Technique of foot amputation according to Pirogov. The main stages of amputation of the lower leg according to Pirogov

Date: 19.07.2019

Hip amputation is a surgical procedure during which the proximal and distal parts of the lower limb are truncated along the length of the bone. TO surgical treatment resort in the presence of vital indications: gangrene, malignant tumors(melanoma, sarcoma), functional vascular diseases, diabetic foot syndrome, etc. In the rehabilitation of patients with leg stumps, prosthetics is of decisive importance. Artificial formation of a supporting limb contributes to the partial restoration of the patient's activity.

Types of amputation

In surgical practice, there are several types of amputations:

By the period of execution - primary, secondary (associated with complications), repeated (reamputation).
By the method of tissue removal - circular (guillotine, one-, two- and three-stage), patchwork (one-two-flap).
In relation to the periosteum - aperiosteal, periosteal, subperiosteal.
According to the method of closing the saw cut, bones are bone-lamellar, myoplastic, skin-subcutaneous-fascial plastic, tenoplastic, periostoplastic.

Primary amputations

The operation for excision of the femur is carried out when diagnosing irreversible pathological changes in soft or bone tissues:

4th degree burns;
gangrene;
total vascular damage;
crush injury of the thigh;
nerve damage;
gunshot wounds.

Most often, the decision to truncate the limb is made by the surgeon after the patient is delivered to the emergency department.

They resort to radical surgery only in situations where there is no chance of saving the leg. In the event of crushing bones, rupture of ligaments and severe damage to the vessels, it is dangerous to save the hip, as this can lead to the development of sepsis and death of the patient.

Secondary amputation

Operations of this type are performed some time after the primary removal of the femur. The indications for amputation are complications after surgery and trauma:

inflammatory processes in the preserved tissues;
burns and frostbite;
the formation of infectious foci in the cult;
pathologies caused by wearing a prosthesis.

Important! With the development of septic inflammation, it is necessary to urgently seek help from a surgeon due to the high probability of blood poisoning.

Reamputation

In this situation, amputation of the lower limb is carried out in order to correct medical errors that may be associated with miscalculations in the process of forming the stump. Reamputation is prescribed for patients if the remainder of the amputated leg is not compatible with the prosthesis or non-healing trophic ulcers form on the surface of the soft tissues. Re-removal of the stump is also indicated under tension. skin in the area of the cut of the femur.

Amputation for complications of chronic diseases

In surgery, several types of sluggish diseases are distinguished, the development of which leads to irreversible pathological processes in the lower extremities:

malignant neoplasms;
diabetes;
Burger's disease;
purulent-necrotic damage to bone tissue;
chronic damage to the blood vessels;
tuberculosis of bones.

The manifestations of the above pathologies are necrotic damage to organic structures. Untimely removal of the femur is fraught with the penetration of toxins into the blood from the foci of inflammation and, as a result, the development of sepsis. The purpose of the operation is to truncate the damaged parts of the leg and prevent the death of the patient from blood poisoning.

Preparing for amputation

In 30% of cases, bone amputation is performed without preparation due to the admission of patients to the emergency department. Before the start of the operation, special attention is paid to pain relief, since insufficient anesthesia is the cause of pain shock.

When carrying out surgical treatment for urgent indications, they resort to intubation (endotracheal) anesthesia. In the case of planned surgery, patients use general or local anesthesia.

Removal of a part of the lower limb at the level of the femur is accompanied by damage to the vessels of the periosteum (periosteum), muscle tissue and nerve trunks, in which many pain receptors are concentrated. Therefore, in surgery, epidural anesthesia is used to anesthetize tissues and reduce the risk of intoxication complications.

The choice of the method of anesthesia is determined by the level of amputation, the likelihood of developing pain shock and the patient's well-being. In most cases, surgeons prefer general anesthesia- so during surgery, patients do not feel anything.

Basic principles of amputation

For a long time, such amputation schemes have been used in surgery, in which not only the affected, but also healthy areas of the bone were removed. Such operations were performed with the aim of "fitting" the shape and size of the stump to a standard prosthesis.

In connection with frequent complications associated with the formation of trophic ulcers and scars, had to resort to re-amputation. Lack of reserve distance for possible reoperation is a key disadvantage standard schemes removal of part of the bone.

Due to the rapid expansion of technical capabilities in surgical practice, many options for prosthetics have appeared, as a result of which the principles of amputation have undergone major changes:

only damaged tissues are subject to removal;
maximum preservation of the functional activity of the limb;
formation of a stump that is compatible with existing variants of prostheses;
prevention of phantom pain in patients.

Note! In surgical practice, each case of removal of the femur is individual in terms of the methods of amputation and rehabilitation programs used.

Regardless of the part of the body to be amputated, surgical intervention is carried out in several stages:

dissection of soft tissues;
bone circumcision and processing of the periosteum;
processing of large nerves and ligation of blood vessels.

Shin amputation

Removal of the tibia is carried out if only the foot tissue has undergone necrotization, and blood circulates to a satisfactory degree in the distal part of the leg. Shin amputation is carried out in several ways:

Osteoplastic amputation - involves excision of the soleus muscle, sawing the shin bones and ligating and suturing large nerves and blood vessels.
Truncation of the lower leg in the middle third according to Burgess is accompanied by excision of two soft tissue fragments - a short anterior and a long posterior one. After the operation, a scar is formed in the upper part of the stump, which creates optimal conditions for prosthetics.
Flap operating technique - involves cutting a long posterior and short anterior flap.

If truncation is performed in the lower third of the tibia, the sciatic nerve is shortened without further processing. Particular attention is paid to resection of cutaneous nerves, as their ingrowth into scar tissue often leads to pain.

Hip amputation

Truncation of the bone above the knee joint leads to a significant decrease in the functional activity of the leg. Amputation of the lower limb at the level hip joint carried out with unsatisfactory blood circulation in the tissues, which occurs against the background of gangrenous lesions. During the operation, surgeons work with the femur, large blood vessels, as well as an extensive layer of muscle tissue.

There are several techniques for forming a support stump:

Albrecht's operation is a osteoplastic resection of the hip, which is performed to change the shape of the vicious stump during the re-amputation process.
Amputation according to Pirogov is a cone-circular truncation of a limb, which is used exclusively in the field to prevent infectious inflammation of an injured limb. On the border of cutting off the bone, two flaps are formed - anterior and posterior. The length of each of them should be 1/6 of the diameter of the surgical wound.

Osteoplastic surgery is not used for total vascular pathologies and ischemic muscle damage.

After suturing, drainage is left in the operated area and an aseptic dressing is applied.

Treatment of the periosteum and toilet of the stump

The most crucial period in the operation to truncate the lower limb is the formation of the stump. From correctness medical manipulations its suitability for prosthetics and the need for re-amputation depend. In surgical practice, two methods of treating the periosteum are used:

Aperiosteal method. At the level of the saw cut, the connective tissue membrane of the bone is crossed with a circular incision. Then the periosteum is slightly displaced, and the bone tissue is sawn just below the area of the periosteum dissection.
Subperiosteal method. During the operation, the periosteum is cut below the bone sawing line, after which it is displaced in the proximal direction. At the final stage, the periosteum is sutured over the area of the bone cut.

The subperiosteal method of processing the periosteum is not used when operating on elderly patients, which is associated with the risk of its fusion with the bone.

When using the stump toilet, the following activities are carried out:

ligation of large and small veins and arteries;
hemostasis (for the prevention of septic inflammation);
processing of truncated nerve endings.

The likelihood of complications in patients depends on the correctness of the above procedures. Failure to process the nerves is fraught with their ingrowth into connective tissue adhesions.

To prevent complications, the nerves are treated in one of the following ways:

The cut nerve endings are carefully sewn into the connective tissue layer.
Angular resection of the nerve trunks with subsequent stitching of the epineurium fibers.
Sewing the ends of the nerves together.

After carrying out the above manipulations, the outer tissues of the stump are sutured. After the operation, muscle fibers quickly grow together with the bone, so they are not sutured.

Amputation techniques

According to the technique of truncation of external tissues, operations are divided into two types - patchwork and circular.

Single-patch

After truncation of the damaged part of the limb, the bone cut is closed with a tissue flap, which consists of fascia, skin and fiber. The edge of the stump formed during the operation has the shape of a torpedo or tongue.

In the process of tissue processing, the surgeon "cuts out" fragments of soft tissues so that the scar formations are outside the supporting part of the stump to which the prosthesis will be attached.

Two-flap

After amputation, the open wound is closed with two soft tissue fragments, which are cut from the opposite surfaces of the leg. When calculating the required length of the flaps, the following factors are taken into account:

the diameter of the surgical wound;
coefficient of contractility of the skin;
method of cutting the bone.

Unlike the above surgical method, a two-flap operation is more laborious. Thanks to this method of closing the bone saw, complications after surgery are rare.

Guillotine (one-step)

In the process of operating soft tissue at the level of the thigh, dissect in a circular motion, after which the bone is sawn through. This method of amputation is more often used in the case of urgent surgery on patients, which may be associated with:

gunshot wounds;
car accidents;
work-related injuries;
falling from a great height, etc.

A significant disadvantage of a one-stage operation is the formation of a vicious conical stump, in which secondary surgery is indicated.

Two-moment

Removing the damaged part of the leg, as well as sawing the bone, is carried out in two stages:

Dissection of the skin, subcutaneous tissue and muscle membrane with their subsequent displacement to proximal limbs.
Cutting muscle fibers along the edge of the stretched tissue and sawing bone.

A significant disadvantage of such an operation is the formation of skin folds in the stump, which subsequently have to be removed surgically.

Three-moment cone-circular

In this case, the areas of the injured leg, in which there is only one bone, are subject to amputation. Three-stage amputations of the hip according to Pirogov are carried out in several stages:

Cutting the skin, fiber, connective tissue membrane of the muscles.
Dissection of muscle fibers along the contracted dermis.
Resection of deep muscles along the edge of the pulled skin.

After the operation, scars often appear in the supporting part of the stump, which, moreover, can have a conical shape. Prosthetics are carried out only after re-amputation, which involves excision of adhesions and a change in the shape of tissues in the area of the cut bone.

Cone-circular amputation was developed by N.I. Pirogov, who used it in the treatment of patients with gas gangrene and combat wounds. The advantage of the method is the possibility of surgical intervention in the field without preparation.

Postoperative complications

During the rehabilitation period, about 23% of patients experience one of the following complications:

necrotization of soft tissues;
preinfarction state;
hospital pneumonia;
bacterial inflammation of the wound;
relapses of chronic gastrointestinal pathologies;
vascular thrombosis;
circulatory disorders in the brain.

For warning negative consequences sick pass antibacterial therapy and physiotherapy treatments. Massage, breathing exercises and physiotherapy exercises reduce the risk of pulmonary diseases and stagnant processes in soft tissues.

Phantom Pain

The painful sensations that occur in an amputated limb are called phantom pains. The true cause of their occurrence has not been established, therefore, etiotropic and pathogenetic methods of their treatment do not exist. Typical manifestations of pathology include:

itching in the heel;
numbness of the toes;
lumbago in the foot;
discomfort in the knee.

Antidepressants and sedatives are used to relieve discomfort. They reduce the severity of symptoms and prevent the development of depression in patients. For the early elimination of the postoperative complication, it is recommended to resort to limb development and training using a prosthesis.

Psychological attitude

Competently organized psychological support in the preoperative and postoperative period allow to accelerate adaptation and habituation of patients to the absence of a leg. Timely assistance and attention from loved ones shorten the rehabilitation period and have a beneficial effect on the psychoemotional state of patients.

A positive attitude reduces the likelihood of pain in the missing limb and other postoperative complications... Experts are sure that this is due to the absence of factors that negatively affect the functioning nervous system... During the recovery period, it is recommended to follow the doctor's instructions and not think about the lack of legal capacity.

Disability group

Rehabilitation of patients after hip truncation takes at least 6-9 months in the absence of serious postoperative complications. Depending on the level of amputation, patients are assigned one of the following disability groups:

Group I - is installed with short stumps in the thigh area of both legs at once with partial limitation of the functions of the upper limbs.
Group II - given to patients with hip prosthetics with a combined lesion of the second leg or both lower limbs at the level of the lower leg.
III group - established when partial recovery functions of the lost leg with the help of a prosthesis.

The disability group is determined taking into account not only the anatomical defect, but also the presence of concomitant complications that affect the quality of life and performance of patients.

Postoperative stump care

The likelihood of developing an infection in the operated tissues largely depends on the thoroughness of patient care. When drawing up a rehabilitation program, the following nuances should be taken into account:

As early as the third day after surgery, patients should develop a stump to prevent contractures.
After two weeks, the stitches are removed and a bandage is applied instead. During this period, active training should begin to increase muscle tone and prepare the stump for prosthetics.
After a month, patients try on a prosthesis and actively develop a limb.

Amputation of the leg at the level of the femur is a complex operation that leads to the patient's disability. Towards a radical surgical intervention resort only if it is not possible to save the limb. Indications for amputation are: gangrene, malignant tumors, vascular diseases, bone necrosis, etc. The likelihood of postoperative complications depends on the method of limb truncation and compliance with the rules of rehabilitation.

Shins. More than a century of testing allows us to make a conclusion about high functionality, full and long-term support of the stumps after osteoplastic amputation according to Pirogov.

The main reason for these qualities is that the stump has a natural bony base - the calcaneal tubercle covered with skin adapted to bear the load, as well as the fact that the posterior tibial artery is preserved.

More than 70 modifications of osteoplastic amputation according to Pirogov have been proposed. In practice, only a few of them are used. for the most part it is produced typically according to Pirogov.

Amputation technique according to Pirogov

A streamer-shaped incision of the soft tissues to the bone is made from the apex of the outer ankle through the sole to the anterior surface of the inner ankle. The ends of the first cut are connected with the back arcuate incision, the bulge facing the fingers.

Open up ankle joint, cross the lateral ligaments and produce a sharp plantar flexion of the foot. In the plane of the plantar incision, saw the heel bone behind the ram and remove the foot. The soft tissues are separated from the shin bones by 2-3 cm. The articular surfaces of the shin bones are sawed off. Tied with catgut a. dorsalis pedis and branches of a. tibialis posterior. The fibula from the outside is cut obliquely and rounded off with a rasp. Shorten n. cutaneus dorsalis medialis and n. cutaneus dorsalis intermedius. The skin flap, including the remainder of the calcaneus, is sutured to the skin of the lower leg. Preliminarily, the calcaneus is fixed to the sawdust of the shin bones with three or two catgut sutures, held through the calcaneus and tibia. Additional catgut sutures are applied to soft tissues, silk sutures are applied to the skin. Glass or rubber is introduced into the outer-lower corner of the wound. Anteroposterior plaster splint is applied for 3-4 weeks. The drain is removed after 48 hours without removing the splints.

With amputation in women, the shin bones are sawed higher, so as to obtain a shortening of 6-7 cm. With this shortening, a more cosmetic type of prosthesis can be made.

To preserve the epiphyseal cartilage in children, the shin bones are cut off directly above the articular surface. This protects against too sharp lag in the growth of the lower leg.

Amputation according to Pirogov can be performed without opening the ankle joint. This method is used for ankylosis or infection of this joint. The sections are the same. After removing the anterior flap, the shin bones are sawn or cut with a chisel, then the calcaneus is sawn behind the talus. Otherwise, the course of the operation is the same.

A good result is obtained after a type of amputation, which consists in the fact that the calcaneus and tibia are sawn not perpendicular to their long axes, but at an angle. This modification was foreseen by N.I. Pirogov. The advantage lies in the fact that the supporting surface of the stump will be the lower surface of the heel, and not the back, as after a typical Pirogov amputation. In the literature, this modification is called the Gunther method, since he used an oblique sawing of the calcaneus and shin bones for all cases /

Other modifications of osteoplastic amputation according to Pirogov are almost never used, since they not only do not have any advantages over conventional methods, but they significantly complicate the operation.

After break or damage sciatic nerve or its branches, along with varus deformity of the foot, trophic ulcers often occur mainly along the outer edge of the sole or in the center of the heel. This is facilitated by the load concentrated on a reduced support area, a sharp decrease or absence of pain and other types of sensitivity. Often trophic changes in the skin are accompanied by osteolysis of the bones of the foot. In some patients, after the elimination of the deformity, the load on the sole is distributed more evenly and the ulcers heal. With ulcers that are not amenable to conservative and surgical treatment, it is necessary to prescribe bulky unloading devices or amputate a limb. Previously, as a rule, an amputation of the lower leg was performed, since there was a fear that the disinnervated skin of the sole would not withstand prolonged stress.

With the localization of non-healing trophic ulcers on the outer or front surface of the foot, osteoplastic amputation according to Pirogov is indicated. The fusion of the calcaneus with the bones of the lower leg occurs at the usual time, the support of the stump is complete. These amputated people use prostheses throughout the day, work, do not present complaints, and, as a rule, they do not develop pathological changes in the skin of the supporting surface.

These observations indicate that the stumps after osteoplastic amputations according to Pirogov, even with disinnervated skin, have complete support, which, apparently, can persist for many years. Therefore, to obtain a support stump, not only good blood supply and tissue innervation, a large support area, but also the structure of the skin are important. Amputation according to Pirogov with disinnervated skin, trophic ulcers the outer and forefoot of the sole is highly recommended.

Prosthetics after shin amputation

Existing splint-leather prostheses with a metal cup and a wooden foot are fragile and heavy. Wooden prostheses without an ankle joint are more cosmetic, lighter and more durable than splint-leather ones, but when walking on them due to difficult rolling, pain and often scuffs occur along the front surface of the lower leg. Men with a long stump can use wooden prostheses, but they can, since they are built with the foot on a medium or high heel. At the Central Research Institute of Prosthetics and Prosthetics (TsNIIPP), new designs of wooden prostheses with an ankle joint and with mobility in the foot have been proposed, with the help of which a smooth roll is provided when walking when resting on a prosthetic limb.

The article was prepared and edited by: surgeon

A. Cutting out skin-fascial flaps.

B. Intersection of the lateral ligaments of the ankle joint.

B. Arthrotomy.

D. Sawing the calcaneus and fibula.

D. Formation of the supporting stump.

What complications can lead to incorrect processing of the nerve during amputation?

A. The onset of phantom pain.

B. The emergence of intrastem hemorrhages.

B. Nevrolysis.

D. Formation of neuromas.

D. The development of hematoma from the vessels feeding the nerve.

What indications for limb amputation are absolute?

A. Gas gangrene

B. Ostroe purulent inflammation threatening to enter the septic phase

B. Complete separation of the distal limb

D. Necrosis of the distal limb

E. Open limb injury, in which a complete rupture of the neurovascular bundles, bone fracture and destruction of more than 2/3 of the soft tissue volume are combined

What stages of limb amputation do you know?

A. Dissection of soft tissues

B. Applying a tourniquet

B. Treatment of the periosteum and sawing bones

D. Toilet stump

E. Vascular ligation

What types of amputations do you know?

A. Circular

B. Transverse

B. Patchwork

G. Complete

E. Partial

What types of circular amputations do you know?

A. One-time

B. Two-stage

B. Three-moment

G. Four-moment

D. Five-moment

How are flap amputations divided according to the number of flaps?

A. Single-patch

B. Two-piece

B. Three-flap

G. Chetyrekhloskutnye

D. Five-scoop

Depending on the composition of the flaps, what are the types of amputations?

A. Fascial-plastic

B. Myo-plastic

B. Periodo-plastic

G. Osteoplastic

E. All of the above

What type of amputation is cuffed amputation?

A. A special case patchwork amputation

B. Two-stage circular amputation

B. Three-stage cone-circular amputation

D. Single-flap amputation

E. This amputation does not belong to any of the named types.

What methods are used to prevent bleeding during amputation?

A. Finger pressure arteries

B. Tight bandaging of the limb above amputation

B. Applying a tourniquet

D. Ligation of an artery throughout

E. Vascular ligation as soft tissue is dissected

What is the "amputation rate"?

A. Place of dissection of soft tissues

B. Place of greatest destruction of soft tissues

B. The place where the bones were cut

D. Place of intersection of nerves

E. All listed signs

How is the flap length calculated for flap amputation?

A. According to the formula for the area of a circle

B. According to the formula for the circumference

B. Flaps are cut out with a margin, and the stump is modeled at the end of the operation.

D. According to the formula for the circumference of the circumference, taking into account the contractility of the skin

E. According to the formula of the area of a circle, taking into account the contractility of the skin

When using the transperiosteal method of processing the periosteum, what should be done after its circular dissection?

A. Move the periosteum proximally by 5-10 mm

B. Move the periosteum distally

B. Move the periosteum proximally and form a cuff for subsequent closure of the bone sawdust

D. Move the periosteum as proximally as possible

E. Move the periosteum distally by 1 mm

How is the saw blade usually set in relation to the length of the bone during amputation?

A. Perpendicular

B. At an angle of 30 °

B. Angled 45 °

D. 60 ° angle

E. Determined by the type of amputation

When using the toilet, the stumps are found large vessels for ligation?

A. Based on topographic and anatomical landmarks

B. By bleeding after removing the tourniquet

B. By pulsation of the artery

D. Using projection lines

E. For all the previously indicated signs

What material is usually used for ligating medium and large vessels in stump toilet?

B. Synthetic yarns

V. Catgut

D. Linen thread

D. Horsehair

Why are the ends of the nerves truncated during amputation?

A. To prevent the development of neuroma

B. To prevent the development of phantom pain

B. To prevent the development of causalgias

D. In order to form a small neuroma

E. For the purpose of better wound healing

At what distance from the level of amputation are the ends of the nerves truncated during limb amputation?

D. Up to 10 cm

Where is desired location postoperative scar upon completion of amputation?

A. On the work surface

B. On non-working surface

B. At the end of the stump

D. On the surface with the toughest leather

E. The location of the scar does not matter

What tissues should be included in the cuff when performing the appropriate limb amputation?

A. Skin and subcutaneous tissue

B. Skin, subcutaneous tissue and superficial fascia

B. Skin, subcutaneous tissue, superficial and intrinsic fascia

D. All soft tissues, including muscles

E. Soft tissues and periosteum

When shaping the cuff, how should you hold the scalpel blade?

A. Parallel to the longitudinal limb

B. Perpendicular to the length of the limb

B. At an angle of 45 ° relative to the length of the limb

D. At an angle of 60 ° relative to the length of the limb

E. The direction doesn't matter

From what surfaces of the forearm are flaps cut out for a two-flap amputation of the forearm in the middle third?

A. From the front and back surfaces

B. From the medial and lateral surfaces

B. From the anterolateral and posteromedial surfaces

D. From the anteromedial and posterolateral surfaces

E. From any surface

What are the features of the movement of the rasp to trim the edges of the bone sawdust?

A. Movements should be directed from the center of the cross section of the bone to the periphery

B. Movement should be directed from the periphery to the center

B. Directions of movement are not essential

D. Movements are directed from top to bottom.

E. Movements are made from bottom to top.

For what purpose should the artery be carefully separated from connective tissue?

A. For better vascular differentiation

B. To prevent slipping of the ligatures

B. To improve microcirculation in the distal stump

D. To prevent the development of edema of the stump

E. For the convenience of work

What device is used to pull soft tissues in the proximal direction after muscle dissection during amputation?

A. Using a gauze retractor

B. Using Farabef hooks

B. Using a metal retractor

D. With the help of Buyalsky's scapula

E. Using a spatula to separate the soft tissue

What is the prerequisite for the surgeon's assistant when cutting a bone?

A. To produce traction of the limb along the longitudinal axis

B. Do not interfere with the surgeon

B. Monitor the condition of the harness

D. Make sure that the edges of the bone sawdust do not interfere with the movement of the saw blade.

E. Monitor the condition of the victim

What tools are used to trim the edges of the bone sawdust?

A. Raspiel

B. Luer Nippers

V. Liston Nippers

G. Dahlgren Nippers

D. Nippers Still

What types of upper limb prostheses do you know?

A. Cosmetic

B. Worker

B. Traction-muscular

G. Myotonic

D. Bioelectric

E. All of the above

G. Correct A, B, D

What is causalgia?

A. Intolerable pain in the limb stump

B. Unbearable burning sensation at the end of the stump

B. Feeling severe pain in a non-existent part of a limb

D. Formation of a painful scar at the end of the stump

E. Formation of an immobile scar at the end of the limb stump

What instrument should be used to truncate the end of the nerve during limb amputation?

A. Laser scalpel

B. Scissors

B. Razor Blades

G. Electroknife

D. Scalpel

What is the advantage of osteoplastic limb amputation over other types of amputations?

A. In technical simplicity

B. In creating a supportable stump

B. In a slight decrease in the length of the limb

D. In preserving the "sense of the earth"

E. In the possibility of using orthopedic shoes instead of a prosthesis

Shins. More than a century of testing allows us to make a conclusion about high functionality, full and long-term support of the stumps after osteoplastic amputation according to Pirogov.

Amputation technique according to Pirogov

Video: Chopard amputation of the left foot

The ankle joint is opened, the lateral ligaments are cut, and a sharp plantar flexion of the foot is performed. In the plane of the plantar incision, saw the heel bone behind the ram and remove the foot. The soft tissues are separated from the shin bones by 2-3 cm. The articular surfaces of the shin bones are sawed off. Tied with catgut a. dorsalis pedis and branches of a. tibialis posterior. The fibula from the outside is cut obliquely and rounded off with a rasp. Shorten n. cutaneus dorsalis medialis and n. cutaneus dorsalis intermedius. The skin flap, including the remainder of the calcaneus, is sutured to the skin of the lower leg. Preliminarily, the calcaneus is fixed to the sawdust of the shin bones with three or two catgut sutures, held through the calcaneus and tibia. Additional catgut sutures are applied to soft tissues, silk sutures are applied to the skin. Glass or rubber drainage is introduced into the outer-lower corner of the wound. Anteroposterior plaster splint is applied for 3-4 weeks. The drain is removed after 48 hours without removing the splints.

With amputation in women, the shin bones are sawed higher, so as to obtain a shortening of 6-7 cm. With this shortening, a more cosmetic type of prosthesis can be made.

To preserve the epiphyseal cartilage in children, the shin bones are cut off directly above the articular surface. This protects against too sharp lag in the growth of the lower leg.

After a break or damage to the sciatic nerve or its branches, along with varus deformity of the foot, trophic ulcers often occur mainly along the outer edge of the sole or in the center of the heel. This is facilitated by the load concentrated on a reduced support area, a sharp decrease or absence of pain and other types of sensitivity. Often trophic changes in the skin are accompanied by osteolysis of the bones of the foot. In some patients, after the elimination of the deformity, the load on the sole is distributed more evenly and the ulcers heal. With ulcers that are not amenable to conservative and surgical treatment, it is necessary to prescribe bulky unloading devices or amputate a limb. Previously, as a rule, an amputation of the lower leg was performed, since there was a fear that the disinnervated skin of the sole would not withstand prolonged stress.

These observations indicate that the stumps after osteoplastic amputations according to Pirogov, even with disinnervated skin, have complete support, which, apparently, can persist for many years. Therefore, to obtain a support stump, not only good blood supply and tissue innervation, a large support area, but also the structure of the skin are important. Amputation according to Pirogov with disinnervated skin, trophic ulcers of the outer and front surfaces of the sole can be fully recommended.

Prosthetics after shin amputation

The operation was proposed by N.I. Pirogov in 1852. It was the world's first osteoplastic operation, which laid the foundation for plastic surgery bones. One of the advantages of Pirogov's operation is that during it there is only a slight shortening of the limb and the patient does not need a prosthesis. Its second advantage is the creation of natural support in the form of a heel tuber with the skin covering it.

Indications: crushing of the entire foot with the intact tissues of the heel region.

Operation technique consists of the following points. On the front (back) surface of the foot, an incision is made from the lower end of one ankle to the lower end of the other. The second incision, stirrup-like, leads from the ends of the first incision through the sole, perpendicular to its surface, in depth to the heel bone. From the front incision, the ankle joint is opened, its lateral ligaments are cut off, the foot is bent and cut back part joint capsule. With an arc saw, the heel bone is cast from top to bottom but the line of the stirrup cut ; the damaged part of the foot is removed, the posterior segment of the calcaneus with the skin, tendons and the neurovascular bundle remains in connection with the soft tissues of the posterior surface of the lower leg. In the anterior flap, the anterior tibial vessels are tied, in the lower - the posterior tibial vessels or their branches; the tibial nerve or its branches are truncated in the usual way.

The distal ends of the guests' shins are exposed from all soft tissues and cut horizontally at the level of the base of the ankles.

The outer edge of the fibula is knocked down with a chisel or cut down and rounded off with a rasp. The sawdust of the calcaneus is applied to the tibial stump and is fixed with three catgut sutures carried out through the anterior edge and both lateral edges of both bones. Also, three catgut sutures connect soft tissues (tendons, fascia, ligaments), suture the skin. An anteroposterior plaster cast is applied to the stump, which captures the knee joint.

The sawdust of the heel bone adhered to the sawdust of the lower leg lengthens the stump almost to the normal length of the limb and creates strong, good natural support.

During Pirogov's operation, some complications are observed, for example, necrosis of the calcaneal tuberosity with the soft tissues covering it as a result of cutting the calcaneal vessels, which is not always easy to avoid.

Osteoplastic supracondylar amputation of the femur according to Gritti-Shimanovsky

The operation was proposed in 1857 by the Italian surgeon Gritti, but practically developed and first performed on a patient in 1861 by a Russian

surgeon Yu. K. Shimanovsky.

The essence of the operation is that the sawdust of the distal end of the femur is covered with an anterior burn-tendon-bone flap containing sawdust of the anterior part of the patella.

Operation technique. In the area of the anterior surface of the knee joint, an arcuate skin flap is cut out. The incision begins 2 cm proximal to the lateral epicondyle of the thigh, is carried out first vertically downward and slightly below the level of the tibial tuberosity, rotated arcuately onto the medial surface, ending 2 cm proximal to the medial supracondylar femur. All soft tissues are dissected along the line of the skin incision. Having separated the lower edge of the skin flap slightly upwards, the patella ligament is crossed immediately above the tuberosity. At the level of the transverse skin fold of the popliteal region, a slightly convex posterior flap is cut out. After separating and pulling this skin flap upwards, the soft tissues of the back of the thigh (muscles, blood vessels, nerves) are crossed at the level of the joint space. The anterior flap is removed along with the dissected synovium, patella and quadriceps tendon upward; at the same time, the entire anterior section of the knee joint cavity and its upper volvulus are opened; the synovium is excised.

Having grabbed the patella's own ligament with a gauze napkin, the patella is pressed against the intercondylar notch of the thigh with its base and its articular surface is filed.

Pull the soft tissues of the front and back of the thigh up; directly above the level of the condyles, the periosteum is incised circularly and sawn through at this level femur... In the tissues of the posterior flap, the popliteal vessels are found and ligated and the tibial and peroneal nerves, the posterior cutaneous nerve thighs, inside. - n. saphenus. After removing the tourniquet, the patella is applied to the sawdust of the femur.

Three catgut sutures, held through the patella and femur along the anterior and lateral edges, fix them to each other, impose catgut sutures on the aponeurosis and connect their own ligament with the flexor tendons. The edges of the skin flaps are connected with interrupted silk sutures.

Vopr. 2 Borders (right and left):

Upper - the line connecting the spinous process of the VII cervical vertebra with the acromion

Bottom - a line drawn horizontally along the lower corner of the scapula

Medial - vertebral line

Lateral - posterior edge of the deltoid muscle

Layers:

Skin, subcutaneous fat, superficial fascia, fascia propria.

Deep lamina of its own fascia forms a case for a large II the small rhomboid muscles, the levator scapula muscle, and the large round muscle. The containers formed by the scapula are of great practical importance. and muscles attached to it.

The supraspinatus fibrous receptacle is formed by the supraspinatus fossa of the scapula and the supraspinatus fascia attached to its edges. It is a closed space lying above the crest of the scapula and having a triangular shape on the sagittal cut. Loose tissue of the supraspinatus is associated with the subdeltoid space and deep tissue of the lateral triangle of the neck.

The infraspinatus fibrous receptacle is formed by the infraspinatus fossa of the scapula attached to its edges by the infraspinatus fascia. The artery surrounding the scapula (a. Circumflqxa scapulae), which is a branch of the subscapular artery (a. Subscapularis), passes in the infraspinatus fibrous receptacle. Anastomoses in this osteo-fibrous receptacle between the branches of the suprascapular and subscapularis arteries form a roundabout path of blood circulation during ligation of the axillary artery.

The subscapular fibrous bone receptacle, in contrast to the supraspinatus and infraspinatus, is located on the anterior surface of the scapula and is formed by the subscapular fossa and subscapularis fascia. The subscapularis osteo-fibrous receptacle is made by the subscapularis muscle and tissue.

The prescapular fissures are located between the costal surface of the subscapularis muscle with the fascia covering it and chest on which it slides. In this case, a narrow space is formed, which is divided by the flat serratus anterior muscle into two isolated slits:

1) anterior (between the subscapularis muscle and the anterior dentate muscle);

2) the back (between the serratus anterior muscle and the chest wall).

Autopsy of phlegmon according to Liston - Rahman

The position of the patient. On the operating table on the back with the arm extended outward and upward, slightly bent at the elbow joint. In this position, the scapula is significantly displaced outward, and the pectoralis major muscle - upward and inward. In front of the surgeon, the subscapular fossa opens, covered with a significant layer of soft tissue.

Operation technique. A skin incision is made 4 cm outward, anteriorly and parallel to the outer edge of the scapula (starting from the most deep point axillary fossa) to the inferior angle of the scapula to gain wide access for full revision. The skin, subcutaneous base, superficial and axillary fascia are dissected. The wound is expanded with hooks. In this case, the edge of the broad back muscle, the outer subscapularis muscle and the fatty tissue of the axillary fossa are exposed. Bluntly penetrate into the posterior prescapular fissure, which is drained.