AMPUTATION

From Big Medical Encyclopedia

AMPUTATION (Latin amputatio — cutting off) — operation of removal of peripheral department of an extremity or other body (a uterus, a mammary gland etc.). Most often the term «amputation» is applied in relation to operation of removal of a part of an extremity, at its crossing between joints. Cutting off of an extremity or a peripheral part through a joint call it exarticulation, or exarticulation (see).

History

And. it is known since the most ancient times. Its main phases were completed by certain rules at Hippocrates. Being afraid of fatal bleeding, And. made then preferential at gangrene of an extremity, through devitalized fabrics. Tsels and Arkhigen did at And. a circular section within healthy fabrics, applying a banner of an extremity and bandaging of vessels places are higher And.

Further these welcome were accorded forgotten, and bleeding at And. stopped the heated iron or the boiling oil. Only in 16 century Ambroise Paré applied bandaging of the crossed vessels. In 17 century J. Young began to impose on an extremity above the place of its truncation a special loop, in 18 century applied-ruyu to J. L. Petit in the form of a tourniquet. The tourniquet was succeeded by a styptic plait (see. Plait styptic ), offered by Esmarkh (J. Esmarch, 1873). Up to 17 century. And. it was made by a section of all fabrics in one plane — a guillotine way then the so-called conic stump, as a rule, formed.

Later, according to Pti and Chizlden's offer (J. L. Petit, W. Cheselden, 1720), began to do And. in two stages. In the beginning cut skin and hypodermic cellulose, then in the area of the delayed skin were crossed perhaps above in one plane of a muscle and a bone that in a nek-swarm of degree prevented formation of a vicious stump.

Fig. 1. A conical and circular method of amputation of a hip according to N. I. Pirogov: 1 — a section of skin; 2 — a section of muscles on edge of the reduced skin; 3 — a section of muscles on edge of the delayed skin; on the right above — a schematic section of a stump after amputation (a wound in the form of a funnel)

The technique of a section of soft tissues underwent changes, all new options were offered. Wide recognition was gained by a conical and circular method A., developed by N. I. Pirogov (fig. 1). Its essence consists in the three-moment crossing of soft tissues providing formation of a wound in the form of a funnel, the cut is the basis skin, and a bottom — bone opit.

Fig. 2. Ways of a section of soft tissues for amputation of the lower extremity: 1 — with formation of front and back rags on a hip; 2 - a circular elliptic section in an upper third of a shin; 3 — with formation of a front rag in an average third of a shin; 4 — with formation of a back rag in the lower third of a shin

The aspiration to closing of a wound for the purpose of its more bystry healing caused development of scrappy ways of a section of soft tissues. There are various modifications of these ways (fig. 2).

However the way of a section of soft tissues completely did not solve a problem of creation of a full-fledged stump.

For creation of an oporosposobny stump at the beginning of 19 century the subperiostal method A was widely adopted., at Krom bone opit it was closed by a periosteum. The method quickly gained recognition. Experimentally it was also clinically proved that the periosteum in such cases very quickly isolates a bone and the marrowy channel from surrounding fabrics, turning into the plate closing them. Further, however, it was established that the shelter of a bone opil a periosteum often leads to growth of a bone tissue in the form of osteophytes. These growths, being in close proximity to a postoperative hem, quite often cause trophic disturbances (ulcerations, decubituses), pain and complicate prosthetics. In this regard the beznadkostnichny method A was offered. [R. Bunge, 1901] at which the periosteum and marrow were removed proksimalny a bone opil on 1 cm. At such processing bone growths are observed seldom, however the necrosis of a bone can develop.

The new chapter in the history of domestic and world surgery was opened by (1852) osteoplastic method A developed by N. I. Pirogov. shins. The method consists in what opit bones of a shin is covered with the sawn round hillock of a calcaneus for which as the feeding leg serve the left soft tissues of foot (see. Pirogova amputation ).

Huge advantage of a stump ambassador A. across Pirogov its argumentativeness and high endurance to loading is. In very short terms the large number of modifications of operation of Pirogov appeared. Moreover, Pirogov's method offered for And. shins, it was used for osteoplastic operations in other areas of a body. As a bone transplant used a patella [R. Gritti, 1857], a bone and periosteal rag from a tibial bone [I. F. Sabaneev, 1890; A. A. Abrazhanov, 1898 - Bir (To. Bier), 1893, etc.] (see. Gritti — Szymanowski operation , Sabaneeva operation ).

Pirogov's idea was also a basis for development of a method of free bone plastics at And. (P. P. Sitkovsky, 1912, etc.). E.g., Kirchner (M. of Kirschner, 1920) entered into the marrowy canal of a tibial bone a pin from fibular or from a remote part of a tibial bone. A peculiar method of free bone plastics in the form of the lock latch at diaphyseal And. hips were offered by Yu. Yu. Dzhanelidze in 1943 (see. Dzhanelidze amputation ). Many of these operations have only historical value.

Fig. 3. Fastsio-plastichesky method of amputation of a shin. Sawing off of a first line of a tibial bone (on the right above). And bone opit muscles are covered with a fascia which edges are hemmed to a front fastsio-periosteal rag

Strongly the method of fascial plastics entered practice (G. N. Lukyanov, 1922), at Krom bone opit takes cover the fascial plate taken on a leg or freely (fig. 3).

Classification

In addition to division by the form a section of soft tissues, to a method of processing of an opil of a bone etc., And. classify also by a run time. Alkok (T. Alcock, 1836) suggested to divide And. at wound of an extremity on primary, secondary and intermediate. Was called primary And., made during the first 24 hours after damage, prior to the beginning of wound fever. Was considered secondary And., carried out after the termination of wound fever, in 8 — 10 days after wound when there came plentiful release of pus from a wound. Called intermediate And., made in the period of wound fever. Over time intermediate And. ceased to allocate. Division And. on primary and secondary remained though the different sense invested in these concepts different authors. N. N. Burdenko called primary And., carried out as primary surgical treatment of a wound, the essence a cut consisted obviously impractical extremity at a distance. Secondary And. it is carried out for the purpose of removal of an extremity as life-threatening sick center of intoxication and infection. And., made at threat of amyloid degeneration of parenchymatous bodies at osteomyelitis, it is long not healing ulcers etc., were called late. N. N. Priorov divided And. on primary as inevitable primary method of treatment of the injured extremity I secondary, following conservative treatment. P. A. Kupriyanov considered more correct to speak about And. according to primary and secondary indications. Distinguish still repeated And., which carry out on higher segments of the same extremity in connection with the insufficient efficiency which is earlier executed And. at a mephitic gangrene, wet gangrene etc. Repeated And., carried out in connection with anatomic and functional unfitness stumps (see) the ambassador A. in the past, call still reamputation (see). Such And. pursues the reconstructive aim.

For a long time the great value was attached to level A. During the doantiseptichesky period in connection with a high lethality the ambassador A. proximal departments of an extremity aimed to amputate as it is possible distalny. Emergence of a large number of disabled people ambassador A. in the years of World War I and development of prosthetics in the subsequent led to review of this question. Many authors [M. S. Yusevich, N. N. Priorov, Tsur-Vert (M. Zur Verth), etc.] developed so-called amputating schemes, to-rymi the most reasonable was defined in relation to technology of prosthetics level A. Stumps shared on valuable, less valuable, useless (or unusable) for prosthetics. Time showed insolvency of such schemes. Achievements of surgery and prosthetics allowed to refuse them and to determine level A. depending on the general condition of sick (victim), the nature of a disease (damage), a condition of tissues of extremity, prevalence of an infection, and also from a situation (military operations etc.). For determination of level A. at diseases of vessels of extremities use special methods of a research (an angiography, a reovazografiya, etc.).

From the point of view of perspectives of prosthetics reasonable to make aspiration And. on more low level since long stumps of any segment of an extremity have advantages at prosthetics (see). Answers it and And. as expanded primary surgical treatment of a wound, to-ruyu make quite often on the level of damage.

Indications

divide Indications to amputation into absolute (unconditional) and relative (conditional). Treat absolute indications: a) full or partial separations of extremities at impossibility of replantation; b) open injuries of extremities with a rupture of the main vessels and nerves, smashing of bones and extensive crush of muscles; c) the extensive damages of soft tissues excluding functional suitability of an extremity even during the use of plastic surgeries; d) gangrene of various origin (an ischemic necrosis at injuries, the obliterating endarteritis and atherosclerosis, thromboembolisms, freezing injuries, burns, an electric trauma, etc.); e) the mephitic gangrene which is violently progressing or with extensive damages of soft tissues and fractures of bones; e) sepsis with extensive suppurations at changes and unsuccessful conservative treatment; g) malignant tumors of extremities; h) chronic osteomyelitis with threat of amyloid degeneration of internals; i) the expressed deformations of extremities which do an extremity functionally unsuitable, disturbing. Absolute indications at injuries of extremities can be primary, caused by the damage rate, and secondary, arising depending on complications.

Relative indications are defined by the general condition of the patient, the nature of pathological process, conditions of a surrounding situation (fighting, etc.). The solution of a question of indications is frequent to And. very difficult. In not clear cases, especially at the damages complicated by an infection «the armed observation» is recommended. N. I. Pirogov wrote: «Any operation does not demand so much reason, it is so much common sense and attention from the doctor as rational, clear drawing up indications to amputation». If in ancient times and even in the Middle Ages of the indication to And. were limited because of danger of bleeding, in 19 century — the beginning of 20 century of the indication to And., especially at gunshot wounds, extremely extended. In the years of World War I number made in all warring armies A. so increased that special organizational measures for restriction of indications to them were required. Broad use of primary surgical treatment of wounds, plaster bandages, and also progress of vascular surgery led to considerable narrowing of indications to And.

Preoperative preparation

Preoperative preparation consists of the general actions (fight against shock, anemia, intoxication) and local (sanitary cleaning of the victim, removal of indumentum etc.). According to indications also blood substitutes transfuse blood. Before And., carried out not in the emergency order, performing antibiotic treatment under bacteriological control, and also the treatment increasing reactivity of an organism is reasonable. Preparation of an opposite extremity for loading is of great importance, and also strengthening of joints is higher than the place And.

Except all-surgical instruments, during the performance And. special are necessary: amputating knifes of different size, saw (sheet, arc, wire), retractor, raspatories, rasp, bone nippers, styptic plait.

Anesthesia

the Choice of a method of anesthesia at And. depends on the general condition of the patient, existence of associated diseases, the nature of damage etc. In days of the Great Patriotic War in our country of 78,6% And. it was executed under anesthetic (F. A. Kopylov). In a crust, time finds broad application an endotracheal anesthesia with muscular relaxants. Did not lose values and local anesthesia according to A. V. Vishnevsky (see. Anesthesia local ). In all cases blockade of 1 — 2% solution of novocaine of nervous trunks before their crossing is important. Local anesthesia can serve as method of the choice at heavy disorders of action of the heart, easy and other bodies and systems. Intra bone anesthesia is connected with an applying a tourniquet and has contraindications (gangrene, an infection). Spinal anesthesia in connection with danger of falling of arterial pressure also has limited use. For anesthesia at And. at patients of senile age with a serious illness of cardiovascular system, at the exhausted patients with septic diseases, and also at heavy shock because of a separation or crush of an extremity a number of surgeons (S. S. Yudin, S. V. Lobachev, N. V. Antelava, etc.) with success used cooling of an extremity.

And. concerning injuries of an extremity it is carried out usually with imposing of a styptic plait. And. at diseases of vessels of an extremity make without plait, resorting to manual pressing of the main vessels since the plait injures vessels, and ischemia of fabrics aggravates frustration in the area A. The way of crossing of soft tissues is chosen depending on indications to And. The circular section is applied more often in the presence of a mephitic gangrene or at serious septic conditions. Resort to a guillotine way only at special circumstances and conditions (e.g., a life-threatening infection in a field situation). The scrappy ways (skin and fascial, muscular and fascial) creating rather good conditions for fight against an infection and allowing to make are widely used And. on more diet flax level, and a hem to have on that place of a stump where it will be injured least of all by a prosthesis (a back surface of a stump of a hip and shin, lower — a shoulder and a forearm). As for destiny of the crossed muscles, most of authors considers that sewing together of antagonists or fixing of muscles to a periosteum, a fascia warns them retraction, promotes preservation of their power balance and increases functional suitability of a stump.

Especially important stage A. crossing of nervous trunks is. N. N. Burdenko considered And. as neurosurgical operation. Many patients ambassador A. have severe postamputating pains (stump neuralgias, a hyperesthesia of a stump, a kauzalgichesky syndrome). Origin of pains variously (existence of neuromas, irritation of nerves cicatricial fabric, osteophytes, the ascending infectious neuritis and so forth). Eventually such pains can become pains of the central origin (see. by the Forfeit of amputated ). Developing of pains contacts way of crossing of a nervous trunk and processing of his stump. In this regard A. Mosetig-Moorhof crossed a nerve on 1 — 2 see above the planes of crossing of soft tissues, warning thereby an union of a nerve with a postoperative hem. It was supposed also that the atrophy of the tail of the truncated nerve can prevent development of neuromas and developing of pains. For this purpose Ritter (Ritter, 1917) cut out on the end of the truncated nerve a wedge, turned from top to bottom then sewed the ends of the split nerve by the basis. N. N. Burdenko subjected the vessels feeding a stump of a nerve, electrothermic coagulation or solution of formalin or 96% alcohol etc. entered into the end of a nerve 5%.

The best prevention of postamputating pains is high crossing of nervous trunks and aseptic healing of wounds, and also rational prosthetics. The nerve after moving away of muscles shall be crossed by the razor or very acute scalpel on 5 — 6 cm proksimalny the planes of an amputating wound. The pulling of a nerve promotes emergence of endoneural neuromas and therefore it is inadmissible. The bleeding vessels of a stump of a nerve tie up a thin catgut. Also process also skin branches of nerves. Blood vessels exempt from surrounding fabrics after their crossing and for the purpose of prevention of alloyed fistulas tie up a catgut (including and main).

During the processing of a bone careful attitude to a periosteum is necessary, to-ruyu cross tsirkulyarno an acute knife at the level of alleged crossing of a bone and carefully otseparovyvat from top to bottom. The bone is sawn on edge of the crossed periosteum so that not to damage it. Marrow in order to avoid bleeding from the marrowy channel is not taken out. Keen edges of an opil of a bone smooth, and on a shin where the bone is covered only with skin and a fascial rag, the acting first line of a tibial bone cut at an angle (fig. 3).

Fig. 4. Extension of soft tissues of a stump for skin using an adhesive plaster or a kleol

In the presence of a heavy infection, and also in need of evacuation of the victim the wound of an amputating stump is not sewn up. Accelerations of a wound repair in such cases reach extension of soft tissues in 8 — 10 days the ambassador A. (fig. 4) with the subsequent imposing of secondary seams.

Treatment after amputation is directed to prevention of shock, suppurations, vicious provisions of a stump, contractures, tromboembolic episodes, pneumonia etc. For the prevention of flexion contractures use plaster splints, appoint early remedial gymnastics. The correct position of a stump from the first days after operation is of great importance. E.g., ambassador A. hips should not be enclosed under a stump of a small pillow, to sharply take away it. The patient needs to be laid on a bed with a board under a mattress with the maximum extension of a stump in a hip joint. Prevention of pneumonia, thromboembolism and other complications is carried out according to the standard schemes.

After an extract from a hospital patients need continuation of treatment (physiotherapeutic procedures, massage, remedial gymnastics, temporary prostheses, sanatorium treatment). The most part of patients in 4 — 6 months the ambassador A. as a result of complex treatment and prosthetics is returned to work (see. Stump , Prosthetics ).

Complications

Complications: bleeding, an infection, a necrosis of soft tissues and a bone, contractures, vicious position of a stump, a conic stump, the pain syndrome with firmness expressed etc. The correct definition of indications to And., observance of rules of the operational equipment and asepsis, complex treatment of patients after operation allow to warn considerably these complications.

Lethality ambassador A. during the doantiseptichesky period was extremely high. In the French army during French-Prussian war (1870 — 1871) a lethality the ambassador A. reached 81,2%. During World War I the lethality in front hospitals of the German army reached 69%. In days of the Great Patriotic War in our country a lethality the ambassador A. was much lower, however too remained high. The main causes of death of the wounded who underwent And., there were a mephitic gangrene and the systemic purulent infection (sepsis). At a mephitic gangrene the lethality reached 50,9%, at sepsis — 24,6%, at shock — 9,6%, at bleeding — 4,6%, at considerable anatomic destructions — 1,3%, at a complication of the postoperative period pneumonia — 0,5%. Other reasons of lethal outcomes made 3,9% and a combination of the listed reasons — 4,6%. A lethality from shock among wounded, at which And. it was made as primary surgical treatment, reached 30,4% (F. A. Kopylov). As ambassador A. at gas gangrene the greatest number of wounded, a problem of decrease in a lethality died at And. depended first of all on prevention and successful treatment of gas gangrene. In peace time average figures of a lethality the ambassador A. 10,4% (V. A. Durmashkin) — 13,2% (L. A. Smirnov) make. At the same time results are more favorable the ambassador A. concerning injuries of extremities and it is much worse the ambassador A. in connection with diseases of vessels of extremities.

Ensuring operation with the modern anesthesia including an endotracheal anesthesia with muscle relaxants and novocainic blockade, an early and full recovery of blood loss, normalization of a hemodynamics and ventilating disturbances, effective fight against an infection promote improvement of results And. and to decrease in a postoperative lethality.

Osteoplastic amputation - the method of amputation providing creation of the stump possessing a trailer opornost. Idea and development osteoplastic And. belongs to N. I. Pirogov (see. Pirogova amputation ). Over 70 modifications of osteoplastic amputation across Pirogov were offered. In the next years a number of the operations based on this principle was offered at And. the lower extremity at various levels [J. Syme, R. Gritti, N. F. Sabaneev, Vir (To. Bier), A. A. Abrazhanov, Yu. Yu. Dzhanelidze].

At And. in the lower third of a shin when it is impossible to use a calcaneal hillock, resort to Sime's operation consisting in exarticulation of foot in an ankle joint, trimming of anklebones and cover of a bone opil a piece of leather from area of a heel. Functional results of operation of Sime are often unsatisfactory. The stump after this operation possesses a trailer opornost in the beginning, but in several years loses it because of the gradual shift of skin back, and a front postoperative hem — kpered and trophic changes of skin on the end of a stump. At And. in the lower third of a shin use osteoplastic is possible And. according to Levi, at a cut the bone plate is found from a lateral anklebone, until the present by Sergiyevska — from a medial anklebone, and according to Yu. M. Irger — both lateral, and medial anklebones are used.

At And. in a diaphyseal part of a shin with success osteoplastic operation of Vir is applied: from a front surface of a bolynebertsovy bone find a bone and periosteal plate on a leg, the cut then is covered by marrowy channels of both bones of a shin, the plate is fixed several seams to a periosteum and muscles. The stump of a shin after Vir's operation has a number of advantages at prosthetics though because of transformation of skin substantially loses a trailer oporosposobnost in the next years after operation. The oporosposobnost of a stump at osteoplastic amputation of Kirchner is much less, at a cut the marrowy channel is closed by a head of a fibular bone or a transplant from a tibial bone.

At And. hips in the lower third apply R. Gritti's operation — Szymanowski or its modification according to Albrecht with use of a patella, and also Sabaneev's operation, at a cut instead of a patella the plate from anterosuperior department of a tibial bone is used.

At And. throughout a diaphysis of a hip use of free bone plastics according to Yu. Yu. Dzhanelidze is possible: get a plate from a femur as the lock latch on the end of a hip. At And. hips across Viru the plate from a diaphysis of a femur on a periosteal leg is used. The bone plate is quicker reconstructed, merging with a diaphysis.

On the basis of long overseeing by a large number of disabled people many authors (M. S. Pevzner, F. A. Kopylov, S. f. Godunov) came to a conclusion that the best oporosposobnost stumps after Pirogov, Vir, R. Gritti's operations — Szymanowski possess.

Amputation at children

Amputation at children shall be made according to strict indications since this mutilating operation results victims in disability since early years. It is carried out at separations of a part or all extremity, extensive crushes of soft tissues with smashing of bones, crushing vascular defeats and malignant tumors.

At children it is impossible to apply the amputating schemes until recently applied at And. at adults since levels of truncation, favorable at the time of operation, can become inconvenient for prosthetics with the end of growth of the child. In formation of a post-amputating stump at children the disproportion of growth of soft tissues and bone fragments has special value, leads edges to a point of a skeleton of a stump with formation of «an age extremity» (M. V. Volkov). Unequal growth of bones is noted also at And. extremities at the level of a forearm and a shin are also tied with the fact that beam and fibular bones grow quicker elbow and tibial (Z. A. Lyandres). At a conic point there is a real threat of trophic disturbances of soft tissues of a stump.

In this regard an operative measure at children at extensive bruises shall have the most savings character, and at absolute indications to And. it shall be made as primary surgical treatment with the subsequent reconstructive operation in favorable conditions.


Fig. 5. The scheme of subperiosteal amputation of a shin at children according to M. V. Volkov; and-e - stages of operation. 1 — a periosteum; 2 — a bone (at the left — tibial, on the right — a little tibial)

During reconstructive operation at children the distal department of a stump should be provided with a good stock of soft tissues and to fix the truncated muscles by the end of a bone stump; to use a periosteum (fig. 5) for the shelter of a bone opil; at the level of pair bones to make cutting off of beam and fibular bones above elbow and bolynebertsovy; to amputate an extremity as it is possible distalny, carefully keeping epiphyseal rostkovy zones.

At And. at children good results are yielded by use of periosteal plastic surgery by M. V. Volkov and S. T. Feoktistov's technique. Opil bones process on subperiosteal type with use of a periosteum. On the periosteal coupling put a catgut purse-string stitch and edges of a periosteum invaginate to the marrowy canal then put a Z-shaped catgut stitch. At And. shins process a periosteum of a bolynebertsovy bone as well as on a hip, saw round a fibular bone 4 — 5 cm above, and it sew the periosteal coupling in a section of a periosteum of a tibial bone. The periosteal plastics creates a good basic switching plate.



Bibliography Burdenko N. N. Amputation as neurosurgical operation, M., 1942; Godunov S. F. Ways and technology of amputations, L., 1967, bibliogr.; Durmashkin V. M. Primary amputations of extremities at razmozsheniye and separations, Gorky, 1958, bibliogr.; Kopylov F. A. Amputations, exarticulations and reamputations, Mnogotomn. the management on the orthopedist, and travmat., under the editorship of N. P. Novachenko, t. 1, page 638, M., 1967; Kopylov F. A. and Pevznyor M. S. Medical bases of prosthetics, L of 1962 bibliogr.; Lagunova I. G. Amputating stumps of extremities, M., 1950 bibliogr.; Young E. K. Amputations and prosthetics of extremities, Mnogotomn the management on hir., under the editorship of B. V. Petrovsky, t. 11, book 1, page 376, M., 1960; Pies N. I. The beginnings of the general field surgery, the p. 2, M. — L., 1944; Yudin S. S. Surgical anesthesia by ice for amputations of extremities, M., 1943; Yusevich M. S. Amputations and prosthetics, L., 1946, bibliogr.; Kessler H. H. Cmeplasty, Oxford, 1947, bibliogr.; Kirk N. T. Amputations, Hagerstown, 1945; Stoichev K. To amputation and the protezirena on a dolnita of a kraynitsa, Sofia, 1970 bibliogr.

And. at children - M. V wolves. Amputations of extremities at children, M., 1955; Doletsky S. Ya. and Isakov Yu. F. Children's surgery, p. 2, M., 1970; Lyandres Z. A. Amputations and reconstructive operations on stumps of extremities at children, L., 1961, bibliogr.


E. V. Lutsevich; V. L. Andrianov (ORT.), V. P. Nemsadze (ped.).

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