RU2547777C1 - Method of amputating extremity at shin level in patients with obliterating lesion of vessels of lower extremities - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopaedics. After sawing the tibia bones on the posterior surface of their distal parts tissues are cut along the periosteum at a distance of 8 cm from the saw cut. By means of hooks the bones are deviated distally, the posterior skin-muscle-fascial flap is cut out after the ligation of the main vessels.

EFFECT: method increases the size of access, which improves the view of the vessel bunches and nerves, reduces the danger of traumatising the main arteries and veins.

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Description

The invention relates to medicine, namely to surgery, and can be used in orthopedics for amputation of limbs.

The number of “large amputations” of an extremity performed annually remains high. During the first year of critical ischemia, limb amputation is performed in 25-35% of patients. In economically developed countries, vascular diseases cause amputations in 70-90% or more cases. So, in East Australia, arterial pathology causes amputation of the limb in 94% of cases, in Western Sweden - in 95%. Only in certain countries of the third world ischemia of the limb gives way to other leading causes of limb loss.

In most European countries and the United States, the number of secondary (after a failed attempt to revascularize) amputations is higher than the primary. However, the total number of primary and secondary limb amputations in different countries varies from 13.7 to 32.3 for every 100 thousand of the population.

Fascioplastic method of leg amputation. Fascia of the tibia is included in the skin flaps, which protects them from trauma and fusion with sawdust bones, helps preserve the physiological muscle tone. The front and back skin flaps are cut out with the inclusion of the own fascia of the tibia, are separated from the muscles and periosteum of the tibia and recline in the proximal direction. Muscles intersect to the bone in the transverse plane 4-5 cm distal to the base of the flaps and also separate to the level of the proposed amputation. Holding soft tissue with a retractor or blunt hooks, a bone knife cut through the periosteum circularly around the tibia (2 cm proximal to the fibula) and shift it 1-2 mm in the distal direction. The tibia is sawn in a strictly perpendicular plane to their long axis, the fibula is 2 cm higher. The tibial crest is cut off or knocked down by a chisel, not spreading further than the medullary canal, and the sawdust is carefully smoothed with a rasp. The main arteries and associated veins are distinguished: the tibia, anterior tibia and fibula, and the arteries and veins are ligated with catgut separately. If necessary, impose additional ligatures. Muscular arteries are stitched with catgut. Nerves are secreted from surrounding tissues and resected 3-4 cm above the sawdust of bones. The muscles above the sawdust of the bones do not stitch. At the base of the posterior flap, a counter-puncture is made, through which tubular drainage is carried out to the sawdust for 48 hours, which is fixed to the skin. Catgut sutures are applied to the fascia, subcutaneous tissue and silk to the skin, avoiding tension. If necessary, additional drainage is introduced in the corner of the wound. Skin sutures are removed 12-14 days after surgery. (Manual on prosthetics and orthosis. Edited by: Hon. Science Worker of Russia, Professor A. N. Keyer and Hon. Doctor of Russia, Professor A. V. Rozhkov. - St. Petersburg. 1999. P.131).

However, in this method of limb amputation after transplantation of the tibia, it is rather difficult to isolate the main arteries and veins, which can lead to damage and bleeding of these vessels, and an increase in the time of surgical treatment.

Closest to the proposed method for limb amputation is the Burgess amputation technique.

This amputation method is applicable for limb removal for any indication, including patients with vascular diseases. The principle of operation involves the formation of a long posterior musculocutaneous flap, which is moved forward to the carefully rounded end of the tibial stump and sutured with a very short front flap. The stitched wound has a transverse scar direction and is outside the load zone. The load on the end of the stump does not stretch the postoperative scar to the sides and excludes its compression. In patients with vascular diseases, a stump of the tibia is usually left up to 12-13 cm long. The length of the anterior flap is only 1-2 cm, the posterior soft tissue flap should be 13-15 cm long with a tibial stump 12 cm long. Skin incision of the anterior and posterior the flap reaches the muscular fascia or periosteum of the tibia. A large saphenous vein is ligated. In the transverse direction, the muscles cross around the fibula. Do the preparation of the peroneal nerve and blood vessels. Then prepare the site of the intersection of the bone. The level of transection of the tibia should be 5 mm higher than the same level of the tibia. The periosteum is displaced only in the distal direction. When sawing bones, we use the Jigli saw. Then, with a few movements of the amputation knife along the posterior surface of the tibia, a posterior flap is cut out. In patients with vascular diseases, blood flow through the soleus muscle is worse than through both gastrocnemius. The muscle is intertwined with a venous network, which, with poor arterial blood flow, is prone to thrombosis. Due to necrosis of the soleus muscle, the risk of wound infection of the stump of the leg increases. Removal of the soleus muscle provides a better view of the tibial vessels and nerves. Tibial vessels are ligated distal to trifurcation, the nerve should be evenly crossed 3-4 cm proximal to the tibial sawdust level. Both bones are rounded with a file. Cutting out a flap from the periosteum is not done. The bone marrow canal burrows independently after a few days. In conclusion, it is necessary to isolate the calf nerve and shorten it by 2-3 cm. It is located in the middle of the posterior flap. Drainage is carried out by two suction drains, one of which must be laid in the back bed with either one or two transversely held open drains. With good blood flow without infection, the superficial fascia of the calf muscles is sutured to that of the fibula bed with 5-6 single sutures using absorbable sutures. In case of poor blood flow or infection, it is better to abandon fascia suturing and limit it to a single-layer moccasin seam. The first seams at a distance of 3-4 cm are deep. They capture the skin, subcutaneous tissue and superficial fascia or medial periosteum of the tibia. Between such sutures without tension, nodal sutures are applied to the skin and subcutaneous tissue. Further adaptation of the edges of the skin wound is done with superficial sutures: a needle is pierced to a depth of about 2 mm and not tightly tied. It is necessary to avoid local impairment of the blood flow of the skin between the sutures and the formation of necrosis (Rene Baumgartner and Pierre Botha. Amputation and prosthetics of the lower extremities. Translation from the German canal of medical sciences A.V. Nizovsky. Edited by Honored Scientist of Russia, Doctor of Medical Sciences professors A.N. Keyer, Medicine, 2002. - 504 p.: ill. p. 170).

Nevertheless, in this method of limb amputation, the technique for isolating vascular bundles is traumatic despite the removal of the soleus muscle to improve the visibility of blood vessels and nerves. Damage to the vascular bundle during excretion can lead to massive blood loss and prolonged surgery time.

The objective of the present invention is to create better conditions for the allocation of neurovascular bundles during amputation of the lower leg by increasing the size of the access and reducing the risk of injury to the great vessels and blood loss.

The task is achieved by the method of limb amputation at the tibia level in patients with obliterating lesions of the vessels of the lower extremities. The method includes amputation of the lower extremity, the formation of the anterior and posterior flaps with an incision to the muscle fascia or periosteum, tibia cutting 5 mm above the tibia, removing the soleus muscle, ligature of the tibial vessels distal to the trifurcation, nerve intersection 3-4 cm proximal to the tibial sawdust bones, allocation and shortening of the calf nerve, closure of the wound. After cutting the tibia bones along the posterior surface of their distal parts with an amputation knife, dissect the tissue along the periosteum at a distance of 8 cm from the cut and remove the bones distally with hooks, the posterior musculo-fascial flap is cut out after ligation of the great vessels.

Novelty of invention

After tibia bone is sawn along the posterior surface of their distal parts, tissues along the periosteum are cut with an amputation knife at a distance of 8 cm from the cut and the bones are distally removed with hooks.

The posterior skin-muscle-fascial flap is cut out after ligation of the great vessels.

The set of essential features of the invention allows to obtain a new technical result:

- the size of access increases, the review of vascular bundles and nerves improves;

- reduces the risk of injury in the allocation of the main arteries and veins;

- blood loss during surgery is minimized, which prevents the development of tissue hypoxia;

- reduces the time of the operation, since extensive access to the vascular bundles and nerves improves the working conditions of the surgeon and reduces the time of their allocation.

This method was worked out in an experiment and tested in the clinical practice of the Department of Vascular Surgery of the FSBI Novokuznetsk Scientific and Practical Center for Medical and Social Expertise and Rehabilitation of Persons with Disabilities.

The implementation of the method of limb amputation at the tibia level is shown in the drawing, where 1 is the proximal part of the tibia, 2 is the proximal part of the tibia, 3 is the distal part of the sawn tibia, 4 is the distal part of the sawn tibia, 5 is the neurovascular bundles.

The method is as follows. Amputation of the limb is performed according to any indication, including patients with diseases of the vessels of the lower extremities. The principle of operation involves the formation of a long posterior musculocutaneous flap, which is moved forward to the carefully rounded end of the tibial stump and sutured with a short front flap. The stitched wound has a transverse scar direction and is outside the load zone. The load on the end of the stump does not stretch the postoperative scar to the sides and excludes its compression. In patients with vascular diseases, a stump of the tibia is usually left up to 12-13 cm long. The length of the anterior flap is only 1-2 cm, the posterior soft tissue flap should be 13-15 cm long with a length of the tibia stump 12 cm. Skin incision of the anterior and posterior the flap reaches the muscular fascia or periosteum of the tibia. A large saphenous vein is ligated. In the transverse direction, the muscles cross around the fibula. Do the preparation of the peroneal nerve and blood vessels. Then prepare the site of the intersection of the bone. The level of transection of the fibula 1 should be 5 mm higher than the same level of the tibia 2. The periosteum is displaced only in the distal direction. When sawing bones, we use a Jigley saw. An amputation knife along the posterior surface of the distal parts of the tibia bones 3, 4 along the periosteum dissect the tissue at a distance of 8 cm from the cut. Bones 3, 4 are taken away by hooks distally, access becomes more extensive, which opens up a better overview of neurovascular bundles 5 and improves the working conditions of the surgeon for their isolation and intersection. The soleus muscle is removed. Tibial vessels are ligated distal to trifurcation, the nerve is evenly crossed 3-4 cm proximal to the level of the tibia sawdust. Both bones are rounded with a file. Next, with the amputation knife, the posterior skin-muscle-fascial flap is cut out. The marrow canal closes independently after a few days. In conclusion, the calf nerve is isolated and shortened by 2-3 cm. It is located in the middle of the posterior flap. Drainage is carried out by two suction drains, one of which must be laid in the back bed, either one or two transversely held open drains. With good blood flow without infection, the superficial fascia of the calf muscles is sutured with that of the fibula bed with 5-6 single sutures using absorbable sutures. In case of poor blood flow or infection, it is better to abandon fascia suturing and confine oneself to a single-layer moccasin suture. The first seams at a distance of 3-4 cm are deep. They capture the skin, subcutaneous tissue and superficial fascia or medial periosteum of the tibia. Between such sutures without tension, nodal sutures are applied to the skin and subcutaneous tissue. Further adaptation of the edges of the skin wound is done with superficial sutures: a needle is pierced to a depth of about 2 mm and not tightly tied. It is necessary to avoid local disturbance of the blood flow of the skin between the sutures and the formation of necrosis.

Example 1. Patient T., 69 years old. He was admitted to the hospital with a diagnosis of atherosclerosis, Lerish’s syndrome. Stenosis of the iliac arteries on both sides, occlusion of the femoral arteries on both sides. Chronic ischemia of the left lower extremity 4 degrees.

Upon admission, the patient complained of pain in the left foot at rest, the presence of a purulent necrotic wound on the back of the foot, constantly lowered his leg from the bed. Critical ischemia was verified by Doppler ultrasound (ankle-brachial index is 0). Duplex scanning revealed stenosis of the iliac arteries on both sides, occlusion of the superfemoral arteries on both sides, and stenosis of the deep femoral arteries on both sides. Occlusion of the popliteal-tibial segment on the left, stenosis on the right. In connection with the defeat of the peripheral arterial bed of the left lower limb from reconstructive surgery, it was decided to abstain and to perform amputation of the lower limb at the lower leg level in / 3 according to the proposed method. General blood test: hemoglobin - 130 g / l, red blood cells - 4.5 · 10 ¹² / l. Surgical treatment was carried out according to the proposed method. In the early postoperative period, a general blood test: hemoglobin - 110 g / l, erythrocytes - 3.9 · 10 ¹² / l. There are no complications. Sutures in the patient were removed on the 10th day. Healing by first intention.

Example 2. Patient P., 70 years old. Was admitted to the hospital with a diagnosis of diabetes mellitus, type 2. Severe course. Decompensation. Diabetic angiopathy of the lower extremities. Tibial artery occlusion on the right. Chronic ischemia of the right lower extremity 4 degrees.

Upon admission, the patient complained of pain in the right foot at rest, the presence of a purulent necrotic wound on the back of the foot, n / 3 of the lower leg. Critical ischemia was verified by ultrasound dopplerography (ankle-brachial index on the right is 0.2). Duplex scanning revealed stenosis of the iliac arteries on both sides, occlusion of the superfemoral arteries on both sides, and stenosis of the deep femoral arteries on both sides. Tibial artery occlusion on the right, stenosis on the left. Complete blood count: hemoglobin - 126 g / l, red blood cells - 4.1 · 10 ¹² / l. In connection with the defeat of the peripheral arterial bed of the left lower limb, it was decided to refrain from reconstructive surgery and perform amputation of the lower limb at the level of / 3-s / 3 of the right lower leg. Surgical treatment was carried out according to the method of the prototype with simultaneous cutting of the anterior and posterior skin-muscle-fascial flaps. During surgical treatment, there was damage to the popliteal artery of its distal part, bleeding was stopped, the operation was completed. The duration of surgical treatment was 1 hour 20 minutes. According to a general blood test in the early postoperative period, hemoglobin is 85 g / l, erythrocytes are 2.5 · 10 ¹² / l.

The proposed method for lower limb amputation at the shin level is available in all surgical clinics. Cutting out of the posterior musculocutaneous-fascial flap after ligation of the main vessels allows increasing the access area and providing a better view of the vascular bundle and nerves. This improves the working conditions of the surgeon and provides an increase in the quality of his work. The method reduces the complications in the postoperative period associated with blood loss, minimizes blood loss in patients with occlusive lesions of the arteries of the lower extremities, which prevents the development of tissue hypoxia. The operation time is reduced, since extensive access to the vascular bundles reduces the time for excretion of the great vessels and nerves.

Claims (1)

A method for limb amputation at the tibia level in patients with obliterating lesions of the vessels of the lower extremities, including amputation of the lower limb, the formation of the anterior and posterior flaps with an incision to the muscle fascia or periosteum, tibia sawing 5 mm above the tibia, removal of the sole of the tibia, vessels distal to trifurcation, nerve intersection 3-4 cm proximal to the tibia sawdust, isolation and shortening of the calf nerve, closure wounds, characterized in that after cutting the tibia on the posterior surface of their distal parts with an amputation knife, dissect the tissue along the periosteum to a distance of 8 cm from the cut and hook the bones away distally, the posterior skin-muscle-fascial flap is cut out after ligation of the main vessels.

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