Amputation through the middle 1/3 of the lower leg

Amputation and joint dissection is a destructive procedure that has long been regarded as the primary means of surgical treatment of malignant bone tumors, saving the lives of patients at the expense of limbs. In recent years, with the widespread use of effective chemotherapeutic drugs and the advancement of surgical techniques, especially the extensive extensive resection of the limbs, attempts to treat malignant bone tumors have yielded satisfactory results, and the indications for amputation surgery have been reduced. According to the new concept of localized tumor resection, the role of amputation and joint dissection in the treatment of malignant bone tumors should be re-recognized. Due to the different planes of amputation, amputation or joint dissection may be radical tumor resection, or extensive tumor resection, or marginal tumor resection. Therefore, amputation or joint dissection does not always achieve radical resection of malignant bone tumors. Nevertheless, amputation and joint dissection are still one of the main methods to achieve radical resection of malignant bone tumors. When the limb is indeed unable to be retained, the amputation or joint dissection should be performed decisively. Curing disease: Indication The 1/3 amputation through the lower leg applies to: 1. A malignant tumor of the foot or ankle. 2. Severe congenital foot or ankle deformity, loss of its function. Preoperative preparation 1. CT and MRI examination to determine the extent of bone tumor involvement. 2. Chest X-ray and whole body radionuclide bone scan, except for lung metastasis and bone metastasis. 3. Biopsy clear pathological diagnosis. Surgical procedure Incision In the plane of the osteotomy, the flaps of equal length are designed before and after, and the length of the flap is equal to 1/2 of the anteroposterior diameter of the calf. 2. Reveal Cut the skin in the direction of the incision, deep into the deep fascia, and in the anterior medial aspect of the tibia, cut the periosteum of the tibia until the plane of the osteotomy. The superficial peroneal nerve is exposed between the extensor digitorum longus and the short sacral muscle, and the proximal end is naturally retracted after being sharply cut. Then, the anterior iliac vessels and the deep peroneal nerve are exposed, and the blood vessels are double-ligated after being cut off, and naturally retracted after the nerve is cut. 3. Amputation The tibialis anterior muscle was cut at about 0.75 cm distal to the plane of the amputation. The humerus at the proximal end of the osteotomy plane was osteotomy at 45° and the vertical osteotomy was reached after reaching the medullary cavity. Then, the soft tissue around the tibia was revealed, and the tibia was cut with a wire saw 2 cm at the proximal end of the humerus plane, and the osteotomy was smoothed with the epiphysis. The periosteal edge is removed. Then, the sacral muscle was excised, the posterior and posterior iliac vessels were cut and double ligated, and the posterior tibial nerve was exposed and cut, and a fascia flap was formed from the iliac membrane of the gastrocnemius to cover the osteotomy stump. 4. Close the incision Loosen the tourniquet, the wound was pressed with hot saline gauze for 5 minutes, and further electrocoagulation to stop bleeding. After washing with saline, the formed gastrocnemius aponeurosis membrane flap is sutured with the anterior periosteum to cover the osteotomy stump. The deep fascia is then sutured intermittently. The vacuum suction tube was placed deep into the gastrocnemius muscle, and the layers of the incision were sutured intermittently layer by layer. complication 1. Hemorrhage and hematoma formation Major bleeding caused by large blood vessel ligation is rare, but it should be highly vigilant. A rubber tube tourniquet was prepared at the regular bedside after surgery. Closely observe the bleeding of the dressing. Once a major bleeding is found, stop the blood band immediately and stop the operation in an emergency. 2. Joint contracture Articular contracture can occur in lower extremity amputation, especially when the sitting time is too long or the lying position is too high, which can cause knee flexion and hip flexion abduction contraction, which will affect the assembly of the prosthesis. Therefore, postoperative application of plaster support to maintain the hip joint and knee joint in the extension position, and encourage patients to stretch the knee extension of the knee muscle contraction exercise and joint function training. 3. Phantom limb pain The patient often feels that the removed limb is still present after surgery, and has a sense of acupuncture and numbness. This phantom limb sensation can gradually disappear and does not affect the wearing of the prosthesis. However, a few have severe phantom limb pain, which is manifested by the unbearable pain of the entire phantom limb, which persists, especially at night, and its pathogenesis is still unclear. Therefore, the lack of effective treatment methods can take acupuncture, physiotherapy and psychotherapy. Procaine closure or sympathectomy is also feasible. 4. Neuroma and residual limb pain The nerve endings have nerve fibers regenerated to form a neuroma, which is an inevitable pathological phenomenon. However, only about 10% of patients develop painful neuroma. It may be related to the compression of the nerve end by the bone end, the surrounding scar tissue wrapping and the scar adhesion. For patients who are not treated with non-surgical treatment, the neuroma can be surgically removed and the stump can be placed in the normal muscle space.