EXARTICULATION (exarticula-tio; lat. the ex-prefix meaning department - j-of late armor. articulatio joint; a synonym exarticulation) — operation of removal of an extremity or its segment at the level of a joint crack.
AA. made already in an extreme antiquity. Hippocrates noted difficulties of a stop of bleeding at an exarticulation. K. Galen considered that E. has advantages before amputation: less time is spent for it and make it by means of only one knife whereas for amputation the tool kit is necessary.
The indication to E. severe damage of an extremity when it is impossible to keep it serves: crush
of distal department of an extremity with damage of the main vessels, nerves, bones, muscles; gangrene of an extremity of various origin: severe forms of a mephitic gangrene; the suppurative focus on site a change with crush of muscles which was complicated by sepsis; the malignant tumors of soft tissues and bones of extremities which are not giving in to treatment by antineoplastic means and radiation therapy. In the latter case E. it is more preferable, than amputation (see) as malignant tumors of bones usually seldom pass to the jointed bone on sheaves and the capsule of a joint. Contraindications to urgent E. the heavy shock, dysfunction of cardiovascular system demanding holding resuscitation actions are; the exarticulation is carried out after elimination of these states.
The choice of a method of anesthesia at E. depends on the volume of operation, character and localization of pathological process, the general condition of the patient; apply vnutrikost-ny, conduction, epidural anesthesia, the anesthesia is more often. The section of skin is made distalny a joint, create one or two skin and fascial and muscular rags. Bare and tie up the main arteries, then veins. After blockade of 1% solution of novocaine cross nervous trunks, then — sinews, muscles, the capsule of a joint, sheaf. Carefully excise all synovial membrane, delete a joint cartilage. The wound is layer-by-layer sewn up, at the same time among themselves sinews antagonists and antagonistic muscles surely sew; enter drainages into a wound. After unwinding on a stump impose a plaster splint.
On an upper extremity E. most often carry out in metacarpophalangeal joints. Find a skin rag on a back of the hand (on I, II and V fingers the section is displaced to the centerline of a brush); on a palmar surface the section of skin is carried out on a cross fold between a palm and a finger. Sinews cross in the provision of nek-ry bending in radiocarpal and metacarpophalangeal joints the sinews of sgibatel and razgibatel of fingers hemmed by silk seams to the remains of the capsule of a joint did not hinder the movements of a hand. At an exarticulation of I and V fingers whenever possible keep places of attachments of muscles, eminences of I and V fingers. At an exarticulation of the I finger of a sinew of long muscles cross cross then carefully hem them to the remains of the capsule of a joint. At an exarticulation II, III and IV fingers of a brush are created a wide interval between the remained fingers at the expense of a spherical head of a metacarpal bone. Therefore with the cosmetic purpose often make amputation of a head of a metacarpal bone at the level of its distal part. On the course of operation provide an opportunity to carry out in the subsequent change of a finger of foot on a brush (see Microsurgery, Replantation).
At E. at the level of a radiocarpal joint the rotational movements of a forearm remain; operation does not interfere with prosthetics of a brush. AA. in an elbow joint it is undesirable. AA. in a shoulder joint make more often at malignant tumors of soft tissues of a shoulder and humeral bone; at localization of a tumor in a proximal part of a shoulder make E. together with a shovel if it is impossible to make safe operation of Tikhov — Linberg (see Ti-Hove — Linberg operation).
AA. on foot make at the different levels taking into account anatomic and statiko-dynamic conditions (see fig. 9, to St. Foot, t. 24, Art. 297). At exarticulation of fingers of foot of a head of plusnevy bones do not resect since they perform basic function. Exarticulation in a shoparovy joint since danger of vicious installation of foot because of excessive draft of gastrocnemius muscles is created is the most adverse; in these cases it is more preferable to perform amputation of foot across Pirogov (see Pirogov amputation). The exarticulation on Lisfranka is applied seldom; carry out economical amputation of plusnevy bones more often to raise an oporosposobnost of a stump. Exarticulation across Garanzho at the level of metatarsophalangeal joints is made at the small volume of defeat of foot; heads of plusnevy bones cover with a skin rag.
found from the bottom party of foot.
AA. in a knee joint carry out seldom in connection with difficulties of the subsequent prosthetics. AA. in a hip joint it is applied more often; it is begun with an exposure and consecutive bandaging of a femoral artery, a vein, crossing of a femoral nerve. Then bare and cut front department of the capsule of a hip joint, a round sheaf (a linking of a head of a femur, T.), dislocate a head of a femur. The wound is closed a back musculocutaneous rag. For the purpose of prevention of formation of a hematoma in an acetabular hollow it is offered to fill it with a muscle. For this purpose sartorial or one of adductors cut a little distalny the others and fix in an acetabular hollow seams. At tumoral defeat of pelvic bones without clear boundary between a tumor and a bone tissue make E. extremities and a half a basin. In this case pelvic bones divide in the field of a pubic symphysis and a sacroiliac joint.
To complications E. carry bleeding, shock, suppuration of a wound, a necrosis of a rag, discrepancy of seams, osteomyelitis, fibrinferments and embolisms, to-rykh start the prevention in the course of operation and in the postoperative period.
Common fault of a method — formation of a stump with club-shaped expansion on the end that complicates the subsequent prosthetics (see). For elimination of this shortcoming often carry out reamputation of a stump (see Reamputation).
Bibliography: Boychevb., Konforti B. of N of the H about to and N about in To. Operational orthopedics and traumatology, the lane with bolg., Sofia, 1961; F and r and yo f JI. Fundamentals of operational surgery, the lane with fr., SPb., 1887;
H and to l and V. D's N. Fundamentals of operational orthopedics and traumatology, M., 1964.
S. T. Zatsepin.