Health, Medicine
Indications for limb amputation. Features of the operation and rehabilitation
Amputation of the 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 the ligation of blood vessels, usually led to fatal outcomes. Doctors were advised to truncate the limb within the affected tissues, this eliminated the deadly bleeding, but did not stop the spread of gangrene.
- Carry out truncation in the level of viable tissues;
- Isolated dressing of stump vessels to prevent bleeding;
- Cutting out a backup shred 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 method of bloodless surgery when Esmarch created the rubber tourniquet, which is still used today.
In the modern world, diabetes and cardiovascular pathologies occupy the leading positions among the indications for amputation.
Amputation is a truncation of the limb, or rather, its distal part, throughout the bone, but it would be a terrible mistake to treat 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 a surgical operation of this kind. Let's consider these indications in more detail.
Indications for limb amputation
- Gangrene.
- Presence of a hotbed of a serious infection that threatens the patient's life (anaerobic infection).
- Irreversible ischemia with muscular contracture.
- Syndrome of prolonged compression.
- Traumatic crushing of the limb with damage to the main vessels and nerves, so-called traumatic amputation is performed.
- Obliterating vascular diseases with outcome in gangrene.
- Haemostatic tourniquet, over 3 hours.
- Common, non-treatable neurotrophic ulcers.
- Osteomyelitis with the threat of injury to internal organs.
- A common tuberculosis lesion of bone tissue in old age.
- Malignant tumors of bones without the possibility of isolated removal of the focus.
Determining the level of resection
Children try to use exarticulation (the extraction of the affected part at the joint level), which does not violate the further growth of the bone.
On urgency of operative intervention allocate Amputation of limbs :
- emergency amputation performed during the first surgical intervention to remove non-viable, damaged tissues;
- urgent operation with truncation of the focus of intoxication with ineffectiveness of conservative methods of treatment;
- planned amputation performed with malignant bone damage , osteomyelitis.
- reamputation for the purpose of correction of an inconsistent stump.
Allocate a circular, ellipsoidal and patchwork amputation. Let's consider these types below.
Circular amputations
The main indications for amputation, namely the guillotine (one-stage circular) amputation, are gas gangrene and resection of limbs hanging on the cutaneous muscle scrap. This intervention is carried out exclusively for emergency life indications. A significant disadvantage of this technique is the creation of a non-functional stump and mandatory subsequent re-imputation 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 shred, even with reduced blood supply.
How is the operation performed? Amputation in the first stage consists of incision of the skin, subcutaneous fat and fascia. The edge of the displaced skin is a further reference point along this edge. At the second stage, the muscles are cut to the bone and further bone is cut. Covering the bone end is due to the skin and fascia.
This species is recommended on the limb sections with a relatively small muscle mass.
For departments with a large muscle mass, a three-moment amputation is recommended (a simple and cone-circular amputation according to Pirogov).
The first two stages of the operation are analogous to a two-stage amputation. Further, after shearing muscles and surface tissues in the proximal direction, the muscles are re-dissected along the edge of the stretched skin. Due to this, deep muscle layers dissect, which contributes to the further formation of a conical stump.
Patchwork methods are divided:
- On single-sculled (the length of one flap is equated to the diameter of the stump);
- Two-scaped (two scrapes of different sizes along the sum of the lengths that make up the diameter of the amputated limb).
When forming the stump, it must be taken into account that the scar should not be on the working surface. Scraps should be formed taking into account the ability to bear loads.
Costonoplastic amputation
How is lower limb amputation performed? A distinctive feature is the presence of a bone fragment, which is covered with a periosteum as part of a scrap.
The method of osteoplastic amputation of the shank according to Pirogov received worldwide recognition in connection with the highly successful anatomical rehabilitation of the terminal support of the operated leg.
The advantages of the method:
- Less pronounced soreness of the stump.
- The presence of an end support stump.
- Preservation of proprioceptive sensitivity of muscles and tendons.
Stages of the operation
Operation on Sharp
There is another method by which amputation of the lower extremities is performed.
When the foot is removed, dissection of soft tissues is carried out a few centimeters distal to the first phalanges of metatarsal bones. After otpreparovyvaniya periosteum is performed sawing the metatarsal bones and smoothing the cutter ends with the cutter. The saw is covered with a plantar shred.
Let us consider the main causes of amputation.
Diabetic microangiopathy
The surgeon's actions depend on the degree of defeat. According to the prevalence of purulent necrotic lesions, five stages are distinguished:
- Surface focus of necrosis without tendon damage.
- Gangrene finger with the involvement of the first phalanx and tendons.
- A common gangrene of the fingers, combined with gangrene of the foot.
- Gangrenous lesion of the entire foot.
- Involvement in the process of the shin.
When a patient with purulent-necrotic ischemia arrives, an emergency sanation of the focus is carried out, consisting of opening abscesses, draining the phlegmon, minimizing the resection of the affected part of the bone, and removing the dead tissue. After excision of nonviable tissues, operations to restore adequate blood flow to the injured limb are recommended.
With ischemia:
- First degree only sanation 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, amputation is performed on Sharp, a special amputation knife is used;
- Treatment of the fourth degree consists in resection at the level of the shin;
- At the fifth degree, amputation is performed at the level of the thigh.
Frostbite of the fingers and other parts of the body
- 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);
- Fever (manifests chronic inflammatory reaction of the skin in the form of bluish-bordea scaly spots with pronounced itching.
There are four degrees:
The first degree is accompanied by reversible changes on the part of the skin: hyperemia, swelling, itching, pain sensations and an unexpressed decrease in sensitivity. A few days later, the affected areas are cleared.
The second degree is characterized by the appearance of blisters with light contents, a pronounced decrease in sensitivity, it is possible to attach 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 a healthy strip of granulations), damaged limb sites are mummified, with the attachment of microbial flora, the development of moist gangrene is possible.
At the fourth degree, necrosis of tissues spreads to the bone, the liquid in the blisters on the skin becomes turbid black, the skin is cyanotic, pain sensitivity completely disappears, the affected limb turns black and mummified.
Treatment
- 1st degree. Warming the patient, UHF-therapy, darsonval, frost-bitten limb is ground with boric alcohol.
- 2 nd degree. Processing of bubbles is carried out. After their opening, the damaged skin is removed, an alcohol bandage is applied to the wound. Recommended systemic antibiotic therapy.
- 3rd degree. Bubbles are removed, necrotic tissue is excised, a dressing is applied with hypertonic saline solution. Antibiotics are used to prevent secondary infection.
- 4th degree. Necrectomy (removal of non-viable tissues) is carried out 1 cm above the necrosis line. Amputation is performed after the formation of a dry scab.
Gangrene
It is characterized by the absence of general intoxication of the organism, the presence of a clear demarcation shaft. In the treatment of possible use of expectant management.
Apply: drugs that improve tissue trophism, systemic antibacterial therapy. The operation is carried out after the formation of a clear demarcation line.
Wet gangrene occurs as a consequence of acute cessation of blood circulation (frostbite of the fingers, thrombosis, compression of the vessels). It is characterized by severe intoxication, the absence of a demarcation line and pronounced edema. Amputation with gangrene is carried out urgently, waiting for tactics is unacceptable. After detoxification therapy, surgery is performed. The amputation line should be significantly higher than the gangrene (for amputation it is recommended to perform amputation at the hip level).
Gas gangrene is an absolute indication for guillotine amputation. Characteristic manifestations: marked, rapidly progressive edema, the presence of gas in tissues and muscles, necrosis and phlegmon with melting of soft tissues. Visually, the muscles are grayish, dull, easily wrinkled when palpated. Skin covers are purple-cyanotic, with crushing and crunching sounds. The patient complains of unbearable, burgeoning pain.
Criteria of 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. Also its physiological form (slightly tapering downwards) and painlessness is important. The mobility of the retained joints and skin scar is assessed (its mobility and lack of adhesion to the bone base).
Signs of a vicious stump
- Distribution of the scar on the working surface.
- Excess of soft tissues.
- Absence of a conical narrowing of the stump.
- Fusion of the scar with tissues, its immobility.
- Too high muscle arrangement.
- Excessive skin tension with bone filings.
- Deviation of bone segments during amputation of paired bones.
- Excessively conical form of the stump.
Disability registration
Assessment of the degree of loss of functional activity, disability and limited life activity, as well as the further appropriation of disability is handled by a medical and rehabilitation expert commission.
When establishing a disability group, it is estimated:
- Ability to self-service.
- Possibility of independent movement.
- Adequacy of orientation in space and time, provided that the pathology of mental activity is absent (hearing and sight are assessed).
- Communicative functions, the ability to gesticulate, write, read, etc.
- Level of control of one's own behavior (compliance with the legal, moral and ethical standards of society).
- Training, the ability to gain new skills, the development of other professions.
- Ability to engage in work.
- Ability to continue to work in the framework of their professional activities after rehabilitation and when creating special conditions.
- Functionality and degree of prosthesis development.
The first group
Indications for the assignment of the first group:
- Amputation of both legs at the hip level.
- Absence of four fingers (including the first phalanx) on both hands.
- Amputation of hands.
The second group
- Amputation of three fingers (with the first phalanxes) 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 on Chopar and Pirogov.
- High resections of one leg, combined with the lack of fingers of one hand or eye.
- Amputation of one hand and eye.
Exarticulation of the hip or shoulder.
Third group
- Unilateral amputation of the fingers without removing the first phalanx.
- Two-sided amputation of fingers.
- High amputation of one leg or arm.
- Removal of both feet by Sharpe.
- The difference in leg lengths is more than 10 cm.
Rehabilitation after amputation
In addition to an anatomical defect, limb amputation leads to severe psychological trauma to the patient. The patient closes on the 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 the further proper care of the stump.
On the 3-4th day after amputation, the prevention of flexion contractures begins, the movement of the stumps. After the removal of the sutures, active training of the stump muscles is recommended. A month later begin to try on the first prosthesis.
The most important goal of rehabilitation measures is the stabilization of the patient's psychological state and the formation of an adequate relation to prosthetics.
Further activities include:
- training in the use of a prosthesis;
- a complex of trainings for the activation of the prosthesis and its inclusion in the general motor stereotype;
- normalization of coordination of movements, use of therapeutic and 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).
When phantom pains occur in the amputated limb, a new blockade, hypnosis and psychotherapy sessions are recommended. In the absence of improvement, surgical intervention with resection of the affected nerve is possible.
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