Amputation/ Lecture

?War is a traumatic epidemic?? said N.I. Pirogov at one time, first of all meaning the big number of limbs? amputations which the injured have to suffer after active military operations.

Year 1812. The famous battle of Borodino. The surgeon of Napoleon?s army Larrey had to perform up to 200 amputations a day with 85% fatal rate.

Crimean War. 10 thousands of amputation performed personally by Pirogov. Fatal rate from 45% to 70% among all amputated in different armies.

The First World War (1914-1918). In English, French and German armies amputations totaled in 16,5% among all injured. Lethal rate was from 25% to 30%. Just in English army 150.000 amputations were performed, 55.000 lead to death.

The Second World War (1939-1945). The logical increase of amount of injured who underwent the amputations. What is more, the statistics of WWII shows us the division into groups by predominant localization: thigh ? 49,4%, crus ? 38,8%, shoulder ? 5,8% from the total amount of amputated. Lethal rate ? 8-10% in average among all the armies, 4,6% in our Army.

During the peacetime amputations are held much less often and make up an insignificant part of the held surgeries. Nevertheless their total amount is quite high: according to the data of Leningrad Institute of Prosthetics for a period of 1930-1938, 2.578 of only upper limb amputations were held.

The goal of today?s lecture is the analysis of the key questions of theory and practice of amputation.

Amputation: this word comes from latin am, ambe (around, near) and putare (discard, clean).

Thus amputation means the removal of the peripheral part of an organ.

Limb amputation - the removal of the peripheral part of the limb throughout the bone.

Exarticulation ? the particular moment of the removal of peripheral part of the limb at the joint.

The history of amputation traces its roots back to the great antiquity. Such surgeries were performed by the Greek and Roman surgeons. Using the performing of such procedures in different historical periods of humanity as an example, we can follow the history of surgery?s development in general.

Middle Ages: Surgeons, without being able to fight with voluminous bleeding, dip the stump amputated by guillotine into the boiling resin, boiling oil or cauterize the wound with scorching iron. They squeeze the limb using wire on a certain level gradually to perform this procedure bloodlessly. The patient suffers an excruciating pain for a long time until the necrosis of peripheral part of the limb.

Amputation started to look like a modern procedure only in the beginning of 18^th century. In 1720 Jean Louis Petit offers to perform this operation considering not only the saving of life, but also providing the functioning of amputated limb.

The middle of the 19^th century. Year 1852. N.I. offers his famous operation ? osteoplastic amputation of the crus, which opened the new page of surgery ? osteoplasty.

And finally nowadays surgeons implement the progress of medicine and perform the operation of limb replantation in such cases in which the amputation was unconditionally performed.

At first glance amputation may seem to be a simple operation. But this simplicity is apparent. ?We can determine the surgeons ripeness and his readiness to be responsible for people?s lives by the way surgeon substantiate the indication for operation and performs it,? said one of the modern surgery manual?s author G.V. Ostroverkhov.

Actually, speaking in the words of N.I. Pirogov ??None of the operations requires as much consideration, common sense and doctor?s attention as the rational precise preparation of indication for amputation.?

Indications:

Absolute (the only way to achieve the therapeutic effect is the operation)

1) All kinds of gangrenes

2) The crushing of soft tissues with the following comminuted bones? fracture with the damage of neurovascular cord in a big extent

3) Malignant tumors

4) Congenital deformations that don?t require the orthopedic alignment
limb on a ?flap? ? is not an amputation, because the amputation itself has already been performed. It?s a surgical treatment of a wound.

Relative (surgical treatment is not the only way to achieve the theurapeutic effect) The operation is performed with full technical ability to preserve the limb.

1) Poor general condition of the patient after the burn, gross bleeding or collapse

2) Tourniquet shock (crush syndrome) with no ability to perform a perfusion of the limb

3) The surgeon?s qualification

4) Technical facilities of the operating room

5) Strategical conditions on the battle-front: offensive ? hospitalization and ability to preserve the limb, retreat ? evacuation with preliminary amputation

At present the consultation of minimum three doctors is considered mandatory for making a decision about amputation by relative indications.

Primary ?indications for removal of the limb (by absolute or relative indications) are set during the first medical examination, i.e. amputation is the first and main metical measure.

Secondary -indications for operation do not arise immediately, but some certain time later, during which the patient receives the complex theuropeutical treatment that was ineffective.

Being primary or secondary is not connected with the time factor.

By urgency:

Planned ? amputation goes according to the schedule (limb?s deformation, tumor)

Emergent ? minimal preparations before the operation (when trauma)

Consecutive ? amputations performed repeatedly because of the same process: hour and days with the anaerobic infection, months with the atherosclerosis and endarteritis.

Reamputation - amputation performed to eliminate stump?s unsuitability to make it suitable for prosthetics.

THE METHODS OF AMPUTATION:

1) By the form of soft tissues? dissection:

a) Circular

b) Ellipsoidal (as a sort of single-flap)

c) Flap

Circular method.Soft tissues? dissection is performed in a plane which is perpendicular to longitudinal axis of the limb.

Depending on the amount on the amount of soft tissues? dissections (not meaning the bone also), 3 types of amputation are recognized: single-, double and triple-stage amputations.

By the moment of amputation we mean the soft tissues? dissection in a definite plane.

The number of stages of amputation depends on the amount of the planes of soft tissues? dissection.

Guillotine amputation is a type of the single-stage amputations.

This operation certainly gives an unsuitable stump (conical) and performance of such operation supposes the mandatory performance of reamputation. It?s a forced measure obviously. The main indication for performing the guillotine amputation is a presence or even a suspicion of anaerobic infection. During the Great Patriotic War most of the amputations were performed by the guillotine method. Performing this imperfect amputation surgeon succeeds in following ? minimal area of the stump?s dissection, removal of ?blind pockets?, which inevitably form during the 1,2,3-stage amputations so this increases the effectiveness of the measures against anaerobic infection.

Date: 2016-06-13; view: 237