Limb amputation is considered one of the oldest operations in the history of medicine. The first descriptions date back to the 4th century BC. e. However, the inability to stop severe bleeding, as well as the lack of knowledge about ligation of blood vessels, as a rule, led to death. Doctors were advised to truncate the limb within the affected tissues, this ruled out fatal bleeding, but did not stop the spread of gangrene.
In the first century AD, Celsus Aulus Cornelius proposed a revolutionary for that time approach to conducting such operations, which included recommendations:
- truncate according to the level of viable tissues;
- isolated ligation of the vessels of the stump to prevent bleeding;
- cutting out a reserve piece of tissue to cover the stump without pathological tension.
Important in improving methodsamputation of limbs was played by the introduction of the method of bloodless surgery, when Esmarch created the rubber tourniquet that is still used today.
In the modern world, diabetes mellitus and cardiovascular pathologies are the leading indications for amputation.
Amputation is a truncation of a limb, or rather its distal part, along the bone, but it would be a terrible mistake to consider it as a simple removal of the affected segment. This term implies plastic and reconstructive operations aimed at further rapid and effective rehabilitation of the patient.
There are certain indications for this type of surgery. Consider these readings in more detail.
Indications for limb amputation
- Gangrene.
- The presence of a focus of severe infection that threatens the patient's life (anaerobic infection).
- Irreversible ischemia with muscle contracture.
- Prolonged compression syndrome.
- Traumatic crush injury of the limb with damage to the main vessels and nerves, the so-called traumatic amputation is performed.
- Obliterating vascular diseases leading to gangrene.
- A tourniquet applied for more than three hours.
- Common refractory neurotrophic ulcers.
- Osteomyelitis with a threat of damage to internal organs.
- Widespread tuberculosis of bone tissue in old age.
- Malignant bone tumors without the possibility of isolated removalhearth.
Determination of resection level
The choice of the level of limb amputation depends on the degree of circulatory disorders in the operated area, the presence of gangrene, trophic disorders, the state of adjacent tissues and the severity of the infectious process and pain syndrome.
In children, they try to use exarticulation (sharpening of the affected part at the level of the joint), which does not disturb the further growth of the bone.
According to the urgency of surgical intervention, limb amputations are distinguished:
- emergency amputation performed during the provision of first surgical aid in order to remove non-viable, damaged tissues;
- urgent operation with truncation of the focus of intoxication with the ineffectiveness of conservative methods of treatment;
- planned amputation performed for malignant bone lesions, osteomyelitis.
- reamputation to correct a failed stump.
There are circular, elliptical and patchwork amputations. Consider these species below.
Circular amputations
The main indications for amputation, namely guillotine (single-stage circular) amputation, are gas gangrene and resection of limbs hanging on a musculoskeletal shred. This intervention is carried out exclusively for emergency vital indications. A significant disadvantage of this technique is the creation of a non-functional stump and the mandatory subsequent reamputation in order to adapt the limb to the further installation of the prosthesis.
The advantage of this amputationis the absence of necrotic changes in the flap even with reduced blood supply.
In a guillotine amputation, the bone is cut at the same level as the soft tissue.
How is the operation performed? Amputation at the first stage consists in incision of the skin, subcutaneous fat and fascia. The edge of the displaced skin is a further guide along this edge. At the second stage, the muscles are dissected to the bone and the bone tissue is further cut. The bone end is covered by the skin and fascia.
This type is recommended for limbs with relatively small muscle mass.
For areas with large muscle mass, a three-stage amputation is recommended (simple and cone-circular amputation according to Pirogov).
The first two stages of the operation are similar to two-stage amputation. Further, after the muscles and superficial tissues are shifted in the proximal direction, the muscles are re-dissected along the edge of the retracted skin. Due to this, deep muscle layers are dissected, which contributes to the further formation of a cone-shaped stump.
Patchwork methods share:
for single-flap (the length of one flap is equal to the diameter of the stump);
double-flap (two shreds of different sizes by the sum of the lengths that make up the diameter of the amputated limb)
When forming a stump, it must be taken into account that the scar should not be on the working surface. The patches must be shaped with load bearing capacity in mind.
Osteoplastic amputations
Howamputation of the lower extremities? A distinctive feature is the presence of a fragment of bone covered with periosteum as part of the flap.
The method of osteoplastic amputation of the lower leg according to Pirogov has received worldwide recognition in connection with the highly successful anatomical rehabilitation of the end support of the operated leg.
Method benefits:
- Less pronounced soreness of the stump.
- Presence of the end support of the stump.
- Preservation of proprioceptive sensitivity of muscles and tendons.
Steps of operation
When removing the lower leg according to Pirogov, two incisions are made. For this, an amputation knife is used. First, a transverse dissection of the soft tissues is performed, exposing the ankle joint, then an arcuate incision is made, passing along the dorsal surface of the foot. After the intersection of the lateral ligaments, the talus is dissected, and the bones of the lower leg are sawed off. The cross section is closed with a patch. Form a stump.
Sharpe operation
There is another method by which amputation of the lower limbs is performed.
When removing the foot, soft tissue dissection is carried out a few centimeters distal to the first phalanges of the metatarsal bones. After the preparation of the periosteum, the metatarsal bones are sawed off and the ends of the saw cut are smoothed with wire cutters. The cut is covered with a plantar patch.
Let's look at the main causes of amputation.
Diabetic microangiopathy
The actions of the surgeon depend on the extent of the lesion. According to the prevalence of purulentThere are five stages of necrotic lesions:
- Superficial necrosis without tendon involvement.
- Gangrene of the finger involving the first phalanx and tendons.
- Widespread gangrene of the fingers, combined with gangrene of the foot.
- Gangrenous lesion of the entire foot.
- Involvement of the lower leg.
When a patient with purulent-necrotic ischemia is admitted, an emergency sanation of the focus is carried out, which consists in opening abscesses, draining phlegmon, minimal resection of the affected part of the bone and removal of dead tissues. After excision of nonviable tissues, operations are recommended to restore adequate blood flow to the injured limb.
For ischemia:
- the first degree only sanitation of the hearth is performed;
- the second degree implies amputation of the affected finger with excision of the tendons involved in the process;
- at the third degree, Sharp amputation is performed, a special amputation knife is used;
- treatment of the fourth degree consists in resection at the level of the lower leg;
- at the fifth degree, amputation is performed at the level of the thigh.
Frostbite of fingers and other body parts
Distinguish:
general freezing (pathological changes in organs and tissues that develop as a result of circulatory disorders and further cerebral ischemia due to prolonged exposure to low temperatures);
chill (manifested by a chronic inflammatory reaction of the skin in the form of cyanotic-burgundyscaly patches with severe itching
There are four degrees:
The first degree is accompanied by reversible changes in the skin: hyperemia, swelling, itching, pain and an unexpressed decrease in sensitivity. After a few days, the affected areas slough off.
The second degree is characterized by the appearance of blisters with light contents, a pronounced decrease in sensitivity, possibly an infection due to trophic disorders.
The third degree is manifested by necrotic changes in soft tissues as a result of their death, a line of demarcation is formed (delimitation of dead tissues from he althy tissues with a strip of granulations), damaged areas of the limb are mummified, with the addition of microbial flora, wet gangrene may develop.
At the fourth degree, tissue necrosis spreads to the bone, the fluid in the blisters on the skin becomes cloudy black, the skin is bluish, pain sensitivity completely disappears, the affected limb turns black and mummifies.
Treatment
- 1st degree. Patient warming, UHF therapy, darsonval, frostbitten limb is rubbed with boric alcohol.
- 2nd degree. Bubbles are being processed. After opening them, the damaged skin is removed, an alcohol bandage is applied to the wound. Systemic antibiotic therapy recommended.
- 3rd degree. Bubbles are removed, dead tissue is excised, a bandage with hypertonic saline is applied. Antibiotics are used to prevent secondary infection.
- 4th degree. necrectomy(removal of non-viable tissues) is carried out 1 cm above the line of necrosis. Amputation is performed after the formation of a dry scab.
Gangrene
Dry gangrene is the result of a slowly progressive disturbance of tissue blood supply, typical for patients with atherosclerosis and endarteritis obliterans.
Distinguished by the absence of general intoxication of the body, the presence of a clear demarcation shaft. During treatment, it is possible to use expectant tactics.
Used: drugs that improve tissue trophism, systemic antibiotic therapy. The operation is carried out after the formation of a clear line of demarcation.
Wet gangrene occurs as a result of an acute cessation of blood circulation (frostbite of the fingers, thrombosis, vascular compression). It is characterized by severe intoxication, the absence of a demarcation line and pronounced edema. Amputation for gangrene is carried out urgently, expectant management is unacceptable. After detoxification therapy, surgery is performed. The amputation line should be significantly higher than the gangrene (if the foot is affected, amputation is recommended at the level of the thigh).
Gas gangrene is an absolute indication for guillotine amputation. Characteristic manifestations: pronounced, rapidly progressive edema, the presence of gas in the tissues and muscles, necrosis and phlegmon with soft tissue melting. Visually, the muscles are grayish, dull, easily crumpled on palpation. The skin is purple-bluish, with pressure, a crunch and creak is heard. The patient complains of unbearablebursting pain.
Criteria for the consistency of the stump and its readiness for further prosthetics
For the full functioning of the prosthesis, the length from the stump to the joint must be greater than its diameter. Also important is its physiological shape (slightly tapering downwards) and painlessness. The mobility of the preserved joints and the skin scar (its mobility and lack of adhesion to the bone base) are assessed.
Signs of a vicious stump
- Extending the scar to the work surface.
- Excess soft tissue.
- Absence of conical narrowing of the stump.
- Fusion of the scar with tissues, its immobility.
- Muscle position too high.
- Excessive tension of the skin with bone sawdust.
- Deviation of bone segments during amputation of paired bones.
- Excessively tapered stump.
Disability registration
Amputation of a limb is an anatomical defect, as a result of which a disability group is assigned indefinitely. If a leg is amputated, a disability group is assigned immediately.
Assessing the degree of loss of functional activity, disability and disability, as well as further assignment of disability, is the responsibility of the medical and rehabilitation expert commission.
When establishing a disability group, it is estimated:
- Ability to self-service.
- Ability to move independently.
- Adequacy of orientation in space and timeprovided there is no pathology of mental activity (hearing and vision are assessed).
- Communicative functions, the ability to gesticulate, write, read, etc.
- The level of control of one's own behavior (compliance with the legal, moral and ethical standards of society).
- Learnability, the possibility of obtaining new skills, mastering other professions.
- Employability.
- Opportunity to continue to work within the framework of their professional activities after rehabilitation and when creating special conditions.
- Functionality and mastery of the prosthesis.
First group
Indications for assignment of the first group:
- Amputation of both legs at hip level.
- Absence of four fingers (including the first phalanges) on both hands.
- Amputation of the hands.
Second group
- Amputation of three fingers (with the first phalanges) of both hands.
- Remove 1 and 2 fingers.
- Absence of 4 fingers with preservation of the first phalanges.
- Amputation of fingers on one hand with a high stump of the second hand.
- Operation according to Chopard and Pirogov.
- High resections of one leg, combined with the absence of fingers of one hand or eye.
- Amputation of one arm and eye.
- Hip or shoulder exarticulation.
Third group
- Unilateral amputations of fingers without removal of the first phalanx.
- Bilateral finger amputation.
- High amputation of one leg or arm.
- Removal of both stops alongSharpe.
- The difference in leg length is more than 10 cm.
Rehabilitation after amputation
In addition to the anatomical defect, amputation of a limb leads to severe psychological trauma to the patient. The patient closes on thoughts of his own inferiority in the eyes of society, believes that his life is over.
The success of further prosthetics is determined not only by the timeliness of the operation, the level of amputation and further proper care of the stump.
On the 3rd-4th day after amputation, prevention of flexion contractures and stump movements begin. After removing the sutures, active training of the stump muscles is recommended. A month later, they begin to try on the first prosthesis.
The most important goal of rehabilitation measures is to stabilize the psychological state of the patient and form an adequate attitude towards prosthetics.
Further activities include:
- learning to use the prosthesis;
- a set of trainings to activate the prosthesis and its inclusion in the general motor stereotype;
- normalization of coordination of movements, the use of therapeutic and training prostheses.
- social rehabilitation measures, patient's adaptation to life with a prosthesis;
- development of an individual rehabilitation program, retraining and further employment (for groups 2 and 3).
In the event of phantom pain in an amputated limb, novocaine blockade, hypnosis and psychotherapy sessions are recommended. If there is no improvement, surgery may be performed.interventions with resection of the affected nerve.
