Flap amputation techniques
In modern operative surgery, flap methods for stump formation are the most widely used. Analyzing clinical practice, it can be stated that they are currently used much more frequently than classical circular methods.
The predominant localization for interventions using flaps is lower leg amputation, and on the upper extremity, the forearm. Depending on the volume of preserved tissues and the surgical task, these techniques are subdivided into two main types:
- Single-flap methods;
- Double-flap methods.
Three-stage conical-circular method by N. I. Pirogov
This principle was introduced into surgery by N. I. Pirogov to solve a crucial task—reliably hiding the bone cut deep within the formed soft tissue cone. The technique is strictly regulated and performed in three surgical steps:
- 1st step: A circular dissection of the superficial layers—skin, subcutaneous tissue, and fascia—is performed.
- 2nd step: Dissection of only the superficially located muscles is carried out. An important feature of this stage is that the transected superficial muscles immediately retract over a significant distance.
- 3rd step: Dissection of the deep muscles is performed. The line of this incision runs strictly along the edge of the superficial muscles that have already retracted after the second step.
Completion of surgery and results: After layered dissection, the entire formed mass of soft tissues is pulled proximally using a special retractor, and only after that is the bone sawed through. This technique is particularly relevant for the femur or humerus. The logical result is that the bone cut ends up hidden deep in the soft tissues, and the postoperative scar is located directly on the terminal (weight-bearing) surface of the stump.
Pirogov's osteoplastic lower leg amputation
Pirogov's osteoplastic lower leg amputation is a complex reconstructive surgery, the fundamental idea of which is preserving the posterior part of the calcaneus to create a natural and strong support.
The course of the intervention can be divided into the following key stages:
- Bone resection diagram: Strictly defined bone structures are removed. The removed areas shaded on classical surgical diagrams include the talus (talus), the distal epiphyses of the tibia and fibula, as well as the anterior part of the calcaneus.
- Soft tissue incision lines: Access is formed using a characteristic stirrup-shaped incision that runs from malleolus to malleolus directly across the sole.
- Sawing the calcaneus: At this stage, the surgeon performs a vertical cut of the calcaneus, separating the anterior part to be removed.
- Stump formation: The remaining portion of the calcaneal tuberosity (tuber calcanei) with the carefully preserved cutaneous plantar flap is specially prepared to cover the bone stump of the lower leg. The calcaneal tuberosity is repositioned and securely fixed to the bone resection line of the lower leg (tibia et fibula), creating a fully functional weight-bearing surface.
Briefly: answers to topical questions
What are the absolute indications for lower extremity amputation?
Absolute indications for amputation are associated with irreversible loss of viability or a direct threat to the patient's life. These include:
- Traumatic limb avulsions — in the absence of replantation capabilities.
- Futile attempts to restore function — in open injuries with multiple fractures, muscle crushing, irreparable damage to major vessels and nerve trunks.
- Life-threatening progressive infectious process — anaerobic infection, sepsis.
- Limb non-viability — due to gangrene of various origins, severe burns, frostbite, electrical injury.
- Malignant neoplasms.
How to properly manage nerve trunks during limb amputation?
Proper management of nerve trunks is critical for preventing the formation of pathological neuromas and phantom pain.
- Preparation — the soft tissues around the nerve are shifted as proximally as possible by 5–6 cm, while pulling on the nerve itself is strictly prohibited.
- Anesthesia — a novocaine solution is injected into the perineurium.
- Transection — the nerve is transected strictly with a sharp razor or a sharp scalpel (using scissors is strictly prohibited).
After transection, the nerve spontaneously retracts deep into the thickness of the soft tissues. Too high of a transection carries the risk of muscle atrophy and the formation of trophic ulcers.
What surgical instruments are used to retract soft tissues and saw through the bone during amputation?
A retractor is used to pull back soft tissues. A Gigli-Olivecrona wire saw is used to saw the bone. After sawing, the sharp edges of the bone stump are smoothed with a rasp.
What methods of periosteum management exist when sawing through bone?
There are two main methods of managing the bone stump and periosteum during amputation.
| Method | Description | Indications and features |
|---|---|---|
| Subperiosteal | The periosteum is incised distal to the resection level and shifted proximally (upward) to cover the stump. | Applicable only in children. In adults, it leads to osteophyte formation and a faulty stump. |
| Aperiosteal | Circular incision of the periosteum with a scalpel and displacing it distally (downward) by 0.5 cm using a Farabeuf periosteal elevator. | Modern standard. The saw is placed 2–3 mm distal to the edge of the periosteum, which prevents its trauma. |
Class and exam questions
Why are the muscles dissected in two separate stages during the three-stage method?
This is necessary due to the differing degrees of their contractility. Superficial muscles are transected first, as they retract over a significant distance, after which the deep muscles are incised guided by the edge of the retracted superficial ones.
Where does the scar form after a cone-circular amputation?
As a result of layered tissue dissection and retraction with a retractor, the postoperative scar is located on the terminal (weight-bearing) surface of the formed stump.
Which bone structures are completely or partially removed during Pirogov's lower leg surgery?
The bones to be resected include the talus (talus), the distal epiphyses of the tibia and fibula, and the anterior part of the calcaneus.
What is the main principle of osteoplastic lower leg amputation?
The main principle consists in preserving the posterior part of the calcaneus (calcaneal tuberosity) along with the skin flap of the sole, which is then fixed to the lower leg bone stump to create a reliable support.
What else to study on this topic
- Biomechanical properties of the calcaneal tuberosity as a weight-bearing surface of the stump
- Comparative characteristics of single-flap and double-flap amputation methods
- Topographic and anatomical rationale for the stirrup-shaped incision on the foot
- Features of retraction of various thigh and arm muscle groups during amputations
- Technique of working with a retractor to protect soft tissues during bone sawing
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