RU2381758C2 - Limb amputation apparatus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical apparatuses applied in limb amputation. The apparatus comprises a hollow fixation cylinder of stainless steel. On a lateral surface of the cylinder, there are cuts in the form of transverse guide slots perpendicular to the longitudinal axis, of the depth equal to half diametre of the cylinder, and of the width equal to slot distance. On the side of the cylinder opposite to the slots, there are control windows. The face segment of one end of the cylinder has unilateral pointed cone neck, while the other segment is blunt. The internal space of the cylinder is filled with a lubricant of the following composition, wt %: Xymedone-5-10; Trimecaine-4.0; Boric acid-4.0; polyethylene oxide of molecular weight 400 - the rest.

EFFECT: invention provides improved medical effectiveness and prevention of complications in operations observing the principle of sparing, careful treatment of the patient's tissues with convenience and safety to the medical personnel.

2 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to devices designed for surgical operations in traumatology and orthopedics.

Amputation of limbs is one of the very first surgical operations, which was known in antiquity as an extreme measure in order to save the patient's life. With the development of medicine, the question of the functional suitability of the stump has become of particular interest. This is of greatest importance for the stumps of the fingers of the hand. An amputated stump acquires the character of a new working organ, the formation of which occurs in completely new unusual conditions of blood supply, innervation and altered function. The nature, duration, and outcomes of the restructuring processes depend on many reasons, including the amputation technique [Lagunova I.G. Amputation stump of limbs. M .: Medgiz, 1950; Burykh M.P. General principles of surgical technology. Rostov-on-Don: Phoenix, 1999; Stepanov N.G. Amputation of the lower leg and thigh (clinical experience). N. Novgorod: DECOM, 2003].

Technical errors are allowed during amputation due to the imperfection of the tools used for this. Such errors, first of all, include improper filing of bones with obtaining an oblique arrangement of sawdust instead of a more rational perpendicular to the longitudinal axis of the bone. The traditional amputation technology using electro-circular hand-held sheet and arc saws, Luer or Liston nippers, Farabef or Oillier fixation forceps [Lopukhin Yu.M., Molodenkov M.N. Workshop on operative surgery. M .: Medgiz, 1960; Fedorov I.G. Surgical Instruments, Kazan, 2001], as a rule, leads to unexpected changes in bones in the form of fractures, kinks (the formation of a marginal bone not sawn protrusion) and cracks, which are subsequently more often manifested by the formation of osteophytes that have a negative effect on the functional capabilities of the organ. It is also possible to leave the sharp edges of the sawdust in places located close under the skin, which, when emphasized, causes pain with the subsequent development of pain when performing any work on the operated organ.

Excessive trauma is observed from the use of bone nippers, when the longitudinal and transverse beam structures of the bone are crushed - blood supply to the wound surface worsens, resulting in complications: abrasions, ulcerations, bone necrosis, chronic osteomyelitis after amputation stumps, suppuration of wounds, cicatricial contracture, prolonged pain sensations, arthrosis-arthritis, ankylosis of nearby joints.

It has long been known and used in medicine, in particular in surgery, the wire saw Dzhigli [Reference room operating and dressing sister. Under. ed. BD Komarova, M., "Medicine", 1976], which consists of a steel wire with sprayed diamond chips and two handles. It is mainly used for cutting large and small tubular bones during amputations. When using the saw, taken by us as a prototype, when sawing small bones (phalanx of the fingers, metatarsal, metacarpal bones), an even bone cut is not formed without additional destruction of the bone structure.

Long-term work with the use of Jigli saw during bone sawing operations revealed the following disadvantages of the prototype: significant difficulty in fixing small bones during their sawing; due to the formation of bone sawdust during sawing, difficulty occurs when the saw seizes during reciprocating movements of the tool due to compression of the saw by the walls of the bone cut, as well as a decrease in cutting ability due to clogging of its grooves;

- requires the use of additional tools (forceps, clamps) to fix the distal bone fragments without the proper effect; the risk of damage to the hands of assisting medical personnel due to instability of bone fixation;

- spraying small fragments of bones, tissues and blood around the surgical field;

- the absence of strictly directed action of the Jigli saw in the plane of bone sawing;

- damage to the remaining intact soft tissues of the finger;

- high frequency of post-amputation complications.

According to the generally accepted amputation technology, previously crossed tissues around the entire circumference before the bone sawing are displaced, most often with a sharp tool or raspator, in the proximal direction, which is traumatic. The mobilization of the skin and subcutaneous tissue with vital anatomical structures located in it (nerves, blood vessels, etc.) is often done with a tool with a pointed end in circular movements, and their further displacement with a blunt instrument, which inevitably entails injury to the periosteum, prolongation of the operation time and an increase in the incidence of postoperative complications. So, tissues are removed from the cut line due to their possible damage and the subsequent need to close the wound of the stump with full-layer skin flaps. Of no small importance is the risk of overheating of the bone due to the pronounced friction of the saw and the walls of the cut, as well as the presence of such a negative effect as the dragging of soft tissues in contact with the saw during its traction.

The surface of the sawdust has an uneven relief, which is caused by the unstable position of the operated part and the constant displacement of the saw. Post-amputation bright bone changes were radiologically detected in the vast majority (75%) of patients in the immediate and long-term postoperative periods. In 10% of cases, re-amputations were carried out due to the developed complications in the stump area (ulcers, disability, etc.). A well-defined radiological closure cortical tire was observed in only 8.5% of patients. Duration of treatment was delayed up to 1.5 months or more.

In addition, the prototype does not enhance the true regeneration of the damaged bone, and the end part of the sawdust heals by the formation of coarse connective tissue. The greatest severity of such torpid secondary healing of sawdust, and hence the stump as a whole, is ascertained in cases of using high-speed electric saws that cause thermal burning of the bone. It should be noted that the invasiveness of such an important stage of amputation as bone sawing is great, which contributes to bacterial contamination of the wound with the genesis of wound purulent-inflammatory complications, abscesses, phlegmon, anaerobic infection, ligature fistulas, inconsistency of sutures, etc. Elimination of the inevitable costs of the operation is carried out processing the edges of sawdust with abrasive tools.

As therapeutic agents in such operations, drugs are used in various forms (solutions, ointments), for example, methyluracil [B. Datsenko et al. Local treatment of purulent wounds. Surgery, 1984; 1: 136-141].

The aim of the invention is to increase therapeutic efficacy and prevent complications during operations for patients with the formation of the principle of a gentle, careful attitude to the patient’s tissues with the convenience and safety for medical personnel.

The goal is achieved by the fact that slots are made on the lateral surface of the cylinder in the form of transverse guide grooves located perpendicular to the longitudinal axis, with a depth equal to half the diameter of the cylinder, and a width equal to the distance between the grooves, and control windows are made on the opposite side of the cylinder grooves, while the front part of one of the ends of the cylinder has one-sided sharp conical sharpening, and the other is obtuse, and the inner space of the cylinder is filled with grease of the following composition in wt.%: xymedon - 5-10, t imekain - 4.0 Boric Acid - 4.0, polyethylene oxide having a molecular weight of 400 - the rest.

Figure 1 - General view of the device; figure 2 is a variant of the cylinder; figure 3 - wedge-shaped elastic seal; figure 4 - device mounted on a finger in the working position, a longitudinal section.

The device (figure 1) contains a hollow locking cylinder 1 made of stainless steel. On the lateral surfaces of the cylinder 1, slots 2 are made by 1/2 of the cylinder diameter in the form of transverse guide grooves located perpendicular to the longitudinal axis, the width of the grooves being equal to the distance between them. On opposite sides of the guide grooves, control windows 3 are cut to observe the progress of bone sawing. The end part of one of the ends of the cylinder 1 has a one-sided sharp conical sharpening, and the other is blunt.

A variant of the device is presented in figure 2-4, where: a is a cylindrical working part; b - a sealant clip; c - the device is in working condition (longitudinal section) with a finger inserted into the cylinder. The design of this embodiment is characterized in that the cylinder 1 has slits 2 from only one end, and at the end contains protrusions 4 for the possible displacement of soft tissues in the proximal direction and keeping them in a stretched position. Additionally, the lubricant is compressed using an elastic cone-shaped seal (Fig. 3), containing a handle 5, a recess 6 and a conical stylet 7, which is inserted into the cylinder 1.

The device uses a specially developed preventive composite lubricant, which is a multicomponent pharmacological mixture, the active principle of which is N- (B - hydroxyethyl-4,6-dimethyldihydropyrimidone-2) -xymedon [Izmailov SG et al. Xymedon in clinical practice. Nizhny Novgorod: NGMA, 2001]. The drug is approved by the Pharmacological Committee of the USSR Ministry of Health for use in clinical practice. The lubricant is a thick homogeneous mass of xymedon, trimecaine and boric acid on a water-soluble basis - polyethylene oxide with a molecular weight of 400 (PEG-400), which has a pronounced hydrophilicity due to the formation of hydrogen bonds between macro- and micromolecules. The components are included in the composition of the lubricant in the following ratio in wt.%:

Xymedon - 5-10

Trimecaine - 4.0

Boric acid - 4.0

Polyethylene oxide (PEG-400) - the rest.

PEG-400 is classified as physiologically indifferent compounds, has a weak bactericidal effect and is not a favorable environment for the development of microorganisms. A lubricant is prepared by mixing the components in accordance with officially accepted pharmacopoeial rules [Pharmacist Handbook. M .: Medicine, 1973]. Sterilization is carried out in an autoclave at a temperature of 100 ° C for 30 minutes Store in a refrigerator at a temperature of 2-4 ° C.

A device for limb amputation is used as follows.

The limb is laid on the bed of the operating table. The level of amputation, for example, the finger of a brush, is determined by applying the device body to it. The dye makes a circular mark on the finger along the border of the end part of the proximal end of the device and, after the proximal limiting line of inclination of the arterial, hemostatic tourniquet, make a circular incision of soft tissues to the bone. Then the cylinder 1 of the required diameter is filled with therapeutic grease and gradually a finger is inserted into its lumen to the line already indicated by the dye. When advancing a finger, the lubricant is squeezed out in a retrograde direction, thus filling the space between the internal wall of the device and the skin surface of the organ. Lubricant serves simultaneously as a sealant, soft fixing gasket. Cylinder 1 is set so that the line of the circular cut - amputation level 8 of finger 9 coincides with slot 2 of cylinder 1. Through the window 3, a Jigley saw is inserted with it placed in the lumen of slot 2 in the projection of the amputation level 8 line. The assistant holds the cylinder 1 by the protruding distal end, and the surgeon performs a bone cut. The device together with the amputated area of the organ is removed, hemostasis is carried out after removing the tourniquet, the wound toilet, a bandage is applied. In cases where the device 1 with an additional elastic seal 7 is used, the latter is used as a tongue. The recess 6 of the seal serves for rational traumatic laying of the stump.

When using the proposed device, the operated organ is reliably stabilized in a rational position. A flat sawdust surface is formed without unnecessary damage. The movement of the saw, which is constantly during the manipulation in the thickness of preventive lubrication, is greatly facilitated. The passage of the saw through the layers of the latter permanently clears the generated and settled sawdust while updating its cover and applying clean portions of lubricant. A preventive pharmacological film, which is synchronously formed after the movement of the saw, prevents primary and secondary bacterial contamination of the wound surface of the bone and soft tissues. Due to the constant lubrication of the surface of the saw, the closure of its recesses throughout the loss of the exciting negative effect of the saw, which when in contact with soft tissues glides, does not drag them, while maintaining a sawing effect when passing through the bone tissue. In addition to the antibacterial protective role, the film enhances the regenerative ability of the bone.

Using the device allowed to change the tactics of treatment of patients with frostbite. They refused free plastic surgery with a split skin graft due to its frequent non-engraftment and poor functional results. The level of truncation of soft tissues coincides with the level of sawdust of the bone, and at the end of the stump a full-fledged skin is created by moving full-fledged tissues.

The device was successfully tested in purulent-septic surgery in the treatment of 20 patients in whom 31 amputations of fingers and metacarpal bones of the hands (18), fingers and metatarsal bones of the feet (13) were performed under various types of anesthesia (intravenous, conductor). The operations were mainly performed during frostbite of the fourth degree. In 26 cases, wounds were closed with a blind suture. After 2-3 days of treatment, the patients stopped signs of perifocal inflammation. When the wounds were left open after 2-3 dressings, the wound surface was cleaned with the appearance of granulations and marginal epithelization. There were no cases of reamputation. The terms of treatment of patients in the experimental group compared with the control decreased by 2.5 days.

We give one observation.

Patient Z., 30 years old, was admitted to the surgical department on 30.01.2005 with frostbite of both feet of the III-IV degree in the late reactive period. Before entering the clinic, he was at home, treated on an outpatient basis by applying ointment dressings. The terminal phalanges of the fingers on the right are dark in color, there is no movement in them. After complex treatment, on the 10th day, all mummified fingers were amputated along clearly formed demarcation lines within healthy tissues using the device we proposed. Stump wounds are covered with local tissue. The postoperative period was uneventful. Wound healing by primary intention. He was discharged home on the 25th day after the operation.

The study of the results of treatment of patients revealed that the amputation technology with the proposed device is much superior to traditional methods, allows you to achieve better results and obtain significant economic effect.

Clinical observations showed the following advantages of the proposed device for amputations:

- the principle of gentle, careful amputation is formed, which is especially important in patients with diabetes;

- increases the safety of operations on bones, which reduces productive injuries among medical staff;

- there is the possibility of directional cutting plane;

- complications of the post-amputation period are prevented;

- reduced treatment time;

- increases the convenience and safety of cutting small bones.

Claims (2)

1. A device for carrying out amputation of a limb, comprising a hollow fixing cylinder made of stainless steel, characterized in that slots are made on the side surface of the cylinder in the form of transverse guide grooves located perpendicular to the longitudinal axis, a depth equal to half the diameter of the cylinder, and a width equal to the distance between grooves, and on the opposite side of the grooves of the cylinder control windows are made, while the end part of one of the ends of the cylinder has one-sided sharp conical sharpening, and the other is blunt Nye, wherein the inner space of the cylinder filled with grease the following composition:%:
Ximedon 5-10 Trimecaine 4.0 Boric acid 4.0 400 molecular weight polyethylene oxide rest 2. The device according to claim 1, characterized in that the slots are made on the side surface of the cylinder from one end, one of the ends contains protrusions, and an elastic sealant is inserted in the cylinder, containing a handle, a recess and a conical stylet.

Images