RU2354312C1 - Method of lower limb amputation at shin level - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to traumatic surgery and orthopaedics and can be applied for lower limb amputation. Anterior and posterior skin-fascial flaps are formed, anterior flap exceeds posterior flap in size, posterior flap includes gastrocnemius muscle. During amputation at level of shin upper third, medial and lateral heads of gastrocnemius muscle are cut between, shin bone sawn surface is covered with placed in cross-like way heads of gastrocnemius muscle. During amputation at the level of shin middle third shin bone sawn is covered with whole tendon of gastrocnemius muscle.

EFFECT: method allows reducing risk of osteomyelitis development, formation of fit for prosthetics stump.

2 ex, 11 dwg

Description

The invention relates to medicine, namely to general surgery, and can be used for the treatment of patients with diabetic foot syndrome (CDS), chronic obliterating diseases of the arteries of the lower extremities (HAZANK), frostbite and traumatic secessions of the lower extremities. Closest to the claimed solution is the "Method of leg amputation according to E. Burgess", used to remove the lower limb according to any indication, including patients with vascular diseases (R. Baumgartner, P. Botta "Amputation and prosthetics of the lower extremities", M .: Medicine , 2002, p. 170-174).

The disadvantage of this method is the movement of the surgical scar completely on the front surface of the lower leg, as suggested by E. Burgess (1967), which is not always advisable, because the postoperative scar is located on the working surface of the stump, which is extremely unfavorable for subsequent prosthetics, and in the early in the postoperative period, there is a coincidence of skin and bone wounds, and if infectious complications occur, the risk of developing tibial osteomyelitis increases.

The objective of the invention is the prevention of osteomyelitis of the tibia and the creation of the most suitable prosthetic stump.

The task is achieved in that the method of amputation of the tibia involves the formation of two flaps, the front of which is larger than the back, which allows you to cover the sawdust of the tibia and fibula with a flap of the calf muscle in a certain way: at the level of the upper third of the leg, the calf muscle is cut between the heads to the tibia sawdust and placed crosswise above the last; at the level of the middle third - they cover the bone fillet with the common tendon of the calf muscle, which is fixed to the muscles of the anterior group of the leg and periosteum, which helps to distinguish the postoperative wound from sawdust of bones and is the prevention of osteomyelitis in case of infectious complications from the wound, as well as favorable for prosthetics and successful rehabilitation this group of patients.

The invention is illustrated by drawings, where

figure 1 - diagram of the cutting of the front flap at the levels of the upper and middle third of the leg;

1 - tuberosity of the tibia;

2 - the upper third of the leg;

3 - the middle third of the leg;

figure 2 - diagram of the cutting back flap at the levels of the upper and middle third of the leg;

figure 3 - diagram of the cutting of the front and rear flaps on the medial surface of the leg (upper and middle third);

a) the inner edge of the tibia;

4 is a diagram of the cutting of the front and rear flaps on the lateral surface of the lower leg (upper and middle third);

4 - a long fibular muscle;

5 - soleus muscle;

6 - calf muscle;

7 - a groove between the peroneal and soleus muscles (posterior groove of the lower leg);

5 is a diagram of a T-shaped skin incision on the back surface of the lower leg (upper and middle third);

8 - calcaneal tendon;

9 - the upper third of the leg;

10 - the middle third of the leg;

6 is a diagram of the separation of the calf muscle from the soleus (upper and middle third of the leg);

11 - lateral epicondyle of the thigh;

12 - head of the fibula;

13 - calf muscle;

14 - soleus muscle;

15 - front skin fascial flap;

16 - posterior skin fascial flap;

l ₁ - the length of the calf muscle;

l ₂ - limb diameter at the level of bone cut;

Fig.7 is a diagram of a section of the calf muscle between the heads to the level of sawdust of the tibia (upper third of the leg);

Fig. 8 is a diagram of a cross-shaped laying of the heads of the gastrocnemius muscle over bone sawdust (upper third of the tibia);

17 - lateral head of the calf muscle;

18 - medial head of the gastrocnemius muscle;

Fig.9 is a diagram of the formation of the posterior flap at the level of the middle third of the leg;

figure 10 - diagram of the laying of the tendon of the calf muscle above the bone filings (middle third of the leg);

11 is a final view of the stump with the location of the scar on its posterior surface.

The method is as follows.

The surgical field is processed in a standard way. Then proceed to cutting two flaps: the anterior cutaneous-fascial (Fig. 1) and the posterior cutaneous-fascial-muscular during amputation at the level of the upper third or the cutaneous-fascial-tendon - at the level of the middle third of the lower leg (figure 2), in which the anterior the flap should be larger than the back, and their length in total should be the diameter of the limb, which is equal to 1/3 of the circumference of the limb at the level of bone cutting (G. Ostroverkhov, 1995). To do this, determine the direction of the incision on the skin surface with a felt-tip pen, which starts from the medial side of the tibia from the inner edge of the tibia at the level of its tuberosity or 5-7 cm lower (upper or middle third of the tibia), depending on the clinical situation and skin condition (Fig. .3), continue arcuate along the anterior surface of the lower leg to the line from the lateral side corresponding to the groove between the peroneal and soleus muscles (Fig. 4), then follow the posterior surface of the lower leg, ending at the inner edge of the pain ebertsovoy bones at the same level at which you started.

After that, a skin incision of the anterior and posterior flaps is performed along the outlined lines.

The skin incision of the anterior flap reaches the muscles and periosteum and includes its own fascia of the lower leg, which is separated from the latter. The skin incision of the posterior flap reaches the fascia and continues down the middle of the posterior surface of the lower leg to the Achilles tendon, forming a T-shaped skin incision (Fig. 5), which allows to isolate and cross the calf muscle, which is part of the posterior flap at the level of the upper third, or its total the tendon - at the level of the middle third of the leg so that the muscle length (l ₁ ) exceeds that of the posterior fascial and fascial flap by the diameter of the limb at the level of bone cut (l ₂ ). Then, on the outer surface from the upper third of the lower leg to the Achilles tendon, the gap between the calf and soleus muscles is found and it is stupidly and sharply separated between them under visual control, the last is excised (Fig.6). On the posterior surface of the lower leg, crossing at the clamps and ligation of the large saphenous vein with simultaneous shortening of 4-5 cm proximal to the sharp scalpel of the saphenous nerve are performed.

The flaps are turned up and complete the first stage of the operation.

At the second stage, the anterior (m. Tibialis anterior, m. Extensor digitorum longus, m. Extensor hallucis longus) and lateral (mm. Peronei longus et brevis) muscle groups of the tibia are crossed in one plane 1-2 cm distal to the base of the skin flaps with a preliminary by flashing them for simultaneous ligation of muscle arteries and veins. After crossing the muscles, the anterior tibial arteries and veins are separately sutured and additionally ligated. Superficial and deep peroneal nerves after perineural anesthesia 3-5 ml of 1% solution of novocaine or lidocaine are crossed with a sharp scalpel 4-5 cm proximal to the plane of the cut muscles. With blunt hooks, the muscles are pushed up.

At the third stage, the fibula is exposed, its periosteum is circularly dissected at the level of the proposed bone section and displaced in the distal direction by 0.5 cm, and in the area deprived of the periosteum, 2-3 mm back from its edge, the fibula is cut using a Gigli saw.

The tibia is sawn with a saw Gigli distal to the fibula by 1.5-2 cm. The outer edges of the bones around the entire sawdust are carefully smoothed with a rasp. And the front surface of the crest of the tibia is cut down by 2-2.5 cm with a jigsaw or knocked down with a chisel, rounded and cleaned with a rasp. After that, the interosseous membrane and part of the muscles of the posterior tibia group (m. Flexor digitorum longus, m. Tibialis posterior) are crossed and the posterior neurovascular bundle (a. Et vv. Tibiales posteriores, n. Tibialis) and fibular arteries and veins (aa . et vv. peroneae) so that the arteries and veins are sutured and additionally ligated separately, and the nerve after perineural anesthesia is cut off with one blow of the blade 4-5 cm above the level of soft tissues. After this, the long flexor of 1 finger and the soleus muscle (m. Flexor hallucis longus, m. Soleus) are crossed, with the exception of the gastrocnemius muscle, which is part of the posterior flap, both at the level of the upper and middle third of the leg, respectively, with its muscular or tendon part. The final hemostasis of the arteries and veins of the lower leg.

At the final fourth stage, plastic stump surgery is started. For this, during amputation at the level of the upper third of the leg, the calf muscle is dissected between the heads to the level of the tibia sawdust (Fig. 7). The latter is covered with cruciform heads, with the lateral head of the calf muscle being displaced medially and fixed to the periosteum of the tibia, while the more powerful medial one is laterally displaced and sutured to the muscles of the anterior tibia above the previously laid lateral head (Fig. 8). When amputation is at the level of the middle third, bone sawdust is covered with a common tendon of the calf muscle (Fig. 9), which is fixed to the muscles of the anterior group of the leg and periosteum (Fig. 10).

Sutures are applied to the superficial fascia, followed by adaptation of the edges of the wound by suturing the skin according to Donati (Fig. 11). The suture line is treated with iodopyron with an aseptic dressing.

The invention is illustrated by the following examples.

Example 1. Patient S., 51, and. No. 10261, was hospitalized in the surgical department of the City Clinical Hospital No. 4 of Kursk from 09/20/05 to 10/14/05 with a diagnosis of type 2 diabetes mellitus, severe course, stage of subcompensation. Diabetic foot syndrome, neuroischemic form, 4 tbsp. by Wagner. Obliterating atherosclerosis of the vessels of the lower extremities 4 tbsp.

Upon admission, he complained of constant pain in the right foot at rest, blackening of 2-3 toes on the right, fever up to 37.2 ° C, general weakness. He suffers from diabetes for about twenty years. In February 2005, an amputation of the left lower limb at the level of the upper third of the lower leg due to wet gangrene of the foot on the left. On examination, the general condition is relatively satisfactory. Skin and visible mucous membranes of normal color. Pulse 92 per minute. HELL - 140 and 90 mm Hg From the local status: 2 and 3 toes of the right foot are black, the skin of the dorsum of the foot on the right to the level of the ankle joint is hyperemic, the foot is swollen, and pain on palpation is noted here. The pulsation of the femoral arteries is preserved, the right popliteal and the arteries of the right foot are not determined. Left amputation stump at the level of the upper third of the leg without features.

The patient performed standard laboratory research methods: 1) general blood test: red blood cells - 4.35; Hb - 133 g / l; CPU - 0.9; white blood cells - 17.2; eosinophils - 2%; stab - 5%; segmented - 64%; monocytes - 1%; lymphocytes - 28%; 2) general analysis of urine: color - sv-yellow .; epiphany - frequent .; beats weight - 1028; the reaction is acidic; protein - no; epithelium - 2-3 p / sp .; white blood cells - 1-3 in s / z .; 3) glucose in the urine - 1.5 mmol / l, acetone in the urine - not detected; 4) biochemical blood test: total bilirubin - 8.4 μmol / l; urea - 5.3 mmol / l; creatinine - 70 μmol / l; glucose - 8.6 mmol / l.

Of the instrumental methods of research, the following were performed: 1) oscillography, while the Wagner ischemic index was calculated, which in this clinical example was 0.5, which is especially important for good healing of stump wounds in the postoperative period; 2) an ultrasound examination of the arteries of the right lower limb, in which the echo signs of a wall-occlusive lesion of the arteries of the lower limb of a combined nature are visualized: secondary vascular damage in the presence of diabetes mellitus in combination with atherosclerotic, characterized by a change in the spectral characteristics of blood flow in PA, ZBA, a decrease in speed parameters in PA, ZBA. , lack of blood flow in PBBA, arteries of the rear foot.

Given the clinical and instrumental data, the patient underwent surgery on September 23, 2005: amputation of the right lower limb at the level of the upper third of the leg using the proposed method.

The operating field is processed in a standard way. Then two flaps were cut: the anterior cutaneous-fascial (Fig. 1) and the posterior cutaneous-fascial-muscular (Fig. 2), in which the anterior flap is larger than the posterior, and their total length was the limb diameter, which is 1/3 of the circumference limbs at the level of bone cut. To this end, the direction of the incision was previously determined on the skin surface with a felt-tip pen, which was started from the medial side of the tibia from the inner edge of the tibia at the level of its tuberosity (Fig. 3), and continued arcuately along the front surface of the tibia to the line from the lateral side corresponding to the groove between the fibula and soleus muscles (figure 4), then extended along the posterior surface of the tibia and finished at the inner edge of the tibia at the same level at which it started.

After that, a skin incision of the anterior and posterior flaps was made along the outlined lines.

The incision of the skin of the anterior flap reached the muscles and periosteum and included its own fascia of the tibia, which is separated from the latter. The skin incision of the posterior flap reached the fascia and continued down the middle of the posterior surface of the lower leg to the Achilles tendon, forming a T-shaped skin incision (Fig. 5), which allowed us to isolate and cross the calf muscle, which is part of the posterior flap, so that the length of the muscle exceeded that of the skin-fascial part of the posterior flap by the diameter of the limb at the level of the upper third of the leg. Then, on the outer surface from the upper third of the leg to the Achilles tendon, the gap between the calf and soleus muscles was found, and in it they are bluntly and acutely separated from each other under visual control, the last is excised (Fig.6). On the posterior surface of the lower leg, intersection at the clamps and ligation of the large saphenous vein with simultaneous shortening of 4-5 cm proximal to the sharp scalpel of the saphenous nerve were performed.

The flaps are turned up and the first stage of the operation is completed.

At the second stage, the anterior (m. Tibialis anterior, m. Extensor digitorum longus, m. Extensor hallucis longus) and lateral (mm. Peronei longus et brevis) muscle groups of the tibia are crossed in one plane 1-2 cm distal to the base of the skin flaps with a preliminary by flashing them for simultaneous ligation of muscle arteries and veins. After crossing the muscles, the anterior tibial arteries and veins are separately stitched and additionally tied. Superficial and deep peroneal nerves after perineural anesthesia 3-5 ml of 1% solution of novocaine are crossed with a sharp scalpel 4-5 cm proximal to the plane of the cut muscles. With blunt hooks, the muscles are pushed up.

At the third stage, the fibula is exposed, its periosteum is circularly dissected at the level of the proposed bone cross section and is shifted distally by 0.5 cm, and in the area deprived of the periosteum, retreating from the edge by 2-3 mm, the fibula was sawn with a saw.

The tibia is sawn with a saw Gigli distal to the fibula by 1.5-2 cm. The outer edges of the bones around the entire sawdust are carefully smoothed with a rasp. And the front surface of the tibial crest is 2-2.5 cm down with a chisel, rounded and trimmed with a rasp. After that, the interosseous membrane and part of the muscles of the posterior tibia group (m. Flexor digitorum longus, m. Tibialis posterior) were crossed and the posterior neurovascular bundle (a. Et vv.tibiales posteriores, n. Tibialis) and peroneal arteries and veins (aa . et vv. peroneae) in such a way that the arteries and veins are stitched and additionally tied separately, and the nerve after perineural anesthesia is cut off with one blow of the blade 4-5 cm above the level of soft tissues. After that, the long flexor of 1 finger and the soleus muscle (m. Flexor hallucis longus, m. Soleus) were crossed, with the exception of the calf muscle, which is part of the posterior flap. The final hemostasis of the arteries and veins of the lower leg.

At the final fourth stage, plastic stump was performed. For this, the calf muscle is dissected between the heads to the level of the tibia sawdust (Fig. 7). The latter is covered with cross-shaped heads, with the lateral head of the calf muscle displaced medially and fixed to the periosteum of the tibia, and the more powerful medial displaced laterally and stitched to the muscles of the anterior group of the leg above the previously laid lateral head (Fig. 8).

Sutures were applied to the superficial fascia, followed by adaptation of the edges of the wound by suturing the skin according to Donati (Fig. 11). The seam line is treated with iodopyron. Aseptic dressing.

The postoperative period was uneventful, the sutures were removed on the 14th day, the wound healed by first intention.

On 07.10.05, an X-ray analysis of the stumps of both lower legs in two projections was performed, in which it was established: the stump of both bones of both lower legs at the level of the upper third with even clear contours, in the soft tissues - the shadow of calcified vessels.

The patient was discharged in satisfactory condition and examined after six months: he uses prostheses and is active.

Example 2. Patient N., 46 l., And.b. No. 1499, was hospitalized in the surgical department of the City Clinical Hospital No. 4 of Kursk from 02/12/07 to 03/16/07 with a diagnosis of frostbite of both feet of 3-4 degrees.

Upon admission, he complained of intense pain in the feet, their cooling, numbness. From the anamnesis he received a cold injury while inxicated. On examination, the general condition is relatively satisfactory. Skin and visible mucous membranes of normal color. Pulse 88 per minute. HELL - 130 and 80 mm Hg From the local status: the toes of both feet are dark brown, the skin of the dorsum of the feet on both sides of the crimson-cyanotic color with swelling of the soft tissues to the level of the lower third of the leg; tactile and pain sensitivity are absent. Ripple on the arteries of the feet is not determined, on the popliteal arteries saved. Active movements are not possible.

The patient performed standard laboratory research methods: 1) general blood test: red blood cells - 4.8; Hb - 159 g / l; CPU - 0.9; white blood cells - 18.7; eosinophils - 1%; stab - 2%; segmented - 80%; monocytes - 2%; lymphocytes - 15%; 2) general analysis of urine: color - sv-yellow .; epiphany - frequent .; beats weight - 1017; the reaction is acidic; protein - 0.33 g / l; epithelium - 1-3 in s / z .; leukocytes - 10-15 in n / a; erythrocytes - 0-1-2 in s / sp .; cylinders - 0-1 in p / sp; 3) biochemical blood test: total protein - 80 g / l; total bilirubin - 19.0 μmol / l; urea - 12.0 mmol / l; creatinine - 135 μmol / l; amylase - 28 g / h · l; glucose - 3.0 mmol / l; 4) IPT - 92%.

Of instrumental methods, rheovasography was performed. Conclusion: pulse blood supply at the level of both feet is reduced to the stage of decompensation, at the level of both legs - to the stage of subcompensation.

Given the clinical and instrumental data, the patient underwent surgery: amputation of the left (02/26/07) and right (02/27/07) lower limbs at the level of the middle third of the leg using the proposed method.

The operating field is processed in a standard way. Then two flaps were cut: the anterior skin-fascial (Fig. 1) and the posterior skin-fascial-tendon (Fig. 2), in which the anterior flap is larger than the posterior, and their total length was the limb diameter, which is 1/3 of the circumference limbs at the level of bone cut. To do this, the direction of the incision on the skin surface with a felt-tip pen, which is started on the medial side of the tibia from the inner edge of the tibia 5-7 cm below its tuberosity (Fig. 3), is preliminarily determined, continued arcuately along the front surface of the tibia to the line from the lateral side corresponding to the groove between the fibula and soleus muscles (figure 4), then extended along the posterior surface of the tibia and finished at the inner edge of the tibia at the same level at which it started.

After that, a skin incision of the anterior and posterior flaps was made along the outlined lines.

The incision of the skin of the anterior flap reached the muscles and periosteum and included its own fascia of the tibia, which is separated from the latter. The skin incision of the posterior flap reached the fascia and continued down the middle of the posterior surface of the lower leg to the Achilles tendon, forming a T-shaped skin incision (Fig. 5), which allowed to isolate and cross the common tendon of the calf muscle, which is part of the posterior flap, so that the tendon length exceeded that of the skin-fascial part of the posterior flap by the diameter of the limb at the level of the middle third of the leg. Then, on the outer surface of the lower leg, a gap was found between the gastrocnemius and soleus muscles, and in it they are bluntly and acutely separated from each other under visual control, the last is excised (Fig.6). On the posterior surface of the lower leg, intersection at the clamps and ligation of the large saphenous vein with simultaneous shortening of 4-5 cm proximal to the sharp scalpel of the saphenous nerve were performed.

The flaps are turned up and the first stage of the operation is completed.

At the second stage, the anterior (m. Tibialis anterior, m. Extensor digitorum longus, m. Extensor hallucis longus) and lateral (mm. Peronei longus et brevis) muscle groups of the tibia are crossed in one plane 1-2 cm distal to the base of the skin flaps with a preliminary by flashing them for simultaneous ligation of muscle arteries and veins. After crossing the muscles, the anterior tibial arteries and veins are separately stitched and additionally tied. Superficial and deep peroneal nerves after perineural anesthesia 3-5 ml of 1% solution of novocaine are crossed with a sharp scalpel 4-5 cm proximal to the plane of the cut muscles. With blunt hooks, the muscles are pushed up.

At the third stage, the fibula is exposed, its periosteum is circularly dissected at the level of the proposed bone cross section and is shifted distally by 0.5 cm, and in the area deprived of the periosteum, retreating from the edge by 2-3 mm, the fibula was sawn with a saw.

The tibia is sawn with a saw Gigli distal to the fibula by 1.5-2 cm. The outer edges of the bones around the entire sawdust are carefully smoothed with a rasp. And the front surface of the tibial crest is 2-2.5 cm down with a chisel, rounded and trimmed with a rasp. After that, the interosseous membrane and part of the muscles of the posterior tibia group (m. Flexor digitorum longus, m. Tibialis posterior) were crossed and the posterior neurovascular bundle (a. Et vv. Tibiales posteriores, n. Tibialis) and peroneal arteries and veins (aa . et vv. peroneae) in such a way that the arteries and veins are stitched and additionally tied separately, and the nerve after perineural anesthesia is cut off with one blow of the blade 4-5 cm above the level of soft tissues. After that, the long flexor of 1 finger and the soleus muscle (m. Flexor hallucis longus, m. Soleus) were crossed, with the exception of the calf muscle, whose common tendon is part of the posterior flap. The final hemostasis of the arteries and veins of the lower leg.

At the final fourth stage, stump plastic surgery was performed by covering the tibial sawdust with the common tendon of the calf muscle (Fig. 9), which is fixed to the muscles of the anterior tibia and periosteum (Fig. 10).

Sutures were applied to the superficial fascia, followed by adaptation of the edges of the wound by suturing the skin according to Donati (Fig. 11). The seam line is treated with iodopyron. Aseptic dressing.

The postoperative period was uneventful, the sutures were removed on the 14th day, the wound healed by first intention.

The patient was discharged in satisfactory condition.

Thus, the task is achieved in that the method of amputation of the tibia involves cutting two flaps, the front of which is larger than the back, which makes it possible to cover the sawdust of the tibia and fibula with a flap of the calf muscle in a certain way: at the level of the upper third, the calf muscle is cut between the heads to the sawdust of the tibia and placed they are crosswise above the last; at the level of the middle third - they cover the bone fillet with the common tendon of the calf muscle, which is fixed to the muscles of the anterior group of the leg and periosteum, which helps to distinguish the postoperative wound from sawdust of bones and is the prevention of osteomyelitis in case of infectious complications from the wound, as well as favorable for prosthetics and successful rehabilitation this group of patients.

Claims (1)

A method of amputation of the lower limb, including cutting two flaps with excision of the soleus muscle, characterized in that first the front fascial and fascial flap is formed, and then the posterior cutaneous-fascial-muscular flap is formed, the front flap is larger than the posterior one, the posterior flap includes the calf muscle, the length of the calf muscle included in the flap is longer than the length of the skin-fascial part of the flap by the diameter of the limb at the level of bone cut, then, when amputated at the level of the upper third of the leg, the medial and the ateral heads of the calf muscle, cover the sawdust of the tibia with the cross-shaped heads of the calf muscle so that the lateral head is displaced medially and fixed to the periosteum of the tibia, and the medial head is displaced laterally and sutured to the muscles of the anterior tibia above the previously laid lateral head, with amputation the level of the middle third of the leg of the sawdust of the tibia is covered with a common tendon of the calf muscle, which is fixed to the muscles of the anterior group of the leg and periosteum tibia, then sutured postoperative wound posterior to the tibia sawdust.

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