Employment 9

Employment 9. Amputations and Disarticulations of the Superior and Inferior Extremities, their Peculiarities for Children. Principles of Amputation and Disarticulation of Hand Phalanxes and Fingers. Tendons Stitches. Denudation of the Limbs’ Vessels and Methods of Extremities Collateral Blood Circulation Improvement after Big Vessels Ligation..

 

Amputation is the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain. Traumatic amputation is the loss of a body part – usually a finger, toe, arm, or leg – that occurs as the result of an accident or trauma. So, amputations is removal of peripheral limb part at different levels of a bone (between joints).

Disarticulation is the surgical removal of peripheral part of limb at articulation level.

History of the Procedure

Amputation is one of the oldest surgical procedures. Archaelogists have uncovered evidence of amputation in prehistoric humans.

Hippocratus recommended to cut a limb withiecrotic tissue because in that case bleeding was absence. It is clear, because in that time methods of arest of bleeding were imperfect (even barbarian). Arest of bleeding was realized by hot iron cauterization of vessels and surrounding tissue, and this procedure led to necrosis of stump tissue and traumatic shock.

In A. D. 1^st centure Cels has offered to perform an amputation of limb within health tissue, to cut a bone above a soft tissue, and to ligate a vessels by ligature for arrest of bleeding.

Indications

All indications to amputations or disarticulations we can divide into 2 group:

1.     absolute

2.     relative

First one is the indications when irreversible processes are present and conservative (therapeutic) methods of treatment cann’t to save a limb

·        traumatic limb rupture

·        gangrene (as result of burn, electrotrauma, endarteritis,frostbite, embolism, anaerobic infection, diabetic angiopathy)

·        the third indication consists of 3 signs:

1) injure of 2/3 of soft tissue

2) injure and crushing of major vasculo-nervous bundles

3) injure of a bone.

Second (relative) indications is the indications when surgery is necessary just in that cases when trauma or disease of limb can led to death of patient.

·        acute infectious process (for example, gas gangrene)

·        chronic infection (chronic osteomyelitis, tuberculosis of bones and joints)

·        massive trophic ulcer

·        irreparable deformation of limb (congenital, posttraumatic, paralytic)

·        limb injure with damage of 2/3 of soft tissue and bone on considerable distance but without injure of vasculo-nervous bundle.

In according to Kuprianoff, all indications are dividing into three groups:

1.                                                                 primary amputation

2.                                                                 secondary amputation (intermediate, intrapyretic)

3.                                                                 re-amputation (repeated amputation).

Primary amputation is performed in earlier termes before development of infections (within first 24 hours). This type of amputation is first surgical debridment of wound.

Secondary amputation is performed in case of development of wound infection. This amputation is called as delayed amputation and is performed after 7-8 days.

Re-amputation – reasons for this amputation are bad results after first amputation. For example, faulty stump or re-amputation for prosthesis fitting.

Contraindications

The only absolute contraindication to amputation an instance in which sparing a limb or part of a limb would leave the patient better able to function than would an amputation.

Relative contraindication is traumatic shock. It is necessary to treat a shock at first and than to perform a surgery. But it cann’t be more than 4 hours.

General principles

I.                   Any amputation has for an object:

1)     to prevent spreading of infection and entrance of products of metabolism from the wound to victim’s organism, and by this way, to save his life.

2)     to perform functional stump for future prosthesis.

II.                Majority of amputations and disarticulations are performed with appling of elastic rubber tourniquet (another types of tourniquets cann’t be used). A surgeon cann;t use a tourniquet when amputation is performed because of gas gangrene or obliterating endarteritis. Major vessels must be ligated before amputation. Bleeding from small vessels is stopped during surgery.

III.             Determination of level of amputation (level of bone cutting). Before an amputation is performed, extensive testing is done to determine the proper level of amputation. The goal of a surgeon is to find the place where healing is most likely to be complete, while allowing the maximum amount of limb to remain for effective rehabilitation. It is clear, that short stump as result of higher amputation is worse for prosthetic device. Pyrogoff said that: “It is necessary to operate as low as it possible”.

So, level of amputation must be the best for victim for following fitting with a prosthetic device.

Steps of amputation

General principle of amputations and disarticulations is that all of them are performed by three steps:

I – cutting of soft tissue

II – treatment of periosteum and cutting of a bone

III – stump treatment.

I step of amputation – cutting of soft tissue

All amputations are divided into closed and circular amputation in according to cutting of soft tissue.

Closed (flap) amputations are divided into single- and double-flap amputation.

Single-flap amputation – bone stump is covered by one flap formed from skin, subcutaneous tissue, superficial and proper fascia. This type of amputation is called as fascioplastic. If a flap contains periosteum, it will be fascioperiosteoplastic method.

After creation of a flap a postoperative scar must be located oon-working (unbearing) surface of stump.

Working surfaces for:

·        lower extremity: anterior and lower

·        upper extremity: palmar

·        I finger – palmar and ulnar surfaces

·        II finger – palmar and radial surfaces

·        V finger – palmar and ulnar surfaces

·        III, IV fingers – palmar surface.

Double-flap amputation – bone stump is covered by two flaps created from opposite limb surfaces. This type of amputation could be fascioplastic and fascioperiosteoplastic.

It is very important to calculate a length of creating flap. This calculation we can express by the formula of length of circumference:

C=2πr,

C=πd,

Where C – length of circumference

π – constant value, 3,14

r – radius of circumference of limb at level of amputation

d – diameter of circumference.

In case of single-flap amputation length of flap is equal to diameter of a limb at level of amputation.

C=2πr= πd

D=C/π=C/3,14≈C/3.

So, diameter is equal to one third of circumference of limb. A circumference we can measure (evaluate) by any lace (belt).

As you understand, when we measure the circumference of limb at level of amputation and this number divide by three we will get length of flap in case of single-flap amputation.

In case of double-flap amputation lengthes of both flaps in sum must be equal to diameter of limb at level of amputation. Longer flap is equal to 2/3 of diameter, shorter – to 1/3 of diameter.

Except this, it is necessary to take into account a skin contractile (retrench).

We must add some cm to flap length for calculation of coefficient (factor) of skin contraction.

 

Coefficient of skin contraction

K=1/6*C or K=C/6.

This value is divided by two.

 

Circular amputation

Soft tissue is cutted perpendiculary to longitudinal axis of a bone.

These amputations are divided into three types in according to methods of cutting of soft tissues:

·        one-step amputation

·        two-step amputation

·        three step amputation.

One-step amputation (guillotine amputation). All soft tissues (skin, subcutaneous tissue, superficial and proper fasciae, and muscles) are cutted the limb across at the level of amputation. Cutting of a bone on the same level.

It is an amputation that could be done quickly, and speed of surgery is sometimes very essential (anaerobic infection, for example). But this type of amputatioeeds re-amputation in any cases because of faulty stump forming. After healing of the wound by secondary infection, revision of the stump usually is necessary to make it suitable for wearing a prosthesis comfortably.

Two-step amputation. Soft tissues are cutted in two motions (stages):

first – skin, subcutaneous tissue, superficial and proper faciae,

second – cutting of muscles at level of contracted skin.

Deficiency of this method is forming of a scar at bearing or working surface of the stump.

Variety of two-step circular amputation is forearm amputation by “cuff” method.

First step – cutting of skin, subcutaneous tissue, superficial and proper faciae. Then all these layers are separated and tucked up like a cuff of sleeve in proximal direction of a limb. Length of a cuff is calculated like in case of double-flap amputation. But use smaller diameter of forearm at level of amputation (because it has ellipse-shaped form). Second step – muscle cutting until the bone at level of turned cuff.

Three-step amputation.

As ussual, this type of amputation is performed on thigh or arm (where just one bone is present). In this case soft tissues are cutted in three motions on different levels.

First step – cutting of skin, subcutaneous tissue, superficial and proper faciae.

Second step – cutting of superficial muscles at level of contracted skin.

Third step – cutting of deep muscles.

Another name of three-step amputation is conico-circular amputation because soft tissues are cutted by circular method. As result of different levels cutting we’ll have cone-shaped stump with apex situated on bone-stump.

Merit: three-step circular amputation is easy to perform.

Deficiency: 1) this method is uneconomical. In the same time flap amputations use tissues more economical but it is difficult to perform.

2) forming of central postoperative scar that situated on bearing surface of stump.

Conico-circular amputation is indicated in case of gas infection.

So, guillotine amputation (one-step) and conico-circular amputation (three-step) are preliminary and need re-amputation for prosthetics.

II step of amputation – treatment of periosteum and cutting of a bone

In this time two methods of periosteum treatment are used:

A)   aperiosteal

B)   subperiosteal.

Aperiosteal – periosteum is cutted at level of supposed bone section by circular incision. After that periosteum is dislocate distally with the rasp. And bone is cutted on 2 mm below than level of periosteum incision.

Why 2 mm? For prevention injure of periosteum of residual bone because it could led to forming of faulty stump and osteophytes. It is impossible to scoop out bone marrow from the bone canal, as was recommended earlier because it led to osteophytes forming or necrosis and osteomyelitis of a bone.

We cann’t left bone without periosteum more than 2 mm because of terminal necrosis of a bone.

Subperiostal method. In this case periosteum is cutted lower than supposed bone section at distance equal to bone radius plus 2 mm and separated in proximal direction.

Periosteum is stitched above a bone stump after its cutting. Injure of periosteum could led to osteophytes forming.

Periosteum treatment in children is performed by subperiosteal method, in old persons – by aperiostal method (because periosteum closely attaches to bone).

III step of amputation – stump treatment

This stage includes treatment of vessels, nerves and stitching of soft tissues above the bone stump.

Treatment of vessels.

Main vessels must be fixated by a clamp and ligated by two catgut ligatures. Small vessels – fixated by a clamp and ligated after removing of the torniquet.

During stump treatment it is necessary to realize hemostasis for prevention secondary infection.

Treatment of nerves

It is performed for prevention ingrowth of nervous fibers into a scar formation of neuromas and beginnings of phantom pains.

There are many methods of treatment of nervous trunks:

A – stitching of cutted nerves to side of same nerve under epineurium

B – angular section of nerve with following epineurium stitching

C – stitching of terminal parts of nerves.

In this time the best method of nerves treatment is its cutting (re-amputation of nerve) by very sharp razor on 6-8 cm above the level of amputations.

Why 6 cm? Speed of nervous fibers growing is approximately 1 mm per 24 hours. Postoperative scar forms during 2 monthes (if wound will heal by primary intention). In this case nervous trunk don’t ingrow into the scar it prevent phantom pain.

Before section of nerve it is necessary to exposure nervous trunk by bluntly dislocation of soft tissues. After exposure – 2 % solution of novocaine is injected under epineurium. It is necessary to cut all nervous branches (cutaneous too). We cann’t cut nerves more than it’s need because of forming of atrophy of stump

Stump stitching

Surgeon stitches skin with subcutaneous tissue, superficial fascia and proper fascia and don’t stitches muscles above the bone stump. They found new points of attachment and growe together with a bone themselves. Postoperative scar must be moveable and don’t connects with a bone.

Bone stump don’t cover by a muscle on lower limb because they will atrophy after fitting of prosthetic device. Fasciomyoplastic method of stump covering is used on upper limb. For this purpose tendons of antagonist muscles are stitched to each other. This surgical procedure is called myoplasty.

Another approach to managing the muscle on the limb during amputation is myodesis. With a myodesis, the muscles and fasciae are sutured directly to the distal residual bone through drill holes. Myodesis is contraindicated in patients with severe peripheral vascular disease, because the blood suppling to the muscles may be compromised.

Complications

The most common complications of amputations are:

·        massive hemorrage that occurs when a suture becomes loose

·        infection

·        rash, blisters, and skin breakdown caused by immobility, pressure, and other sources of irritation

·        pneumonia, blood clots, and breathing problems associated with immobility

·        formation of nerve cells tumor (neuromas) at severed nerve endings

·        joint contractures, phantom limb pain, neuroma formation, stump breakdown, and, in children, bone overgrowth.

Mistakes of I step of amputation

1.                                                           Conical stump – lack of soft tissue because of wrong calculation during I step of amputation in case of flap-amputation or guillotine amputation.

2.                                                           Mace-shaped stump – is characterized by surplus of soft tissues, and wrong calculations of flap length or level of amputation in case of circular amputation.

Mistakes of II step of amputation

3.     Terminal necrosis of bone – as result of excessive removing of periosteum (more than 2 mm from residual part of a bone).

4.     Forming of large osteophytes – as result of injure of periosteum on residual part of bone during it’s sawing or after scooping out an bone marrow.

Mistakes of III step of amputation

5.                                                                 Forming of trophic ulcer – as result of: a) wrong level of amputation; b) higher ligation of arteries and cutting of nerves.

6.                                                                 Phantom pain – as result of ingrowing of nerves fibres into a scar.

7.                                                                 Chronic osteomyelitis – forms because of secondary infection inside the wound.

All these complications led to defect of stump development, and need correction – performing of re-amputation.

Phantom pain

feels like it’s coming from a body part that’s no longer there. Experts now recognize a physical cause for this pain – and that it actually originates in the brain. Most people who’ve had a limb removed report that it sometimes feels as if their amputated limb is still there. Now experts recognize a physical cause for this pain – and that it actually originates in the brain. Most people who’ve had a limb removed report that it sometimes feels as if their amputated limb is still there. This painless phenomenon, known as phantom limb sensation, can also occur in people who were born without limbs.

Osteo-plastic amputation

Keep in your memory, that this type of amputation always is repeated amputation (re-amputation).

Performing of it is possible when wound is clean (without any smallest infection). So, osteo-plastic amputation cann’t be performed because of primary indications. Exception of this rule is malignant tumors.

First and third steps of amputation are analogical to ordinary amputation. Second step has some peculiarities – forming of osteo-periosteal flap by which surgeon covers a cutted bone.

Pyrogoff proposed to cover the cutted leg bones by a flap created by skin, subcutaneous tissue, superficial fascia and tuber of heel bone with periosteum.

Gritti’s method – cutted femoral bone is covered by osteo-periosteal flap created by patella.

Albreht’s method – form tenon from patella and fixate it in intramedullary canal of femur.

 

Osteo-plastic amputation is never performed at upper limb!!! In case of amputations a surgeon tries to perform cinematization of forearm stump because of its’ functional peculiarities (Krukenberg’s surgery). For this purpose ulnar and radial bones are separated one from another. Muscles are divided into two groups: radial and ulnar.

Peculiarities of amputation in children

Disarticulations are preferred in children because amputations (through bone) tend to be less satisfactory because continued irregular growth of bone at the amputation causing stump pressure points and discomfort.

The image demonstrates a Symes’ amputation, the commonest amputation of lower extremity performed in children. The Syme’s procedure is an ankle disarticulation with a long posterior flap brought forward. This provides an end bearing stump and preserves physeal growth. The malleoli are not trimmed.

 

You have to remember that:

1.                            bones grow more quickly than soft tissues. It cause forming of conical stump with following trophical ulcers. For prevention this complication it is necessary to leave surplus of soft tissues.

2.                            another fact – pair bones (arm, leg) grow with different speed. So, radial and fibular bones grow quickly. Because of it cutting of these bones must be performed higher.

3.                            growth zones are present in child’s bones. At amputation, surgeons must cut below to this plate for prevention dysproportional growing of extremities in future.

 

Terminal overgrowth occurs to some degree in all children with amputation. Pediatric patients with disarticulations don’t demonstrate terminal overgrowth because the articular cartilage acts as a natural barrier to this activity. For this reason, disarticulations are the treatment of choice in children whenever possible. The only treatment for symptomatic terminal overgrowth is revision amputation.

After surgery a soft, compressive dressing is applied to the stump. If a drain is used, it’s removed within 24-48 hours.

Following an amputation, the patient usually waits six to eight weeks before being fitted with a prosthetic device.

 

Types of amputations (lower extremity):

• Transphalangeal amputation – Excision of part of 1 or more toes

• Toe disarticulation amputation – Resection through the metatarsophalangeal joint or joints

• Ray amputation – Resection of the toe and part or all of the corresponding metatarsal

• Transmetatarsal amputation – Resection through all metatarsals

• This amputation is designed to provide a functional, weight-bearing foot with an adequate forefoot lever arm to permit reasonably normal walking without major prosthetic restoration. 

• Lisfranc amputation – Resection through the metatarsal and tarsal joints

• Because the insertions of the dorsiflexors of the ankle are sacrificed with this amputation, to provide for a balanced ankle and avoid development of an equinovarus deformity the distal tendons of the peroneus brevis and the anterior tibialis must be reattached proximally in the residual foot to the cuboid and to the neck of the talus, respectively.

• The shape and shortened length of the residual foot increases the difficulty of fitting it with a partial foot prosthesis that can provide adequate suspension and/or a forefoot lever for ambulation. Successful prosthetic restoration often requires a prosthetic or orthotic design that is more substantial and extends proximal to the ankle.

• Chopart amputation – Resection through the calcaneocuboid and talonavicular joints

• To prevent equinovarus deformity, the peroneus brevis tendon must be transferred to the cuboid and the anterior tibialis tendon must be transferred to the neck of the talus.

• The shape and length of the residual limb make the limb even more difficult to fit with a partial foot prosthesis than it would be after the Lisfranc amputation.

• Syme amputation – Ankle disarticulation with or without removal of the medial/lateral malleoli and distal tibia/fibula flares

• The advantage of this amputation is that it provides a residual limb with an end-bearing surface.

• The length of the residual limb limits the prosthetic foot options compared with a more proximal transtibial (below-knee) amputation.

• This amputation leads to a poorer cosmetic prosthetic result because of the need for the prosthesis to accommodate the bulbous distal shape of the residual limb (which is produced by the malleoli). This is especially true for slim patients.

• Careful surgical technique is required to prevent heel pad migration from the distal end of the residual limb. If this occurs, the weight-bearing advantage of this amputation level could be compromised.

• Transtibial amputation – Below-knee amputation (BKA); resection through the tibia and fibula

• The ideal length is from the proximal one third to the middle of the limb. 

• Knee disarticulation amputation – Through-the-knee amputation; resection through the knee joint

• The advantage of this amputation is that can provide a broad, end-bearing surface for the residual limb and a maximal lever arm for powering and controlling a prosthesis

• The disadvantage of this amputation is that it does not provide an ideal length for prosthetic restoration, because it limits the amount of space available for the knee joint components in the prosthesis. This limits the options for prosthetic knees that can be used to maintain the symmetry of the knee-joint centers.

• Transfemoral amputation – Above-knee amputation (AKA)

• The ideal length is about 8 cm proximal to the knee joint, so that the femoral condyles are excised with adequate room to accommodate prosthetic knee options

• Hip disarticulation amputation – Resection through the hip joint; pelvis intact

• Hemipelvectomy amputation – Resection of all or part of the hemipelvis and of the entire lower extremity

 

 

AMPUTATIONS OF THE UPPER EXTREMITIES

Upper extremity amputations, excluding finger amputations, account for 15% to 20% of major extremity amputations. More than 90% of all upper-extremity amputations are a result of trauma, and most of these occur in men between the ages of 20 and 40 years.’ Less common causes of upper-extremity amputation are peripheral vascular disease, tumors, congenital malformations, neurologic disorders, and severe infections.

The loss of an upper extremity has more devastating consequences than the loss of a lower extremity. Lower-extremity amputations are performed most often in elderly, dysvascular patients, and advanced lower-extremity pros-therics allow any amputee to be ambulatory if he can meet the increased energy demands associated with prosthetic ambulation. Upper-extremity amputations are performed primarily in young male trauma victims, and wound healing is not generally a major concern, with the rare exception of a diabetic patient with gangrene of the upper extremity. Despite advances in upper-extremity prosthetics, the success rate for adult prosthetic rehabilitation after amputation is less than 50%.

INDICATIONS

Trauma is the major cause of upper-extremity amputations, and there are two subgroups of of these injuries: severed limbs and irreversible brachial plexus injuries. Other causes, such as peripheral vascular disease and tumors, are far less common. The indications for upper-extremity amputation for peripheral vascular disease and tumors are similar to those for lower-extremity amputation in these conditions.

 

SURGICAL TECHNIQUES

Upper-extremity amputations should be at the most distal level compatible with uncomplicated wound healing. Soft tissues should be handled atraumatically. Nerves should be sharply divided and allowed to retract to adequate soft-tissue coverage. A tourniquet may be used, but exsanguination is contraindicated in limbs being amputated because of infec­tion or tumor.

 

BELOW-ELBOW AMPUTATION

If the vascular status of the limb is satisfactory, amputation at the most distal level provides the optimal stump for pros­thetic use. If the vascular status of the limb is compromised, healing at the distal third of the forearm may be difficult due to the avascular, tendinous nature of this area.

A tourniquet may be used. Fashion equal anterior and posterior flaps, and ligate the radial and ulnar arteries with suture. Identify the major nerves (ie, radial, ulnar, median), sharply divide them as far proximally as possible, and allow them to retract into the soft tissues. Then section the radius and ulna proximal to the most proximal portion of the skin incision. Smooth the rough edges with a rasp or rongeur, and perform a myoplastic closure. If the amputation level is proximal to the myotendinous junction of the flexor and extensor tendons of the forearm, suture the palmar compartment muscles over the end of the bone to the extensor compartment.

The most proximal level compatible with below-elbow prosthetic fitting is the level of the biceps tendon insertion on the radius. If circumstances require amputation at this level, the distal 2.5 cm of the biceps tendon can be released, providing a longer stump for prosthetic fitting. If the level of amputation is in the distal one third of the forearm, bring the tendinous portion of the flexor digitorum superficialis over the end of the bone, and suture it to the extensor com panment fascia. Obtain hemostasis. If necessary, use a soft drain. Close the wound without tension, and apply a rigid dressing.

 

 

 

 

 

FIG. A below-elbow amputation, demonstrating equal dorsal and volar flaps.

 

 

 

The site of election in FOREARM AMPUTATIONS is at the junction of the lower and the middle thirds. However, any site above this junction to within 3 or 4 inches of the elbow will produce a good stump. A short forearm stump is difficult to fit because the biceps muscle pushes the limb socket when the elbow is flexed. In amputations of the forearm, anterior and posterior U-shaped incisions are made through the skin and the superficial fascia, thus outlining the flaps. The vertical incisions are carried through the muscles to the bone. The muscles on the anterior and the posterior aspects of the forearm are divided to the bone, and the periosteum is freed and retracted upward. The interosseous membrane is cut transversely at approximately the saw line, the soft parts are retracted, and the bones are sawed. Attempt is made to ligate separately the radial, the ulnar, and the anterior and the posterior interosseous arteries. The median, the ulnar and the radial nerves are cut short. The muscles and the deep fascia are closed over the bone ends, and the skin is closed with interrupted sutures.

FIG. Site of election in forearm amputations.

 

 

ELBOW DISARTICULATION

Amputation at the elbow has the same advantages as a through-knee amputation in the lower extremity. The bul­bous distal humerus allows suspension of a prosthesis. The long lever arm allows humeral rotation of the prosthesis, alleviating the need for a mechanical turntable required in more proximal brachial amputations. However, the soft tissue is thin at the elbow, and fitting of the prosthesis must be exact.

A sterile tourniquet may be used. Fashion equal anterior and posterior flaps, with the posterior flap extending to a point 2.5 cm distal to the olecranon and the anterior flap extending to the biceps insertion on the radius. Ligate the brachial artery with suture. Sharply divide the radial, ulnar, and mediaerves proximally, and allow them to retract into soft tissue. Disarticulate the elbow by dividing the in­sertion of the biceps (ie, radius) and the insertion of the brachialis (ie, ulna) anteriorly and by dividing the triceps tendon at its olecranon insertion. Release the medial flexor and pronator mass from the medial femoral condyle, and divide the extensors from the lateral humeral epicondyle. Perform an anterior capsulotomy, and remove the forearm, leaving the articular surface of the distal humems intact. Bring the triceps tendon anteriorly, and suture it to the ten­dons of the biceps and brachialis muscles over the trochlea of the humerus. Place a drain, close the wound without ten­sion, and apply a rigid dressing.

 

ABOVE-ELBOW AMPUTATION

To allow fitting of an above-elbow prosthesis, which includes an elbow lock mechanism for flexion and extension and an elbow turntable for rotation, an above-elbow amputation should be done 3.8 cm proximal to the joint. Proximally, transection of the humerus at the level of the surgical neck requires a shoulder disarticularion prosthesis, which is es­sentially cosmetic. However, amputation at this level has the cosmetic advantage of preserving normal shoulder contour.

For amputations through the midbrachium, fashion equal anterior and posterior flaps. Identify and ligate the brachial artery. Divide the anterior compartment muscles approximately 1.3 cm distal to the intended bone section. Divide the triceps 5 cm distal to the intended bone section. Section the humerus and remove its rough edges. Perform a myoplastic closure, suturing the anterior compartment

For amputations through the surgical neck of the humerus, make an incision anteriorly from the coracoid process along the anterior border of the deltoid to the lateral insertion of the deltoid on the humerus. Extend the incision posteriorly along the posterior margin of the deltoid to the posterior axillary fold, and connect the two incisions by an axillary incision. Ligate the cephalic vein in the deltopectoral groove. Release the deltoid muscle from its humeral insertion, and reflect it proximally. Release the pectoralis major muscle from its humeral insertion, and reflect it medially. Identify the neurovascular bundle, and ligate the axillary artery with suture. Sharply divide the musculocutaneous nerve, mediaerve, ulnar nerve, and radial nerve, and allow them to retract proximally. Divide the teres minor and la-tissimus dorsi muscles close to their humeral insertion. At a point approximately 2 cm distal to the intended bone section, divide the coracobrachialis and biceps muscles, and reflect them distally. Amputate the humerus at the surgical neck, and suture the biceps and coracobrachialis muscles to the triceps muscle over the stump of bone. Trim the deltoid laterally, and suture it medially. Place appropriate drains, and close the skin without tension.

 

AMPUTATIONS ABOUT THE SHOULDER

Amputations about the shoulder, which include shoulder disarticularion and the forequarter or scapulothoracic am­putation, are performed almost exclusively for tumors. Functional prosthetic usage is not feasible after these am­putations. The Tikhor-Linberg amputation is performed for malignant tumors of the shoulder girdle if there is no tumor involvement of the neurovascular bundles. The amputation resects the proximal humerus, scapula, and clavicle, but it preserves the brachium and distal arm.

 

SHOULDER DISARTICULATION

For shoulder disarticularion, begin the anterior incision at the coracoid process, and proceed distally along the anterior margin of the deltoid to its humeral insertion.⁵ Continue posteriorly along the posterior margin of the deltoid, and connect the anterior incision with a posterior incision across the axilla. Identify the neurovascular bundle in the interval between the coracobrachialis and the short head of the bi­ceps, and ligate and divide the axillary artery and vein. Sharply divide the median, ulnar, and musculocutaneous nerves, and allow them to retract into soft tissue.

Detach the deltoid from its humeral insertion, and retract it along with its overlying skin proximally. Release the coracobra­chialis and short head of the biceps from their origin from the coracoid, and release the humeral insertion of the pec­toralis major. Externally rotate the arm, and divide the an­terior joint capsule and the subscapularis muscle. Internally rotate the arm, and divide the short external rotators and the teres major. Divide the triceps and inferior capsule, and remove the arm. Suture the muscle ends into the glenoid to fill dead space. Bring the deltoid with its overlying skin in-feriorly, and suture it inferior to the glenoid to the margin of the posterior axilla incision, completing the procedure.

 

SCAPULOTHORACIC DISARTICULATION

For scapulothoracic disardculation, begin the incision lateral to the clavicular insertion of the sternocleidomastoid muscle, and extend the incision distally along the clavicle to the acromioclavicular joint over the acromion to the spine of the scapula and posteriorly along the vertebral border of the scapula⁷ Begin the lower incision at the middle third of the clavicle. Proceed distally to the deltopectoral groove and cross the axilla horizontally, and join the first incision posteriorly at the spine of the scapula. Release the pectoralis major from the clavicle, and divide the clavicle lateral to the insertion of the sternocleidomastoid. Excise the clavicle to the level of the acromioclavicular joint. If necessary, ligate the external jugular vein. Release the pectoralis major and minor from their insertions, exposing the neurovascular bundle. Ligate and divide the subclavian artery and vein. Section the components of the brachial plexus, and allow them to retract. Release the latissimus dorsi and axillary fascia from the humerus, allowing the limb to fall posteriorly. Hold the arm across the chest, and divide from superiorly to inferiorly the remaining muscles that fix the shoulder to the scapula. Divide the muscles that hold the scapula to the thorax, starting with the trapezius and continuing through the omohyoid, levator scapulae, rhomboid major and minor, and serratus anterior. Remove the arm and scapula. Suture the remaining muscle over the lateral chest wall. Close the skin flaps over suction drainage.Delayed Repair of Severe Brachial Plexus Injuries.

 

AMPUTATIONS AND DISARTICULATIONS at the wrist joint prevent the proper fitting of artificial hands; if possible, they should be avoided. However, there are times when carpometacarpal disarticulation is indicated; if possible, the thumb and a finger or other parts of the hand should be saved. A U-shaped incision is begun on the palmar side about ½ inch below the styloid process of the radius, passing down to the middle of the 2nd metacarpal, where it arches across the middle of the remaining metacarpals and ends about 1 inch below the styloid of the ulna. The dorsal incision is placed transversely across the carpal bones and connects with the palmar incision. The palmar flap is deepened to the flexor tendons and is reflected to the joint. The extensor tendons and ligaments are divided, the joint is traversed, and the flexor tendons and the remaining tissues are severed in similar fashion. Tendons and nerves are cut short. Some authorities advocate suturing the tendons together, but others permit them to retract. After careful hemostasis has been achieved, the wound is closed in layers.

 

AMPUTATIONS OF THE LOWER EXTREMITIES

More than 30,000 lower-extremity amputations are per­formed annually in the United States, primarily in elderly patients with ischemic disease. The medical, social, and economic ramifications of these amputations are enormous. In series of amputations for dysvascular disease reported in the 1960s, amputation rates for the comralateral limb av­eraged 15% to 28% within 3 years of the initial amputation, and patient survival averaged only 50% at 3 years. Despite recent advances in preoperative evaluation, post­operative prosthetic care, and geriatric medicine, the con-tralateral amputation and long-term survival rates have not significantly improved for dysvascular amputees.” Amputations are considered to be the ultimate measure of failure in orthopaedic surgery and vascular surgery and are often relegated to junior house officers. However, much attention is given to the patient undergoing an amputation of the femoral head and neck with immediate prosthetic replacement (eg, total hip replacement), a procedure that is seldom relegated to a junior surgeon. It seems more appro­priate to view lower-limb amputation as the initial step in the rehabilitation of a patient to an ambulatory, pain-free, and independent status than as a final stage of treatment failure.

Amputation of a lower extremity requires a team approach similar to trauma because the medical, surgical, social, rehabilitative, and economic implications are far too extensive for one health care worker to manage. In treating vascular amputees, who constitute most of the lower-extremity am­putees, the modern amputation surgeon must recognize the systemic nature of the disease. Coronary artery disease, cerebrovascular disease, and contralateral limb ischemia should be evaluated to allow rehabilitation to the maximal level possible. Amputations in diabetics with dysvascular or neu-rotrophic ulcers can be avoided with conservative, nonoperative care and education,Tobacco use in all amputees should be discouraged to prevent the need for additional amputations and to improve the amputee’s tolerance for the increased energy demands of prosthetic ambularion.

INDICATIONS

PERIPHERAL VASCULAR DISEASE

The largest group of patients undergoing lower-extremity amputations in the United States consists of those with dys-vascular disease. As the population ages, the number of pa­tients evaluated for dysvascular disease in the lower extremity will increase. Immediate amputation and rehabilitation with a prosthesis often offers the best solution for a painful, dys­vascular limb. However, before undergoing amputation, many of these patients should be considered as candidates for vascular reconstructive procedures, which may permit limb salvage or amputation at a more distal level.

The superficial femoral artery conducts the major blood supply to the calf and foot and is often involved in arterial occlusive disease. The profunda femoris (deep femoral) artery, which arises in the lateral aspect of the common femoral artery, supplies the thigh and anastomoses with branches of the popliteal and geniculate arteries. If there is superficial femoral artery occlusion, the patent and usually nondiseased profunda femoris artery provides the collaterals to the calf and is a major determinant in the success of a below-knee amputation. Several large series have demon­strated the efficacy of profundaplasty in patients with oc­clusion of the superficial femoral and the profundus femoris arteries in promoting healing of ischemic ulcers distal to the knee and allowing a below-knee amputation instead of an above-knee amputation

Vascular reconstruction surgery to allow limb salvage or a more distal amputation has some drawbacks. Arterial re­construction surgery is expensive, it may delay eventual definitive treatment, and success is not certain. However, several surgeons have reported large series in which failed revascularization procedures had no ad­verse effects on amputation level or clinical results of amputation.

Five of six major lower-extremity amputations for dys­vascular disease occur in diabetics. Diabetics with dysvas­cular limbs often are thought to have “small vessel disease” not amenable to vascular reconstruction. This concept probably originated in a study by Goldenberg in 1959, in which limbs with and without diabetes were studied at au­topsy with light microscopy. Patients with diabetes were found to have arteriosclerosis of the arterioles, which was thought to be unique to diabetes. Subsequent studies have not confirmed small vessel disease as unique to diabetes mellitus. When modern techniques of vascular sur­gery are applied to diabetics, the long-term limb salvage rates are comparable to those in similarly treated patients with no diabetes. Patients with diabetes mellitus and isch­emic limbs should not be excluded from consideration for vascular reconstruction.

Diabetics have problems that require special consideration. Neuropathy develops in most diabetic patients, and minor traumatic events in the desensate limb can result in limb-threatening ulcers. The altered metabolic state in uncon­trolled diabetes mellitus can decrease granulocyte function and collagen synthesis, resulting in increased susceptibility to infection and delayed wound healing. Vigorous control of blood glucose in diabetics undergoing lower-extremity amputations, especially in the perioperative period, can en­hance collagen  synthesis and the inflammatory  response to infection. In some series, healing of amputations of the lower extremities in patients with diabetes mellitus has been similar to healing iondiabetics.

TRAUMA

Modern advances in emergency transportation, vascular surgery, and operative stabilization of fractures have resulted in limb salvage in many traumatized lower extremities that previously would have been amputated. However, the am­putation rate for lower-extremity trauma with arterial injury remains significant. In World War II, there was a 72% amputation rate of  lower-extremity injuries with popliteal artery laceration, because treatment at that time consisted of pri­mary ligation of the popliteal artery. With the advent of new techniques in vascular reconstruction during the Korean War, the amputation rate in popliteal vascular injury de­creased to 32%. Despite improvements in vascular recon­struction, including an emphasis on vein repair, the ampu­tation rate of popliteal vascular injuries in the Vietnam War was 32%. Civilian experience has demonstrated a similar amputation rate after lower-extremity trauma with popliteal artery lacerations.

Attempts at limb salvage in the severely traumatized ex­tremity should be reserved for limbs with a reasonable ex­pectation of acceptable function. Lange and coworkers re­viewed their experience in open tibial fractures with associated vascular injuries and suggested that primary am­putation is indicated in limbs with anatomically complete disruption of the posterior tibial nerve in adults or in limbs with warm ischemia time longer than 6 hours. Primary amputation should be considered in tibial fractures with as­sociated vascular injury if two of the following three con­ditions exist: serious associated polytrauma; severe ipsilateral foot trauma; or anticipated prolonged course to obtain soft-tissue coverage and tibial reconstruction. Other groups have developed more comprehensive rating systems for severe tibial injuries, which allow the use of more objective criteria for limb salvage or amputations.

After a decision is made to attempt limb salvage in a se­verely traumatized limb, a protracted and expensive course can be expected. Several series have shown significant mor­bidity and psychologically adverse effects for limb salvage of severely traumatized lower extremities. If limb salvage is “successful,” the final functional and cosmetic results (eg, joint range of motion, limb shortening, angulatory malalign-ment, pain) are often unsatisfactory.

TUMORS

The field ofmusculoskeletal oncology is rapidly evolving. In the 1960s and early 1970s, 5-year survival rates for patients with osteogenic sarcoma were usually less than 20% The advent of more sophisticated radiographic preoperative staging and the use of preoperative and postoperative ad-junctive chemotherapy have improved current 3-year survival rates in osteogenic sarcoma to 60% to 85% in some studies

En bloc resection of osteosarcomas and limb salvage with customized orthopaedic implants or allograft implantation has been developed in the last decade. Several institutions report similar overall survival rates for patients who underwent primary amputation and those who under­went en bloc resection and limb salvage. Survival rates may be improved in those who undergo en bloc resection, because the patients selected for this treatment are likely to have more limited disease.⁸⁴ However, the German-Austrian osceosarcoma trials revealed an increased incidence of pul­monary metastases with segmental resection compared with primary amputation. However, the incidence of local re­currence ofosteosarcoma with limb salvage is slightly higher than for amputation. The incidence of infection in massive allografts used for the management of bone tumors was 12%, with significantly decreased functional results. However, energy expenditure during gait is less with en bloc resection and endoprosthetic replacement for osteosarcoma of the distal femur than for above-knee am­putation. En bloc resection with limb salvage for osteo­sarcoma should be done in centers with experience in che­motherapy and the surgical techniques for allograft or prosthetic replacement.

 

PREOPERATIVE CONSIDERATIONS

SITE OF AMPUTATION

Before World War II, most lower-extremity amputations were above-knee procedures because they yielded healing rates approaching 100% in ischemic limbs. In the 1960s and early 1970s, several factors combined to reverse the ratio of above-knee amputations to below-knee amputations. The use of a long posterior flap in dysvascular patients, with its increased blood supply, improved the success rate in be­low-knee amputations. It was determined that there was less energy expenditure with prosthetic ambulation by below-knee amputees than by above-knee amputees. The devel­opment of preoperative objective criteria for amputation-site viability allowed more distal amputations to be done.

Lower-extremity amputations in the dysvascular patient should be performed at the most distal site compatible with wound healing to achieve the optimal potential for ambu-lacion. Several well-documented studies have shown that energy expenditure is markedly increased in more proximal amputations. Waters and coworkers found that energy ex­penditure during ambulation, as measured by Oz consump­tion per kilogram of body weight per meter traveled was significantly increased in above-knee amputees compared with below-knee amputees. Fisher and associates found that below-knee amputees with dysvascular disease ex­pended 55% more kcal/m/kg with a 41% slower gait velocity thaonamputees. Above-knee amputees expended the same energy, but they ambulated at rates 66% slower thaonamputees. Huang and associates showed that consumption during ambulation was increased 9% in below-knee amputees, 49% in above-knee amputees, and 280% in bilateral above-knee amputees compared with nonamputees.

Preservation of the knee joint has more significance if the rate of contralateral limb amputation is considered. Mazet and coworkers, for their series of dysvascular amputees, re­ported a 33% contralateral limb amputation rate within 5 years. Other researchers reported contralateral amputation rates of 15% to 28%. Ambulation ability in bilateral amputees is less than in unilateral amputees. For most ge-riarric patients with bilateral above-knee amputations, am­bulation probably is not feasible, and wheelchair locomotion is indicated. Recent studies have demonstrated the en­hanced ambulation potential of patients with at least one knee joint preserved compared with patients with bilateral above-knee amputations. However, in elderly, de­bilitated patients with limited or no ambulatory function, above-knee amputation is preferable to below-knee ampu­tation to prevent knee flexion contractures and subsequent breakdown of the stump.

Various methods have been developed to determine the most distal level at which amputation is likely to be suc­cessful. The use of clinical parameters, such as lowest pal­pable pulse, skin temperature, and bleeding at surgery, have been used with various degrees of success to predict healing of amputation sues. The use of Doppler ul-trasonography to measure arterial blood pressure at the pro­posed amputation site has been advocated as a predictor of amputation success. Barnes and coworkers found that below-knee amputations healed in all patients with below-knee systolic pressure of more than 70 mm Hg. Wagner suggested comparing the pressure at the proposed amputation site to that of the brachial artery; a difference of more than 35% is adequate for healing in the nondiabetic, and a difference of 45% is adequate for the diabetic.

There are inconsistencies with Doppler determinations of amputation site. A calcified, noncompressible artery gives falsely elevated values. The pressure in a deep artery may not correlate with skin healing. Some physicians suggest that the segmental arterial pressure in diabetics is not always helpful in preoperative determination of amputation levels.

Two methods use clearance of xenon 133 to measure der­mal vascularity. In one method, cutaneous diastolic pressure is estimated by determining  the applied pressure necessary to stop clearance of intradermally injected ‘”Xe. Holstein, in a study of 60 below-knee amputees, found that when the skin perfusion pressure was less than 20 mm Hg, only 25% of below-knee amputations healed; when the skin perfusion pressure was more than 30 mm Hg, 90% healed. From 20 to 30 mm Hg of pressure, 67% of amputations healed.

In a second method, cutaneous blood flow is measured by determining rate of clearance of ‘”Xe injected intrader­mally or epicutaneously. The skin blood flow per unit volume is inversely related to the time required for the detected activity of the ‘”Xe to decrease by one half. With intrader­mally injected, Moore found that amputation sites with a value of 2.7 ml/min/100 g or greater healed successfully 97% of the cases. Kostuik injected ‘”Xe epicutaneously and determined that wound healing was predictable with skin blood flow above 0.90 ml/min/100 g of tissue. Other physicians have not found the skin flow measurements with ‘”Xe to be as reliable. The method is exacting, and the trauma of injecting ‘”Xe may elevate the skin blood flow.

Measurement of transcutaneous is another method of determining amputation level. It is not invasive and does not require radioactive isotopes. This method involves warming the skin to 44°C, and with an electrode measuring the Oi emanating from the skin. The Oi tension measured over locally warmed skin reflects the metabolic and perfusion capabilities of the skin and therefore its healing potential. In a study of 37 dysvascular patients, Burgess found that with transcutaneous Po; values of 40 mm Hg or greater, below-knee amputations in 15 patients healed with no de­lay. Three patients with transcutaneous levels of 0 had below-knee amputations that failed. In 17 of 19 patients with transcutaneous POi values of between 1 and 40 mm Hg, below-knee amputations healed. Despite the correlation in this study between transcutaneous Pdi levels and wound healing, transcutaneous Po; levels do not always accurately predict wound healing. Cardiac output, hemoglobin level, and skin temperature affect the results.

Other preoperative methods of determining amputation level, such as fluorescein angiography, skin temperature measurements, and pulse volume recordings, are less widely used. Laser Doppler velocimetry (LDV) has been used to assess viability of amputation sites. In a study of 28 dysvascular patients, 96% (25 of 26 patients) healed below-knee amputations with LDV readings greater than 20 mV, and 100% of patients (3 of 3) failed to heal below-knee amputations with LDV measurements less than 20 mV.

Burgess observed that preoperative measurements to de­termine amputation level are more beneficial in predicting failure than in predicting success. Factors such as alteration in collateral circulation and decreased distal vascular runoff as a result of surgery, surgical technique, the nutritional status of the patient, infection, concomitant medical illnesses, and postoperative care cannot be assessed in the preoperative period. However, the tests described can indicate if adequate circulation exists for a favorable outcome after amputation.

SURGICAL TECHNIQUES

In below-knee and above-knee amputations, a tourniquet may be used, but exsanguination by wrapping with an elastic bandage is contraindicated in ischemic limbs, infected limbs, and limbs being amputated for cancer. Skin must be handled in a nontraumatic manner during all amputations, especially in dysvascular patients. Skin hooks should be used to retract the skin rather than forceps or clamps.

In severely infected limbs or in traumatized limbs with significant muscle necrosis, the amputation stump should be left open. It is necessary to prevent skin retraction before definitive amputation; this may be accomplished by suturing the skin edges to the subcutaneous tissue and fascia with interrupted sutures. Methods of skin traction should be avoided, especially in dysvascular patients.

 

BELOW-KNEE AMPUTATIONS

Indications

In below-knee amputations, the longest stump compatible with adequate soft-tissue coverage is most satisfactory. Gon-zaies reported decreased energy expenditures in below-knee amputees with long below-knee stumps. He defined the stump as long if it is 50% of the length of the remaining contralateral limb; medium if 20% to 50% the length of the contralateral limb; and short if 25% or less of the length of the contralateral limb. Compared with nonamputees, he found consumption during ambulation to be 10% higher in amputees with long stumps and 40% higher in amputees with short stumps.

The residual tibia should measure 12 to 17 cm from the medial joint line, depending on the height of the patient. There is no advantage in amputation distal to the muscu-lotendinous junction of the gastrocsoleus, because soft-tissue coverage will be inadequate.

In most cases, a long posterior flap should be used. Several studies have shown that the posterior compartments of the leg have a greater blood supply than the anterior soft tis­sue. In cases of inadequate posterior soft tissue, side-to-side flaps (ie, sagittal technique) may be used.

Technique

Prep and drape the patient in the standard fashion. Drape the infected draining areas out of the surgical field with im­pervious drapes. With a sterile marking pen, divide the limb into four quadrants, as described by Wagner, from the tibial plateau to the tendinous junction of the gastrocsoleus muscle. Then draw the skin incisions.Make the anterior incision directly to the tibia, and elevate the periosteum for a distance of about 1.5 cm. Divide the anterior and lateral compartment muscles. Identify the neu-rovascular bundle in the imerosseous space, and ligate the anterior tibial artery with suture. Sharply divide the anterior tibial nerve and superficial peroneal nerve (in the interval between the extensor digitorum longus and peroneus brevis) as proximally as possible, and allow them to retract into soft tissue. Then section the tibia slightly proximal to the level of the anterior skin incision using a Gigli saw. Gently bevel the anterior cortex for a short distance. Section the fibula about 1 cm proximal to the tibia. Elevate the deep posterior muscles from the posterior surface of the tibia and fibula, and remove the lower leg. Identify and divide the posterior tibial neurovascular bundle. With an amputation knife, bevel the gastrocnemius, soleus, and deep flexor muscles to the level of the distal portion of the posterior flap. Perform a myoplastic closure, suturing the fascia of the posterior flap to the anterior pretibial fascia. Place a Penrose drain deep in the wound unless the wound is exceptionally dry. Loosely close the skin with interrupted sutures, avoiding damage to the skin with forceps. Do not attempt to remove “dog ears” on either side of the stump. Apply a rigid dressing.

 

THROUGH-KNEE AMPUTATIONS

Indications

Until recently, through-knee amputations were avoided in the United States because of concerns about poor soft-tissue padding at the stump, possible synovial fistulas, and poor cosmetic prostheses. A prosthesis fitted at the through-knee level resulted in a prosthetic limb longer than the nonam-putaced limb. However, a through-knee amputation has sev­eral advantages It allows an end weight-bearing stump similar to that of a Syme’s amputation; it retains a long fem­oral lever arm stabilized by muscle; and it leaves a large distal stump that allows easier prosthetic suspension (Fig. 5). In elderly, dysvascular patients with no ambulatory potential, a through-knee amputation, with better muscle balance, avoids the hip contractures that sometimes occur in above-the-knee amputations and allows more surface area for wheelchair sitting.

Mazet introduced a modified amputation technique and prosthetic design that have eliminated some of the problems with through-knee amputation.” Burgess developed a mod­ified amputation technique, which is described later. His method involves shortening the amputation stump by re­moving the distal portion of the femoral condyles, allowing easier prosthetic fitting. Through-knee amputation is pri­marily reserved for young, traumatic amputees and selected dysvascular amputees if salvage of a below-knee amputation is not feasible.

Technique

A sterile tourniquet may be used. Equal anterior and posterior or medial and lateral (sagittal) skin incisions are acceptable, depending on the condition of the skin. Bring the dissection anteriorly to the patellar tendon, and section it close to the tibial tubercle. Medially, divide the pes anserinus and semi-membranosus tendons close to their tibial insertion. Later­ally, divide the biceps femoris and iliotibial band distally, close to their tibial insertion. Enter the knee joint anteriorly, and divide the anterior and posterior cruciate ligaments at their tibial insertion. Divide the posterior capsule and neu-rovascular bundle, and ligate the popliteal artery distal to the superior geniculate artery. Remove the patella subperi-osteally, and reapproximate its bed with interrupted sutures. Using a saw parallel to the long axis of the femur, remove the femoral condyles 1.5 cm proximal to the level of the knee joint. Remove any sharp edges from the distal femur. A synovectomy is unnecessary. Pull the patellar tendon into the intercondylar notch, and suture it under moderate ten­sion to the remnants of the cruciate ligaments. Bring the semitendinosus muscle and biceps tendons into the inter­condylar notch, and suture them to the patellar tendon and cruciate anastomosis. Place a drain in the knee joint, and close the wound in layers without tension. Apply a rigid dressing in the operating room.

 

ABOVE-KNEE AMPUTATIONS

Indications

An above-knee amputation was once the most common am­putation performed for dysvascular disease because it healed reliably. Satisfactory prosthetic fitting for above-knee am­putations requires a shortened stump to allow the amputated limb to be equal in length to the contralateral limb; the junction between the middle and distal thirds of the thigh is the optimal level for this. A short above-knee stump (<5 cm distal to the lesser trochanter) is treated prosthetically as a hip disarticulation.

Technique

A sterile tourniquet may be used. Equal anterior and posterior flaps are commonly used, but medial and lateral (sagittal) flaps may be used instead. Because the blood supply and muscle mass are greater in the thigh than the lower leg, atypical flaps are more easily tolerated in an above-knee amputation (eg, with traumatic skin loss).

Fashion equal anterior and posterior (laps to accommodate the planned femoral transection at the level of the proximal portion of the flaps. Carry dissection anteriorly through the quadriceps muscle to the femur. Posteriorly, divide the hamstrings, identify the sciatic nerve, and sharply divide it as far proximally as possible. Identify the femoral artery and vein in the adductor canal, and doubly ligate and transect them. Section the femur with a Gigli saw, and bevel the cut ends. Trim the anterior and posterior myofascial flaps, and carry out a myoplasnc closure, suturing the anterior myofascial flap to the posterior myofascial flap.

In a well-vascularized amputation in a young patient (usu­ally traumatic), a myodesic closure can be done. Secure the anterior and posterior myofascial flaps to the distal femur through drill holes. Because the quadriceps (rectus femoris) and hamstrings span two joints, a myodesic closure can assist hip flexion (quadriceps) and hip extension (hamstrings). Af­ter closure, place a deep drain and close the wound in layers without tension.

SUPRACONDYLAR AMPUTATION The author described a supracondylar amputation in 1942. The procedure is accomplished through a simple circular incision placed on a level of the upper border of the patella. The internal saphenous vein is isolated and severed. This acts as a guide to the sartorius muscle. Four structures are identified and divided over the medial aspect of the lower end of the thigh. They are: the sartorius muscle, the gracilis tendon, the semimembranosus muscle and the semitendinosus tendon. Laterally, the tensor fasciae latae and the biceps femoris tendon are divided. The femoral vessels and the sciatic nerve are isolated, ligated and divided at the lower aspect of the thigh. The attachment of the quadriceps femoris muscle to the linea aspera is severed. The bone is sawed from 2 to 3 inches above the level of the skin incision. The fascia and the skin are approximated.

FIG. Supracondylar amputation. (A) A circular incision is placed at the level of the upper border of the patella. (B) The 4 medial muscular structures have been severed, and the femoral vessels are identified. (C) The periosteum is incised and dissected 2 inches cephalad to the skin incision. (D) The fascia lata is approximated.

 

 

HIP DISARTICULATION

Indications

Hip disanicularion is almost exclusively reserved for malig­nant tumors, which often occur in young patients. In the past, postoperative management of these patients involved use of a prosthesis primarily for cosmesis rather than am-bulation. However, recent advances in preoperarive and postoperative chemotherapy and aggressive treatment of metastases have increased long-term survival rates for these patients. Lightweight prostheses allow ambulation for these patients, although energy expenditure during ambulation is significantly higher than by nonamputees.

 

Technique

The most common technique is that of Boyd. Make an anterior racquet incision beginning at the antero-superior iliac spine and proceeding distally and medially, almost parallel to the inguinal ligament, to a point 5 cm distal to the origin of the adductor muscles. Ligate and divide the femoral artery and vein and the femoral nerve. Develop the incision in the posterior thigh approximately 5 cm distal to the ischial tuberosity. The incision should cross the lateral aspect of the leg approximately 8 cm distal to the vastus tubercle at the base of the greater trochancer and join the anterior incision at the base of the amerosuperior iliac spine.

Divide the sanorius and rectus femoris muscles at their origins, the amerosuperior iliac spine and anteroinferior iliac spine, respectively, and reflect them proximally. Then divide the pectineus approximately 0.6 cm from the pubis. Exter­nally rotate the leg, and release the iliopsoas from the lesser trochamer, and reflect it proximally. Detach the adductor and gracilis muscles from the pubis, and divide the adductor magnus from the ischium. Identify and ligate the obturator artery in the interval between the pectineus and obturator externus and the short external rotators of the leg. Transect the obturator nerve. Internally rotate the leg, and divide the gluteus minimus and medius at their greater trochanteric insertion. Divide the fascia lata and the most distal fibers of the gluteus maximus muscle in the line of the skin incision. Separate the tendon of the gluteus maximus from its insertion on the linea aspera, and reflect it proximally. Identify and transect the sciatic nerve. Divide the short external rotators close to their femoral insertion. Release the hamstring mus­cles from their origin on the ischial tuberosity. Enter the hip joint through the anterior capsule, and divide the ligamentum teres, allowing the hip to be disarticulated. Remove the leg.

Bring the gluteal flap anteriorly, and suture it to the origin of the pectineus and adductor muscles. Place several drains in the inferior portion of the incision, and close the skin without tension.

LEG AMPUTATION

The technic for leg amputation in the middle third utilizes a long anterior flap and a short posterior flap. The deep fascia is included in these flaps, and in those patients whose circulation seems to be adequate, an additional 2 or 3 inches of deep fascia is cut downward from the posterior incision so that a fascial flap remains attached. The anterior flap of skin and fascia is separatedat a little higher level than that point at which the bones are to be sawed. All soft tissues are severed to the bone about 2 inches distal to the point of bone section. The tissues are separated from the bone and retracted high enough to promote free use of the saw. The periosteum is elevated upward. The fibula should be made about 1 inch shorter than the tibia, because if it is left as long as the tibia, it becomes prominent and tender, producing a stump that will be difficult to fit. The nerves are drawn down as far as possible, ligated and divided. The vascular stumps are secured, and the muscles are approximated with fascial sutures. The fascia of the posterior flap is sutured over the end of the stump so that the muscle surface is carefully covered. The anterior skin-fascia flap is pulled downward and sutured to the posterior fascial layer.

FIG. Leg amputation. In C it should be noted that the fibula is cut at a higher level than the tibia; the tibia is beveled.

 

SYME’S AMPUTATION THROUGH THE ANKLE JOINT

This is a disarticulation with removal of both malleoli and the articular surface of the tibia. The incision passes under the heel, from the tip of the lateral malleolus to a corresponding point on the medial malleolus. The distal ends of the tibia and the fibula are exposed, and these bones are sectioned about 1 cm. proximal to their articular surfaces. The terminal branches of the peroneal vessels and the posterior tibials should be preserved. The anterior tendons are united to the calcaneus tendon or to the periosteum of the tibia. This amputation provides a good end-bearing stump, but it is difficult to fit with a prosthesis without producing a wide and ugly-looking ankle.

In the Pirogoff amputation, the posterior portion of the calcaneus is sawed off and ap proximated to the sawed end of the tibia and the fibula. Therefore, it is a modified Syme’s amputation, the only difference being that part of the calcaneus is retained and brought into contact with the divided lower ends of the tibia and the fibula.

FIG. Amputation through the ankle joint (Syme).

 

DENUDATION OF THE UPPER AND LOWER LIMBS’ VESSELS

         The surgery of the vessels is one of the contemporary medicine’s actual problems. This part of the medical science obtained the considerable development and the general recognizing only in the middle of the XX century. Its successes are interlinked with the working out of the renewing blood flow methods in the organs and extremities by the different pathology appearances.

         The surgery of the damaged vessels reaches by its roots the old time. The first information about bleeding stop from the vessels with the ligation belongs to times of Erazistrat (350-300 B.C.), Cels (I century A.D.) and Galen (130-200 A.D.). C.Cels the pupil of Hippocrates’ school who was at first the gladiators’ doctor for the first time offered to ligate the vessel in the wound by the ligature for the bleeding stop. But this instruction was quickly forgotten. The bleeding stop during a long time was realized by scorching iron or hot oil. Only in the XVI century the French surgeon Ambruaz Pare revived the application of the ligatures’ using for the ligation of the damaged vessels in the wound and for the extent.

         The first works in Russia on the surgery of the vessels fall down of the beginning of XIX century and were associated with Pelican’s labours. It’s important to observe that the idea about the expediemtness of the ligation at the same time the big artery and vein of the same name which is undeservedly attributed to Langenback was said by Pelican for 58 years before Langenback.

         In 1823 year the second big work on the curing of the aneurisms appeared and it was belonged to the pen of the famous expert of the vessels surgery I.V.Buyalskiy. His contemporary and not less famous surgeon prof. Salomon wrote: “If i must be operated on the occasion of the aneurism among all surgeons of the world I will trust only two: Estly-Cooper in England and I.V.Buyalskiy in Russia”. By the way this characteristic of Salomon is more important for us because he was first in Russia who did the ligation of the general and external iliac arteries on the occasion of the aneurism with the succes – the extraordinary difficult and considerable operation for those times.

         N.I.Pyrogoff did the big contribution in the development of the vessels surgery. His work “Is the ligation of the abdominal aorta by the aneurism of the inquinal part the easy for fulfilment and safe intervention” (1832) lied into the base of the teaching about the collateral blood ciculation. And in the work “Bases of the military-field surgery” the basic regulations about the operations by the wounding of the magistral vessels were formulated. Already in that time N.I.Pyrogoff offered an opinion about the coming time when the surgeons will be able to restore the integrity of the vessels by the wounding and don’t ligate them.

         It’s difficult to over-estimate the importance of the vessels. It’s known the blood in the arteries transport the nutrients and oxygen to the tissues and in the veins – take out the metabolism products and carbonic acid gas. This thesis is known from Harvey time yet, when in 1626 year the blood circulation physiology was described by him.

         Chosing the operative intervention in that or another part of the human body it’s very important to know the topographic anatomy of the part, where the operation is carring out, surgical anatomy of the vessel-nervous wall and pathophysiological peculiarities of the blood circulation. Just those moments determine the basic principles and tactics of the surgeon during fulfilment of the operative intervention.

All vessels can be divided on three groups: the afferent or transport vessels – the arterial group; the efferent ones – the vein link and the metabolic – the microcircular channel. It’s known that the arterial wall consists of three layers: the external one – the adventitia, the middle – muscular and internal – endothelial. Taking into account the prevalence of those or another structural elements in the wall of the afferent vessels all arteries are divided on three types: the elastic, muscular and mixed. The aorta, brachiocephalic trunk, carotic and subclavial arteries and other big vessels are belonged to the elastic type. The blood pressure is high in them, in the systole of the left ventricle it is the same as the pressure in the aorta. The arterial wall bears the pressure to 300 mm Hg. The arteries of the lesser diameter are the vessels of the mixed or muscular type. While the pressure lowering from the centre to the periphery the contraction of the arterial wall muscular layer becomes stronger that promote the blood passing into the arterioles, precapillares, capillares and veinuls system. According to this regulation the structure of the vessels wall is closely interlinked with the function of that or another part of the arterial system. As a result of the amortisational action of the elastic framework in the vessels wall they soften the shock wave of the blood stream from the left ventricle. The kinetic energy of the ventricle muscle contraction is converted by the elastic fibres in the potential energy of the arterial vessel wall. If it does not take place then the aortic wall after some time will the dystrophic changes and stop to fulfil its peculiar function. The presence of the elastic framework in the vessels wall ensure their tension, length and width strain, gaping of their hole in the wounds. But the potentional possibilities of the overstretch vessels and the contractive impulses itselves of the heart are not able to push the blood to the capillres, and then into the veins channel. The muscular layer in the vessels wall can help them. The last one in the vessels wall is always more expressed nearer the periphery of the vessels means the increasing the distance from the heart. It’s known the heart, the small muscular organ size as a fist, did extraordinary big work. According statistics of I.A.Kasirskiy the heart during 70 years of the human life pumps over 16 thousands tones of the blood. At the same time the pressure in the vessels of the different level remain constant. Two factors promote this – the contraction of the heart and presence of the vascular resistance which exceeds the pressure in the aorta into 10⁶. Certainly the contractions of the myocardium won’t enough for overcoming of such resistanse. The rhytmic contractions of the vessels muscular layer help it – just this phenomenon is called “the peripheric heart” or “the second heart“.

         The structure peculiarities of the venous system and its distinctions from the arterial one are conditioned by its function. The blood circulation in the veins is the result of the influence of two factors: the suck influence of the heart and thorax from one hand and the permanent entering of the blood from the arterial system into venous one on the other hand. The speed of the blood moving in the veins is slowed and more lesser the in the arteries. By it the pressure decreases to 10 mm Hg, and in the big venous trunks becomes zero or eveegative.

         The capacity of the venous system is bigger than the arterial one. The increasing of the venous channel capacity ensured for the account of the veins dimeter and their number increasing. Often one artery is accompanied by two veins on the extremities. The veins have a weel developed valvular apparatus which promotes the centripetal blood moving. Also it creates obstacles the reverse blood moving. The veins wall is more thin and elastic than the artery. It consists of three layers but there is no clear border between the layers as that is in the arteries. The middle layer is represented by the odd muscular fibres as the separate brunches and they are absolutely absent in the superior cavum vein.

         The microcircular channel includes the arterioles, precapillares, capillares, postcapillares and veinuls. Just on the capillares level the metabolism is provided. The arterioles have in their wall one layer or odd smoothmuscular cells which regulate the blood flow to the capillares and transcapillares metabolism by their contraction or weaking. However in the pathology condition or decreasing the volume of the microcircular channel the precapillares and even arterioles join.

         Operating on the vessels the surgeon must remember not only the structure peculiarities of the veins and arteries but have the clear notion about correlation of the vessel-nervous bunch parts and their correlation with the surrounding tissues – that’s the topographic anatomy.

         The vessel-nervous fascicules topography is determined mainly by two factors: in the first place the correlation of the vessel-nervous bunchs with the muscles and intermuscular spaces, in the second place their correlation with the fascias and the role of them in the creating the vascular vaginae. N.I.Pyrogoff payed the attention just to this regulation and his merit is that he firstly formulated the basic rules of the vascular vaginae structure. In detail these rules were stated by N.I.Pyrogoff in the book “The surgical anatomy of the arterial trunks and fascias” published in 1837.

         It’s important to pay the attention to the surgeons before N.I.Pyrogoff often use the vessels’ ligation operations but they compile the atlasses of the arteries surgery anatomy with this aim. But they payed the main attention to the form, size and direction og the incision for the approach to the vessels, leaving out the questions about vessels vaginae. The arteries in the atlasses were imaged isolationaly, without taking into account their correlation with the surrounding tissues.

         M.I.Pyrogoff does the new scientific point of view to the studying of the vascular-nervous formations topography. He wrote: “The searching of the arteria only then can be done with the exactliness and thoroughly …, when the position and attitude of the fibrous vaginae which contain the arteries, veins, nerves etc. are known by the surgeon perfectly”.

         As a conclusion M.I.Pyrogoff proposed three rules of the vascular-nervous brunch topography:

         The first and basic rule is that all vascular vaginae are formed by “the fibrous”, dense connective tissue and closely knitted with the fascia. On the extremities the vascular vaginae always merge with the posterior wall of the muscular vaginae and it’s possible to see them as the doubling of these deep fascial plates. By the other words the posterior wall of the muscle vagina in the anterior parts of the extremities is the anterior wall of the vascular-nervous fascicule which pass near the muscle. The muscular vagina at this time either unite with the vessel one or even create it.

It’s possible to give many evidences for the first rule confirmation. For example, on the shoulders the vagina of the two-headed muscle, and just its posterior plate, forms the vagina for the humeral artery, vein and medial nerve. Such conformity to natural laws in the vaginae structure is easy to see also on the thigh. So the sartorial muscle vagina is closely knitted with the vagina which envelope the femoral vessels.

         The second rule of Pyrogoff concerns the form of the vascular vagina. The vascular vaginae are three-rib prysm form in the transversal dissection. Also the prysm base is turned to the front and the top – to the back. Telling about the prysmatic form of the vagina Pyrogoff means the three-rib prysm placed so that one rib is turned to the front and two other – to the middle and front.

         The third rule of Pyrogoff concerns the correlation of the vascular vaginae to the deep tissues. The top of the prysmatic vagina is situated in the direct proximity with the neighbouring bone. The connecting of the vagina with the bone is accomplishing by a way of the periosteum knitting with the fascia or with the participation of the dense fibres.

         Beacause the vascular vaginae are connected with the adjoining tissues the muscular contractions can influence on the vessels. It’s especially seen in the fractures of the extremities with the fragments moving.

         There are the basic rules proposed by M.I.Pyrogoff. The vascular-nervous fascicules obligatory include the arteries, veins and nerves, and are not dependense of the body region. The anatomic unity of this fascicule excites in it. But there is also the functional unity besides the anatomic one. The artery brings the blood saturated of the oxygen and nutritive substances. It gives them the nerves, arteries and veins wall through the thinnest branches, it supplies them by the blood. At the same time the vein takes away the blood from the nerve and artery and in that way supports the constant metabolism. The nerve through the smallest branches innervates the arteries and veins walls. The nutrition of the vessels is disturbed without nervous regulation. It’s neseccary always to account it in the extracting of the vessels. It’s not deserve to extract the artery on the strech of the long interval it leads to the dystrophic processes in the vascular wall and can lead  to the arteria aneurism formation finally.

         Accordingly the rules of P.F.Lesgaft it’s necessary to remember that:

         1. All main trunks of the arteries are situated on the concaved, bended body and extremities surfaces. Just the concaved surfaces are the shortest ways of the blood passing.

         2. The arteries trunks wall according to the structure of the bone’s base and unite on the periphery by the arterial arcs. So there is only one bone on the shoulder and thigh and accordingly there are by one big artery. There are by two bones on the forearm and shin and accordingly – by two big arterial vessels; there are five rays on the brush and foot and accordingly – by five big vessels. The second part of this rule testifies that the arterial trunks on the periphery united archwise. And really, for example, there are the complex anatomic arcus (nets) which are characterised by the big potential possibilities in the violated blood circulation compensation in the region of the ulnar, genus, talocrural and other joints.

         3. All trunks on their stretch give the branches. The dimensions of each branch are correlated to the organ activity energy.

         4. The arteries make the thick nets and by-passing collaterals in the mobile places. The functional sense of this rule is very important. If the collateral ways will be absent, for example, in the region of the ulnar joint then slipping with the bent elbow you can to awake with the necrotic forearm, since all vessels would be pressed in those conditions. The presence of the collateral ways prevents these complications.

         Taking into account the placing of the extremities’ vascular-nervous fibres in the operative approaches to them we must use theproectal lines as a refference-point for the incision.

         The proectal lines are conducted mostly in the intermuscular intervals direction in which the blood vessels pass. The outgoing points for this are most permanent anatomic formations which are not liable to the displacement. So the proectal line of the humeral artery passes from the middle of the inquinal hollow to the middle of the elbow dimple, the radial – from the middle of the elbow dimple to the internal edge of the ray awllike processus. On the lower extremity: the proectal line of the femoral artery passes from the middle of the inquinal ligament to the posterior edge of the thigh internal epicondyle (Ken’s line) etc.

         It’s  necessary to account the directed moments in the making the operations on the vessels. But that’s not enough yet. The surgeon must remember about main – means the anatom-physiologic mechanisms of the blood circulation renewing after the ligation or thrombosis of the big arterial trunks. At last the bleeding stop and renewing of the violated bloof circulation are one of the main surgery tasks which determine the successes of the majority of the operations.

On the contemporary stage of the surgery development it’s necessary to see the ligation of the main-way vessel as the forced operation, often these actions testify about the surgeon’s weakness. The ideal of the surgical operation in the big vessels damaging must be the operation which is directed to the renewing of the violated blood circulation – the vascular suture and vessels plastic.

         All operations in the blood vessels diseases and damages are divided into four groups:

 1) the operations conducing to the liquidation of the vessels hole (the ligation of the vessels);

 2) the operations directed to the renewing of the vessels passaging (the vascular suture, shunting etc.);

 3) the palliative operations;

 4) the operations on the vegetative nerves which innervate the vessels.

         The ligation of the vessels is the most spreading method of the bleeding stop in the blood vessels wounds. The great destruction often have a place in such wounds that doesn’t be able to connect their edges for the vascular suture putting on.

         The ligation of the vessels is possible to do by two methods: in the wound and on the extent.

The ligation of the vessels in the wound is done mainly in the process of the primary surgical wound working up or in the traumas that accompany with the gap of the artery or vein wall.

The ligation of the arteries on the extent means above the wound place is done in such cases when the search of the bleeding springs in the wound is difficult or there is the danger to contaminate the surrounding tissues in the manipulations, also in the higher amputations or exarticulations of the extremities. Such cases are the bleedings og the splintered tissues, the contaminated wounds, the damaging of the vessels the ligation of those is connected with the searching of the bleeding springs in the big muscle mass (the gluteal arteries) etc.

The operative approach is realised by the layer incision of the tissues taking the proectal lines of the arterial trunks bearings. The straight approach to the vessels is shortest. But many vascular-nervous fascicules are built so that the artery is covered by the nervous trunks in the proectal line and it’s easy to damage them in the straight approach. That’s why the approach in such cases is realized not in the proectal line but step back from it to 1-2 sm means it’s realized by the round way. The axillar and humeral arteries on the upper extremity, the popliteal and posterior wall arteries in the middle third on the lower extremity are ligated in the round approach.

The soft tissues are incised on the own fascia in the round approaches. The nearing muscle is moving out after the incision of the own fascia which create the anterior wall of the muscle vagina and then the posterior wall of the vagina, which is at the same time the anterior wall of the vascular-nervous fascicule vagina according the first rule of M.I.Pyrogoff, is incised. It’s neccessary to enter the solution of the novocainum in the vagina incision. The novocainum on the one hand performs the hydravlic preparing, on the other – supplies the blockade of the reflexogenic zones. The arterial vessel is ligated by the silk ligatures after its removing. We must to put on the central end two ligatures one of which is lace inserted. The last prevents the slipping down of the proximal ligature and possible bleeding. The peripheral end of the vessel is ligatured by the separate silk ligature. In the incomplete incision of the vessel the last one is cut without fail between the peripheric and lace inserted ligatures. It’s neccesary to remember that the nuding of the vessel on the long extent (more than 5 sm) can lead to the violation of its wall trophic and aneurism formation in the postoperative period. The switching the big vascular main-ways off is accompanied the decreasing of the blood flow to the distal extremity partand so to the tissues’ hypoxia, the general contraction of the microciculatory channel most violation of the blood flow in the distal extremity part. That’s why the choice of the ligation place for each vessel on the extremity must always be anatomically based, most optimal for the collaterals appearance in the postoperative period.

The interval of the vessel placed distally branching of the neck-thyroid trunk can be the ligation place for the subclavicular artery. The collateral blood circulation develops through the shoulder-blade vascular circle namely: the anastomosis between transversal neck artery, its descending branch and artery circumflexing the shoulder-blade; the transversal shoulder-blade artery and artery circumflexing shoulder-blade, branch of the subshoulder-blading artery.

The ligation of the axillar artery is most worth while to do above branching the subshoulder-blading artery. The renewing of the blood circulation in the humeral artery means more distally the place of the ligation will take place through the same collaterals which functioned after the ligation of the subclavicular artery.

It’s most worth while to ligate the humeral artery in the middle third of the shoulder. The collateral blood circulation develops through the ulnar joint after the ligation. The ligation of the humeral artery above the the branching of the deep artery is often accompanied the gangrene development on the extremity (6-9%).

After the ligation of the ulnar artery the renewing of the blood circulation in the distal parts of the extremity will be done through the radial artery and deep arterial palmar arcus, and the ligation of the radial artery leads to the development of the blood flow through the superficial palmar arcus and ulnar artery.

It’s worth while to do the nuding of the femoral artery and its ligation above the branching of the deep femoral artery. The collateral blood circulation in such cases will renew through the anastomosis between the lower gluteal and lateral artery circumflexing the femoral bone, also between the medial artery circumflexing the femoral bone and obturative one. The ligation of the femoral artery lower of the deep artery branching involves the arterial net of the genus joint into the collateral blood circulation. The same collaterals will develop also after the ligation of the popliteal artery. The collateral blood circulation in the distal part of the shin and foot will renew through the anterior tibial and fibular arteries in the ligation of the posterior tibial artery, and through the posterior one after the ligation of the anterior tibial artery.

The effectiveness of the collateral blood circulation is in the straight dependense of the following factors:

1) the diameter of the intervascular anastomosis;

2) the presence of the preexisting collaterals, their degree of the functioning intensivity;

3) the kind of the pathologic process. The gradual reorganization of the collateral net is done, the collateral blood circulation renews in the whole size in the chronic processes, assosiated with the blood circulation violation in the main-way; the development of the compensational blood circulation is done very difficult in the acute obturation of the main-way vessel;

4) the functional condition of the tissues, their needing in the oxygen’

5) the general condition of the haemodynamic (the minute volume, blood pressure).

The sufficientless of the collateral blood circulation must be accounted by the surgeons in the preoperative period from the view-point of the vascular ramus branching from the basic main-way.

It was established by the works of M.I.Pyrogoff, B.O.Dolgo-Saburov, V.V.Covanov and others that the blood circulation stop in the big trunk leads to the functional intensification of the existing anastomosis, and later there is the developing of the preexisting collateral ways, also the additional intervascular connections develop. The sudden ischemia arising in the first days after ligation of the vessels decreases gradually. The maximal mobilisation of the compensational functions has a place here.

Analysing the anatomic ways of the by-pass blood circulation it’s possible to divide them in such kinds:

 1) the round vessel by-pass channel (paravasalic) in which the collateral blood circulation becomes more intensive by means small vessels of the big vessles wall in the obliteration of the main trunk; the paranevral ones – they are especially expressed along the gluteal nerve;

 2) the arterio-venous anastomosis – the arterial blood, doesn’t come to the capillares, can have a good influence on the improvement of the blood supplying of the extremities periphery in the damaging of the main arterial trunk;

 3) the main by-pass ways of the blood circulation by means the anastomosis between the branches of the arterial vessels which take part in the vascularisation of the determined region or neighbouring regions which pass the blood to the lowerlaying parts of the ligatured big vessle through the anastomosing one with another vessels of the muscles, skin etc.

         But the existense of the by-pass ways of the blood circulation doesn’t quarantee their fubctional full value since the blood volume which flows through the collateral vessels is not efficient for the supply of the full value metabolic processes in the extremities tissues. The development of the collaterals is closely connected with the peculiarities of the tissues structure in which the vessels pass. The functional possibilities of the collaterals in the dense tissues, for example, in the region of the ligaments of the ulnar and genus joints, are not sufficient.

         The vessels can’t increase to the dimensions which can pass the blood in the sufficient volume because the density of the surrounding tissues.

         The many measures are used for the improvement of the by-pass blood circulation after the operation:

   1. Before the operation:

         1) the training of the collaterals;

         2) the novocaine blockade of the vessels;

   2. During the operation:

         1) the cut the artery between two ligatures;

         2) the extirpation of the sympathetic nodes, desympathisation, denervation of the vessels;

         3) the ligation of the artery and same name vein (Oppel, 1906) for the slowing down the blood flow and to support the sufficient blood pressure above the ligation place;

   3. After the operation:

         1) the infusion of the oxygenic blood with small portions;

         2) the warming of the extremities but not with the hot things because that leads to the local hyperemia and collecting of the blood in one place;

         3) the entering of the spasmolythics;

         4) the massages, physical procedures which promote to the widing of the small vessels.

 

THE VESSEL SUTURE

         The second group of the operative interventions on the vessels are the operations directed on the renewing of the blood flow in the vessels. These groups of the operative intervention are most difficult and pay the special attention of the surgeons. The operations which are directed on the liquidating of the vessels space often ends by the gangrene of the extremity or necrosis of organ’s part. The vessel suture payed the attention of the surgeons long since. First Hellowell seamed the wound of the artery with the good result in 1759.

         In the antiseptic period the performance of the circular suture mainly end as a failure. The impulse for the discovery in this problem was a research of N.Shults and S. Lubnitskaya who first prove the possibility to the autohealing of the small (for example after treating bleeding) wounds of arteries. Also the investigations of M.V.Ekk for the providing of the anastomosis between superior cavum vein and vein porta. The basic principles of the vessel suture was written in the classical experimental research of Y.I.Yasinovskiy and mean such as: the carefull hemostasis, little trauma of the vessel wall, especially inthime, prevention of the constriction of the vessel on the suture place. Just middle and external vessel coat must be seamed. The invasion of the suture material in the vessel space always increase the making of the thrombs.

         Such theoretical basic of the vessel seaming is actual now too.

         Firstly, in the clinical practice the vessel suture was used by V.G.Cegen-Muytenfel in the town Derpt, I.P.Sabanejev in Odessa, L.V.Orlov in Charkov.

         If the suture in the vessel wall was put in the whole perimetre – it is the so-called circular suture. In the case when seamed just part of the vessel – it is the side suture. Today it is known over 60 types of vessel connections, they able to divide in the mechanical, hands, without seaming. During longtime by the vessel seaming severe follow such rules:

         1) the vessels ends which seaming must touch to the seams line for their smooth internal surfaces, but vessel seaming must don’t make trauma of the internal coat of the vessel;

         2) for the prevention of the thrombosis the material of the suture don’t expand to the vessel space or minimal contact with the blood;

         3) the suture must provide germeticness of the vessel joint. Also it must don’t constricts the vessel in the suture place.

         It is known today the plenty of the vessel suture modifications are offered which are based on the classic Charrel’s method. This method means: the ends of the vessels approach by three suture-fixers which made through all thickness of the vessel wall on the equal distance one from another. Then they are extended so for transversal section was the equal sides triangular. On the place of wall contact provide around suture through all coats of the wall. Such measure supply the tough touching of the wound edges and help the surgeon don’t injure the internal vessel wall. But simultaneously it prevents the the constriction of the vessels anastomosis. It’s imporatant to put the sutures correctly, the distance between them must be not over 1-2 mm.

When one side of the triangular seamed the basic throd ties with the throd of the suture-fixer. For the comparing of the germeticity of the suture fixing instruments take away first from the proximal edge of the vessel, lately – from the distal edge. If the germeticity is damaged it’s necessary to put the additional П-shaped sutures.

Such suture was discovered by A.M.Morozova. oppositionally the previous one the author advises to use just two suture-fixers, one opposited to the another one. The lack of the twine-round circular suture is that seam material always expand in the vessel space. Also the interval coat of the edges don’t tough contact in all surface.

The principle of the precise touching of the internal coats of the vessels (inthime to inthime) performed in A.A.Polyantsev’s modification (1945). The author offer to approach the edges of the vessels by means of three П-shaped sutures which turn the wall of the suture. After the extension of the edges and their contacting the circular suture is put. G.L.Ratner (1965) improve that suture – instead three П-shaped suture-fixers he put just two, then to equaling of the regularity sutures, offer twine-round suture combine.

With the overputing for better touching of the internal coats of the vessels and prevention penetrating v through the wall in the vessel space Gorsley offered uninterruptive circular suture by which distal and central edge’s inthime conducting in the fold shape make small bank.

For such aim the invaginative methodics of the vessel seam were irented by G.M.Solovyov (1952) and Y.N.Kryvchykov (1959). The methodics are especially useful in the conduction of the vessels with the different diameters.

 

THE METHOD OF THE VESSEL CONDUCTION WITHOUT SUTURES

         Payer investigation (1900) found the beginning of the vessel conduction without sutures. For such aim the author offered the magnesium tubes (1 sm long) which are reduced in the organism during certain time. On the tubes surface was printed little horrows for the fixing of the vessel wall. But it follow to the unpossibility of the anastomosis. Also later on the place of the magnesium tubes vessels constricted. Later this method was improved choosing of the material for the tubes stay more severe, the forms of the tubes stay more plenty shaped. Frequently for the corrective material the celoydinum, fibrinum, tube-shaped decalcificated bones are used. In the past for the conduction of the vessels “end to end” or “side to side” spreadly used the iron rings by Donetskiy. In this method the central edge of the vessel is inserted in the ring, the edge is turned as small cuff, penetrate from the thorns which are situated on the ring. Then the central edge of the vessel is inserted in the space of the distal edge which also penetrate from the thorns. The lack of this method is present in the vessel wall rigid unelastic ring, also the problems of the conductions of the vessels in the inflammatoried conditions.

 

THE MECHANICAL SUTURE OF THE VESSELS

         For the easing of the technic of the vessel suture the shorting of the operation time in the surgery use the aplicements for th e vessel seaming which firstly was created by Gudov, Petrova, Androsov. The joint of the vessels by this type of the circular suture implements by the П-shaped tantalum screps. The screps pass through both walls of the vessel automatically bowed (similar to seam of the paper sheats in the copybooks). It provide according the germeticity of the sutures.

         The operations for the restoring of the vessels passage include large and relatively young department of the surgery – the vessel plastic:

         a) the plastic of the side deffects of the vessels;

         b) the insteading of the circular deffects of the vessels, if the wounding deffects along over 4 sm, restoring must be provided with the transplantants. Relatively to the conditions of the tissues which are used for the restoring the circulation are such types of the artificial vessels: autoplastic, alloplastic, xenoplastic, explantation of the artificial vessels.

         The autoplastic of the vessels. Such operation includes the usage for the plastic the tissue of the organs. For the insteading of the circular deffects of the arteries Carrel offered in 1912 to use the veins with the different diameters. The autovenous plastic today spreading in the medicine. In the suture must be put double venous wall because the thickness of the vein is more thin then in the arteria, anastomosis line must be forced by the different small cuffs from the tissues or the synthetic matters. It’s necessary to note in such operations the presence and the direction of the valves in the vein – proximal edge of the autovein matter necessary seam with the distal edge of the artery.

         The venous autoplastic is some limited in the spreading because is not always able to obtain adequate transplantants in long and diameter. The insteading of the circular deffects by the arterial autotransplantants is used rarely.

         The alloplastic – it’s the operation for the  insteading of the circular deffects of the vessels by the material from the organism in same species. Thus, here are the repositions of the arteries segments from one human to another so use conservated and lyophilisated vessels from the corpses. The lyophilisation decreases the antigen properties of the transplantants and reaction “hostverse gift” for the foreign tissue become less expressed. The satisfactive results was obtained in the clinics by the insteading of the large segments of the aorta, superior and inferior cavum veins. The later results are well investigated too. But frequently the calcinisis of the transplated segments, increasing of the fragileness, tearness of the vessels wall with the death occurs.

         The xenoplastic – it’s the transplantation of the segments of the arteries and veins between the different biological species (from the dog to the monkey, from the pig to the human). Such type of the plastic operation is not spread in the clinical practice, the similar operations had not left the borders of the experiment.

         The explantation – means the transplantation of the nonalive matter namely the synthetic artificial vessels, for the substitution circular deffects of the veins and arteries. Certainly the success of this part of the surgery connected with the achievements in the chemistry of the polimeric joints because for the substition usable dacron, thephlone, orlon, polypropilen, others. The industry produced the bunched, weared and tissue artificial vessels, they can be necessary shapes and dimension. Best from other are suck artificial vessels the water penetratibility of which is about 0,94-1,2 litre per minute. By littre penetratibility probably occurs the treating of the rude thick inthime. Whole endothelysation of the transplantants remain in 4-6 months after the operation. But dure long being in the organism the firmness of the transplantants stay less. Today use the half-artificial biological vessels which penetrated of the collagenum with the adding the heparine and antibiotics for the prevention of the contamination.

         Sometimes by the vessels thrombosis use the shunting of the vessels. The shunt – is the English word the surgeons have borrowed it from the machinery. In the vessels surgery the shunt sagnificates the creating of the new temporary or permanent round-about circulation. Properly creating of the shunt make the possibility to put the seam on the vessel. The shunting is one of the prevention methods of the oxygen lack for the head and spinal brains by the operation of the aorta’s removal and usege of the hypothermia make possibility to the best achievements of the results in the postoperative period. But the squeezing of such large vessel as aorta always can follows to the brodening of the ventricals that is caused by the pressure’s increase in the heart spaces. The usage of the hypothermia with creating of the shunt make possibility to the avoking of the difficult complications.

         There are the temporary and permanent shunts. We must again as a certain a fact that the idea of the circulation restoring through the inner shunt as a autovenous plastic of the deffects belongs to Sweden scientist Carrel. As the author of the vessel suture, usage of the veins to the autoplastic operation, method of the vessel shunting Carrel was rewarded from the Nobel’s prise. After breaking of the operation temporary shunt must be removed.

         Accordingly to the opinion of the majority of the scientists – B.P.Petrovskiy, O.O.Vyshnevskiy, N.I.Krakovskiy, De Becci, Culi the external or temporal shunt is the best method for the tissue ischemia prophilaxy.

         The acute arterial occlusion can be a result of the embolia or thrombosis of the vessel. So in such case the choice operation is the embolectomia. The sense of the operation significates the removal of the embolic particle of the valves after sclerosis which have torn from the vessel space. The success of the operation is directly dependent from the time of the implemention. Accordingly to data by G.L.Ratner (1974) the healing and later well results have place in 84 % of the patients who have the operation in the first 12 hours after the vessel damaging in time where the process which connected with the ischemia is reverseble. In the progressing of the ishcemia signs the embolectomia is the acute surgery obligatory invasions.

         For the patients with the acute thrombosis of the arteries the surgery treating indicated only in cases with the segmentary process. In the segmentary thrombosis of the large arterial trunks indicated the thrombectomia – the removal of the thromb from the inner coat of the vessel wall.

 

THE PALLIATIVE OPERATIONS

         Such operations don’t eliminate the basic disease but frequently decrease the risk of the pathologic cases or are one from another preparing stages before the radical operation. For example the ligating by the silk ligature of the afferent vessel in the aneurisma’s case (the method of Anel-Gunter), the afferent and efferent vessels (the method of Vreden-Gorsley) and also covering of the eneurismatic sacc in the case of the unoperable aneurismae that decrease the degree of the risk of the aneurisma tearing.

         It’s necessary to verify to the palliative operations the invasions on the vegetative nervous system (the operation of Diets). The sense of the operation is the removal of the sympathetic nodes in the lumbal regions. Mainly the operation is performed in the early stages in case of the obliter endarteriyitis or other sclerosis of the lower extremity vessels.

 

THE OPERATIONS ON THE VEINS

         The operations on the veins are one of the most actual problems of the vessel surgery. The difficultness of this department of the surgery caused first from the especialities of the anatomical structure and circulation in the venous system. As early mentioned wall of the vein is thin, have the valves, collapsing easy. Slowly blood circulation promote the stasis and increasing of the hydrostatic pressure in the veins it can cause the permanent boarening of the veins and valve insufficiency. The increasing of the venous pressure can promote throwing of the arterial blood in the veins through the numerous arterio-venous anastomosis. It’s known tough connection between the superficial and deep venous systems. The circulation changes in the one system cause the pathological changes in the other one. Thus, dure long time increasing of the pressure in the system of the deep veins accompanies with the functional insufficiency of the valve apparatus of the communicant and small superficial veins, later in the pathology enlist the superficial venous mains too.

         It’s important to note the varicosis of the low limbs veins more frequentle occurs in the wemen. This phenomenon can be explained as the especialities of the anatom-functional conditions of the women organism namely:

         1) more wide pelvis than in men it causes the increasing of the angle of the confluence veins of the low limbs in the pelvis vein and slowly blood flowing in the superficial venous system;

         2) overflowinf of the the pelvis vein from the blood dure menorhea;

         3) also the pregnancy mainly assit veins’ boardering;

         4) more soft resistance to the vessels from the near laying tissues;

         5) the female’s wall of the vessels are more thin and accordingly easy boarden.

         The phenomenon of the stagnation of the vein leads to the trophical violations in the soft tissues of the low limbs. Thus the aim of the surgery treatment of the vein varicosis is the elimination of the blood stagnation in the superficial veins. Such aim we can achieve by the way of the removal the superficial venous net and creating the optimal condition for the circulation through the deep veins. There are the next methods:

         1) the Madelung’s method – the general removing of the boardened veins of the thy and ankle along all extent from the longitudinal incision;

         2) the Narhat’s method – the removal of the veins parts from the separate cutting of the skin and soft tissues;

         3) the Bebcock’s method – the subcutaneous dragging out of the veins by means of the special medical probe.

         For the elimination of the blood throwing from the deep venous net in the superficialis one spreads the method of Kocket-Linton when simultaneously with cutting out of the superficial veins provide the ligature of the over- and subaponevrotically situated the perforant veins. It’s understandly that all surgery invasions able just of the deep veins. In the case of the violations of the deep venous net functioning early indicated operations are unreasonable.

         Sometimes the surgeons use more delicate correction of the venous stagnation such provide the reposition of the superficial ways under the wide fascia (the Ratner’s method) or even in the muscles bodies (the Check-Katsenstein’s method). Last years appear the new method of the creating of the venous valves through the invagination of the own vein’s wall (the method by Giano) or ligaturing of the channels of the large subcutaneous veins of the thigh. Sometimes the correction of the valves implements by the extravasal constriction of the subcutaneous vein of the thigh by means of the spiral (the A.M.Vedenskiy’ method).

         Touch to the venous pathology of the upper extremity it is coonected with the violations of the circulation. For example Pedget-Shretter syndrome is a result of the acute thrombosis of the subclavial vein. Featurly here is the swelling of the upper extremity, acute pain. The removal of the thromb or thrombosis by means of the pharmacological measures assist the whole restoring of the extremity function. For the disorders of the circulation in the upper extremity we can add – the overextension of the anterior interscalenus muscle (the Nefcyger’s syndrome) or the pressing of the subclavial vessel by the trapezoid muscle, by remain of the neck’s ribs (neck’s ribs syndrome), by small chest muscle (the muscular pelvis minor syndrome) and others. But with the elimination of the causes of the circulation’s disorders the function of the extremity restore rapid.

         Thus marking the conclusion of the surgery invasion on the vessels we have all reasons to note that the modern stage of the development of the vessel surgery assist us to the providing of the restoring blood system for the prevent of the acute complications and save the patient’s life.

 

 

RECOMMENDED LITERATURE:

1.     Mark W. Wolcott. Ambulatory Surgery End The Basic Of Emergency Surgical Care.-Philadelphia:J.B.Lippincott Company,2001.-752p.

2.     Michael F. Mulroy.Regional Anesthesia /The Virginia Mason Medical Center/ Little, Brown and Company,1998.-327p.

3.     Richard M. Stilman,M.D.,E.A.C.S. General Surgery /Review And Assessment/ Appleton Century Crofts, 1999.-328p.

4.     Kent M. Van De Graff, Stuart Ira Fox, Karen M. Lafleur. Synopsis of Human Anatomy and Physiology /WCB McGraw-Hill/, 2004.-675p.

5.     John J. Jacobs. Shearer’s Manual Of Human Dissection /McGraw-Hill Information Services Company, 1998.-300p.

6.     Branislav Vidic,S.D. Manual Of Dissection /The C.V.Mosby Company/ St.Louis Toronto Princeton, .1997.-120p.

7.     Philip Thorek. Anatomy In Surgery /J.B.Lippincott Company/,1996.-935p.