xià zh and jié zh and 2
According to different amputation planes, there are the following operations. 3 Foot and ankle amputation < P > The advantages of amputation in this part are that the stump is long, the stump can bear weight, and the required prosthesis is short, which can retain the position feeling of the calf, especially for bilateral foot and ankle amputees. However, it should also be noted that wound healing may be difficult or non-healing, and even amputation is needed. Therefore, elderly patients should be carefully considered, and patients with occlusive vascular disease should generally not have toe and forefoot resection. The toe amputation through the proximal phalanx of any toe should adopt a tennis racket-like incision. The extension of the incision of the first and fifth toes is equivalent to that of the handle of the tennis racket, but the second, third and fourth toes should be in the same direction as the metatarsal bone of that toe. When amputating the foot through tarsometatarsal joint and its upper part, all extensor dorsi tendons should be fixed on the bone end to balance the plantar flexion force and prevent the drooping deformity of the posterior part of the foot. 4 Syme amputation < P > In the neutral position of the ankle joint, the starting and ending points and the direction of the plantar and dorsal flap incisions are marked at the front and lower points of the medial and lateral ankle tips. The starting point of the self-contained medial incision cuts vertically down to the bone surface, passes through the plantar surface to the starting point of the lateral foot incision, and then makes a connected incision from the two starting points of the incision. Cut the tendons of peroneal long and short muscles, extensor digitorum, anterior and posterior tibialis muscles. The anterior tibial artery and vein were cut and ligated respectively. Incision of the anterior joint capsule at ankle plantar flexion, and then cutting off the medial and lateral ligaments and joint capsule. Pull the posterior part of talus with a retractor, so that the ankle joint is extremely plantar flexion, and the posterior ankle joint capsule and achilles tendon are cut. After cutting and ligating the tibia at the distal end of the metatarsal flap, it is dynamic and static. Cut the tibialis anterior, posterior and peroneal nerves and tendons with a sharp knife and let them retract above the plane of medial and lateral malleolus. After peeling off the anterolateral ankle flap, the periosteum of the slightly upper part of the medial and lateral malleolus was cut circularly, and the tibia and fibula were sawed vertically with the tibia and fibula shafts at .5 ~ 1 cm on the ankle joint surface. After stopping bleeding and washing the wound, sew the periosteum at the back of calcaneus to the periosteum corresponding to the lower end of tibia. Make the plantar skin flap close to the lower end of tibia, sew the plantar and dorsal fascia and skin flap, and put a rubber drainage strip from the inside and outside of the wound. The wound was covered with a long gauze, and the plantar flap was fixed on the lower end of tibia and the front, back, left and right sides of the leg stump in a cross shape with two cm-wide long rubber strips. Closure, suture and fixation of plantar flap is one of the keys to the success of this amputation. 5 Leg amputation < P > Ischemic necrosis and severe rolling injuries at the lower end of the foot and leg are more common, so amputation below the knee is more than amputation at other levels. Because the blood circulation of the muscles and collateral branches in the posterior side of the leg is richer than that in the anterior side, a flap with a long posterior side and a short anterior side should be used or only a long posterior side flap should be used for amputation of patients with occlusive vasculitis and necrosis of the lower leg. For patients with acute popliteal artery occlusion and irreparable leg vascular injury, flap amputation can be performed with anterior and posterior equal-length flaps. The amputation of the posterior long and anterior short leg flaps is to mark the osteotomy site 1 ~ 12 cm below the knee, and measure the length of the anterior and posterior diameter of the site and divide it into three equal parts, with 2/3 as the length of the posterior flap and the remaining 1/3 as the length of the anterior flap. Mark the osteotomy plane and draw the incision line. Cut the skin and fascia along the direction of the incision line, turn the flap up and cut off the anterolateral calf muscles. In the absence of tourniquet, if there is no active bleeding point or jet bleeding in the muscle, it is an indication to switch to above-knee amputation, otherwise, continue the following surgical steps. First, the peroneal nerve was severed between the extensor digitorum longus and the peroneal brevis, and then the lateral calf muscles were severed. Expose and treat anterior tibial artery, vein and anterior tibial nerve. The soft tissue around the fibula was protected by a periosteal stripper. The periosteum of the fibula was cut and peeled off distally 2cm above the plane where the tibia was expected to be cut off, and the fibula was sawed off with a wire saw. Separate muscles from the lateral posterior side of tibia to protect muscles and neurovascular bundles. Saw off the tibia at the mark where it was cut off. Saw off a wedge-shaped bone block at the angle of 3 ~ 4 between the anterior tibial crest and the tibial shaft. File off the periphery of the tibia and fibula. Cut off the muscles at the back of the calf. Ligate posterior tibial artery and vein and peroneal artery and vein. The posterior tibial nerve and peroneal nerve were treated according to the points for attention in amputation. After drainage, the wound was sutured in layers, and the residual limb was fixed with wooden board or plaster support.
6 amputation of thigh
The amputation of the lowest thigh is on the femoral condyle, where a long residual limb can be preserved, but the wound healing is more difficult than that at the junction of the middle and lower third of the thigh. Therefore, amputation through the middle thigh or the junction of the middle and lower 1/3 is often chosen. Its advantages are that the wound is easy to heal, the length of the residual limb is appropriate, and it is convenient to assemble and use the prosthesis. The anteroposterior and posterior flaps of the amputated thigh are of equal length, and their lengths are equal to 1/2 of the anteroposterior diameter of the thigh at the femoral osteotomy plane. The flap incision starts from 2 ~ 3 cm above the expected osteotomy plane of the medial thigh line, and is tangential to the distal side in an arc shape, passing through the front of the thigh to the lateral thigh line and ending at the same plane as the starting point of the medial thigh incision. Make a flap with the same length and shape as the anterior flap on the posterior thigh. Cut the subcutaneous tissue and fascia according to the shape of the flap. Stretch the sartorius muscle in the femoral canal far from the retraction edge of the flap, first cut off the femoral nerve branch and saphenous nerve, then cut off and double ligate the femoral artery respectively, and ligate the femoral vein once. The deep femoral artery is behind the femur, in the gap between adductor major, biceps femoris and quadriceps femoris, and is also treated by the above method. Because the muscles of the anterior and medial thighs are richer than those of other lateral posterior thighs. The contraction force is large, so the muscles of the front and inner thighs should be cut off obliquely from the osteotomy plane slightly below the fascia retraction, but the muscles of the outer and rear thighs should be cut off transversely from the fascia retraction. Treat the sciatic nerve according to the points for attention in amputation, such as ligation of the broken end bleeding, and then let it retract to above the expected osteotomy plane. Circumferentially cut off the periosteum, saw off the femur in the direction perpendicular to the longitudinal axis of the femoral shaft, file the edge of the bone end, and loosen the tourniquet. Thoroughly stop bleeding, wash the wound, put a drainage strip, sew the incision in layers, and fix the hip joint in a straight and neutral position with a front plaster support. 7 Hip amputation < P > It is more difficult to assemble prosthetic limbs after hip amputation than thigh amputees. This amputation is mostly used for femoral condylar malignant tumors and femoral artery embolization. A tennis racket-shaped incision is made in the front of the hip, which is connected by the following three incisions: ① It is cut vertically down from the anterior superior iliac spine to the level of the femoral neck, which is equivalent to the "racket handle", and then parallel to the inguinal ligament, it is cut down to 5cm below the starting point of adductor muscle. (2) Starting from the "racket handle", it cuts downward and outward in an arc shape to 8cm below the greater trochanter of femur. (3) From the stop point of the medial incision, it cuts backward and downwards in an arc shape to a position about 5cm below the ischial tubercle from the midline of the posterior thigh, and then continues to cut the posterior lateral thigh to the stop point of the second incision.
Cut the deep fascia along the incision direction of the anterior hip flap, peel off and open the flap to expose the femoral artery, vein and nerve, cut off and double ligate the femoral artery and vein, and ligate its branches. Treatment of femoral nerve according to the precautions of amputation. Cut the sartorius muscle at the anterior superior iliac spine and the rectus femoris muscle at the anterior inferior iliac spine, and cut the pubic muscle slightly below the pubic bone, and then turn the abdomen of each muscle to the far side. External rotation of the hip joint, exposing the femoral trochanter, cutting off the iliopsoas tendon stopped on it, and turning its belly to the proximal side. Cut off the starting points of gracilis muscle and adductor muscle group on pubic bone and ischium, separate the gap between pubic muscle and obturator external muscle and hip external rotation muscle group, first explore and ligate obturator artery and its branches, and then cut off the muscles near the obturator external muscle stop. In adduction and pronation of hip joint, tensor fascia lata was cut from below its muscle abdomen along the direction of flap incision, gluteus maximus tendon was cut at the thick femoral line and pulled upward, and gluteus medius, gluteus minimus and piriformis tendon were cut at the top of greater trochanter. Ligate superior and inferior gluteal arteries and veins, treat sciatic nerve in the same way as femoral nerve, and ligate the bleeding point of this nerve. After the hamstring muscle was cut at the ischial tubercle and the hip external rotation muscle group was cut at the posterior side of femur, the hip joint was completely exposed. After circular incision of the hip joint capsule and cutting of the round ligament, the hip joint is severed. Thoroughly stop bleeding and wash the wound. Sew the gluteal muscles at the starting point of pubic muscle and adductor muscle, and sew fascia and flap in layers. Put a drain at the bottom of the incision and take it out in 24 ~ 36 hours. 8 hemipelvic resection 8.1 Anterior incision < P > From the iliac crest to the anterior medial side of the anterior superior iliac spine, along the inguinal ligament to the pubic tubercle. The medial and lateral oblique muscles, transverse abdominal muscles and inguinal ligament were cut off at the iliac crest and anterior superior iliac spine. Expose and free the spermatic cord, and pull it inward, pull the abdominal muscle inward and upward, make a retroperitoneal blunt dissection, and push the peritoneum and intra-abdominal organs inward and upward. The rectus abdominis and inguinal ligament were cut from the superior margin of pubic bone and its tubercle. Bluntly separate the anterior Retzius space of the bladder, so as to temporarily protect the bladder in the lower pelvic cavity. At this time, you can see and touch the ureter moving inward along the posterior abdominal wall. In order to determine whether hemipelvic resection is appropriate, it is necessary to explore the boundary of the tumor. If the tumor is huge and its inner edge exceeds the belly line, or invades the sacrum or lumbar spine, the operation should be stopped and the wound should be sutured and radiotherapy or chemotherapy should be used instead. If the tumor is huge, but the whole tumor can be removed by breaking the sacroiliac joint, the operation should be continued. The external iliac artery and vein were cut off and double ligated, and the femoral nerve was treated according to the above precautions in amputation. 8.2 perineal incision
The assistant holds the affected thigh with both hands to abduct the hip joint. Make an arc incision from the pubic tubercle of the first incision along the thigh root, and cut it backward and downward to the ischial tubercle through the pubic bone and ischial branch. Expose pubic bone and sciatic branch, make subperiosteal dissection, and open ischiocavernous muscle and transverse perineal muscle from the inner edge of sciatic branch. Expose the pubic symphysis, and use your fingers to probe the * * * shaped spinous bone from the pubic symphysis and the posterior side, then put a periosteum stripper in this treatment to protect the posterior urethra, and then cut off the pubic symphysis with an osteotomy knife. The posterior incision < P > is flexed and retracted in the hip joint, cutting from the starting point of the anterior incision to the posterior superior iliac spine, then turning to the greater trochanter of femur, and then connecting to the ischial tubercle along the hip wrinkles and the stop point of perineal incision. Cut the muscularis gluteus maximus and gluteus maximus along the direction of skin incision. Blunt dissection was made on the deep surface of gluteus maximus, and the muscle flap was turned to the midline of the spine, exposing the gluteus medius, hip external rotation muscle group, sciatic nerve, superior and inferior gluteal arteries and veins. Treating sciatic nerve with the same method of treating femoral meridian. Then the superior and inferior gluteal nerves were cut off, the superior and inferior gluteal arteries and veins were ligated, and the piriformis muscle was cut off. The latissimus dorsi and quadratus lumborum were cut off from the posterior part of the iliac crest, and the gluteus maximus was stripped and pulled away to the midline. From the ischial notch, the iliac bone is sawed off from the bottom to the top as close as possible to the sacroiliac joint, or the sacroiliac joint is severed, the affected limb and iliac bone are externally rotated, the obturator artery and obturator nerve are ligated in the pelvic cavity, and the psoas major is severed in front of the sacroiliac joint. Levator ani muscle was severed from the pelvic side of the pubic bone. After the sacrospinous ligament and sacral tubercle ligament were cut off, the affected hemipelvis was removed.