., Art. 368, fig. 1); obliterating diseases of arteries — on fingers of foot; inborn vascular changes — on a shin, foot and a brush; an idiopathic hypertensia — on a front or outer surface of a shin; diseases and injuries of a spinal cord and peripheral nerves — on a bottom surface of foot and in calcaneal area (tsvetn. tab., Art. 368, fig. 2); a diabetes mellitus — on a bottom surface of foot and the I finger groans (blossom, the tab., Art. 368, fig. 3). T. I. because of collagenic diseases are located on shins (symmetrically), at decubituses more often — in the field of a sacrum and heels. T. I. at burns quite often happen multiple, irregular shape (tsvetn. tab., Art. 368, fig. 4).
T. I. has roundish, oval irregular shape of a pla, the sizes it can reach 200 cm2 of l more; sometimes the ulcer tsirkulyario covers a shin. Edges of T. I. are usually edematous, condensed, during the progressing of an ulcer subdug are more often. Skin around T. I. gets brown or tsiano-tpchny coloring, an infiltrirovan, it is dense. At a so-called neyropatichesky diabetic ulcer of foot (see Foot diabetic) temperature of skin of the affected extremity is increased. Bottom of T. I. it is usually covered with granulations with moderate purulent separated, otsutstvo not to-rogo (at a so-called dry ulcer) speaks about areactivity of fabrics. Greenish coloring of pus is a sign of existence in an ulcer Xing of a purulent stick (see). Ilxoroznoye and ge-pestilence a ragichesky discharge with in idetel - with - tvuyet about the adverse course of ulcer process. Sudden uve-lpchen not separated, not p r p yat i i y and a smell are observed irp malpgnpza-tspp by T. I. Pains in the area T. I. are more often moderate; at defeat of a nervous system of ii of diabetic neuropathy of pain can be absent. Sharp strengthening of pains is connected usually with flash inf. inflammatory process in surrounding fabrics. At obliterating diseases of arteries of T. I. are sharply painful.
Dangerous complication of T. I. so-called intense allergization of the patient, especially to antibiotics is; cases of an acute anaphylaxis are known, (see). Quite often owing to an application medicinal allergy in a zone T. I. the outbreaks of dermatitis (see), eczemas (see), an erysipelatous inflammation are observed (see the Ugly face).
At a diabetes mellitus of T. I. feet can be complicated by phlegmon with purulent zateka on the course of sinews. Various forms of septic complications are described. At further development of T. I. the epifayetspalny gangrene of hypodermic cellulose and skin (see Gangrene) demanding broad excision of the changed fabrics, and sometimes the emergency amputation at the level of a hip is observed. For a long time existing T. I. can become the soil for development planocellular orogovevayushcheg9 cancer (see), is more rare — ■ than sarcoma (see).
The diagnosis is based on data of comprehensive inspection of the patient (see). Special attention is paid to studying of a condition of veins, arteries, limf, vessels and bones of a sore extremity, nevrol. to inspection of the patient. Due to tekhm that T, various by the nature. I. on a gross appearance and a current have much in common, for the differential diagnosis quite often resort to a repeated biopsy (see) a bottom and edges of an ulcer, conduct a cytologic and bacteriological research of prints from their surface (see. Bacteriological techniques, Cytologic research).
For treatment of T. I. apply conservative and operational methods. Conservative treatment can yield in some cases good result, naira. at a diabetes mellitus and nek-ry collagenic ‘diseases (at prolonged and adequate treatment of a basic disease), and also at diseases of veins if it is possible with the help of conservative methods to remove venous staz (see). Conservative therapy at a bed rest is most effective, to-ry appoint especially in cases of an inflammation of the fabrics surrounding an ulcer; the sore extremity is given sublime situation. For topical conservative treatment of T, small on the area. I. use proteolytic enzymes (trypsin, hnmotrtsheyn, himop-sin, etc.), artificial coverings T. I. on the basis of collagen (Combutecum, etc.), fibrin, gelatin or by means of tinned kseno-skin and an allokozha. Use also the laser (see), ultrasound (see. Ultrasonic therapy) and other forms of physical therapy, balneol. procedures (see Balneoterapiya), physiotherapy exercises (see).
In out-patient conditions for reduction of the staz caused by a disease of veins apply so-called compression therapy. Over a bandage impose a rubber or porolonovy sponge, create a compression by means of elastic medical roller. Use long-term zinc less often - gelatinous bandages (see the Desmurgy). At T. I. feet for unloading of a zone of maximal pressure recommend to wear orthopedic shoes with replaceable insoles (see Footwear), and also functional devices, the corrective movements of foot during the walking.
Operational treatment is more effective, than conservative. Before operation with the purpose of normalization of microcirculation appoint xavinum, anginin, solkoserit. Rheological properties of blood improve injection of solution of a low-molecular dextran (reopoliglyuki-on), and also by means of anticoagulants and dezagregant. At the same time hold events for desensitization (see) and increases in reactivity of an organism (see) the patient (vitamin therapy, according to indications hemotransfusion and blood-substituting liquids). At a diabetes mellitus normalization of carbohydrate metabolism is necessary. Success of operation in many respects depends on the maximum decrease in a bacterial obsemenennost of fabrics in a zone T. I. Best of all it is reached with the help gnotobiol. cameras (see. The managed abacterial environment), in to-ruyu for 8 — 10 days before operation place an extremity.
It is long the existing T. I. extremities from cicatricial induratsiy skin, hypodermic cellulose and a fascia exsect within healthy fabrics. The formed defect is closed the free split perforated skin autograft (see. Skin plastics). At beam ulcers excise nekrotizirovanny fabrics with the subsequent plastics of defect a kozhnopodkozhny rag on a leg. T. I., arisen after burns, freezing injuries and bruises of soft tissues and bones, especially proceeding against the background of osteomyelitis, considerably exsect within healthy fabrics with the subsequent plastics of defect a local musculocutaneous or fascial and muscular rag on a leg. Other ways of plastics — Indian, Italian — by means of a pedicle graft across Filatov keep the value. New perspectives for plastics of big defects a difficult rag on a vascular leg are opened by microsurgery (see), thanks to a cut at extensive T. I. different ethnology make amputation of an extremity more and more seldom. To plastic of small T. I. with well-marked granulations in the absence of infiltration of surrounding fabrics carry out a free skin rag without preliminary excision of an ulcer.
At T. I., the main arteries tied with segmented occlusions, make pkh bypass shunting (see Shunting of blood vessels), an endarteriek-tomiya (see Blood vessels, operations), balloon dilatation (see. X-ray endovascular surgery). In case of thrombosis of a distal arterial bed carry out a lumbar sympathectomy (see). At patients with a posttrombo-flebitichesky syndrome make Linton's operation — subgaleal bandaging of an anastomosis between deep and superficial veins of a shin. At a varicosity excise expanded superficial and tie up the perforating veins.
At T. I., the peripheral nervous trunks which arose in connection with damage, perhaps early nerve operation — sewing together of a nerve or an autotransgshanta-tion of nervous trunks is shown (see. A nervous seam), a neurolysis (see) etc.
In a package of measures of rehabilitation after the carried-out operational or conservative treatment of T. I. the dignity can be used. - hens. treatment with its various balneol. medical factors. Careful care of skin of an extremity, bandaging of foot and a shin an elastic roller or wearing an elastic stocking is necessary.
The forecast at uncured T. I. it is almost always adverse. At adequate treatment the forecast depends on features of a disease: the forecast is better at diseases of veins, damages of vessels, passability to-rykh manages to be recovered in the operational way, injuries of soft tissues worse at obliterating diseases of arteries, damages and diseases of c. N of page.
Prevention of a recurrence of T. I. consists in the prevention of injuries — grazes, having combed, bruises in the field of an ulcer, and also treatment of the basic disease which caused emergence of T. I. At T. I. feet it is necessary to wear special shoes. The rational employment providing reduction of load of the lower extremities is important.
Bibliography: And with to e r x and N about in R. P. A pathogeny and surgical treatment of trophic ulcers at damage of veins of the lower extremities, Surgery, No. 8, page 32, 1976; Grigoryan A. V., GOST and-shch e in V. K. and Thick P. I. Trophic ulcers. (Pathogeny, clinic, treatment), M., 1972; M. I. Cousins and d river. A pathogeny and treatment it is long not healing ulcers at diseases of vessels of extremities, Surgery, No. 3, page 24, 1979; Petrovsky B. V. Basic bases of a reconstructive and plastic surgery, in the same place, No. 9, page 3, 1982; P about in with t I am a N about y H. E. and To at to au l e in and M. I. Plastika of fabrics at beam necroses in the field of a projection of large vessels, Vestn. hir., t. 114, No. 5, page 101,1975; V. I Pods. Purulent infection in surgery, Surgery, No. 12, page 12, 1981; Block P. The diabetic foot ulcer, Miiit. Med., v. 146, p. 644, 1981; Edmonds M. E., Roberts V. C. a. Watkins P. J. Blood flow in the diabetic neuropathic foot, Diabeto-logia, v. 22, p. 9, 1982.
M. I. Kuzin, V. Ya. Zolotorevsky.