Surgical foundations of successful rehabilitation
The patient's quality of life and the possibility of using a prosthesis are established right in the operating room. A properly formed stump is the primary condition for successful adaptation.
- Bone management: Sawing is performed using a Gigli saw. The most important rule is constant irrigation of the sawing zone with physiological saline to prevent thermal burns and bone tissue necrosis. Sharp edges must be smoothed with a rasp. In leg amputation, there is a nuance: the fibula is shortened 2–3 cm proximal to the tibia, and the anterior edge of the latter is beveled.
- Vessels: Major arteries and veins are ligated before they are transected. It is strictly prohibited to suture a large vessel together with the surrounding muscle mass, as this threatens ligature cutting through and secondary hemorrhage. Thorough hemostasis is performed after removing the tourniquet.
- Nerves: In terms of significance, this stage is equivalent to neurosurgical intervention. Errors lead to the formation of painful neuromas, nerve entrapment in scar tissue, and severe phantom pain requiring re-amputation. Soft tissues are gently shifted proximally (the nerve itself must not be pulled!), a novocaine solution is injected into the perineurium, and then the nerve trunk is transected strictly with a sharp razor. After being severed, the nerve spontaneously contracts and retracts deep into the tissues.
Wound closure tactics and the early postoperative period
The choice of wound closure method depends on the indications for surgery:
- Emergency ("guillotine") amputations: Sutures are not applied at all. The wound remains gaping and the bone exposed. This is necessary to prevent the development of anaerobic infection (gas gangrene). Only alignment sutures to approximate the skin edges are permitted; the stump is not formed at this stage.
- Planned interventions and re-amputations: The myoplastic method is used, in which the bone stump is covered by suturing antagonist muscles over it. This increases the functionality of the future stump and improves its blood supply. The skin scar is formed so that it is located outside the weight-bearing zone (on the lower extremity it is shifted posteriorly, on the upper extremity to the dorsal side). Drains must be left in the wound.
In the postoperative period, proper immobilization is critically important. To avoid the development of contractures in a malposition, the limb is fixed with a plaster splint. Early rehabilitation begins as early as 5–7 days—therapeutic exercise (isometric muscle contractions) is prescribed to the patient.
Prosthetics: criteria, stages, and types of designs
Prosthetics is the replacement of a missing segment with special devices to compensate for form and function, as well as to prevent secondary deformities of the musculoskeletal system.
The decision on the feasibility of prosthetics is made after a comprehensive assessment of local status (condition of the stump and adjacent joints), neurovascular, and general somatic condition. The psychological factor plays a huge role—the patient's motivation to master the prosthesis and return to social life.
The process requires adaptation of the entire organism and begins with the mandatory use of training prostheses for initial habituation. Modern technologies make it possible to select a lightweight design at any level of amputation.
Classification of prostheses by functional purpose:
- Cosmetic — replace only the external defect.
- Actively cosmetic — combine aesthetics with the restoration of lost movements.
- Working — designed for highly specialized production or household tasks.
- Myoelectric-controlled — high-tech devices with external energy sources capable of performing a complex set of movements.
The goals of prosthetics differ radically. For the lower extremity, the absolute priority is weight-bearing capacity (ability to move). For the upper extremity, range and precision of movements (restoration of grasp and manipulation) come to the fore, as well as maximum cosmetic effect.
Nerve management rule SNOB: Shift tissues proximally, Novocaine into the perineurium, Obtain transection with a Blade (Razor). This will prevent the formation of pathological neuromas and phantom pain.
Class and exam questions
Why are sutures not applied in an emergency amputation?
In a "guillotine" amputation, the wound is left open to prevent the development of anaerobic infection (gas gangrene). The stump is not formed at this stage.
How to properly saw bones during a leg amputation?
The fibula is sawed 2–3 cm proximal to the tibia, and the anterior edge of the tibia must be beveled.
What is the difference in priorities when fitting arm and leg prostheses?
For lower extremities, the main function is to restore weight-bearing, while for upper extremities, it is to ensure the range and precision of movements (grasp), as well as to achieve a cosmetic effect.
What else to study on this topic
- Assessment of neurovascular and local status before starting prosthetics.
- Features of the myoplastic method for covering the bone stump.
- Prevention of contractures in malpositions using plaster splints.
- Myoelectric prostheses: mechanisms of operation with external energy sources.
- Orthopedic supporting devices (orthoses, corsets) and special footwear.
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