Absolute and relative indications for amputation. Amputation, types of amputation

Hip amputation is a surgical intervention during which the proximal and distal parts of the lower limb are truncated along the length of the bone. Surgical treatment is used if there are vital indications: gangrene, malignant tumors (melanoma, sarcoma), functional vascular diseases, diabetic foot syndrome, etc. In the rehabilitation of patients with leg stumps, prosthetics is of decisive importance. Artificial formation of a supporting limb contributes to the partial restoration of the patient's activity.

Types of amputation

In surgical practice, there are several types of amputations:

1. By the period of execution - primary, secondary (associated with complications), repeated (reamputation).
2. By the method of tissue removal - circular (guillotine, one-, two- and three-stage), patchwork (one-two-flap).
3. In relation to the periosteum - aperiosteal, periosteal, subperiosteal.
4. According to the method of closing the saw cut, bones are bone-lamellar, myoplastic, skin-subcutaneous-fascial plastic, tenoplastic, periostoplastic.

Primary amputations

The operation to excision the femur is carried out when diagnosing irreversible pathological changes in soft or bone tissues:

• 4th degree burns;
• gangrene;
• total vascular damage;
• crush injury of the thigh;
• nerve damage;
• gunshot wounds.

Most often, the decision to truncate the limb is made by the surgeon after the patient is delivered to the emergency department.

TO radical surgery resort only in those situations when there is no chance of saving the leg. In the event of crushing bones, rupture of ligaments and severe damage to blood vessels, it is dangerous to save the hip, as this can lead to the development of sepsis and death of the patient.

Secondary amputation

Operations of this type are performed some time after the primary removal of the femur. The indications for amputation are complications after surgical intervention and injuries:

• inflammatory processes in the preserved tissues;
• burns and frostbite;
• the formation of infectious foci in the cult;
• pathologies caused by wearing a prosthesis.

Important! With the development of septic inflammation, it is necessary to urgently seek help from a surgeon due to the high probability of blood poisoning.

Reamputation

In this situation, amputation of the lower limb is carried out in order to correct medical errors that may be associated with miscalculations in the process of forming the stump. Reamputation is prescribed to patients if the remainder of the amputated leg is not compatible with the prosthesis or non-healing trophic ulcers form on the surface of the soft tissues. Re-removal of the stump is also indicated under tension. skin in the area of \u200b\u200bthe cut of the femur.

Amputation for complications of chronic diseases

In surgery, several types of sluggish diseases are distinguished, the development of which leads to irreversible pathological processes in the lower extremities:

• malignant neoplasms;
• diabetes;
• burger's disease;
• purulent-necrotic damage to bone tissue;
• chronic damage to the blood vessels;
• tuberculosis of the bones.

The manifestations of the above pathologies are necrotic damage to organic structures. Untimely removal of the femur is fraught with the penetration of toxins into the blood from the foci of inflammation and, as a result, the development of sepsis. The aim of the operation is to truncate the damaged parts of the leg and prevent the death of the patient from blood poisoning.

Preparing for amputation

In 30% of cases, bone amputation is performed without preparation due to the admission of patients to the emergency department. Before the start of the operation, special attention is paid to pain relief, since insufficient anesthesia is the cause of pain shock.

When carrying out surgical treatment for urgent indications, they resort to intubation (endotracheal) anesthesia. In the case of planned surgery, patients use general or local anesthesia.

Removal of part of the lower limb at the level of the femur is accompanied by damage to the vessels of the periosteum (periosteum), muscle tissue and nerve trunks, in which many pain receptors are concentrated. Therefore, in surgery, epidural anesthesia is used to anesthetize tissues and reduce the risk of intoxication complications.

The choice of the method of anesthesia is determined by the level of amputation, the likelihood of developing pain shock and the patient's well-being. In most cases, surgeons give preference to general anesthesia - this is how patients feel nothing during surgery.

Basic principles of amputation

For a long time, such amputation schemes have been used in surgery, in which not only the affected, but also healthy areas of the bone were removed. Such operations were performed with the aim of “fitting” the shape and size of the stump to a standard prosthesis.

In connection with the frequent complications associated with the formation of trophic ulcers and scars, it was necessary to resort to reamputation. The lack of a reserve distance for possible reoperation is a key disadvantage of standard bone removal schemes.

Due to the rapid expansion of technical capabilities in surgical practice, many options for prosthetics have appeared, as a result of which the principles of amputation have undergone major changes:

• only damaged tissues are subject to removal;
• maximum preservation of the functional activity of the limb;
• formation of a stump that is compatible with existing variants of prostheses;
• prevention of phantom pain in patients.

Note! In surgical practice, each case of removal of the femur is individual in terms of the methods of amputation and rehabilitation programs used.

Regardless of the part of the body to be amputated, surgical intervention is carried out in several stages:

• dissection of soft tissues;
• bone cutting and processing of the periosteum;
• processing of large nerves and vascular ligation.

Shin amputation

Removing more tibia carried out if only the foot tissue has undergone necrotization, and the blood circulates to a satisfactory degree in the distal part of the leg. Shin amputation is performed in several ways:

• Osteoplastic amputation - involves excision of the soleus muscle, sawing the shin bones and tying and suturing large nerves and blood vessels.
• Truncation of the lower leg in the middle third according to Burgess - accompanied by excision of two soft tissue fragments - a short anterior and a long posterior. After the operation, a scar is formed in the upper part of the stump, which creates optimal conditions for prosthetics.
• Flap operating technique - involves cutting a long posterior and short anterior flap.

If truncation is performed in the lower third of the tibia, the sciatic nerve is shortened without further processing. Particular attention is paid to the resection of cutaneous nerves, as their ingrowth into scar tissue often leads to pain.

Hip amputation

Truncate the bone above knee joint leads to a significant decrease in the functional activity of the leg. Amputation of the lower extremity at the level of the hip joint is performed in case of unsatisfactory blood circulation in the tissues, which occurs against the background of gangrenous lesions. During the operation, surgeons work with the femur, large blood vessels, and an extensive layer of muscle tissue.

There are several techniques for forming a support stump:

1. Albrecht's operation is a osteoplastic resection of the thigh, which is performed to change the shape of a vicious stump during re-amputation.
2. Amputation according to Pirogov is a cone-circular truncation of a limb, which is used exclusively in the field to prevent infectious inflammation of an injured limb. On the border of cutting off the bone, two flaps are formed - front and back. The length of each of them should be 1/6 of the diameter of the surgical wound.

Osteoplastic surgery is not used for total vascular pathologies and ischemic muscle damage.

After suturing, drainage is left in the operated area and an aseptic bandage is applied.

Periosteum and stump toilet

The most crucial period in the operation to truncate the lower limb is the formation of the stump. Its suitability for prosthetics and the need for re-amputation depend on the correctness of medical procedures. In surgical practice, two methods of treating the periosteum are used:

1. Aperiosteal method. At the level of the saw cut, the connective tissue membrane of the bone is crossed with a circular incision. Then the periosteum is slightly displaced, and the bone tissue is sawn just below the area of \u200b\u200bthe periosteum dissection.
2. Subperiosteal method. During the operation, the periosteum is cut below the bone sawing line and then displaced in the proximal direction. At the final stage, the periosteum is sutured over the area of \u200b\u200bthe bone cut.

The subperiosteal method of processing the periosteum is not used when operating on elderly patients, which is associated with the risk of its fusion with the bone.

When using the stump toilet, the following activities are carried out:

• ligation of large and small veins and arteries;
• hemostasis (for the prevention of septic inflammation);
• processing of truncated nerve endings.

The likelihood of complications in patients depends on the correctness of the above procedures. Failure to process the nerves is fraught with their ingrowth into connective tissue adhesions.

To prevent complications, the nerves are treated in one of the following ways:

1. The cut nerve endings are carefully sewn into the connective tissue layer.
2. Angular resection of the nerve trunks with subsequent stitching of the epineurium fibers.
3. Sewing the ends of the nerves together.

After carrying out the above manipulations, the outer tissues of the stump are sutured. After surgery, muscle fibers quickly grow together with the bone, so they are not sutured.

Amputation techniques

According to the technique of truncation of external tissues, operations are divided into two types - patchwork and circular.

Single-patch

After truncation of the damaged part of the limb, the bone saw cut is closed with a tissue flap, which consists of fascia, skin and tissue. The edge of the stump formed during the operation has the shape of a torpedo or tongue.

In the process of tissue processing, the surgeon "cuts out" fragments of soft tissues so that the scar formations are outside the supporting part of the stump to which the prosthesis will be attached.

Two-flap

After amputation, the open wound is closed with two soft tissue fragments, which are cut from the opposite surfaces of the leg. When calculating the required length of the flaps, the following factors are taken into account:

• the diameter of the surgical wound;
• coefficient of contractility of the skin;
• method of cutting the bone.

In contrast to the above-described surgical method, the two-flap operation is more laborious. Thanks to this method of closing the bone cut, complications after surgery are rare.

Guillotine (one-step)

During the operation, soft tissues at the thigh level are dissected roundabout, after which the bone is sawn through. This method of amputation is more often used in the case of urgent surgery on patients, which may be associated with:

• gunshot wounds;
• car accidents;
• work-related injuries;
• falling from a great height, etc.

A significant disadvantage of a one-stage operation is the formation of a vicious conical stump, in which secondary surgery is indicated.

Two-moment

Removing the damaged part of the leg, as well as sawing the bone, is carried out in two stages:

1. Dissection of the skin, subcutaneous tissue and muscle membrane with their subsequent displacement to the proximal part of the limb.
2. Cutting muscle fibers along the edge of the stretched tissue and sawing bone.

A significant drawback of such an operation is the formation of skin folds in the stump, which subsequently have to be removed surgically.

Three-moment cone-circular

In this case, the areas of the injured leg, in which only one bone is located, are subject to amputation. Three-stage amputations of the hip according to Pirogov are carried out in several stages:

1. Cutting the skin, fiber, connective tissue membrane of muscles.
2. Dissection of muscle fibers along the contracted dermis.
3. Resection of deep muscles along the edge of the pulled skin.

After the operation, scars often appear in the supporting part of the stump, which, moreover, can have a conical shape. Prosthetics is carried out only after re-amputation, which involves excision of adhesions and a change in the shape of tissues in the area of \u200b\u200bthe cut bone.

Cone-circular amputation was developed by N.I. Pirogov, who used it in the treatment of patients with gas gangrene and combat wounds. The advantage of the method is the possibility of surgical intervention in the field without preparation.

Postoperative complications

During the rehabilitation period, about 23% of patients experience one of the following complications:

• necrotization of soft tissues;
• preinfarction state;
• hospital pneumonia;
• bacterial inflammation of the wound;
• relapses of chronic gastrointestinal pathologies;
• vascular thrombosis;
• circulatory disorders in the brain.

To prevent negative consequences, patients undergo antibiotic therapy and physiotherapy. Massage, breathing exercises and physiotherapy exercises reduce the risk of pulmonary diseases and congestion in soft tissues.

Phantom Pain

The painful sensations that occur in an amputated limb are called phantom pains. The true cause of their occurrence has not been established, therefore, etiotropic and pathogenetic methods of their treatment do not exist. Typical manifestations of pathology include:

• itching in the heel;
• numbness of the toes;
• lumbago in the foot;
• discomfort in the knee.

For relief of discomfort, antidepressants and sedatives are used. They reduce the severity of symptoms and prevent the development of depression in patients. For the early elimination of the postoperative complication, it is recommended to resort to limb development and training using a prosthesis.

Psychological attitude

Competently organized psychological support in the preoperative and postoperative period can speed up the adaptation and habituation of patients to the absence of a leg. Timely assistance and attention from loved ones shorten the rehabilitation period and have a beneficial effect on the psychoemotional state of patients.

A positive attitude reduces the likelihood of pain in the missing limb and other postoperative complications. Experts are sure that this is due to the absence of factors that negatively affect the functioning of the nervous system. During the recovery period, it is recommended to follow the doctor's orders and not think about the lack of legal capacity.

Disability group

Rehabilitation of patients after hip truncation takes at least 6-9 months in the absence of serious postoperative complications. Depending on the level of amputation, patients are assigned one of the following disability groups:

• Group I - it is installed with short stumps in the thigh area of \u200b\u200bboth legs at once with partial limitation of the functions of the upper limbs.
• Group II - given to patients with hip prosthetics with combined lesions of the second leg or both lower extremities at the level of the lower leg.
• Group III - is established when the functions of the lost leg are partially restored with the help of a prosthesis.

The disability group is determined taking into account not only the anatomical defect, but also the presence of concomitant complications that affect the quality of life and performance of patients.

Postoperative stump care

The likelihood of developing an infection in the operated tissues largely depends on the care taken in patient care. When drawing up a rehabilitation program, the following nuances should be taken into account:

1. On the third day after surgery, patients should develop a stump to prevent contractures.
2. After two weeks, the stitches are removed and a bandage is applied instead. During this period, active training should be started to increase muscle tone and prepare the stump for prosthetics.
3. After a month, patients try on a prosthesis and actively develop a limb.

Amputation of the leg at the level of the femur is a complex operation that leads to the patient's disability. They resort to radical surgical intervention only if it is not possible to save the limb. Indications for amputation are: gangrene, malignant tumors, vascular diseases, bone necrosis, etc. The likelihood of postoperative complications depends on the method of limb truncation and compliance with the rules of rehabilitation.

- surgery to remove the distal segment of the limb along the bone or bones.

The indications for amputation are currently as follows:

ABSOLUTE:

Traumatic avulsion of a limb (complete or almost complete).

Open multiple bone fractures with significant damage to soft tissues, blood vessels and nerves.

Burns and frostbite when it is impossible to save the limb (Art. III-IV).

Extremity gangrene of various etiologies:

Malignant inoperable tumors of the bones or soft tissues of the extremities.

RELATIVE:

1. long-term trophic ulcers that are not amenable to conservative treatment;
2. chronic osteomyelitis with signs of amyloidosis of internal organs;
3. severe, irreparable deformities of the limbs of a congenital or acquired nature;
4. large bone defects.

SELECTING THE AMPUTATION LEVEL

the principle of NI Pirogov: "amputate as low as possible"

Currently, the main principle is the maximum preservation of the length of the limb to facilitate its prosthetics. Almost the only exception to this rule is the amputation of the thigh in the lower third. Too long a stump does not allow the use of an artificial knee joint for prosthetics.

METHODS OF DISSECTING SOFT TISSUE

1. I. Circular (circular) - the skin and soft tissues are dissected in the transverse direction in relation to the axis of the limb.

a) guillotine amputation - all tissues are dissected at the same level;

b) one-step - after cutting the skin along the border of its mixing, cut through soft tissues and bone;

c) two-stage - along the border of the dissected and displaced skin, the muscles are cut, the bone is sawn at the level of the displaced muscles;

d) three-stage, when, after dissection and displacement of the skin along its border, the superficial muscles are crossed, displaced and cross the deep ones, shifting them upward with the help of a retractor: after that, the bone is sawn through.

Considering that the performance of guillotine amputation leads to the formation of a vicious stump, the indications for this type of operation are anaerobic infection and an extremely serious condition of the patient.

II. Patchwork (see Fig. 1) - based on cutting out one or more skin flaps with which to cover the stump after amputation. This method is more economical and the best in terms of modern prosthetics. The flap should be cut so that the postoperative scar is located on the non-working surface of the stump.

III. Oval (see Fig. 1) - the skin is dissected along an ellipse located at an angle to the axis of the limb.

MAIN STAGES AND TECHNIQUE OF PERFORMANCE OF AMPUTATIONS

Patient position : on the back, the operated limb is taken to the side and placed on the side table. The removed part of the limb should be located to the right of the surgeon.

Anesthesia:general anesthesia, it is possible to use local anesthesia in combination with epidural.

Application of a hemostatic tourniquetused to reduce blood loss. especially with traumatic amputations. The tourniquet is applied as close as possible to the intended site of tissue intersection to reduce the degree of limb ischemia.

Recently, amputations for obliterating diseases of the arteries of the extremities are performed without the application of a tourniquet to prevent additional vascular trauma and the development of postoperative bleeding from small vessels.

Dissection of the skin and subcutaneous tissueproduced with a scalpel or amputation knife. The skin, subcutaneous tissue and its own fascia are simultaneously dissected. The level and shape of the incision are decided individually in each case in order to maximize the length of the stump.

With the circular limb truncation method, the skin incision is made distal to the estimated level of the bone cut by the size of the limb diameter with the addition of 1/6 for the contractility of the skin. When performing amputation by the flap method, the sum of the lengths of both flaps should be equal to the diameter of the limb at the level of the proposed cut of the bone, taking into account the contractility of the tissues. As a rule, one of the flaps is 2/3 of the diameter and is cut out so that the postoperative scar is located on the non-working surface.

The bone stump should be covered with a sufficient amount of soft tissues, otherwise a vicious stump that is not suitable for prosthetics may arise. Therefore, the inclusion of its own fascia in the skin flap promotes the formation of a movable scar.

Muscle intersectionis performed with an amputation knife, depending on the method of amputation, in one or more steps.

TECHNIQUE OF TREATMENT OF SUPPOSITION AND BONE

There are 3 main methods of processing the periosteum: I. subperiosteal (subperiosteal); II. aperiosteal (nonperiosteal); III. transperiosteal (the periosteum and bone are dissected at the same level).

Subperiosteal -consists in the fact that the periosteum is intersected circularly distal to the level of the proposed cut of the bone and, with the help of a raspator, is exfoliated in the proximal direction. The bone is sawn through and the surface of the sawdust is covered with excess periosteum. This method prevents the formation of osteophytes and sharpening of the bone, thereby increasing the support of the stump. The high regenerative capacity of the periosteum in children leads in this case to the formation bone platecovering the bone stump.

Aperiosteal -consists in the fact that the periosteum is dissected proximal to the expected level of the bone cut by 0.5 cm and exfoliates in the distal direction. After sawing the bone, a section of it remains, devoid of a periosteum, which quite often leads to the development of osteophytes and osteomyelitis as a result of a violation of the periosteal blood supply.

Transperiosteal- is the most rational and widespread at present when performing amputations in adults. With it, the bone is sawn in close proximity to the intersected periosteum, retreating from its edge by 1-2 mm distally.

When sawing a bone, certain rules must be followed. First, a small gash is made to prevent the saw from slipping when sawing the smooth and dense outer surface of the bone. After the bone has been sawn, careful processing of the edges of the saw with a rasp, chisel and file is necessary in order to make the end of the bone smooth and even, which will prevent soft tissue injury in the postoperative period and facilitate the possibility of rational prosthetics.

Processing of vessels.In traumatic amputations, large vessels are ligated before the tourniquet is removed. The found vessels are captured with a hemostatic clamp (separate artery and vein), separated from the surrounding tissues and ligated with catgut to prevent the formation of ligature fistulas. On the large main arteries, 2 ligatures must be applied, one of which is stitched. Small vessels are ligated after removing the tourniquet, sometimes together with the surrounding tissues. In case of amputations without the imposition of a tourniquet, a preliminary isolation and ligation of the vessels is performed until the muscles are completely intersected.

Nerve processing.Nerve transection is performed proximal to the amputation level of at least 5-6 cm.Nerve trunks that are not truncated according to all the rules can lead to the formation of neuromas soldered to the ruby \u200b\u200btissue of the stump, therefore the nerve is carefully isolated from the surrounding tissues and crossed with one movement of a safety razor. Preliminarily, 3-5 ml of 2% novocaine solution with 1 ml of 96% alcohol (alcohol-novocaine blockade) is injected perineurally. A.commitans walking next to the nerve is tied with catgut. It is unacceptable to pull the nerve trunk out of the soft tissues and cross it with scissors, as this will lead to intra-trunk hemorrhages and the formation of painful neuromas and adhesions. Sometimes after amputation, phantom pains occur (painful sensations in the form of cutting, squeezing, stabbing, burning pains in the missing limb). This condition is a consequence of a trace reaction of the cerebral cortex to severe irritation of the nervous system during trauma or processing of the nerve during amputation (insufficient pain relief).

Phantom pains do not disappear even after repeated surgery and can only be relieved after the use of physical and psychotherapy.

CULT FORMATION METHODS

Depending on what tissues cover the bone sawdust, the following methods are distinguished:

1. skin-fascial - sawdust is covered by a flap of skin, subcutaneous tissue and fascia (Fig. 3);
2. tendoplastic - sawdust is covered by muscle tendons;
3. osteoplastic - to cover the bone sawdust, a part of the other bone is used (for amputation in n / 3 thighs, the patella is used) (Figure 4);
4. myoplastic - antagonist muscles are sutured over the bone opil (Fig. 5).

When stitching the antagonist muscles, the possibility of improved arterial blood supply and the elimination of venous stasis at the end of the stump is created. If the antagonistic muscles are not sewn together, then the percentage of defects and diseases of the stump increases, and the possibilities of prosthetics deteriorate significantly.

All materials on the site have been prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and inapplicable without consulting your doctor.

Amputation of the lower extremities is an operation that, in most cases, is performed for health reasons, when the patient has no chance of survival without the use of radical surgery. Amputation is the removal of a section of a limb along the length of a bone, and truncation of a peripheral section of a limb within a joint is called disarticulation (or articulation in the joint).

There are two main reasons for leg amputation - trauma and chronic functional diseases of the vascular system. In turn, severe trauma is the basis for primary and secondary surgery.

Types of amputation

Primary amputations

Primary amputation is an operation to remove the lower limb, in the tissues of which irreversible pathological changes have occurred. Total damage to the neurovascular bundles and bones occurs after falling from a height, as a result of road accidents, gunshot wounds, burns and other traumatic effects.

The doctor decides on the primary amputation after the patient is delivered to the emergency department in the event of an accident. If there is even one chance of saving a limb, it will definitely be taken. But with crushed bones and torn ligaments, it is dangerous to keep the leg - sepsis develops instantly after such extensive damage.

Secondary amputation

Secondary amputation is an operation performed some time after the previously applied surgery. The basis for the radical method is extensive infection, leading to the death and decomposition of tissues. Inflammatory processes that cannot be eliminated without preserving the limb can be caused by frostbite, burns, prolonged squeezing of blood vessels, as well as wound infection.

Reamputation

Reamputation is a re-operation after limb truncation. Implemented to correct medical error (in general, miscalculations are allowed during the formation of the stump), or to prepare for prosthetics. Re-amputation is used if the stump formed during the first operation is not compatible with the prosthesis, or trophic ulcers form on its surface. A sharp protrusion of the end of the bone under the taut skin or postoperative scar is an unconditional reason for a second surgical intervention.

Amputation for complications of chronic diseases

There are several chronic diseases that lead to the development of irreversible processes in the limbs:

• Diabetes;
• Osteomyelitis;
• Bone tuberculosis;
• Obliterating atherosclerosis;
• Malignant neoplasms.

development of limb necrosis due to ischemia due to atherosclerosis, obliterating thromboangiitis, diabetes and other chronic diseases

The purpose of the operation is to prevent the ingress of toxins produced in the lesion focus into healthy organs and tissues of the body, as well as to maintain the musculoskeletal balance necessary for prosthetics.

Preparing for amputation

Very often, amputation has to be carried out urgently, as soon as the patient is admitted to the trauma department. It is extremely important in this difficult environment to pay due attention to the issue of pain relief. With insufficient anesthesia, painful shock can develop, which negatively affects the general condition of the patient, and worsens the prognosis of recovery. Exactly strong painexperienced during preparation and during amputation, generates fear and anxiety in the postoperative period.

If the operation is performed according to urgent indications (without preliminary preparation), intubation anesthesia is more often used, and in case of planned amputations, a form of anesthesia is chosen taking into account the state of the body. This can be regional or general anesthesia.

Amputation at the hip level is associated with extensive damage to the nerve trunks, muscles, vessels of the periosteum - that is, those areas where there are many pain receptors. Epidural anesthesia, which has found wide application in modern surgery, reduces the risk of intoxication complications after limb truncation (as compared with the endotracheal method), and also creates conditions for effective postoperative pain relief.

In any case, when preparing for a planned amputation, the possibility of using one or another form of anesthesia, as well as the patient's physical condition, are taken into account. General anesthesia, with all its disadvantages, is often preferred, since the patient does not perceive the severity of the event during the mutilating operation.

Basic principles of lower limb amputation

typical levels of NK amputation

In surgical practice, amputation schemes have been used for a long time, according to which limb truncation was carried out in such a way that, in the future, a standard prosthesis could be used. This approach often led to unnecessary removal of healthy tissue.

Excessively high amputation increased the likelihood of the formation of a vicious stump, which could only be corrected with a secondary operation. The main disadvantage of amputation schemes in classical field surgery is the lack of a reserve distance for re-amputation and for creating an individual prosthesis.

Since medical technologies for rehabilitation are rapidly developing, and the number of variants of prosthetic structures is tens of units, each case of amputation in modern traumatology can be considered individual from the point of view of the applied technique and scheme of postoperative recovery.

Thus, the main principles of the operation that underlie the amputation are: the maximum possible preservation of the anatomical functionality of the leg, creation of a stump that is compatible with the prosthesis design, prevention of phantom pain syndrome

General rules for amputation

All types of amputations and exarculations are performed in three stages:

1. Dissection of soft tissues;
2. Sawing a bone surgical debridement periosteum;
3. Vascular ligation, treatment of nerve trunks (stump toilet).

According to the technique used for dissecting soft tissues, amputations are divided into flap and circular operations.

Single-flap amputation provides for the closure of the processed (sawed) bone and soft tissues with one skin flap with subcutaneous tissue and fascia. The flap is shaped like a rocket or tongue. Cutting out a fragment is carried out in such a way that the postoperative scar passes as far as possible from the working (supporting) part of the stump.

Two-flap amputation - the wound after truncation is closed with two fragments cut from opposite surfaces of the limb. The length of the flap with the surgical techniques described above is determined by calculation, based on the diameter of the truncated limb, taking into account the coefficient of skin contractility.

Circular amputation - the dissection of soft tissues is carried out in a direction perpendicular to the longitudinal axis of the limb, resulting in a circle or ellipse in the cross section. This technique is used on those parts of the limb where the bone is deep in the soft tissues (femoral region). Dissection of soft tissues is carried out in one, two or three movements (respectively, amputation is called one-stage, two-stage, or three-stage).

One-step (guillotine) operation provides for the dissection of tissues to the bone in a circular motion, after which the bone is sawed at the same level. The technique is used in emergency situations related to saving the patient's life (this happens after an accident, gunshot wounds, natural disasters). The main disadvantage of the guillotine technique is the need for a secondary operation (reamputation) to correct a vicious (conical) stump that is unsuitable for prosthetics.

example of three-stage amputation according to Pirogov

Two-moment amputation is performed in two steps. First, the skin, subcutaneous tissue layer, fascia are dissected. Further, the skin in the operated area is displaced (with tension) towards the proximal part of the limb. The second stage - the muscles that run along the edge of the stretched skin are dissected. The disadvantage of the operation is the formation of excess skin on both sides of the stump. These fragments are subsequently truncated.

Three-stage cone-circular amputation - an operation performed on areas of the limb where one bone passes, surrounded by soft tissues. The surgeon makes an incision on different levels, in three steps. First, the superficial skin, subcutaneous tissue, superficial and intrinsic fascia are dissected. Further, the muscles are dissected according to the level of the contracted skin. The third stage is the dissection of deep muscles in the proximal direction (along the edge of the pulled skin).

The disadvantage of the operation is extensive scars in the stump area (on the supporting surface), the tapered profile of the bone sawdust site. After cone-circular amputation, it is technically impossible to carry out prosthetics (re-amputation is required). The cone-circular technique developed by the Russian surgeon N.I. Pirogov, is used in surgery for gas gangrene, in the field, where the wounded constantly arrive, and there are no conditions for carrying out planned operations.

Periosteum and stump toilet

The most crucial moments in the operation for amputation of the lower limb are the processing of the periosteum and the toilet of the stump.

When aperiostealin this way, the periosteum is intersected with a circular incision at the level of the bone sawdust, after which it is displaced in the distal direction. The bone is sawn 2 mm below the periosteum dissection site (a larger fragment cannot be left due to the risk of bone necrosis).

When subperiosteal In this way, the periosteum is dissected below the level of sawing of the bone (the cutoff level is determined by the formula) and is shifted towards the center (in the proximal direction). After sawing off the bone, the periosteum is sutured over the place of its processing (sawdust). This method is rarely used for amputation in the elderly due to the close fusion of the periosteum with the bone.

When using the stump toilet:

• Ligation of the main and small vessels;
• Hemostasis (to prevent secondary infection);
• Treatment of nerve trunks (prevention of neuroma formation)

Technically competently performed nerve treatment can significantly reduce the intensity of phantom pain that occurs in most patients after amputation, as well as prevent nerve ingrowth into scar tissue.

The following techniques are used:

1. The transected nerve is sutured into the connective tissue sheath;
2. Angular transection of the nerve is used with further stitching of the epineurium fibers;
3. Suturing the ends of the crossed nerve trunks.

The nerves are not stretched to avoid damage to the internal vessels and the formation of hematomas. Excessive intersection is unacceptable, as this can lead to atrophy of the stump tissue.

After the treatment of the vessels and nerves, the stump is sutured. The skin is sutured with adjacent tissues (subcutaneous tissue, superficial and intrinsic fascia). The muscles grow well with the bone, so they are not sutured. Postoperative scar must remain mobile, and, in no case, must not be soldered to the bone.

Exarticulation of the finger

In severe forms of diabetes, the most dangerous complication is gangrene of the foot and the distal phalanx of the toe. Unfortunately, leg amputation in diabetes mellitus is not a rare case, despite significant advances in the treatment of endocrine diseases, achieved by medicine over the past decade. The level of limb truncation is determined by the state of tissues and blood vessels.

With a satisfactory blood supply to the limb, flap exarticulation of the finger is performed, cutting out the dorsal and plantar flaps together with the subcutaneous tissue and fascia. The articular surface of the metatarsal head is not damaged. After removing the cat tissue, primary sutures are applied, drainage is installed.

Several types of surgical techniques are used to amputate the diabetic foot and toe phalanges. Sharp amputation is performed for gangrene of several toes and feet while maintaining satisfactory blood flow. Large flaps (dorsal and plantar) are cut out, after which the tendons of the muscles responsible for flexion-extension movements of the fingers are cut, the metatarsal bones are sawn through. After processing the bone tissue with a rasp, primary sutures are applied, and drainage is established.

When performing a Chopard amputation, two incisions are made in the area of \u200b\u200bthe metatarsal bones, followed by their isolation. The tendons are transected at the maximum height, the amputation incision follows the line of the transverse tarsal joint (the calcaneus and talus are preserved, if possible). The stump is closed with a plantar flap immediately after the inflammation has subsided.

Shin amputation

The decision to amputate the lower leg with gangrene of the foot is made if the blood flow in the foot is stopped, and in the lower leg itself, the blood supply is maintained at a satisfactory level. The operation technique is patchwork, with cutting out two fragments (long posterior and short anterior flap). Osteoplastic amputation of the lower leg involves cutting the fibula and tibia, processing the trunks of nerves and blood vessels, and removing the soleus muscle. Soft tissues in the area of \u200b\u200bbone sawdust are sutured without tension.

Amputation of the lower leg in the middle third according to Burgess involves cutting out a short anterior (2 cm) and a long posterior flap (15 cm) covering the wound. Scar formation is carried out on the anterior surface of the stump. The technique provides great opportunities for early prosthetics.

Hip amputation

Amputation of the leg above the knee significantly reduces the functional mobility of the limb. Indications for surgery (except for trauma) are weak blood flow in the lower leg with gangrene of the foot. During surgical manipulations on the thigh, one has to work with the femur, large vessels, nerve bundles, anterior and posterior muscle groups. After cutting, the edges of the femur are rounded off with a rasp, layer-by-layer tissue suturing is carried out. Aspiration drains are installed under the fascia and muscles.

The various techniques for forming the abutment stump are named after the surgeons who developed the amputation techniques. So, for example, cone-circular amputation according to Pirogov is used in military field surgery, when it is urgently necessary to prevent infection of a seriously injured limb.

Amputation of the thigh according to Gritti-Shimanovsky, or surgery according to Albrecht, is used for reamptuations for a defective stump (in case of incompatibility of the stump with a prosthesis, with the appearance of manifestations in the scar area, decreased mobility of the limb due to improper fusion of muscles and ligaments). Osteoplastic technique of amputation of Gritti-Shimanovsky is not used for ischemic muscle disease and total vascular pathologies that develop with obliterating atherosclerosis.

Postoperative complications

After amputation of the lower extremities, the following complications may occur:

• Wound infection;
• Progressive tissue necrosis (with gangrene);
• Preinfarction state;
• Violation of cerebral circulation;
• Thromboembolism;
• Hospital pneumonia;
• Exacerbation of chronic gastrointestinal diseases.

Properly performed surgery, antibiotic therapy and early activation of the patient significantly reduce the risks of developing fatal consequences after complex amputations.

Phantom Pain

Phantom pain - this is the name for pain in the severed limb. The nature of this phenomenon is not fully understood, and therefore there are no absolutely (100%) effective ways to combat this extremely unpleasant syndrome that worsens the quality of life.

A patient with a thigh amputation often complains of numbness in the fingers, shooting pain in the foot, aching knee, or severe itching in the heel area. There are many medical regimens that are used to eliminate phantom pain syndrome (FBS), but only a comprehensive approach to solving the problem gives positive results.

An important role in the prevention of FBS is played by drug therapy used in the preoperative and postoperative period. The second important point is right choice surgical techniques and, in particular, the treatment of transected nerves.

Prescribing antidepressants in the first days after amputation helps to reduce the intensity of phantom pain. And, finally, early physical activity, limb development, hardening, training walking with a prosthesis - all of the above methods used during the rehabilitation period can minimize the manifestation of severe postoperative complications.

Psychological attitude

Not a person for whom the message of the doctor about the upcoming mutilation operation would not cause great stress. How to live further? How will close people perceive the news? Will I become a burden? Will I be able to serve myself? Then comes the fear of having to endure suffering postoperative period... All these thoughts and worries are natural reactions to the upcoming event. At the same time, it should be said that, thanks to well-organized psychological support, many people manage to overcome the rehabilitation period quickly enough.

One patient said that he was not going to worry about amputation as it would not lead to recovery. "It is important for me to find my place in life after the operation - all my thoughts are about this." Indeed, people with a positive attitude are much less likely to experience phantom pain, and the patients themselves quickly adapt to new conditions of life and communication (including those who have survived amputation of two limbs). Therefore, you must calmly follow the doctor's recommendations, do not panic, do not feel sorry for yourself, do not fence yourself off from friends. Believe me, with such a life attitude, others will not notice disability, and this is very important for social adaptation.

Disability group

The recovery period after lower limb amputation is 6-8 months.

Disability of the II group is established for persons with prosthetics of the stumps of two legs, with a stump of the thigh in combination with the defeat of the second limb.

Group I is given for short stumps of the thigh of two limbs in combination with limited functionality of the upper limbs.

III group of disability without specifying the period of re-examination is established for persons who have completed the process of prosthetics and have sufficiently restored the lost functionality of the limbs.

- This is the separation of a limb as a result of traumatic impact. It can be complete or incomplete. It can occur at any level, but the distal parts of the upper limb (fingers and hand) are more often affected. The reason is mechanical separation, crushing or guillotining. Usually accompanied by profuse bleeding, may be complicated traumatic shock... X-rays are used to assess the condition of the affected limb. Surgical treatment - the formation of a stump or replantation of the severed part of the limb.

ICD-10

S48 S58 S78 S88

General information

Traumatic amputation - partial or complete separation of a limb as a result of traumatic impact. With complete detachment, the distal segment is completely separated from the body; with partial amputation, damage to bones, tendons, nerve trunks, arteries and veins occurs, with partial preservation of the skin and soft tissues. Traumatic amputations are treated by orthopedic traumatologists and specialists in hand microsurgery. Treatment tactics are determined depending on the condition of the tissues and the safety of the distal fragment.

The reasons

Most often, traumatic amputations occur in the workplace. At the same time, in recent decades, due to the widespread use of household power tools, the number of traumatic separations of extremities in everyday life (usually when working in the country) has increased, while, as a rule, one or more fingers are damaged, less often damage is detected at the level of the hand. Separation of limbs can occur during a rail injury (moving a limb with a wheel of a tram or train), as well as when large loads fall and the limb is pulled into driving mechanisms.

Symptoms of traumatic amputation

The limb is completely or partially separated from the body. Falling heavy loads and rail trauma can reveal scalped or lacerated wounds to the proximal limb. Sometimes, with partial separations, the limb in the area of \u200b\u200bdamage and below resembles a shapeless bag with crushed contents. The wound is usually heavily soiled. For separations by moving mechanisms, extensive lacerated and scalped wounds are also characteristic; in some cases, the amputated section of the limb is divided into several fragments.

With guillotine amputations, the stump is even. As a rule, traumatic amputations are accompanied by profuse bleeding, exceptions sometimes occur with a rail injury and crushing of a limb with a heavy object (in these cases, bleeding is absent or minimal due to compression of damaged vessels). The general condition of the patient moderate or heavy. There is growing anxiety, pallor of the skin, a drop in blood pressure, increased respiration and pulse rate. Loss of consciousness is possible.

Diagnostics

Making a preliminary diagnosis is straightforward. To assess the condition of the proximal limb and exclude fractures above the level of traumatic amputation, X-ray of the stump is performed. In the presence of other injuries, various studies are prescribed: X-ray of the corresponding segments of the trunk and limbs, laparoscopy, echoencephalography, etc. To determine the degree of blood loss and general condition the body is performed a set of laboratory tests. In the course of preoperative preparation, ECG, radiography of the OGK and other studies are performed.

Treatment of traumatic amputation

At the first aid stage, the action of the traumatic agent can be stopped as soon as possible (remove the weight from the limb, turn off the rotating mechanism, etc.). If necessary, resuscitation measures are carried out: indirect heart massage and mouth-to-mouth breathing. If bleeding is present, immediate measures are taken to stop it. A pressure bandage is applied to the stump. If the bandage is quickly soaked in blood, it is not removed, but another bandage is applied on top. The limb is raised above the level of the heart, immobilization is performed using a special splint or improvised materials (boards, cardboard, rolled magazines, etc.).

If the bleeding cannot be stopped with a tight bandage, a tourniquet is applied to the middle third of the thigh or shoulder. With high traumatic amputations of the hip and shoulder, the application of a tourniquet is impossible; in such cases, the bleeding is stopped by pressing the artery in the groin or axillary region. The amputated part of the limb is preserved regardless of its condition - only a doctor can make a decision on the possibility or impossibility of replantation. If the limb is partially torn off, the distal part is carefully placed on the splint and bandaged together with the proximal part, taking care not to damage the remaining parts and not break the contact between the proximal and distal parts.

If the traumatic amputation is complete, the torn part is wrapped in dry sterile gauze or a clean cloth and placed in two plastic bags (one in the other). The bags are tied, placed in plastic dishes, the dishes are covered with bags of cold water or ice. A note is tied to the package node indicating the date and time of the injury. Under no circumstances should the amputated fragment be treated with alcohol or other disinfectant liquids, or soaked, placed in water or on ice - this may damage, soak or cold damage the tissues.

Upon admission to the department of traumatology and orthopedics, the severity of the victim's condition and the approximate amount of blood loss are assessed, if necessary, resuscitation measures are taken, blood and blood substitutes are transfused. The operation is carried out after removing the patient from the state of shock, stabilizing respiration and hemodynamic parameters. The tactics of surgical intervention are chosen taking into account the state of the tissues of the stump and the amputated section. If replantation is not possible, a typical amputation is performed, trying to keep the stump as long as possible. When the tissues are crushed, PCO is performed: non-viable tissues are removed, the vessels are bandaged, etc. No stitches are applied upon admission, the wound is left open. Subsequently, dressings are made, and then delayed sutures are applied or re-amputation is performed.

When choosing the level of amputation in children, the location of the growth zones is taken into account and a supply of soft tissues is created in order to avoid the formation of a cone-shaped stump; in some cases, instead of amputation, disarticulation is performed. Prosthetics in children and adults is carried out 2-3 months or more after the wound has completely healed.

In the absence of pronounced crush damage and the safety of the amputated limb, replantation is possible. Fingers and phalanges of fingers with crush injuries and multiple fractures, as well as torn off nail phalanges of V and IV fingers, are not subject to replantation. Contraindications to replantation are old age, the serious condition of the patient, the presence of other injuries requiring urgent surgical intervention, as well as exceeding the critical period from the moment of traumatic amputation.

If the amputated part is stored at a temperature of +4 degrees, the critical period for the fingers is 16 hours, for the hand - 12 hours, for the shoulder, forearm, thigh, shin and foot - 6 hours. In the case of storage at temperatures above +4 degrees, the critical period is reduced for fingers to 8 hours, for a hand - up to 6 hours, for a shoulder, forearm, thigh, shin and foot - up to 4 hours. Storage at temperatures below +4 degrees can lead to frostbite of tissues, after which engraftment will become impossible.