Amputation of limbs 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 deaths. Doctors were recommended to truncate the limb within the affected tissues, this eliminated fatal bleeding, but did not stop the spread of gangrene.
In the first century AD, Celsus Ausl Cornelius proposed a revolutionary approach for conducting such operations at that time, 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 backup patch of tissue to cover the stump without pathological tension.
An important role in improving the methods of limb amputation was played by the introduction of the bloodless operation method, when Esmarch created the rubber band used so far.
In the modern world, diabetes mellitus and cardiovascular pathologies occupy a leading position among indications for amputation.
Amputation is a truncation of a limb, or rather its distal part, throughout the bone, however 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 quick and effective rehabilitation of the patient.
There are certain indications for a surgical operation of this kind. Consider these readings in more detail.
Indications for amputation of limbs
- Gangrene.
- The presence of a focus of severe infection that threatens the patient's life (anaerobic infection).
- Irreversible ischemia with muscle contracture.
- Syndrome of prolonged compression.
- Traumatic crushing of a limb with damage to the great vessels and nerves, the so-called traumatic amputation.
- Obliterating vascular diseases with an outcome in gangrene.
- A hemostatic tourniquet applied over three hours.
- Common, non-treatable neurotrophic ulcers.
- Osteomyelitis with the threat of damage to internal organs.
- Common tuberculosis bone damage in old age.
- Malignant bone tumors without the possibility of isolated removal of the focus.
Determination of the level of resection
The choice of the level of limb amputation depends on the degree of blood supply disturbance in the operated area, the presence of gangrene, trophic disorders, the condition of adjacent tissues and the severity of the infectious process and pain.
In children, they try to apply exarticulation (isolating the affected part at the joint level), which does not violate further bone growth.
According to the urgency of surgical intervention emit amputation of limbs :
- emergency amputation performed during first aid in order to remove non-viable, damaged tissues;
- urgent surgery with truncation of the focus of intoxication with the ineffectiveness of conservative methods of treatment;
- planned amputation carried out with malignant bone damage, osteomyelitis.
- re-amputation in order to correct an insolvent stump.
Allocate circular, ellipsoidal and patchwork amputations. Consider these types below.
Circular amputations
The main indications for amputation, namely the guillotine (simultaneous circular) amputation, are gas gangrene and resection of the limbs hanging on the musculocutaneous graft. This intervention is carried out exclusively for emergency vital indications. A significant drawback of this technique is the creation of a non-functional stump and the mandatory subsequent re-amputation in order to adapt the limb to the further establishment of the prosthesis.
The advantage of this amputation is the absence of necrotic changes in the flap, even with reduced blood supply.
With guillotine amputation, the bone is sawn off at the same level as the soft tissue.
How is the operation performed? Amputation in the first stage consists of incision of the skin, subcutaneous fat and fascia. The edge of the shifted skin is a further guideline along this edge. At the second stage, the muscles are cut to the bone and the bone tissue is further cut. Covering the bone end is due to the skin and fascia.
This species is recommended for parts of the limb with relatively small muscle mass.
For departments with large muscle mass, three-moment 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 surface tissues are shifted in the proximal direction, the muscles are re-dissected along the edge of the drawn skin. Due to this, deep muscle layers are dissected, which contributes to the further formation of a conical stump.
Patchwork methods share:
- on one-flap (the length of one flap is equal to the diameter of the stump);
- two-flap (two shreds of different sizes by the sum of the lengths that make up the diameter of the amputated limb).
When forming the stump, it must be borne in mind that the scar should not be on the working surface. Shreds should be formed taking into account the ability to withstand loads.
Osteoplastic amputations
How is lower limb amputation performed? A distinctive feature is the presence of a fragment of bone covered by the periosteum in the patchwork.
The Pirogov method of osteoplastic amputation of the lower leg was recognized worldwide in connection with the highly successful anatomical rehabilitation of the end support of the operated leg.
Advantages of the method:
- Less pronounced soreness of the stump.
- The presence of the terminal support of the stump.
- Preservation of proprioceptive sensitivity of muscles and tendons.
Operation stages
When removing the lower leg according to Pirogov, two incisions are performed. An amputation knife is used for this. First, a transverse dissection of the soft tissues is made, exposing the ankle joint, then an arcuate incision is made, passing along the dorsum of the foot. After crossing the lateral ligaments, the talus is broken out and the leg bones are sawn off. The cross section is closed with a patch. Form a stump.
Sharpe operation
There is another method by which amputation of the lower extremities is performed.
When removing the foot, soft tissue dissection is carried out several centimeters distal to the first phalanges of the metatarsal bones. After preparation of the periosteum, metatarsal bones are cut and the ends of the saw are smoothed with nippers. The cut is covered with a plantar rag.
Consider the main causes of amputation.
Diabetic microangiopathy
The surgeon's actions depend on the degree of damage. According to the prevalence of purulent necrotic lesions, five stages are distinguished:
- Superficial focus of necrosis without damage to the tendons.
- Gangrene of the finger with the involvement of the first phalanx and tendons.
- Common finger gangrene, combined with gangrene of the foot.
- Gangrenous lesion of the entire foot.
- Involvement in the shin process.
Upon admission of a patient with purulent-necrotic ischemia, an emergency sanitation of the focus is performed, which consists in opening abscesses, draining phlegmon, minimizing resection of the affected part of the bone and removing dead tissue. After excision of non-viable tissues, operations to restore adequate blood flow to the damaged limb are recommended.
With ischemia:
- of the first degree, only sanitation of the outbreak is performed;
- the second degree involves the amputation of the affected finger with excision of the tendons involved in the process;
- in the third degree, Sharpe amputation is performed, a special amputation knife is used;
- treatment of the fourth degree consists in resection at the tibia level;
- with the fifth degree, amputation is performed at the hip level.
Frostbite of fingers and other parts of the body
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);
- chills (manifested by a chronic inflammatory reaction of the skin in the form of bluish-maroon peeling spots 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 are desquamated.
The second degree is characterized by the appearance of blisters with light contents, a pronounced decrease in sensitivity, infection may be due to trophic disorders.
The third degree is manifested by necrotic changes in the soft tissues as a result of their death, a demarcation line is formed (demarcation of dead tissues from a healthy strip of granulation), damaged areas of the limb are mummified, with the addition of the microbial flora, the development of wet gangrene is possible.
With a fourth degree, tissue necrosis spreads to the bone, the fluid in the blisters on the skin becomes cloudy black, the skin is cyanotic, pain sensitivity disappears completely, the affected limb blackens and mummifies.
Treatment
- 1st degree. Patient warming, UHF-therapy, darsonval, frostbitten limb are rubbed with boron alcohol.
- 2nd degree. Bubbles are being processed. After opening them, the damaged skin is removed, an alcohol dressing 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 tissue) is carried out 1 cm above the necrosis line. Amputations are performed after the formation of a dry scab.
Gangrene
Dry gangrene is a consequence of a slowly progressing violation of the blood supply to tissues, typical for patients with atherosclerosis and
obliterating endarteritis.It is distinguished by the absence of general intoxication of the body, the presence of a clear demarcation shaft. With treatment, the use of expectant tactics is possible.
Apply: drugs that improve trophic tissue, 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 fingers, thrombosis, compression of blood vessels). It is characterized by severe intoxication, the absence of a demarcation line and severe edema. Amputation with gangrene is carried out urgently, wait-and-see tactics are unacceptable. After detoxification therapy, an operation is performed. The amputation line should be significantly higher than the gangrene (in case of damage to the foot, amputation is recommended at the hip level).
Gas gangrene is an absolute indication for guillotine amputation. Typical manifestations: severe, rapidly progressing edema, the presence of gas in tissues and muscles, necrosis and phlegmon with melting of soft tissues. Visually, the muscles are grayish, dull, easily wrinkle upon palpation. The skin is crimson-cyanotic, when pressed, a crunch and creak are heard. The patient complains of unbearable, bursting 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 should be greater than its diameter. Its physiological form (slightly tapering downward) and painlessness are also important. The mobility of the preserved joints and the skin scar (its mobility and the absence of adhesion to the bone base) are evaluated.
Signs of a Vicious Stump
- The spread of the scar on the work surface.
- Excess soft tissue.
- Lack of conical narrowing of the stump.
- Fusion of the scar with tissues, its immobility.
- Too high muscle position.
- Excessive skin tension with bone filing.
- Deviation of bone segments during the amputation of paired bones.
- Excessively conical stump shape.
Disability clearance
Amputation of a limb is an anatomical defect, as a result of which a disability group is assigned indefinitely. If leg amputation occurs, a disability group is assigned immediately.
The medical and rehabilitation expert commission is engaged in assessing the degree of loss of functional activity, disability and limited life activity, as well as further assignment of disability.
When establishing a disability group, it is evaluated:
- The ability to self-service.
- The possibility of independent movement.
- Adequacy of orientation in space and time, provided there is no pathology of mental activity (hearing and vision are evaluated).
- Communicative functions, the ability to gesticulate, write, read, etc.
- The level of control of their own behavior (compliance with legal, moral and ethical standards of society).
- Learning, the ability to acquire new skills, the development of other professions.
- Ability to engage in labor activities.
- The ability to continue to work as part of their professional activities after rehabilitation and in the creation of special conditions.
- Functionality and degree of development of the prosthesis.
First group
Indications for the assignment of the first group:
- Amputation of both legs at the level of the hips.
- The absence of four fingers (including the first phalanx) on both hands.
- Amputation of hands.
Second group
- Amputation of three fingers (with the first phalanges) of both hands.
- Removal of 1 and 2 fingers.
- Lack of 4 fingers with preservation of the first phalanges.
- Amputation of fingers on one hand with a high stump of the second hand.
- Operation on Shopar and Pirogov.
- High resections of one leg, combined with the absence of fingers of one hand or eye.
- Amputation of one arm and eye.
- Exarticulation of the hip or shoulder.
Third group
- Unilateral finger amputations without removing the first phalanx.
- Bilateral amputation of fingers.
- High amputation of one leg or arm.
- Removing both feet according to Sharpe.
- The difference in leg lengths is more than 10 cm.
Amputation Rehabilitation
In addition to the anatomical defect, amputation of the limb leads to severe psychological trauma to the patient. The patient closes himself to 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 3-4th day after amputation, the prevention of flexion contractures and the implementation of stump movements begin. After removing the sutures, active training of the muscles of the stump is recommended. After a month, they begin to try on the first prosthesis.
The most important goal of rehabilitation measures is the stabilization of the psychological state of the patient and the formation of his adequate attitude to prosthetics.
Further activities include:
- training in the use of 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 medical-training prostheses.
- social and rehabilitation measures, adaptation of the patient to life with a prosthesis;
- development of an individual rehabilitation program, retraining and further employment (for the 2nd and 3rd groups).
In the event of phantom pain in the amputated limb, novocaine blockade, hypnosis and psychotherapy sessions are recommended. In the absence of improvement, surgical intervention with resection of the affected nerve is possible.