AMPUTATIONS and EXARTICULATIONS

THE CONTENTS:

Common principles of amputations and exarticulations

Definition amputation and exarticulation, their purposes and problems The indications to amputations and exarticulations Principles of classification of amputations and exarticulations Classification by terms of performance THE BASIC STAGES of AMPUTATION of EXTREMITIES Choice of a level of amputation Anesthesia at amputations Technique of an applying a tourniquet Classification of amputations by the form of a incision of soft tissues Classification of amputations by a method of closing of an osteal stump Processing of soft tissues Processing of an osteal stump Processing of vessels and nerves Peculiarities of performance of amputations at children Typical amputations through the upper and lower extremity

Technique of amputations and exarticulations through the upper extremity

Amputations and exarticulations of fingers Amputations through the forearm Amputations through the arm

Technique of amputations and exarticulations through the lower extremity

Amputations and exarticulations on a foot Amputations through the leg Amputations through the thigh

COMMON PRINCIPLES of AMPUTATIONS and EXARTICULATIONS

Concepts amputation and exarticulation, their purposes and problems
Amputation - operation of removal of a distal part of an organ. Amputation of an extremity - ablation of its distal part on distance of the bone or bones. Exarticulation - ablation of an extremity at a level of a joint. Amputation and exarticulation of extremities are a serious surgical

intervention. The patient who has undergone to such cripple operation, becomes the invalid, have a serious physical and mental trauma. Therefore such operations are carried out only with the purpose of rescue of life of the injured at impossibility of keeping of the struck extremity. Problems of amputation: 1) removal of an affected extremity, 2) creation of a high-grade stump, which would not cause discomfort for the patient and would allow effectively to use a prosthesis.

The indications to amputations and exarticulations.

The absolute indications: 1) Trauma of an extremity: - Complete or nearly so complete dividing of an extremity at a wound or trauma; - Extensive damages with obvious attributes of a non-viable extremity (open damage of an extremity with fragmentation of bones and joints, with damage of main trunks of vessels and nerves, with an extensive crush of muscles (more than 2/3 circles) etc.); 2) Gangrene of an extremity As a result of damage or ligation of a main vessel of an extremity, Anaerobic, Diabetic, sclerotic, As a result of an obliterating endarteritis, thrombosis or embolism of main vessels, As a result of a frostbite, combustion, As a result of an electric trauma, radiative defeats etc. 3) Presence of a serious infection developed in the center of a affected extremity and menacing life of the patient by development of an intoxication and a sepsis; 4) Malignant tumours, when the radical local removal of the center of a tumor is impossible. The relative indications: 1) Chronic infection resistant against treatment and threatening life of the patient: - The chronic wide-spread tuberculosis of bones and joints (is especial at the persons of elderly and senile age), chronic osteomyelitis with threat of an amyloidosis of internal organs; 2) The congenital and acquired deformity and underdevelopments of extremities, when the surgical treatment and the prosthetic repair is impossible and extremity is functionally unsuitable.

Principles of classification of amputations and exarticulations

On terms of performance and indications: 1. Primary; 1. Preliminary, 2. Secondary; 2. Final; 3. Late (planned); 4. Repeated (reamputation). II. In accordance with the form of a section of soft tissues. 1. Circular: 1) One-stage (one-moment), 2) Double-stage (two-moment), 3) Three-stage (three-moment). 2. Ellipse (oval); with a racquet incision. 3. Flap: 1) One-flap (single-flap), 2) Two-flap (double-flap): a) equal flaps, b) unequal flaps; III. By appearance of tissues closing the end of bone: 1. Cutaneo-fascial; 2. Cutaneo-fascio-muscular; 3. Fascio-periostoplastic; 4. Fascioplastic; 5. Tendoplastic; 6. Myoplastic; 7. Osteoplastic; IV. On a method of processing of a periosteum: Aperiostal method, Subperiosteal method. Classification of amputations depending on terms of their performance and indications. Distinguish primary, secondary, late amputations and reamputations. Primary amputations (the amputations on primary indications) made at rendering the first surgical aid in early terms - within 24 hours after a trauma before development of clinical attributes of an infection. Thus obviously nonviable extremity removed. Such amputations named also urgent. Secondary amputations (amputation on secondary indications) is carried out in later terms after a trauma, if the complications menacing life of the patient developed, after all other methods of treatment (conservative and surgical) have not given a positive result. Such amputations carried out for removal of an extremity as center of an intoxication or infection at presence of the common phenomena threatening life of the patient. The primary and secondary amputations carry out on the absolute indications.

The late amputations carry out on the relative indications, when immediate threat to life of the patient is not present. They made at long and unsuccessful treatment of a chronic osteomyelitis with fistulas and threat of development of an amyloidosis of internal organs; with the purpose to remove functionally or anatomically useless extremity etc. Such amputations also named as planned. The repeated amputations, or reamputation, are made after unsatisfactory results before made ablations of an extremity: 1) If the first amputation has not reached its basic purpose (for example in case of the further diffusion of process at a gas gangrene, purulent process at a diabetes mellitus etc.); 2) At pathological (vicious) stumps blocking a prosthetic repair; 3) With the purpose of creation of a functionally high-grade stump: (phalangization of a I metacarpal bone, Krukenberg operation etc.). The pathology of a stump being the indication to a reamputation and other surgical methods of correcting, is determined by the length, form and condition of tissues of a stump. 1. Length of a stump - too long or too short stump block a prosthetic repair. 2. The form of a stump. The pathological conical (pencil-point) stump - bone prominent above a level of soft tissues - is formed after circular amputations (Fig. 1); The club-shaped stump (extended on the end) is formed after low amputations or exarticulations. Fig. 1. A conical stump 3. Condition of soft tissues of a stump. Usually after long inflammatory process on a stump the extensive cicatrix accrete with adjoining tissues is formed. The nerves, tendon and muscle so are involved in cicatrix, that the movements cause a pain, the contraction of a stump develops. Because of a unsufficient blood supply in a distal part of a stump an atrophy of a skin, cracks, trophic ulcers develop. Difficulty or complete impossibility of usage of a prosthesis arise. In case of an inefficiency of conservative methods the reamputation of a stump with a complete cicatrectomy and closing of a wound with use of a dermal plasty is indicated. 4. Condition of an osteal stump. Bone, prominent from soft tissues, osteomyelitis of the end of a stump, the fistulas, growth of osteophytes on the osteal end break basic function of a stump. The primary and secondary amputations can be final and preliminary.

The preliminary amputations are carried out when there is no opportunity of applying of a primary suture, as it is impossible exclude occurrence of inflammatory process. The final amputations finished by applying primary, delayed or secondary suture. They are made in cases, when there is no the causes for development of dangerous inflammatory complications.

THE BASIC STAGES of AMPUTATION of an EXTREMITY:

1) 2) 3) 4) Section of soft tissues; Processing of a periosteum and sawing of a bone; Processing of vessels and nerves; Suture of tissues and close of stump (Table 2).

Choice of a level of amputation.

At a choice of a level of amputation are followed by two criteria: 1) character and localization of damage and 2) availability of the formed stump for a prosthetic repair. First of all, the level of amputation is determined by a place and character of damage, danger of a wound infection and conditions, at which an operation made. The amputation should be carried out within the limits of healthy tissues and at a level, which guarantees salvage of life of the patient and provide favorable postoperative course of a wound. The second important task Table 1. Guidelines amputations of amputation - formation of a Forearm Optimum length of stump is 20 cm as functionally suitable stump. From measured from tip of olecranon. An 8 cm stump is the minimum for useful positions of a prosthetic repair of a function. Between these levels as much bone as possible should be saved. stump the various length have Optimum length of stump is 20 cm as various functional value. As a rule, Upper arm measured from acromion. Above this than the stump is longer, the better level as much bone as possible should be saved. results of a prosthetic repair. At the same time, are non-useful as a too Lower Syme's amputation. The tibia and fibula leg are divided at or immediately above the short stump (difficulty of level of the ankle joint. Site of election. Length of tibial stump is management of a prosthesis and 14 cm. An 8 cm stump is the minimum its fixation), and too long stump for useful function. Between these levels as much bone as possible should be (difficulty of selection of a saved. prosthesis and accommodation of Thigh Optimum length of stump is 25-30 cm, as a joint of a prosthesis on identical measured from tip of trochanter. Above this level as much bone as possible with a healthy extremity level). should be saved. In connection with difficulty of a prosthetic repair of excessively short and too long stumps, after the First

World War the so-called amputating schemes (Table 1) were offered and

Table 2

The basic stages of performance of amputations

Stages of amputation Kind of amputation Section of soft tissues
Skin, subcutaneo us tissue, superficial fascia Deep fascia Superficial layer of muscles (or their tendon)

Processin Deep layer g of a of muscles periosteu m and (or their sawing of tendon) a bone

Proces sing of vessels and nerves

Suturing

Onemoment Twomoment Threemoment One-flap Two-flap Flap 1st moment 1 moment

st

1st moment 2nd moment 2 moment 3rd moment

nd

1 row of sutures: muscles and deep fascia. Aperiostal method at the adult Ligation of vessels. Truncati on of nerves. 2 row of sutures: skin.

Circular

Subperiost eal method Formation of two The cut on edges of at children flaps identical or turned away flaps or little different length bit more distal Formation of one flap

The first row of sutures depend from the method of closing of a stump - a periosteum, tendons, muscles or deep fascia sewed. Then a skin sewed.

were repeatedly modified, in which the extreme allowable sizes of a stump are determined, at which else can be made prosthetic appliance. The similar amputating schemes can be used only at repeated and planned amputations and completely have lost the importance at urgent operations. At urgent operations the gravity of a condition of the patients not always allows at once to form a usable stump for the subsequent prosthetic repair. At a choice of a level of urgent amputation it is necessary to follow a principle of the maximal save of an extremity of N.I. Pirogoff - to amputate as low, as it is possible. The level of urgent amputation should be chosen whenever possible most distally (without allowing of the amputating schemes) with the purpose of save of length of the future stump, because to make prosthetic appliance more easy at long stumps. In case of necessity it will be possible to perform a repeated planned operation and to form most functional length of a stump. The good results of a prosthetic repair depend not only on length of the stump, but also from amplitude of movements in joints. Always it is necessary to try to keep a joint, as the loss of a joint most breaks functions of an extremity. At exarticulations even the most perfect prostheses do not give good results. Therefore exarticulations are usually applied only at children. The exarticulation at the adult needs to be surveyed as a preliminary intervention at a serious condition of the patient, as it is less traumatic, than amputation. Anesthesia at amputations. For all urgent patient, is especial at a trauma and serious infection, the complex antishock therapy should be performed. The amputations should be made under a general narcosis. If there are no conditions for its performance or there are contraindications (for example, at the elderly people with deep disturbance of cardiovascular activity) the application of various kinds of a local anaesthesia (infiltration, sheath, conduction) or spinal anaesthesia is admitted. Technique of an applying a tourniquet or elastic bandage of Esmarh. If there are no contraindications (disease of vessels, obliterating endarteritis, danger of a mephitic gangrene and etc.), the amputations made under a garrot. Extremity lift up for draining of blood. The place of an applying a tourniquet on an extremity is wrapped by a towel for protection a skin from damages by a garrot. The garrot should be applied closer to a root of an extremity and far from a place of operation. The especially important this has at manipulations on the upper extremity, as on middle of a brachium the applied

garrot can squeeze a radial nerve. The garrot before applying should be strongly stretched and in such kind is led around of an extremity. It is enough to lead round a garrot 2 times and then to make simple knot, that at the necessary time during operation (after a ligation of the main vessels) it is easy to untie it. The advantage before a haemostatic garrot has elastic (rubber) bandage of Esmarh, which injures tissues much less.

Classification of amputations of extremities in accordance with the form of a section of soft tissues.
At the form of a section of soft tissues the circular, oval (ellipse) and flap amputations distinguished. At circular amputation - the line of a incision is perpendicular to axes of an extremity. At a flap method the soft tissues dissect as one or two flaps. At an oval or ellipse method the incision of a skin is made as an ellipse obliquely in relation to an axis of an extremity. This method is intermediate between circular and flap. The circular methods are one, two and three-moment (Fig. 2). They are applied on those departments of extremities, where a bone from different sides evenly surrounded by soft tissues. Moment of circular amputation understand a simultaneous section of soft tissues by one circular movement of an amputating knife. Fig. 2. A section of soft tissues at circular amputations
1 one-moment (guillotine), 2 two- moment, 3 three- moment

At an one-stage (guillotine) method all soft tissues are dissected simultaneously in one plane (with preliminary displacement of a skin or without it). This amputation is carried out at a serious condition of the patient, when he can not transfer more difficult methods of amputation and at a mephitic gangrene. Constriction of a skin, superficial fascia and muscles is various, and they after crossing form a cone with top inverted distally (a conical stump) (Fig. 1). At a mephitic gangrene the extremity is amputated within the limits of healthy tissues, and the stump remains widely open for aeration of tissues. The open method of treatment results in formation of a pathological conical stump

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with a bone, prominent above soft tissues, but at the same time allows at the appropriate treatment by serums and antibiotics to keep life of patient. Two-moment method. By the first circular incision a skin, subcutaneous fat and superficial fascia cut. By second - at a level of a displacement skin muscles. At a level of reduced and drawn back muscles a bone sawed; an osteal stump cover by muscles with a fascia and by skin. Three-moment method (on an example of conical-circular amputation of a femur on N.I. Pirogoff) (Fig. 20). At first is the skin, subcutaneous fat and superficial fascia dissected (first moment). Then on edge of the reduced skin the muscles to a bone are dissected (second moment). The superficially posed muscles have own fascial sheets and consequently at an incision are reduced to appreciable distance. And, at last, on edge of the reduced and maximum retracted proximally superficial muscles deeply posed muscles attaching to a bone and unable to be reduced on large distance dissected (the third moment). In depth of the formed muscular funnel (cone) the bone is sawn. As a result of this operation it is possible to close stump of bone by muscles, fascia and skin. The principle of two- and three-moment sections of soft tissues at circular amputation is entered by N.I. Pirogoff. This method enables to close the end of a bone in depth of a cone of soft tissues. At a circular method of amputation the dermal cicatrix has the central locating on basic surface of a stump. All circular methods of amputation are connected to an opportunity of formation of a conical stump and now they are not recommended, however, can be applied at primary preliminary amputations. The flap amputations can be one-flap (single long flap is formed) and two-flap (two flaps are formed) (Fig. 3). At a two-flap method the flaps can be of identical or different length (equal and unequal). Usually one flaps made longer. In most cases length of a long flap is 2/3 of diameter of an extremity at a level of Fig. 3. Incisions at flap amputations amputation. Length of a short flap is 1/3 1 - one-flap, 2 - two-flap of diameter. In the sum length of flaps should be equaled to a diameter of an extremity at a level of amputation with addition 1/6 parts of a diameter on constriction of a skin. At such method of amputation the dermal suture of a stump will located on a surface of a stump, which is not exposed to pressure of a prosthesis, for example, on a posterior surface of a femur (at a long anterior flap).

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The flap method of amputation now is recognized by a method of a choice. Thus the flaps aspire to form from a skin, muscles and fascias for better closing of end of bone.

Classification of amputations by appearance of tissues closing the osteal stump

Depending on layers closing osteal end, the following methods differ: Cutaneo-fascial method closing of the osteal end by a flap (flaps) including an deep fascia and a skin; Fascioplastic method closing of osteal end by an deep fascia; Cutaneo-fascio-muscular method closing of end of a bone by cutaneofascio-muscular flap; Myoplastic - suture of muscles above bone stump; Tendoplastic - osteal end is covered with tendons of muscles; Fascio-periostoplastic - closing stump of a bone by periosteal and cutaneo-fascial flaps; Osteoplastic - closing stump of a bone by the replaced bone. The fascioplastic method of amputation is most acceptable for the upper extremity, when the osteal stump is covered with an own fascia. Thus the normal anatomic relation are kept: the skin is separated from a bone by a fascia. The fascia serves a place of attachment for muscles and prevent an adhesion of a skin with a bone. The skin keeps the mobility, the fascia, growing together with end of a bone, promotes fast formation closed plate of bone with a smooth and equal surface. For a lower extremity the good results formation of a strong stump - osteoplastic amputations give.

Processing of soft tissues at amputations.

Processing of skin. Excess of a skins formed at amputation, made of such length, that the edges of a skin could be connected without a large tension. The strong tension of a skin can entail a compression of its vessels and necrosis. The excess of a skin at amputation (diameter of flaps) should be equaled to a diameter of an extremity at a level of sawing of a bone with addition 1/6 parts of a diameter on contraction of a skin. At primary amputation at absence at the given level of the kept skin it is necessary to resort to a primary or late plasty. The dermal flaps formed so that the postoperative cicatrix located on a non-working surface of a stump. Processing of muscles. The muscles should be crossed equally, smoothly, therefore to a section apply the large (amputating) knives. At myoplastic amputations, that the muscles have kept the function, i.e.

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provided movement of a stump, they sewed at a level stump of a bone. Fixed, that the no suture of muscles-antagonists above an osteal stump lead to their supraplacement, bad blood supply, atrophy, loss of ability to contract, venous stagnation in a stump. As a result of it a percent of development of a pathological stump is enlarged.

Processing of an osteal stump.

The simple sawing off of a bone with a periosteum can further result in formation on an osteal stump of osteophytes - acute osteal thorns which are formed as a result of traumatic (and sometimes infectious) inflammation of a periosteum. For get of a smooth surface of stump of a bone there are some methods of processing: aperiostal, subperiosteal etc. (Fig. 4) Fig. 4. Methods of processing of a periosteum a - aperiostal method, b - subperiosteal method, 1 - level of crossing of a periosteum, b 2 - level sawing of a bone a At a subperiosteal method the periosteum is dissected circularly below a planes of section of a bone. Flap from a periosteum as a cuff moved up, then a bone sawed, after that a flap lowered downwards and closes the end of a bone. At such method of amputation the periosteum protects a bone marrow from an infection, normalizes venous pressure in the medullar canal and, besides forms a closed plate faster. However this method does not guarantee from growth of osteophytes, therefore this method is applied only in children's practice, as at amputations at children the osteophytes practically it not happen. The aperiostal method is applied now frequently, but not in its initial kind, when not only the periosteum from the end of an osteal stump left, but also the bone marrow was taken out; and in modern updating. In order to prevent development of an osteomyelitis the bone marrow is not taken out. At an aperiostal method a periosteum circularly dissected above than place of sawing of bone and displaced distally. Further bone sawed so 2 - 5 mm of the osteal stump remained without covering by a periosteum. Acute edges of end of bone round by rasp.

Processing of vessels and nerves of a stump at amputation.

After sawing off of a bone make truncation of nerves and ligation of vessels in soft tissues of a stump. The large (main) vessels are ligated before remove of a garrot on distance 1,5 - 2 cm from the cut end. Before a ligation the vessels carefully

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isolated. Artery and vein ligated separately, applying a thick catgut thread to not cause an eruption of walls of a vessel. To reliability double ligatures applied. The ends of the threads cut after taking out of a garrot, that it was easier to find a vessel in case the ligature has appeared applied not reliably. The silk ligatures now use seldom, as they can cause is long of not healing ligature fistulas. They applied only at threat of development of an inflammation in a wound, which can result to disintegration of catgut and bleeding. Fineer (muscular) vessels indiscernible on a section, ligated after taking out of a garrot, when they begin to bleed. The ligatures on these vessels applied by a underrunning them together with an environmental muscular tissue. Processing of nervous trunks. N.N. Burdenko on importance of this moment of amputation named the given surgical intervention as neurosurgical operation. After crossing a nervous trunk on the its end the neuroma physiologically natural formation caused by chaotic growth of axons is always formed. The formation of a neuroma and is especial involving it in a cicatrical tissue is accompanied by strong pains. Quite often pains wear causalgic character and do not remit by analgesic. Sometimes formation of a neuroma causes so-called phantom limb pain (stump neuralgias), i.e. sensation of pain in amputated, removed areas. All methods of processing of nerves put by the task retardation of a growth of a neuroma or removal (or bound) neuroma from a place of formation of cicatrix. The various methods of mechanical, physical and chemical action on a nerve with purpose of its destruction and retardation of growth concern to the first group (ligation of the end of a nervous trunk after a preliminary compression crash of a nerve on a place of a ligature or without it; introduction in a stump of a nerve of absolute alcohol or any of other sclerosing substance; freezing, electrocoagulation etc.). To the second group include closing of a stump of a nerve by any plastic material, suture of a nerve to muscles, suture of two nerves, implantation of a nerve through a trepanation opening into a bone, high truncation of a nerve etc. But any of all offered methods does not protect from formation of a neuroma. But the neuroma can be a source be pains only when it adjoin with cicatrix and stretches during usage by a prosthesis. Therefore main task of a surgical treatment of a stump of a nerve is the creation of the most favorable conditions for free growth of nervous fibers.

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Technically simple and less traumatic method of processing of a nerve is the high section of a nerve and plunge it in healthy tissues. Previously tissues surround a nerve dissected and separated up to a level of the planned truncation. Thus it is important to not extend a nerve, as it results in ruptures of its fibers, intratrunkal hemorrhages and adhesions with adjacent tissues. After allocation of a nerve on 5 - 6 cm are higher than a level of amputation in a perineurium 1 % a solution of Novocainum introduced and a nerve crossed by one movement by the blade or by acute scalpel. The large nerves for prophylaxis of a bleeding ligated by catgut.

Peculiarities of performance of amputations at children

At performance of amputations at children the following circumstances should be taken into account: 1. After amputation the growth of soft tissues lags behind growth of bones, owing to what the conical stump is formed, which end is pointed and punches tissues posed above osteal stump. With the purpose of the prevention of this complication it is necessary to frame a stock of soft tissues above an osteal stump, cutting them much lower than at the adult. Thus it is necessary to take into account large contraction of a skin at children, than at the adult. The suture of muscles-antagonists or fixation them to the truncated bone is prophylaxis of an age conical stump. In all cases it is necessary to keep a zone of growth (area of epiphyseal cartilages). Therefore, where it is possible, it is necessary to replace amputation in a distal department of an extremity by an exarticulation in the nearest distal segment. 2. Irregular growth pair bones of a leg and forearm: fibular and radial bone outstrip accordingly growth of tibial and ulnar bones. Therefore pair bones are truncated at different levels, at amputation of a leg a fibular bone sawed on 3 - 4 cm higher in comparison with tibia. Taking into account a disproportion of body height of pair bones, the osteoplastic and periostoplastic methods of amputations are more often indicated for children. 3. After amputations there is a backlog in growth of a stump of a femur from stumps of an leg, as the zone of the greatest activity of growth on an leg is in a proximal epiphysis, and on a femur - in distal. By virtue of these circumstances it is necessary to protect seedling cartilage. Therefore at children more often the exarticulations at a level of knee, elbow and radiocarpal joints, instead of truncation of extremities during a bone (or bones) are carried out. 4. At children are observed more often than at adult static deformations of bones of a stump.

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5. The amputations of lower extremities at children result in reorganization of all locomotorium, to deformation and atrophy of the appropriate half of pelvis. Sometimes displacement of organs of mediastinum and deformity of the vertebral column arise.

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Table 3

Typical amputations through the upper and lower extremities

Place Level of of amputa amputa tion tion
Forearm Arm The inferior third The inferior and middle third The superior third The inferior third

The name of Amputations

Two-flap fascioplastic Circular with a cuff Two-flap fascioplastic Three-moment circular One-flap fascioplastic on Farabeuf Osteoplastic on the Pirogoff and its updating (Hunter, LeFor, high amputation on the Pirogov) Syme's amputation

Peculiarities of a incision or principle of operation

Equal anterior and posterior flaps To circular section is two lateral incisions add Long anterior and short posterior flap

Leg

The incision corresponds to a contour of the inferior edge of a deltoid muscle Fixation of a calcaneus to end of bones of a leg

The middle third

Two-flap fascioplastic

Two-flap fascioperiostoplastic Thigh The inferior third The middle third Osteoplastic on GrittyShimanovsky Tendoplastic on Kalender Three-moment circular on the Pirogoff Two-flap fascioplastic Two-flap myoplastic The superior third Two-flap fascioplastic

Sawing of tibial and fibular bones is immediate above a talocrural joint and closing of a stump by a flap from heel The long anterior and short posterior flaps (at obliterating diseases are recommended to form a long posterior flap) The periosteal flap for close of osteal stump is formed Osteal stump of a femoral bone is covered with a patella Osteal stump of a femoral bone is covered with a tendon of quadriceps muscle Long anterior and short posterior flaps Long anterior and short posterior flaps. Suture of musclesantagonists above osteal stump Long anterior and short posterior flaps

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TECHNIQUE of AMPUTATIONS and EXARTICULATIONS through the UPPER EXTREMITY

Amputation and exarticulation of fingers
The basic principle of truncation of fingers - maximal economy, dissecting away only of non-viable parts with save, if is possible, places of an attachment of tendons. At presence of defect of a skin the plasty by local tissues or primary transplantation of a free dermal flap is used. It is desirable, that the cicatrix located on back - non-working surface. If the maintenance of the given condition conducts to shortening of a finger, they can be neglected. Position of the patient on a back, the hand is allocated on additional little table and pronated. After amputation or exarticulations the fingers are necessary for fixing in the slightly bent position. Anesthesia. At amputation of phalanxes of fingers - local on Lukashevich-Oberst: a needle stick in a lateral surface of the basis of a finger and 0,5 - 1 % of a solutions of Novocainum introduced for blockade of back and palmar neurovascular fascicles. Having entered 10 15 ml of a solution, on the basis of a finger the rubber tourniquet applied (Fig. 5). At an exarticulation of fingers - conduction anaesthesia on the BrownUsolcseva: anesthetic introduced at a level of an median third of intermetacarpal intervals or in the field of a wrist. Amputations of phalanxes of fingers. Fig. 5. An The first stage of operation consists in formation of anaesthesia of a a dermal flap on a healthy surface of a finger for close of finger on a stump. Length of a flap should be a little bit more Lukashevich-Oberst diameter of a phalanx at a level of truncation of a phalanx. By scalpel put parallel to palmar surface a palmar flap formed. Skin of the back surface cut in a transversal direction, bridging the ends of palmar incision (Fig. 6). The second stage of operation provides displacement of a periosteum and sawing of a removed phalanx. Distal part of a finger removed. The third stage - ligation of back and palmar vessels by catgut Fig. 6. Amputation of a distal phalanx. and truncation of nervous trunks. If during a trauma there was an disturbance of integrity of tendons, their crushed sites deleted within the limits of healthy tissues and tendons fixed to a periosteum. The rare sutures on a wound are applied. The amputation of a distal phalanx of a finger is more economically, than the exarticulation in interphalanx joint, after it in a lesser degree function breaks, as the points of attachment of a deep flexor and extensor of a finger are kept. Exarticulation in interphalangeal joints Dermal incision on a dorsum made on a projection of an articular slit. The projection of an articular slit is determined on the line passes through middle of

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a lateral surface of more proximal phalanx on back of a deleted phalanx at an as much as possible bent finger (Fig. 7). After a section of soft tissues a capsule of a joint opened. By scissors entered into a cavity of a joint, the lateral ligaments dissected, then the joint is completely opened. An articular capsule and ligaments exsected. Finger dislocated. The scalpel is entered behind of a phalanx and the dermal flap on length equal to a diameter of a finger on a place of an exarticulation is formed from a palmar surface. Phalanx cut, legation of Fig. 7. An exarticulation of distal phalanx. a determination of a projection of an articular slit, 1 - line which is taking place through middle a phalanxes, 2 line of incision), b - c stages of formation of a flap. vessels and processing of nerves carried out. Suturing of a wound. Exarticulation of fingers (Fig. 8). The exarticulation of the thumb on Malgen is carried out with the ellipse incision. The incision of a skin and subcutaneous fat is passes from a metacarpophalangeal joint on a back of the hand almost up to an interphalangeal fold on a palmar surface and further to the beginning of a cut on back. Joint opened on the back. After a section of ligaments a thumb dislocated. At removal of a finger it is necessary to keep integrity of sesamoid bones on an anterior surface of a capsule of a joint, by which the short muscles of the thumb attached, which ensure mobility of I metacarpal bone. With this purpose the anterior part of a capsule of a joint is not opened and does not removed, and a section of soft tissues on a palmar surface made by a scalpel closely adjoining to a phalanx. Processing vessels and nerves carried out. Infrequent sutures on a wound applied. After an exarticulation of the thumb a phalangization of the first

Fig. 8. a - incisions at exarticulations of fingers and phalanxes b - form of incisions at an exarticulation of fingers I finger - on Malgen, II - V - on Farabeuf, III - with a racquet incision, IV on Luppy.

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metacarpal bone frequently is carried out. The essence it consists in mobilization of the first metacarpal bone and formation of finger similar thumb, which function further is provided by adductor and long muscles. Exarticulation of II - V fingers made by flap methods with formation of flaps from a working surface and locating of cicatrixes on a non-working surface. For III - IV fingers a working surface is palmar, for II - radial and palmar, for V - ulnar and palmar. The exarticulation of III and IV fingers is made on Luppy or with a racquet incision. On a method of Luppy the T-shaper incision of a skin is made, which transverse-circular part passes a little more distally than palmar-digital fold; the longitudinal part of a incision coincides with an axis of the appropriate metacarpal bone; it length is 1,5 - 2,0 cm. Such kind of an access allows to displace cicatrix on the non-working (back) surface for these fingers. A racquet incision begin on back of a metacarpal bone, passes obliquely on the lateral side of the basic phalanx on a palmar surface, further on a palmar-digital fold and on other side of the basic phalanx to a longitudinal incision on back. The flaps separate from adjacent tissues and displace proximally. Finger flexed. A tendon of an extensor dissected and a metacarpophalangel joint opened from the back side. A capsule and lateral ligaments of a joint, tendons of flexors and all tissues, on which the finger fixated, dissected. A finger deleted. A careful hemostasis and processing of nerves carried out. Suturing of a skin. A resection of the heads of metacarpal bones and removal of a cartilage now do not apply. Exarticulation of II and V fingers on Farabeuf. Formation of dermal flaps is made in view of working surfaces: for II finger the greater length of the flap should be on the part of a radial bone, and for V finger - on ulnar. Other technique of operation is similar to an exarticulation of III and IV fingers racquet incision.

Amputation through a forearm.

At amputation of a forearm most valuable with a point of vision of a functional prosthetic repair is the stump in the inferior third. Amputations of a forearm in inferior third is carried out by a two-flap method or circular method with a cuff. At a flap method the anterior and posterior flaps of a skin together with a subcutaneous fat and deep fascia are formed. At a circular amputation the circular incision of a skin, subcutaneous fat and deep fascia is carried out. The tissues turn away proximally as a cuff, for what on a forearm having the form of a cone, it is necessary to make two lateral incisions. Sticking an amputating knife between bones and muscles all tendons and muscles of a back and anterior surfaces dissected at one level. An interosseal membrane cut. Periosteum of radial and ulnar bones dissected and moved together distally by raspator. With the help linteum bifissum (the band of a cloth or gauze double cut up to middle of length) muscles displace proximally and a bone sawed. A wound sewn up according to layers: by catgut edges of an deep fascia and by silk skin. An immobilize of extremity. (Fig. 10).

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b
Fig. 9. Amputation of a forearm a - circular method with a cuff b - two-flap amputation

a
Splitting of a forearm on Krukenberg. The indication for its performance is the bilaterial amputation of a forearm, paralysis or amputation of the other extremity at any level. The essence of a method of a kineplasty of a forearm consists in formation of two claws - large . 10. Krukenberg operation fingers, capable to be closed and to be disconnected. Their formation is carried out by separation of bones of a stump, suturing to them of muscles and closing by dermal flaps (Fig. 10).

Amputation through the arm

Optimum from positions of a prosthetic repair the stump of a brachium after amputation is in the inferior and middle third. The most rational method of amputation is two-flap cutaneo-fascial (Fig. 11). The cutaneo-fascial flaps formed from both sides of a arm, anterior should have greater length. After separation from adjacent tissues the flaps displaced back up. The section of muscles is made in one plane Fig. 11. Two-flap amputation of an which is taking place below the future sawing arm of a humeral bone. The biceps muscle is reduced more strongly, therefore it should be dissected more distally others. The reduced muscles displace by a retractor up. Then a periosteum cut and a bone sawed. Distal department of an extremity removed. A brachial artery, its deep and muscular branches stitch and ligated by catgut, separately venous vessels ligated. The median, ulnar, musculocutaneous nerves of a brachium and forearm are truncated. According

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to layers a fascia and skin sutured. The stump of a brachium is fixed by a plaster bandage in the abduct position (30 40).

TECHNIQUE of AMPUTATIONS and EXARTICULATIONS THROUGH a LOWER EXTREMITY

Amputations and exarticulations on a foot.
The exarticulation of fingers on Garango is indicated at a frostbite, crush or gangrene of all fingers of a foot. The operation begins with formation of plantar and dorsal dermal flaps. Inferiorly an Fig. 12. A incision passes a little more distally than line of plantar-digital fold. On a dorsum the incision incisions on of a skin will be carried out below line of back of a foot interdigital folds. The formed flaps displaced at an up. Tendons of extensors, ligament, capsule of exarticulation metatarsophalangeal joints and tendons of of fingers on flexors cut. The fingers removed. Processing of Garango vessels and nerves. On dermal flaps infrequent sutures applied (Fig. 12). Amputation of a foot on Sharp. Amputation made by a two-flap method: the flap from the plantar side should be longer, than with back. The skin is dissected on both surfaces of a foot by the two arcuate incisions, initial and final points of which coincide and correspond by the bases of I and V metatarsal bones. The distal part of a dermal flap on a sole reaches a level of a heads of metatarsal bones, and on dorsum of foot - their basis. Together with a skin all soft tissues dissected. The flaps move up and metatarsal bones sawed. Distal part of an extremity deleted. A dorsalis pedis artery, medial and lateral plantar arteries and veins are ligated. The nerves are truncated. Tendons and muscles of a sole fixated to a Fig. 13. Amputation of a foot on Sharp dorsum of a foot. A wound drain and sutured (Fig. 13).

Amputations of a leg
Syme's amputation. A stirrup-shaped incision is carried out from one malleolus to another through a sole, perpendicular to its surfaces. The ends of a incision connected on an anterior surface of a foot. On a course of a section all formations up to a bone crossed. The cavity of a joint is opened and foot dislocated in a plantar direction. Further Achilles tendon is crossed and the calcaneus removed. The tibial and fibular bones are sawed immediate above articular surfaces or the malleoluses are deleted. The operation finished by suturing of a plantar flap and drainage of a wound (Fig. 14).

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Fig. 14. A Syme's amputation a - form of a incision; b-cclosing stage of operation

Fig. 15. The scheme and basic moments of osteoplastic amputation of an leg on N.I. Pirogoff Osteoplastic amputation of a leg on N.I.Pirogoff. Incision made as at a Syme's amputation. A foot strongly displace to bottom, and the back flap to up. A capsule of a talocrural joint is opened. The ligaments of a talocrural joint are dissected. At a cut of ligaments there is a danger to damage a posterior tibial artery, that can result in a necrosis of osteal calcaneal graft. The talocrural joint is widely opened and the posterior wall of its capsule is dissected. The calcaneus is sawn off, then the distal part of an extremity removed. The distal ends of bones of a leg are exposed and are sawn off. Obliquely an lateral surface of a fibular bone is sawn off. The anterior and posterior tibial arteries ligated. The cutaneous nerves and also lateral and medial plantar nerves are truncated. Calcaneum is attached to stamp of bones of a leg and then is fixed by catgut or silk threads to a periosteum of a tibial bone. Suture of wound (Fig.15). Amputation of a leg through the middle third. The two-flap cutaneo-fascial amputation is usually carried out. Two cutaneous flaps together with a subcutaneous fat, superficial and deep fascia of a leg formed. The anterior flap should be longer as posterior (at vascular diseases it is recommended to form to a long posterior flap, as it is better supply). The muscles dissected in one plane on 4 - 5 cm distally from the bases of flaps. The reduced muscles displace in the direction of a knee joint. After typical processing of a periosteum, fibular bone sawed on 1,5 - 2,0 cm above tibial. Then anterior and posterior tibial Fig. 16. Amputation of a leg through the middle third

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arteries ligated. The nerves are truncated. Suture of a deep fascia and skin.

AMPUTATION THROUGH A THIGH

Amputation of a thigh in inferior third Osteoplastic amputation of a thirh on Gritty-Shimanovsky Arcuate incision of a skin, subcutaneous fat and superficial fascia on a anterior surface of a knee joint passes from lateral to a medial epicondyle of a femur. Beginning and end of a incision go on 2 cm above than epicondyles, its middle part passes at the inferior border of tuberositas tibia. A patellar ligament is dissected and the posterior flap is formed. Its length is half of anterior. Having

a
Fig. 17. Osteoplastic amputation of a thigh on Gritty-Shimanovsky a - scheme of operation, bthe basic stages

separated a anterior flap together with a capsule of a knee joint, patella and its ligament, a flap elevated so the internal cartilaginous surface of a patella remained accessible to processing. A cartilaginous surface of a patella sawed. The soft tissues of anterior and posterior flaps removed by a retractor and the femoral bone immediately above condyles of a femur is sawed after cut of a periosteum. The vessels ligated with a suturign, the nerves are truncated. A patella and femoral bone are fixed by 3 4 catgut sutures. A stump drained and according to layers sewed up (Fig. 17). The tendoplastic amputation of a femur on Kalender is based on use of a Fig. 18. Tendoplastic amputation of tendon of a quadriceps muscle for close of a thigh on Kalender stump of a femoral bone (Fig. 18). Amputation through a thigh in the middle third Two-flap fascioplastic amputation of a femur. Two flaps including a skin, subcutaneous fat and deep fascia are formed. The anterior flap should be longer as posterior. The muscles of a femur cut on one plane on 5 - 6 cm distally than the basis of flaps. A femoral bone on edge of the reduced muscles sawed. Ligation of vessels. Truncation of nerves. Deep fascia is sewed by catgut and skin - by silk (Fig 19). Three-stage conical-circular amputation on N.I. Pirogoff (Fig. 20)

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The principles of operation are described on pages 8 - 9.

Fig. 19. Two-flap amputation of a thigh

I moment II moment III moment Fig. 20. Tree-moment circular amputation through middle third of thigh on N.I.Pirogoff