Amputation is the operation of cutting off a limb along its segment. Cutting off a limb at the level of the joint is called exarticulation or articulation. These operations should be considered full-fledged means of surgical care for patients. They are carried out when other methods of treatment are ineffective or impossible.
Indications for amputation
1. Traumatic injuries of the extremities: crushing of a segment over a considerable extent with tissue non-viability, separation of a limb segment, if its replantation is impossible or if it is absent, it will not significantly affect the function of the limb (distal phalanges of the fingers, IV-V finger, etc. .). After traumatic detachments, primary surgical treatment wounds with stump formation.
2. Traumatic toxicosis, which is not treatable and threatens the life of the patient.
3. Acute purulent-necrotic post-traumatic processes (anaerobic infection,).
4. Chronic purulent processes of the extremities, which exhaust the patients and threaten with amyloidosis internal organs(kidney) or cancerous degeneration of fistulas (about 10% of patients with chronic osteomyelitis), trophic ulcers.
5. Thrombosis and embolism, if it was not possible to restore blood flow or if signs of demarcation necrosis of limb tissues appeared.
6. Gangrene of limb segments due to vascular insufficiency (endarteritis,), frostbite, IV degree burns (sometimes with endarteritis, amputation is performed until tissue necrosis occurs due to severe ischemic pain, which exhausts the patient).
7. Malignant tumors of bones and joints.
8. Irreparable congenital and acquired orthopedic deformities, if after amputation, rational prosthetics, the function of the limb will be much better.
If there is any doubt whether or not to do an amputation, given the seriousness of the operation and the significant responsibility, the issue should be decided by a council. Before the operation, the patient is explained the reasons for and the need for amputation, informed about prosthetics and his social rehabilitation. In cases where the patient does not give consent to amputation and absolute indications for it, it is necessary to explain to his relatives about the possible consequences.
Choiceamputation level limbs is of great practical importance in connection with prosthetics. At one time, amputation schemes were proposed (Tzurvert, Yusevich), which were reduced to a certain type of prosthesis and facilitated the work of prosthetists. Now, when choosing the level of amputation, the surgeon takes into account the nature pathological process, age, social status, nature of labor (physical or mental) of the patient and the most rational way prosthetics. Therefore, the level of amputation is chosen so that the stump is as durable as possible (the larger the lever, the easier it is to use the prosthesis) and is most beneficial for prosthetics. For example, the stump of the lower leg is suitable for prosthetics if it is not shorter than 7-10 cm. When it comes to preserving the knee joint, then when choosing the length of the stump, one should proceed from the fact that now it can be lengthened using distraction according to G. A. Ilizarov.
Amputation methods
1. Guillotine: section of all limb tissues, including bones at the same level. This is an old method of amputation that existed even before the introduction of anesthesia. Now it is not used, because the wound suppurates and heals for a long time, soft tissues contract, and the bone protrudes even after the wound has healed, reamputation (repeated amputation) is required.
2. The circular method of amputation, which differs from the guillotine method in that it is possible to stitch the wound and close the bone. If a three-stage circular amputation method according to N. I. Pirogov is used (the section of the skin and fascia is at the same level, the muscles are slightly higher, and the bones are even higher), the edges of the skin are sutured without tension, the scar is mobile, but large, and the wound heals secondary tension. Such stumps are in most cases unsuitable for prosthetics.
3. The clavicle method of amputation is the most rational and is used most often. Its advantages: the section is made so that the postoperative scar is not injured in the prosthesis; Better conditions for wound healing. After applying this method, there is no need for reconstructive interventions.
Distinguish between closed and open clavate method of amputation. Closed - this is when the wound is sewn up tightly after the operation. They use it in the case of planned operations, when there is no threat of suppuration. Classic skin-fascial flaps are formed, providing the stump with a normal shape.
The open clavate method is used in all cases of open injuries when there is a threat of infection and purulent-inflammatory processes.
2) the need to form a stump suitable for prosthetics, in cases where this could not be done during amputation;
3) diseases and defects of the stump, excluding prosthetics.
In connection with the technical improvement of prosthetics, as well as the improvement in the quality of treatment of patients with a pathological condition of the stump, the indications for reamputation have narrowed significantly.
Reamputation is carried out mainly by the closed clavate method. In all cases, reamputation should be the last operation for the patient. To do this, one should appreciate the local pathological condition stump, prepare it, choose the optimal time and method for reamputation in order to prevent recurrence of complications. This is especially true of inflammatory-purulent processes of the stump.
Amputation technique
Amputation is performed under general or epidural anesthesia. To reduce blood loss, you can use a tourniquet, but only in cases where there is no purulent-inflammatory process or vascular pathology. The dimensions of the skin flaps are calculated so that the wound can be sutured without tension. The incision of the skin, subcutaneous tissue and superficial fascia is carried out simultaneously with.
When amputating within the thigh, it is advisable to first isolate the main artery, tie it with two ligatures (with final firmware) and cross. After exsanguination, the main vein is ligated. The superficial muscles cross slightly above the skin flap, and the deep ones even higher.
The nerve trunk is isolated, anesthetized with a 2% solution of novocaine, clamped with a clamp, and the nerve is cut in one fell swoop with a sharp razor so that there are no fibrillations. The nerve stump is isolated from the intersection of the muscles and possible hematoma in the fascial beds by applying a suture to the fascia. Disintegration of the nerve stump leads to the formation of neuromas, and its involvement in the scar leads to pain.
The periosteum is cut with a scalpel and shifted with a rospator distally from the intersection. The bone is crossed with a Gigli or sheet saw, retreating 0.5 cm below the intersection of the periosteum. The disintegration of the periosteum with a saw leads to the formation of exostoses, and the section of the bone exposed from the periosteum to a greater distance of 0.5 cm leads to marginal necrosis and cricoid sequestration.
When amputating within the tibia, the sharp anterior edge of the tibia, which can cause decubitus and perforation of the skin flap, should also be smoothed with a rasp. If the amputations are planned, after control of hemostasis, the antagonist muscles and shreds of skin are sutured together in layers, and the wound is drained for 24 hours.
With an open clavate amputation, the wound is sutured and covered with a bandage with an antiseptic and antibiotic solution. After amputation, a plaster splint is applied to immobilize the limb.
exarticulation
exarticulation is carried out very rarely, despite the fact that this operation is technically simpler and less bleeding, since fibrous soft tissues are intersected and the bone is not damaged, and there is also less risk of osteomyelitis when the wound suppurates. The exception is exarticulations at the level of the shoulder and especially the hip joints, which are technically complex, traumatic, and do not create opportunities for a full-fledged.
Stumps after disarticulation of the foot and lower leg are also unsuitable for prosthetics, since after prosthetics the segment of the limb left becomes longer due to the functional units of the prosthesis. Taking this into account, it is inappropriate to do an exarticulation at the level of the hip, knee, ankle and shoulder joints, but it is better to carry out an amputation based on a full-fledged prosthesis. Therefore, disarticulations are carried out mainly within the hand and foot, where prosthetics are not required or do not affect the function of the limb or are only cosmetic. In addition, when it comes to saving every millimeter of a finger, disarticulation in many cases makes it possible to do this.
Features of amputation in children
When carrying out amputation in children, the characteristics of the child's body should be taken into account. First, when amputating, you need to remember that there is a growth cartilage in the bones. If it is kept within the stump, the growth of the bone in length continues, although to a lesser extent, since the degree of loading of the limb in the prosthesis is somewhat less. Therefore, if it is necessary to amputate the distal end of the femur, it is desirable, if possible, to preserve the distal growth cartilage by disarticulation in knee joint or intersection femur below it.
When amputated above the growth cartilage, bone growth is significantly reduced. For example, after amputation of the femur in its lower third, after a few years, the femoral stump is shortened so much that it barely reaches the middle of a healthy femur. In this case, when choosing between amputation of the lower third and disarticulation, one should prefer the disarticulation of the lower leg in.
If it is necessary to amputate the lower leg within its upper end, the proximal (more active than the distal) tibial growth cartilage should also be preserved, if possible, even when a short stump is formed. In the process of growth, the stump lengthens and becomes suitable for full-fledged prosthetics.
Secondly, in children there is an uneven growth of paired bones of the amputated segment due to different activity of the growth cartilages of these bones. The fibula grows faster than the tibia, and the radius faster than the ulna. As a result, there is a curvature of the stump. Therefore, when amputating the lower leg in children at the age of 10-12, the fibula must be crossed 2-3 cm higher than the tibia, and at a younger age, 3-4 cm.
After amputation in children, muscle growth lags behind bone growth in length, which eventually leads to a pointed stump and complications for prosthetics. Therefore, in children during surgery, when forming a stump, it is necessary to leave the maximum amount of muscle.
Treatment of patients with amputations in the postoperative period
It is carried out according to the generally accepted technique in surgery. After removing the sutures, the patient is prescribed physiotherapy, exercise therapy, bandaging the stump to reduce its swelling and rapid involution. It is important that the patient retains the sensation of the phantom (the absence of part of the limb and especially the fingers) and movements in it. To do this, the patient symmetrically inserts the lower limbs and simultaneously performs active movements in the joints of both the healthy and the missing part of the limb. According to the range of motion in the joints of a healthy limb, the methodologist monitors the range of motion of the phantom. This method of treatment allows you to prevent the occurrence of phantom, gives the best functional results of prosthetics.
If the patient does not develop movements, there are sensations of contractures in the joints of the missing segment of the limb, especially the fingers and the hinged in the equinus position of the supinated foot.
Prosthetics on the operating table
Currently, early prosthetics of patients on the operating table is widely used - express prosthetics. The very idea of immediate prosthetics appeared a long time ago, but in healthcare practice it was developed and implemented thanks to Marshan Weiss (Warsaw Rehabilitation Center), and in Ukraine - A. Korzh and V. A. Berdnikov. The essence of the method is to perform a myoplastic surgery with limb prosthetics on the operating table. Express prosthetics is used mainly when performing planned operations (tumor and vascular diseases limbs, consequences of injuries, etc.).
Advantagesexpress prosthetics:
1) the patient in the first days after the operation can get out of bed and walk, dosed loading the limb;
2) when loading the leg, the patient does not lose the feeling of the ground after amputation, walking stereotype, and this prevents the occurrence of phantom contractures;
3) the patient adapts to the prosthesis faster, and this contributes to faster preparation of the stump for primary permanent prosthetics;
4) positive psychological factor because the patient is able to walk.
If for some time the patient is not prosthetized after amputation, then, for example, in case of vascular pathology, this leads to a deterioration in the condition of the second overloaded limb, and sometimes there are complications from crutches (paresis of the upper limb). The patient loses the feeling of the ground and the stereotype of walking, which affects his condition after permanent prosthetics.
After classically performed myoplastic amputation, the wound is drained for 1-2 days with a long nipple tube, which is taken out of the prosthesis. A sterile stocking is pulled over the aseptic bandage, and then a prosthesis is applied with a stump holder, which is formed from plastic or plaster bandages. A standard express prosthesis for the thigh and lower leg is produced at the prosthetic factory. It contains articular nodes and a telescopic tube, which allows you to individually adjust the length of the prosthesis according to the healthy limb segment.
After removing the sutures, the plastic stump holder is replaced with a plaster stump holder with a soft elastic bottom and walls. This prosthesis stimulates local circulation, while walking acts like a pump, which helps to reduce swelling and the formation of a stump. When using a therapeutic and training prosthesis, the stump becomes suitable for permanent prosthetics after 1-1.5 months. Thus, with express prosthetics, the patient does not have an inactive period after amputation until the time of permanent prosthetics.
Disarticulation of the thigh in hip joint it is produced by one of the existing classical methods - more often according to Farabeuf (Farabeuf).
In this case, it must be borne in mind that complete disarticulation of the thigh is undesirable. If there are no contraindications, it is better to leave the head of the femur in the articular cavity. A large excess of soft tissues, especially muscles, after hip disarticulation is also inappropriate. Such a stump makes prosthetics difficult.
Farabeuf hip disarticulation technique
Make a rocket cut. The femoral vessels are exposed, tied with two ligatures and cut, the femoral artery is ligated above the origin of a. profunda femoris. The anterior muscle group is dissected in layers, ligating the simultaneously meeting vessels. The anterior wall of the hip joint capsule is cut along the neck of the femur. Having rotated the thigh inward, the muscles attached to the greater trochanter are cut off; then dissect the capsule of the joint and tendons of the muscles; dislocate the femoral head and cut the round ligament. Release the posterior surface of the femur from soft tissues and dissect the muscles rear surface hips along the edge of the skin incision. The vessels are tied up, the nerves are shortened by crossing them with a razor or a sharp scalpel. Sutures are applied to the muscles, fascia and skin. Enter . If there are contraindications to suturing, the wound is tamponed with gauze.
Petrovsky hip disarticulation technique
In the position of the patient on the back, a semi-oval flap is cut out along the anterior surface of the thigh. Above the pupart ligament, the iliac vessels are exposed and ligated. Below the pupart ligament, mm is dissected in layers. sartorius, iliacus and pectineus. The neurovascular bundle is exposed. Cross n. femoralis and between ligatures - the femoral artery and vein. After that, the mm is dissected in layers. tensor fasciae latae, rectus femoris, gracilis, adductor longus, adductor brevis, adductor minimus, obturator externus, adductor magnus.
Next, the anterior surface of the hip joint is exposed, and it is opened along the anterior edge of the acetabulum. The thigh is somewhat retracted to the side, and due to gravity it is partially dislocated anteriorly; complete dislocation is prevented by the round ligament of the thigh, it is crossed with scissors, and then the head of the femur is completely dislocated anteriorly, exposing the posterior semicircle of the joint. This part of the capsule is crossed with a scalpel, mm. gemelli; after additional anesthesia cross n. ischiadiciis. Dissect the posterior thigh muscles and remove the limb.
Hip disarticulation can be done in other ways. After preliminary ligation of the femoral artery, a posterior skin-aponeurotic flap is cut out large sizes convex downward and smaller anterior flap. After detaching the anterior flap and throwing it up, the femoral vessels are ligated; muscles at the level of the apex of the greater trochanter cross in the same plane; nerves shorten. The femur is cut at the level of the trochanter. The muscles are stratified above the neck, the joint capsule is opened; the bone stump is grasped with forceps and, by rotating, is released from the muscles, ligaments and capsule. Remove the head with the rest of the femur. Produce final hemostasis. The posterior skin flap is sutured to the anterior. The wound is drained. The advantage of this method lies in the fact that the scar is located on the anterior surface of the stump, and not on the lower one, as after the Farabeuf extraction. In addition, the stump does not have an excess of soft tissues, mainly muscles, which facilitates prosthetics.
Prosthetics
An amputee after hip disarticulation sits in a prosthesis, loading the lower surface of the stump, which does not contain scars and is covered with skin of the back of the thigh, adapted to pressure.
Prosthetics after hip disarticulation is carried out with a prosthesis consisting of a leather or cloth cover for the pelvis; the pelvic part is hinged to the femoral sleeve. With the help of modern designs of prostheses, disabled people sit well and move quite satisfactorily.
Removal of half of the pelvis along with the lower limb (exarticulatio interilioabdominalis) is performed for malignant tumors upper third femur and pelvic bones or after severe injuries of these parts of the limb and pelvis. Prosthetics after exarticulatio interilioabdominalis is very difficult and is performed only in highly qualified special institutions.
The article was prepared and edited by: surgeonLimb prosthetics - Orthopedicsurgery.ru - 2012
Amputations in the hip joint include resection of the femur above the lesser trochanter, disarticulation directly in the hip joint, and hemipelvectomy (surgery to remove half of the pelvis), the main causes of which are traumatic injuries and tumors.
In addition, complications after arthroplasty often force such a step, for example, if the pelvic artery was damaged during surgery or a severe infection developed in the postoperative period, and there are no other ways to cope with it.
The key to high-quality amputation in the area of the hip joint is the creation of a stump on which the patient is comfortable to sit. If it is possible to keep the femoral neck intact along with the trochanteric array, the sitting surface is significantly larger than that left after exarticulations, when only the ischium of the pelvis is available.
A hemipelvectomy often sacrifices both the ischium and some part of the iliac crest. Moreover, regardless of the level of amputation, the distal end of the stump must necessarily be sufficiently wide in size and fully supportable. An important counter-support here is the waist and the iliac crest. Where there is no iliac crest, additional support on chest, but it is not absolutely necessary.
After such operations, only the pelvis, the muscles of the back and abdomen and a healthy limb remain to control the prosthesis and movements on it. A particularly important role for prosthetics is given to strong muscles and the best possible mobility of the joints of the second leg and the lumbar spine.
By the way, successful replacement of the entire lower limb with a prosthesis for a long time considered impossible. The artificial hip assembly was installed mainly on the side, it was either too wide, or not strong enough, or had to be closed in the standing position, so bringing the prosthetic leg into working condition required a lot of effort and / or not quite natural movements.
In 1954, McLaurin and his team put forward the concept of the so-called Canadian prosthesis (basket prosthesis). By moving the hip assembly forward, this design proved to be stable in the standing position even without locking in the hinges. In the transfer phase or while sitting, one tilt of this prosthesis was enough for passive movements to begin in the hinges. True, there is a drawback - this is a discrepancy between the dimensions of the prosthesis-basket intended for the pelvis and the prosthesis-leg, both in their mass and in the lever arm. The heavier the artificial lower limb, the more massive the prosthesis-basket for the pelvis is made. And the higher the pelvis is covered with a stump sleeve, the more it prevents movements in lumbar spine and contributes to the development of atrophy of the muscles of the back and abdomen. Due to such a high-standing rigid prosthesis-pelvis, in most cases, it is difficult for patients to breathe and eat, and in females, the corset of the prosthesis sometimes reaches the mammary glands, which also causes discomfort. In addition, there are hygienic problems.
In this regard, the creators of the prosthesis decided to limit themselves to a small corset-basket and, accordingly, minimum weight artificial limb, so as not to worsen the quality of life of patients so much. To get closer to this goal, in particular, allowed modern methods modular production of prostheses with fitting parts made of titanium alloy.
Hip stump prosthetics
In preparation for prosthetics of the femoral stump, based on the length of the femur, the length of the lever arm is calculated. For the strength of the lever, the diaphyseal part, that is, the tubular bone located distal to the lesser trochanter, serves as a measure.
Also for the femoral stump is of great importance the possibility of full load on the end of the stump. As a rule, in situations of this kind, this ability is limited somewhere by 20-30%. In fact, the small dimensions of the diameter of the tubular bone make it possible to only partially load the leg prosthesis along the axis. In addition, when it is put on, in the process of retracting the stump into the sleeve with the help of a ventilation hole and a stocking, the soft tissues located here are preliminarily stretched.
In the case of an ultrashort femoral stump, there is usually nothing left of the femoral shaft. The amputation line goes through the spongy bone of the trochanters. For prosthetics, the rules are similar to those for amputation in the area of the hip joint. But here we are talking about the fact that such an ultra-short stump is an important part of the surface required for sitting, and therefore, if possible, should be preserved.
Due to the fact that under natural conditions the femur is surrounded by a more or less pronounced array of soft tissues, the end of the stump must also be covered with muscles, while their excessive thickening, usually observed after myoplasty operations, should be avoided. If the muscles do not fit well in the sleeve of the prosthesis, when standing, they seem to turn out, which leads to perforation of the femur outward through the soft tissues. sciatic nerve cross at least five centimeters above the level of sawdust, while protecting it from mechanical pressure acting on the end of the stump.
Only the large trochanter protruding to the side remains poorly covered - it is covered with purely skin and tendons, so it is especially accurately and accurately placed in the prosthesis sleeve. Last in modern conditions It is considered, perhaps, the only design designed for additional transmission of forces above the level of the location of its hinge assembly. That is, if during prosthetics after exarticulation in the knee joint it would be a serious mistake to expand the sleeve of the prosthesis beyond the thigh, then during amputation performed through the tubular femur, in the process of prosthetics, additional support on the pelvis is no longer enough. According to the features anatomical structure the transfer of axial forces to the end section of the stump is only partially possible and barely reaches 30%. For the remaining share, the corresponding mechanical prerequisites are formed in the pelvic region.
Shelter of the femoral stump, depending on the specific clinical situation, is performed using one of the following methods. The first is the so-called loose lining without interaction between the prosthesis sleeve and the stump. The second is an enclosing prosthesis in the absence of contact in end section. The third is an enclosing prosthesis with full contact, but no load on the end of the stump. And the fourth one is an enclosing prosthesis with both full contact and maximum load on the end of the stump.
Prosthesis after hip disarticulation
In 1954, a group of Canadian scientists led by K.A. McLaurin (S.A. McLaurin), a special design was created, intended for prosthetics of persons who underwent amputation of the lower limb through the operation of disarticulation in the hip joint. In practice, their invention, as well as its modifications in the endoskeletal modular design, are referred to as the “Canadian prosthesis after hip disarticulation.”
Unlike its prototypes, the modern prosthetic hip joint does not have a lock and is absolutely free to bend. Brace resistance from unwanted bending in it is ensured by means of its initial location, which is set immediately during the assembly of the prosthesis. The hinge is mounted at an angle of approximately 45 ° and is installed in front and somewhat downward in relation to the natural center of rotation of the "native" hip joint.
Due to this localization, the physical axis of the prosthesis hinge is displaced anteriorly from the common center of mass, and thus the weight of the patient's body affects the prosthetic hinge when walking and standing only in terms of hyperextension, but not in the sense of flexion of the hip joint.
It turns out that this hip joint, even without a lock, similar to those used in previous designs, is insured against unexpected bending. However, at the same time, in the transfer phase, it does not prevent the leg prosthesis from performing characteristic rocking movements. Unwanted overextension is prevented by a stop, which can now even be partially adjusted.
The stump sleeve of the prosthesis, after the hip is disarticulated, fits snugly enough to the body. It seems to cover the stump and about half of the pelvis on the side of the amputation, at least in the form of a half-cup. But, taking into account the fact that in the locomotional act of walking, control is more reliably exercised, prosthetists still try to cover the entire pelvis of the patient. Sleeves are made at the present stage from casting resins or thermoplastics.
The hinge itself consists either of a metal sleeve with plates welded to it for fastening, or of a wooden block with a standard sleeve glued in, which is fixed on it at an angle of about 30 ° to the horizontal surface.
Due to the fact that in this situation there is no structure of physiological load transfer, since the hip joint is dissected, the ischium is used as the main point of application of the concentrated force, and the ilium on the side of the amputation is used as an auxiliary surface for the application of this force. Soft tissues go to the background in the implementation of load transfer, which, after deformation with preliminary compression, are placed in the cup-shaped receiving cavity of the pelvis.
It should be noted that at present, Canadian prostheses after articulation are quite a rare species prosthetic support. Therefore, not every orthopedic workshop can provide such hinges in reserve, or it may not be possible to order them from manufacturers.
Prostheses after bilateral hip amputation
Prosthesis of persons who have undergone bilateral amputation of the hip is by no means an easy task. The ability to balance and strut stability, that is, the equally reliable fixation of the knee joint at absolutely any moment at any position of the lower leg relative to the thigh, are properties that, in the case of unilateral amputation, are achieved thanks to the preserved healthy lower limb and which are lost after bilateral amputation of the legs. A person loses the feeling of a supporting surface, and his fear of falling increases in direct proportion to the length of the prostheses.
For this reason, patients with bilateral amputation hips tend to use two crutches, which prevents them from using their hands for other activities. To eliminate this problem, at one time, scientists had the idea to design prostheses based on the advantages of the wheel. The meaning here lies in the fact that on a flat surface the axis of the wheel is always supported perpendicularly, remaining at the same height during rotation. This is how prostheses were built, consisting only of a stump sleeve and an erratic foot with a movement surface in the form of a circular papier-mâché type segment. Such short hip prostheses are part of the radius of the circle, the center of which is the hip joint of the disabled person. In this case, the sleeve plays the role of a spoke, and the rolling foot - part of the wheel rim.
Flexion contractures in the hip joints, which often occur in bilateral amputees due to prolonged sitting, can be compensated for by moving the rolling feet posteriorly. Thus, even with a slightly bent and relaxed position of the hip stumps, a fairly direct support of the general center of mass of the human body is provided.
The toe parts of the foot do not need to be done here, because the rolling movements with the rear push are within the vertical position of the stump. When viewed from the front or from behind, the rolling feet should be in such a supination position (when their outer edge is lowered and the inner edge is raised) so that the feet, with the stumps of the legs slightly apart, lie on the surface of the support with the entire width of their soles. If the roll is carried out purely by the inner edge of the foot, the inner wall of the sleeve presses, and a kind of pocket is formed near the outer wall between the stump and the receiving sleeve, and besides, the foot wears out more on this side.
In the process of manufacturing the landing edge, attention must be paid to ensure that the platform under the tubercle of the ischium has an adequate selection inside the receiving cavity, and the ischium can freely slide in the desired direction during extension of the hip joint.
When the landing site is made horizontal, the ischium, when extended in the hip joint, raises the stump, the center of rotation of this joint shifts to the site, balance during movement suffers, and piston movements of the stump appear in the receiving sleeve. As a result, the common center of mass must rise higher, which requires more energy.
In principle, if we take into account all these structural remarks, the disabled person will be able to stand confidently and quite relaxed, and his hands will remain free.
Indications for amputation of the upper limb are gangrene due to obliterating atherosclerosis (extremely rare); diffuse arteriovenous angiodysplasia, accompanied by a violation of macro- and microcirculation, a violation of trophism, severe pain syndrome and the impossibility of surgical correction of blood flow; advanced forms of thromboangiitis obliterans Buerger.
Amputations upper limbs produce according to the principle of maximum economy, as far as possible with ischemic ulcerative-necrotic lesions. Truncations at all levels are performed only in a patchwork way. In this case, both classic and atypical flaps are used from tissues that have retained a satisfactory blood supply and viability. Adhering to the principle of savings
However, the level of amputation of the upper limb should correspond to the border of viable soft tissues, and not to the so-called amputation schemes promoted in the special literature.
Amputation and disarticulation of fingers. Indications for amputation and disarticulation of the fingers are ulcerative-necrotic lesions of the phalanges, gangrene of the phalanx or the entire finger, purulent-destructive lesions of the bones and joints of the finger due to the occlusive-stenotic process. In these situations, depending on the volume of the lesion, the finger is amputated at the level of one of the phalanges, exarticulation of one of the phalanges or the entire finger. The operation is performed in a patchwork manner, observing all the principles of amputation described above.
Amputations at the level of the hand. Indications for resection and amputation of the hand are ischemic purulent-necrotic lesions of the fingers with involvement of the tissues of the hand. Depending on the volume of the lesion, marginal and sectoral resections of the hand, amputations of the hand at the level of the metacarpal bones are performed. Atypical schemes of resection and amputation of the hand are possible in order to preserve its function.
Exarticulation of the hand. An indication for disarticulation of the hand is dry or wet gangrene of the hand. The truncation line and the possibility of preserving one or another carpal bone depends on the viability of the soft tissues in the amputation area. In cases of forced removal of the bones of the wrist, the styloid processes of the radius and ulna resect. The stump is formed in a patchwork way.
Amputation of the forearm. Amputation of the forearm is performed in cases where the purulent-necrotic process, due to occlusive lesions of the vessels of the upper extremities, spreads and covers part of the forearm.
At all levels of the forearm, fascioplastic amputation is performed in a patchwork manner, using classic and atypical flaps. It is also possible to perform myoplastic amputation. However, this type of operation is associated with a large shortening of the bones of the forearm, which leads to a loss of the length of the stump.
Processing of soft tissues, vessels and nerves is carried out according to the generally accepted method. The bones of the forearm are filed transperiosteally at the same level and rounded with a rasp.
Exarticulation of the forearm. An indication for disarticulation of the forearm is a subtotal lesion of the latter by a necrotic process. Exarticulation of the forearm currently has the right to life, since a long and functionally more advantageous stump of the upper limb is formed than with amputation of the shoulder.
Shoulder amputation. Amputation of the shoulder at any level is performed by a fascioplastic method using one or two flaps. The use of the myoplasty method results in a greater shortening of the humeral stump and thus a reduction in the length of the stump arm. Both classical flaps and atypical flaps are formed from tissues that have retained viability.
Shoulder exarticulation. Shoulder disarticulation is rarely used in vascular surgery. Isolation is carried out in a patchwork manner. After crossing the pectoralis major muscle, they tie up and cross the vessels above the axillary fossa. The nerves are processed above the level of the shoulder joint. The axillary nerve is preserved if possible.
With large lesions of the paraarticular tissues, the disarticulation in the shoulder joint is performed atypically. In these situations, to replace the defect of integumentary tissues, it is advisable to use full-thickness
flaps cut on the chest wall.
A similar surgical technique has found its application in more distal amputations of the upper limb, when the damage to the integumentary tissues is much larger in size than the damage to the muscles and bones.
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Putelis R.A. Causes of death of patients after amputation of limbs with lesions of the arteries//Surgery. - 1982. - No. 7. - S. 52-53.
Veith F.J. Limb salvage//Ann. Surg, - 1981. - Vol. 194, No. 4. - P. 386-401.
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Rice. 8-210. Surgery for rupture of the tendon of the supraspinatus muscle: a) skin incision, b) reattachment of the tendon plate on the humerus
passes through the deltoid muscle. On x-ray the head of the humerus, due to a decrease in the tone of the muscles fixing the shoulder, can fall down into a state of "subluxation". It happens that a small thick calcareous shadow under the acromion indicates an older damage.
Treatment for supraspinatus tendon rupture is not uniform. Anglo-American authors (De Palma, Watson-Jones) are in favor of the operation, other authors try to carry out first conservative treatment. Conservative treatment includes fixation on diverting splints or in a plaster cast covering the chest and upper limb, followed by physiotherapy exercises. By MatzenAndKnSfler with a fresh supraspinatus tendon avulsion, it would be advantageous if surgeons would decide more often to immediately perform surgical reconstruction. This opinion is also shared by the author, therefore, the technique of operations of these authors is described here.
The outcrop begins at the posterior margin of the acromion. The skin incision is carried out, bypassing the bone, forward to the projection on the large tubercle. The deltoid muscle is crossed at a distance of 1 cm away from the bone and retracted distally. At the same time, the tendon becomes visible
plate of rotator muscles, i.e., the torn part of the tendon. The distal stump remaining at the greater tuberosity is usually small and cannot be sutured. Therefore, it is necessary to fix the proximal stump again To humerus bones. The shoulder is abducted and rotated outward, a hole is drilled in the bone into which the tendon is retracted (rice. 8-210). When, after a chronic injury, this is possible only under tension, then the reverse attachment is made with a preserved tendon. After the operation, an abduction bandage is applied for 3 weeks.
Disarticulation of the upper limb in the shoulder joint
This operation is carried out mainly malignant tumors and in exceptional cases, in case of injuries that have destroyed the shoulder area, or to prevent the spread of severe inflammatory processes emanating from the shoulder.
The skin incision begins on the outer third of the clavicle and continues in the deltoid-thoracic groove to the edge of the armpit. From there, a transverse incision is made to the apex of the acromion. The vein is crossed between two ligatures. The muscles extending from the coracoid process are separated, and then the muscles extending from the clavicle are crossed. Under the clavicle, the vessels and nerves of the upper limb passing here are searched for. Vessels after double ligation intersect. The nerves are cut as high as possible. The articular capsule is cut near the glenoid cavity of the scapula. Then the head of the humerus is taken out of the articular cavity with a bone hook, and the stretching tendons and muscles are crossed one by one. Following this, the upper limb may be removed. After the bleeding has stopped, a suction drain is inserted into the wound, and the muscles are sutured over the glenoid cavity without tension.
Injury to the humerus Access to the diaphysis of the humerus
The diaphya of the humerus is exposed mainly for injuries and their consequences. This intervention, however, may become necessary for other reasons than bone surgery, namely to expose brachial artery or nerve.
Access to the proximal end of the shoulder has been described in shoulder surgery (see page 972). Exposure of the distal end of the humerus will be discussed in the section on elbow surgery (see page 986).
Rice.. 8-211. Lateral exposure of the humerus
Rice. 8-212. Exposing the humerus from the side of the triceps muscle
bones can, like any diaphysis, be reached from several sides. Characteristic in this case is the fact that the penetration to the bone is made between the muscles, while it is necessary to spare the skin vessels and nerves of this area.
Access to the diaphase of the humerus from the lateral side. Lateral exposure of the humerus is made in one large incision (rice.8-211), suitable for exposing the entire bone. The skin incision corresponds to the localization of the exposed bone area. After crossing the skin, the thin fascia is split. Passing deep between the muscles, they reach the abdomen of the brachial muscle under the deltopid muscle. This is the only muscle that needs to be cut to expose the lateral surface of the bone. Under the brachialis muscle on the brachioradialis muscle passes the radial nerve, one of the most important formations in this area. As long as the brachialis muscle has not yet been cut, the radial nerve can be damaged even by compression of the hook. After crossing the muscle, the nerve may already be directly damaged by the scalpel, and therefore it is advisable to find it in advance. After the radial nerve has been isolated, nothing prevents lateral access to the distal third of the diaphysis. When the wound is closed, the severed shoulder muscle is again sutured, after which the subcutaneous fascia and skin are connected.
Access to the Opaphysis of the humerus from behind. In the region of the distal half of the humeral spine, it is better to choose one that provides more wide view posterior access, especially when part of the bone needs to be exposed; located close to the elbow joint. The patient is operated on in the prone position. A rolled pillow is placed under the elbow, and the entire upper limb is placed on a table and covered with sterile linen. The incision is started at the anterior edge of the place of origin of the deltoid muscle and then carried out on the back surface of the shoulder along the midline, in the distal direction. (Fig-8-212). If necessary, the incision is extended over the top of the olecranon in the radial direction. The fascia is transected and the triceps tendons are dissected near the lateral muscle belly, parallel to the course of the tendon fibers. The medial head of the triceps extends below the brachial nerve, and the lateral head above it. Therefore, to expose the bone, it is necessary to separate the medial belly of the triceps muscle from the bone. If you have to go up, then in the middle of the shoulder they find the radial nerve, which here crosses the bone in an oblique direction. If the intervention is made in this area,. it is advisable to dissect the nerve to avoid damaging it. Access to the nerve is relatively easy, proximally there is still enough room to expose the nerve. A pneumatic tourniquet is used to ensure good hemostasis. If the middle of the humerus should be exposed behind, then the radial nerve is first isolated and only then the bone lying under it is exposed. In this way, it is possible, without damaging the nerve, to ensure the exposure of a large segment of the bone.
Medial approach to the humerus necessary if you need to find the main vessels and nerve formations. The pulsation of the brachial artery is felt in the medial groove of the biceps muscle, here a longitudinal incision is made above the vessels. After splitting the fascia, an artery, vein and median nerve are found in the loose connective tissue. The ulnar nerve passes down behind the anterior artery and then enters on the palmar surface of the medial head of the triceps muscle to the ulnar groove of the humerus.
Finally, it may also be necessary exposure of the distal end of the humerus from the ulnar side. A skin incision is made parallel to the bone, then the ulnar nerve is sought. It is released to prevent damage. After that, they go deep to the bone, which is exposed subperiosteally.
Fractures of the diaphysis of the humerus
Fractures of the diaphysis of the humerus are not common. IN Lately, however, due to the frequency of transport injuries, the number of these injuries
Rice. 8-213. Plaster cast on BBhler for the treatment of a fracture of the humerus
Rice. 8-214. "Hanging plaster cast" with eyelets for hanging
denia increased, as they are a frequent manifestation of polytraumatization. This circumstance must be emphasized because it plays a role in the formulation of evidence for surgical treatment fractures of the diaphysis of the humerus.
Humeral shaft fractures are usually treated conservatively. This is especially recommended when the fracture is a monotrauma.
The reduction of closed long spiral and oblique fractures or multifragment fractures is relatively simple. Fixation in a plaster cast works well, because one only needs to try to accurately correct deviations along the axis, while shortening by a few millimeters and shifting to the side by the width of half the diaphysis does not lead to serious consequences on the shoulder. Since the humerus has a good blood supply, the prerequisites for its regeneration are favorable. A humerus fracture usually heals in 6-8 weeks.
A plaster cast is suitable for fixation of a repaired fracture. Bohler. The gypsum covers the humerus like a U-shaped splint from the medial and lateral sides and is fixed with bandages going along the back to the armpit of the opposite side and from there through the chest again to the damaged side (rice.8-213). This splint fixes both joints of the broken bone, but leaves the elbow free to move in the glenohumeral joint. Both the hand and the wrist joint are freely movable while wearing a plaster cast.
For the treatment of fractures of the diaphysis of the humerus, the so-called. suspended plaster cast ("hanging cast"). This circular plaster cast, provided with soft padding, begins at the level of the insertion of the deltoid muscle.
When the injured limb hangs, the weight of the cast pulls the distal fragment down. From the wire loops inserted into the cast for hanging around the neck, the one that best provides correction of rotational and abduction misalignment is selected. (rice. 8-214). This type of cast is used, however, only for fractures of the humerus proximal to the insertion of the deltoid muscle (see page 974).
For the treatment of fractures of the diaphysis of the humerus, abduction splints are not used. A plaster bandage covering the chest and shoulder is used only in exceptional cases in young patients. If the above types of plaster cast do not provide sufficiently reliable fixation of the fracture, then osteosynthesis is provided and the "displacement of the fragments" is prevented. Such fixation is performed mainly in elderly patients by providing percutaneous wire immobilization. Wire is used for this purpose. Kirschner 2.5 thick or 3mm before the introduction, it is properly shortened. The wire is passed through the large tubercle into the humerus. Under the control of the intensifying screen, the trocar is inserted into the bone, after removing the awl, a wire is inserted, which thus penetrates into the bone marrow canal (rice. 8-215). Although conservative treatment for fractures of the diaphysis of the humerus has paid off well, nevertheless, in the cases listed below, they choose surgical treatment.
1. With open fractures, first of all, if they are associated with the destruction of soft tissues. 2. For transverse fractures that cannot be reduced or fixed. Especially with fractures localized at the level of the place of attachment of the deltoid muscle, to reposition the bone fragment and place it in its place. All this is an indication for early osteosynthesis, otherwise pseudarthrosis occurs.
Rice. 8-215. Splinting of the medullary canal on the humerus after trocar injection
Rice. 8-216. With an inflexible elbow joint, it is advisable to apply a metal plate to the palmar surface of the humerus, where it is subjected to traction
3. With a bilateral fracture of the humerus of the forearm on the same side, or with a combination of a fracture of the humerus and severe damage to the chest.
4. A fracture of the humerus complicated by radial nerve palsy is operated on only if it is not possible to fix the fragments in a good position or else. if 6-8 weeks after the fracture, improvement in nerve function cannot be established (electromyographic control is required for this purpose). However, as experience shows, the vast majority of paralysis is cured without consequences.
5. False joints of the humerus are also operated on. Difficult-to-repair and fixed transverse fractures are treated by splinting with a bundle of wire along Hackethal in those cases when the reposition succeeds without exposure of the fracture. For this purpose, an intensifying screen is used. For the introduction of wires, the patient is placed on the stomach and a small incision is made above the elbow. Through the tendon of the triceps muscle drilled at the cranial edge of the fossa of olecranon with an oblique stroke, the medullary canal of the bone is opened. Here, so many wires with a thickness of 2.5-3.0 are introduced next to each other mm, how much enters the medullary cavity. The wires are driven through the fracture gap to the head of the humerus. You-standing ends of the wire are bitten off by 2 mm above the bone (see pp. 853, 8-46). If the internal fixation is reliable, then the plaster cast is not applied. For this purpose, at least three wires must be inserted into the medullary canal. The removal of the wires is a safe intervention, with no risk of collateral damage.
If it is not possible to close the repositioning of the barrow, because, for example, interposed tissue interferes with this, then splinting with a bundle of wire is not performed, but osteosynthesis is performed with an AO plate. For this purpose, a plate with at least 6 holes is required, since plates with 4-5 holes do not provide reliable bone fixation. If the elbow joint is freely movable, then the plate is applied dorsally, since. the strength of the flexor muscles is greater than that of the extensor muscles. If the elbow joint is immobile or its movement is limited, then it is advisable to fix the plate on the flexor side, since it has a better fixing effect here (rice. 8-216). Closed spiral fractures with a large surface are usually not operated on. If this is still required, then at least four screws are applied or the neutralization plate is removed from the tibia.
Bone marrow splinting and internal fixation Rush is a method that is rarely used to treat fractures of the humerus. Shoulder medullary canal
bone, although it can be drilled, is more difficult to open than the medullary canal of the tibia or femur. Therefore, bone splinting should not be performed on the humerus. Instead of curved nails Rushbetter apply splinting with a bundle of wire according to Hackelhal or an AO plate.
Interventions for complications and long-term consequences of fractures of the humerus
Treatment of pseudarthrosis of the humerus
A common cause of pseudarthrosis of the humerus is interponat, inconsistent conservative or incorrect surgical treatment. Rarely, defective pseudarthrosis occurs due to open injury or osteomyelitis. Although it is possible to count on smooth healing of the cancellous bone, pseudarthrosis occurs in the proximal third of the humerus. However, in this place it rarely causes complaints, and usually elderly patients are satisfied with even limited mobility in the shoulder joint. Therefore, fewer pseudarthroses are operated on than are encountered. As a rule, in young patients, as well as in older patients, not only bone healing can be expected from the operation, but also the restoration of mobility of the shoulder, if the joint was not already immobile before the operation. In cases where there is pseudoarthrosis with an almost complete lack of mobility in the shoulder joint, the body performs the necessary movement with the help of a false joint. Therefore, it is very important to stop moving between fragments. With too long fixation of a wrinkled joint, it becomes completely immobile. If, after surgery for pseudarthrosis, it is too early to mobilize a still barely mobile joint, then the internal fixation of the fragments in a fresh bone scar relaxes, and as a result, movement occurs again, pseudarthrosis does not ossify.
For the surgical treatment of pseudoarthrosis located close to the shoulder joint and causing complaints and functional disorders, osteosynthesis with T plates is most suitable (see p. 974, Fig. 8-205).
After the bone surfaces have been refreshed, the fragments are connected by a plate T, and compression is applied so that the cortical part of the bone is pressed into the spongy substance. This increases internal fixation, which promotes bone healing.
Treatment of pseudarthrosis that has arisen on the humeral shaft as a complication of conservative or surgical treatment is usually required when mobility remains at the fracture site, limiting the function of the limb.
Rice. 8-217. Operation of supracondylar pseudoarthrosis of the humerus with a Y-shaped plate and a plate in the form of one third of the tube. View A) behind, b) side
If interposed soft tissues or fragments cannot be properly reduced, then the fracture should be opened and the surfaces of the fragments should be refreshed. After reposition, an AO plate is implanted, which is fixed with at least six screws. Right choice the location of the plate is very important, for this you need to know direction of forces acting on fragments. Additional cancellous transplantation is performed only if there is a bone defect or if the operation is performed in a heavily scarred area, and therefore poor blood supply to the bone fragments must be taken into account.
With a fracture of the lower third of the humerus in the region of the anterior arc of the radial nerve and below it, a false joint often occurs. This may be due to the fact that such fractures are not exposed enough due to fear of the possibility nerve damage, resulting in insufficient internal fixation. After such operations, it is more difficult to eliminate pseudarthrosis, because in order to achieve good internal fixation, the bone must be exposed in scar tissue without damaging the nerve. For the treatment of pseudarthrosis of the humerus located close to the elbow joint, access from behind is recommended. In this case, it is possible to perform osteosynthesis under the radial nerve with straight or Y-shaped plates of appropriate length and thickness. If stabilization by one plate is not sufficient, then it can be supplemented by a radial attachment of a plate in the form of 1/3 tube, which is fixed only with short 2.7 mm screws (rice. 8-217). After osteosynthesis, to eliminate pseudarthrosis, exercises are performed early to stimulate blood circulation and to maintain free joint mobility.
