庆祝上市 全新改版

Re:【文献翻译】——JBJS文献翻译系列报道(May、2007)

Controversies in
Lower-Extremity Amputation下肢截肢术中存在的争议

By Michael S. Pinzur, MD, Frank A. Gottschalk, MD, Marco Antonio Guedes de
S. Pinto, MD, and Douglas G. Smith, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Using the experience gained from taking care of World War II veterans with amputations, Ernest Burgess taught us that amputation surgery is reconstruc-tive surgery. It is the first step in the re-habilitation process for patients with an amputation and should be thought of in this way. An amputation is often a more appropriate option than limb salvage, irrespective of the underlying cause. The decision-making and selection of the amputation level must be based on realistic expectations with regard to functional outcome and must be adapted to both the disease process being treated and the unique needs of the patient. Sometimes the amputation is done as a life-saving procedure in a patient who is not expected to walk, but more often it is done for a patient who should be able to return to a full active life. This lecture addresses amputations done to return the patient to full activity. Our purposes are to assist the reader in (1) establishing reasonable goals when confronted with the question of limb salvage versus amputation,(2) understanding the roles of the soft- tissue envelope and osseous platform in the creation of a residual limb, (3) un- derstanding the method of weight-bearing within a prosthetic socket, and(4) determining whether a bone bridge is a positive addition to a transtibial amputation.
Ernest Burgess利用照顾II次世界大战中截肢的退伍军人所得的经验,教导我们截肢手术是重建性手术。它是截肢病人恢复过程中的第一步,而且应该这么认为。截肢经常是比救肢更恰当的选择,而不论其根本原因是什么。决策的制定和截肢平面的选择必须基于功能结果的现实期望值,且必须适合所要治疗的疾病过程和病人的独特需要。有时候截肢是用于无行走期望的病人的救命性措施,但是它更经常情况下是用于应该能够恢复完全独立生活的病人的。我们的目的是帮助读者:1)在面对救肢VS截肢的问题时建立合理的目标;2)理解残余肢体建立时软组织包埋和骨质平台的作用;3)理解假肢接受腔内承重的方法;4)决定骨桥是否是经胫骨截肢术的一个积极条件。
The Lower Extremity Assessment Project (LEAP) has provided objective outcome data on patients with
mutilating limb injuries1. Five hundred and sixty-nine consecutive patients with mutilating limb injuries treated at eight academic trauma centers provided objective observational outcome data relative to limb salvage and
amputation.One hundred and forty-nine under- went lower-extremity amputation dur- ing
the course of their care. This ongoing study is providing a realistic understanding of the less-than-favorable results associated with both limb salvage and amputation. Much of what has been learned from LEAP can be
applied to the care of patients with a non- traumatic amputation.
下肢评估工程(LEAP)提供了肢体残废损伤病人的客观结果资料。8个研究院的创伤中心的569例肢体残废损伤病人提供了有关肢体救治和截肢的客观观察结果数据。149例病人在治疗期间进行了下肢截肢术。这个正在进行的研究提供了与肢体救治和截肢相关的良好以下结果的现实性理解。从LEAP中获悉的许多东西可以应用于治疗非创伤性截肢病人。A reasonable functional goal should be established before an extremity amputation is performed. The goals for a young individual who is going to reenter the workforce after a traumatic amputation are very different from those for an elderly debilitated patient with diabetes who has a limited life expectancy. Before surgery is performed, four issues need to be addressed, in order to create a needs assessment:
1. If the limb is salvaged, will the functional outcome be better than it would be after an amputation and fitting of a prosthetic limb? This question needs to be addressed regardless of whether the patient has a mutilating limb injury, a diabetic foot infection, a tumor, or a congenital anomaly.
2. What is a realistic expectation following treatment? The realistic expected functional outcome is the average functional outcome for patients with the same comorbidities and level of amputation; it is not the best possible outcome.
3. What is the cost of care? This cost goes beyond resource consumption. Can the patient and his or her family afford the multiple operations and the time off from work necessary to accomplish limb salvage, or are they best served by amputation and fitting of a prosthetic limb?
4. What are the risks? Limb- salvage surgery for any diagnosis is riskier than an amputation. When a patient has had an infection in an ischemic limb, the risk of recurrent infection and sepsis is far lower when the limb is removed than when it is retained.
应该在截肢进行前确立合理的功能性目标。对于一个在创伤截肢术后要重新回到工作岗位的年轻人来说,其目标和寿命有限的年老体衰的糖尿病病人非常不同。在手术进行前,须列出四点来建立一个需要评估。
1. 如果肢体被救下了,其功能性结果是否会比截肢和安装假肢更好?这个问题需要列出,无论病人是否存在肢体残废损伤、糖尿病组感染、肿瘤或先天性畸形。
2. 治疗的现实期望是什么?期望的现实性功能结果是有着同样并存病和截肢水平的病人能够达到平均功能性结果;这不是最好的可能结果。
3. 治疗的费用是多少?这个费用超出资源消耗。病人和他(或她)的家庭能否负担得起完成截肢所必需的多重手术的费用和需要脱离工作的时间,或者他们能否通过截肢和安装假肢而得到最好的治疗?
4. 风险有什么?任何诊断的救治手术都要比截肢术风险大。当病人缺血性肢体存在感染时,移除肢体时感染复发和败血症的风险要远比保肢时高。
Once these issues have been addressed, the patient and the surgical team generally have sufficient data to support the decision-making process.
When performing an amputation as a reconstructive effort after trauma, infection, tumor, or vascular insufficiency, one should strive to create:
1. Optimal residual limb length without osseous prominences.
2. Reasonable function in the joint proximal to the level of the ampu- tation to enhance prosthetic function.
3. A durable soft-tissue envelope. Although new prosthetic technology allows compensation for a suboptimal soft-tissue envelope, it is well accepted that amputees fare better with a durable soft-tissue envelope and fare worse when the skin is adherent to bone or there is a split-thickness skin graft in areas of high pressure or shear. Therefore, muscles should be secured to bone to prevent retraction. When possible, full- thickness myocutaneous flaps should be used, with muscle cushioning in areas of high pressure and shear (Figs. 1-A through 1-D).
一旦这些条目列出,病人和手术组通常有充分数据来支持决策制定过程。
当把截肢作为创伤、感染或血管功能不全后的重建性努力时,应当努力争取以下几点:
1. 无骨质突起情况下的最佳残余肢体长度。
2. 截肢平面近端关节的合理功能来加强假肢功能。
3. 耐久的软组织包封。尽管新的假肢技术可以代偿欠佳的软组织包封,但是一般认为截肢者在有耐久的软组织包封时行走更好一些,当皮肤附着于骨或高压力或剪应力区域有中厚皮片时行走较差。因此,肌肉应当固定于骨来防止其回缩。可能情况下应当采用全厚肌皮瓣,使肌肉在高压力和剪应力区域起缓冲作用。
Disarticulation Compared with Transosseous Amputation关节离断术同经骨截肢术的比较
The more distal the level of lower- extremity amputation, the better the walking independence and functional outcome, unless the quality of the residual limb creates so much discomfort that it negates the potential benefits of limb-length retention. Therefore, the amputation should be done at the most distal level that will result in a functional residual limb. Efforts to create a functional residual limb should take into account the method of weight-bearing (load transfer) and the tissues available to create a soft-tissue envelope.
下肢截肢术平面越靠近远端,行走的独立性和功能性结果就越好,除非残余肢体的质量产生了许多不舒服以至于抵消了肢体长度保留的可能益处。因此,截肢应当在可以获得功能性残余肢体的最远端水平进行。尝试创造功能性残余肢体时应当考虑承重(荷重转移)的方法和可用于创造软组织包封的组织。The best residual limb cannot duplicate the unique weight-bearing properties of a normal foot. The foot has multiple bones and articulations that function as a shock absorber at heel strike, a stable platform during stance phase, and a “starting block” for stability at push-off. The multiple bones and joints allow positioning of the durable plantar soft-tissue envelope in an optimal orientation for accepting load. An amputee has, in place of a foot, a residual limb that must tolerate weight- bearing (load transfer) with the socket of a prosthesis.
最佳的残余肢体不可以复制正常足的独特承重特性。足有多块骨头和关节,它们在脚后跟撞击地面时像减震器一样起作用,是蹋脚位的一个稳定平台,在推开时是维持稳定性的一个起始块。多个骨头和关节允许耐久的跖软组织包封在接受荷重的理想定位时的体位保持。截肢者的残余肢体必须通过假肢来承重(荷重转移)以代替正常足。When the amputation is through a joint (disarticulation), the load transfer can be accomplished directly; i.e., there is end-bearing. When the amputation is done through the bone (trans-osseous), the load transfer must be accomplished indirectly by the entire residual limb, through a total-contact socket of the prosthesis, as weight-bearing on the end of the residual limb is too painful. Disarticulation allows dissipation of the load over a large surface area of less stiff metaphyseal bone. With a well-constructed soft-tissue envelope to cushion the residual osseous platform, the direct-transfer prosthetic socket need only suspend the prosthesis. This differs from transosseous amputation at the transtibial or trans- femoral level, where the surface area of the end of the bone is small and the diaphyseal bone is less resilient. The end of the bone must be “unweighted” by dissipating the load over the entire surface of the residual limb. This indirect load transfer requires a durable and mobile soft-tissue envelope that can tolerate the shearing forces associated with weight-bearing. The socket fit becomes crucial. When a patient loses weight the residual limb tends to bottom out, and painful end-bearing or tissue breakdown develops. Patients who gain weight are not able to fit the limb into the prosthesis. The choice of disarticulation or transosseous ampu- tation must be individualized for each patient.
当截肢是通过关节时(关节离断术),荷重转移可以直接完成,即末端承重。当截肢是通过骨头时(经骨的),荷重转移必须通过整个残余肢体的假肢的全接触式接受腔间接完成,因为残余肢体末端承重很痛苦。关节离断术允许荷重耗散于比较不僵硬的干骺端骨头的巨大表面区域。有着结构良好的软组织包封来垫残余骨质平台时,直接转移的假肢接受腔仅需要使假肢悬挂。这不同于胫骨或股骨平面的经骨截肢术,因为这些骨头末端的表面区域小和骨干无弹力。骨末端必须通过将荷重消散在残余肢体的整个表面来减重。这种间接荷重转移需要耐久性的合可移动的软组织暴风,可以耐受承重相关的剪应力。接受腔的安装成为关键。当病人体重减轻时,残肢倾向于降至最低点,会发生痛苦的末端承重或组织破坏。体重增加的病人不能够使肢体适应假肢。每个病人的关节离断术或经骨截肢术的选择必须个体化。
Transtibial (Below-the-Knee) Amputation经胫(膝下)截肢术The standard transtibial prosthetic socket is fabricated with the knee in approximately 10° of flexion, in order to unload the distal part of the tibia and optimally distribute the load. Load transfer is accomplished by distributing the load over the entire surface area of the residual limb, with a concentration over the anterior-medial and anterior-lateral areas of the tibial metaphysis.
标准的经胫假肢接受腔以大约10度的屈曲与膝焊接,目的是解除胫骨远端部分的负担和最佳分配荷重。荷重转移通过将荷重分配到残肢的整个表面区域来完成,集中于胫骨干骺端的前内侧和前外侧区域。

Mutilating limb injuries frequently disrupt the interosseous membrane, disengaging the relationship between the tibia and fibula. This loss of integrity of the interosseous mem- brane prevents the fibula from participating in normal load transfer. In other situations, the residual fibula may become unstable following transtibial amputation because of loss of the integrity of the interosseous membrane or as a result of loss of the integrity of the proximal tibiofibular joint even without an obvious traumatic disruption.
肢体残废损伤经常使得骨间膜断裂,打乱了胫骨和腓骨之间的关系。骨间膜完整性的丢失妨碍了腓骨参与正常的荷重转移。其它情况下,残余腓骨可能会在经胫截肢术后变得不稳定,原因是骨间膜完整性的丢失,或由于近端胫腓关节完整性的丢失,甚至实在没有明显的外伤性断裂的情况下。Individuals with instability of the residual fibula following transtibial amputation can have pain due to several causes. When the residual limb is compressed within the prosthetic socket, the residual fibula may angulate toward the tibia with prolonged weight-bearing. The result is a conical, pointed residual limb, which tends to bottom-out during prolonged weight-bearing. The conical residual limb acts as a wedge, leading to painful end-bearing and soft- tissue breakdown over the terminal tibia. When the residual limb is short, or the interosseous membrane has been disrupted, the residual fibula can be abducted as a result of unopposed action of the biceps femoris muscle (Fig. 2)4,5.These alterations of the load-bearing platform become accentuated in younger, more active amputees, with higher demand, or with prolonged activities.
经胫截肢术后残余腓骨不稳定的个体的疼痛可能有几个原因。当残余肢体在假肢接受腔内受压时,残余腓骨可能会朝向持续承重的胫骨成角。结果是圆锥形的尖的残存肢体,在持续承重时易于降至最低点。圆锥形的残存肢体像一个楔子一样,导致终末胫骨的疼痛性的末端承重和软组织破坏。当残存肢体短,或骨间膜断裂时,残存肢体会由于无对抗的股二头肌的作用而外展。承重平台的这些改变在年轻的更活泼的活动需求更高或活动更长的截肢者中变得明显。During World War I, Ertl proposed the creation of an osteoperiosteal tube, derived mostly from tibial periosteum, and affixing it to the fibula to create a stable residual limb8. Following World War II, his concept was success- fully introduced in the United States by Loon4, Deffer9, and others10. Arthrodesis, or bone-bridging, of the distal parts of the tibia and fibula has recently become a controversial topic, with both ardent supporters and strong detractors. Recent investigations suggest that the technique may provide a potential benefit for an active amputee by creating a stable platform with an enhanced surface area for load transfer5,11,12 (Figs.3-A and 3-. Most supporters suggest that the technique should be reserved for younger, more active amputees who will benefit from the potentially enhanced functional residual limb and are more able to tolerate the increased morbidity risk associated with the additional surgery necessary to obtain the bone bridge.
I次世界大战期间,Ertl提出骨与骨膜管的建立,大部分从胫骨骨膜而来,并将它固定于腓骨以创建稳定的残肢。II次世界大战后,他的概念被Loon、Deffer和其它人成功引入美国。胫骨和腓骨远端部分的关节融合术或骨桥最近成为有争议的主题,有热忱的支持者,也有强烈的排斥者。最近的调查表明该技术可能会通过创建稳定的荷重转移表面积增加的平台而给活泼的截肢者带来益处。多数支持者建议该技术应该保留用于年轻的活泼的截肢者,这些人将会从可能增强的功能性残肢中获益,并更能够耐受获得骨桥所必须的额外手术相关的并发症风险增加。The surgery can also be performed as a late reconstruction for active amputees with residual limb pain that appears to be associated with an unstable or disengaged residual fibula. These patients may have a conical end- bearing residual limb, usually with pain at the end of the residual limb and occasionally with tissue breakdown. Others may have pain along a prominent or unstable fibula. On examination, the fibula usually can be felt to be unstable.
手术也可用于残肢疼痛可能与不稳定或自由的残存腓骨有关的活泼截肢者的晚期重建。这些病人可能会有一个圆锥形的末端承重残肢,残肢末端通常会有疼痛,偶尔会有组织破坏。其他患者可能会有沿突出的或不稳定的腓骨的疼痛。体检时,通常会感觉到腓骨的不稳定。

The operation involves use of a long posterior myocutaneous flap. For the average 6-ft (1.8-m)-tall patient, the optimal residual tibial length should be a minimum of 10 to 12 cm in order to create an adequate weight-bearing platform, but it should not be longer than 15 to 18 cm. (An excessively long residual limb requires the prosthetic
socket to be put into full extension. This leads to increased distal pressure, increased end-bearing, and more stump failures.) The fibula is divided 4 cm distal to the tibia to allow the creation of the bone bridge. Care is taken to maintain as many muscular attachments to the distal aspect of the fibula as possible. One centimeter of the fibula is removed at the level of the distal tibial cut to allow rotation of the vascularized bone. A notch is made in the lateral cortex of the residual tibia to accept the rotated fibular segment. Stability can be obtained by suturing the fibular segment through drill-holes, or with screw fixation (Fig. 3-.
手术时涉及长的后面的肌皮瓣的使用。对于平均6-ft(1.8m)高的病人来说,最佳残存胫骨长度应该是最小10-12cm,以便创建足够的承重平台,但是不应该长于15-18cm。(过长的残肢需要残肢延伸入整个假肢接受腔。这导致远端压力增加、末端承重增加和更多的残肢失败。)腓骨在胫骨远端4cm处截断,从而允许骨桥的建立。要注意使腓骨远端部分保留尽可能多的肌肉附件。在远端胫骨截断水平应该移除1cm腓骨从而使得血管化的骨头能够旋转。在残存胫骨的外侧皮质作一凹槽来接受旋转的腓骨节段。通过钻孔或螺钉固定缝合腓骨节段可以获得稳定性。The transferred fibular segment used between the distal parts of the fibula and tibia can be supplemented with a vascularized periosteal sleeve taken from the tibia, as described by Ertl. The periosteum on the anterior surface of the tibia, which is quite thick, is raised from the tibia distal to the level of the tibial transection. When the periosteum is raised, it is important to keep it attached proximally and to take a thin slice of cortical bone with it. This almost guarantees that the periosteum obtained has maintained its vascular supply. A 1-in (2.5-cm) osteotome is used to raise the periosteum and the thin slice of cortical bone. The periosteal sleeve is sutured over the rotated fibular segment. The periosteal graft alone has also been used in place of the fibula, but we have no experience with that technique and do not recommend it.
用在腓骨和胫骨远端部分之间的转移的腓骨节段可以用从胫骨上取下的血管化骨膜套来增补,如Erel所描述的。胫骨前表面上的骨膜非常厚,从胫骨横断水平以远取下。骨膜取下时,保持其近端附着和一同取下薄层皮质骨很重要。这几乎保证了所得骨膜血供的维持。采用1-英寸(2.5cm)骨刀来取骨膜和薄层皮质骨。骨膜套缝合于旋转的腓骨节段上。单单骨膜移植物可以用来代替腓骨,但是我们没有该技术的经验,因此不推荐它。The anterior aspect of the distal surface of the tibia is beveled, and a durable full-thickness myocutaneous flap is repaired to the anterior aspect of the tibia through drill holes or by suturing the posterior gastrocnemius fascia to the anterior periosteum of the residual tibia and the anterior compartment fascia.
胫骨远端表面的前面部分斜削,将耐久性的全厚肌皮瓣修补于胫骨的前表面,通过钻孔的方法,或将后面的腓肠肌筋膜缝合于残存胫骨的前骨膜和前室筋膜。When the surgery is performed as a late reconstruction or if there is no distal part of the fibula with which to create the bone bridge, a tricortical iliac crest bone graft is wedged between the terminal residual tibia and fibula after the inner surfaces of both have been prepared with a burr (Figs. 4-A, 4-B, and 4-C).
当手术是作为晚期重建时或在没有创建骨桥所需的腓骨远端部分时,可以在末端的残存胫骨和腓骨内表面用锉修补后,以髂嵴骨皮质移植物来桥接它们。Postoperative Care术后监护A rigid plaster dressing is applied to protect the residual limb and to control postoperative swelling. Another option is to use elastic bandages for a compressive dressing, but these need to be put on carefully so as not to pro- duce a pressure sore. This is especially important when a patient has a peripheral neuropathy. Our experience has been that if the patient has pain at the end of the stump or in the stump shortly after surgery it is due to a local problem and the dressing needs to be changed, but pain that seems to be in the distal, amputated part of the limb
is the so-called phantom-limb phenomenon. Phantom sensation is a normal response after an amputation that usually resolves. Telling the patient before the surgery that they will have phantom sensations tends to decrease anxiety about this phenomenon.
用坚硬的石膏包扎来保护残肢和控制术后肿胀。另一个选择是用弹力绷带加压包扎,但是这需要仔细使用以免产生褥疮。病人有外周神经病时这尤其重要。我们的经验是如果病人术后残肢末端或内部存在疼痛,那是由于局部问题,需要更换包扎,但是如果疼痛在远端的已截掉的肢体,就是所谓的幻肢现象。幻觉是截肢术后的正常反应,通常可以消退。在术前告知病人他们将会有幻觉易于减轻关于这种现象的忧虑。Weight-bearing with a temporary prosthesis is initiated when the residual limb appears capable of tolerating weight-bearing. Pain with weight-bearing lasts longer for patients who have had a bone-bridge reconstruction than it does for those without a bone bridge. The pain may last for six to nine months and seems to resolve as the bone bridge heals. It is assumed that the site of healing between the fibula and tibia remains tender until the bone becomes solid. The pain should be treated nonoperatively unless there is a sign of inadequate placement of the
graft or sutures. Usually, the patient can be fitted for a prosthesis, but he or she may not be able to bear full weight until the tenderness resolves.
当残肢能够耐受承重时,临时性假肢的承重即开始了。骨桥重建病人的承重性疼痛要比无骨桥患者持续时间长。疼痛可持续6-9个月,骨桥愈合后消退。可设想腓骨和胫骨之间的愈合部位直到骨变得坚硬前会一直保持疼痛。除非有移植物或缝合的不适当固定的迹象,否则疼痛都应非手术治疗。通常,病人可以适应假肢,但是他或她可能会直到触痛消退后才能够承受完全的重量。

Skin Flap for Transtibial (Below-the-Knee) Amputation经胫骨(膝下)截肢术的皮瓣Load transfer following transtibial amputation appears to be enhanced when the residual limb has a large osseous surface area covered with a durable soft-tissue envelope composed of a well-cushioned mobile muscle mass and full-thickness skin. This desired result is best achieved through use of a long posterior myofasciocutaneous flap. Despite the fact that the standard posterior flap for transtibial amputation is satisfactory for most patients, retraction of the flap over time can lead to a troublesome pressure point overlying the anterior aspect of the distal part of the residual tibia. The standard transtibial amputation technique, popularized by Burgess et al., often places the surgical incision directly over that portion of the residual tibia. This raises the potential for adherent scarring of the skin to that part of the tibia or for inadequate cushioning of this region during weight-bearing. When the anterior aspect of the distal part of the residual tibia is not sufficiently padded, there is an increased likelihood of localized discomfort, blistering, or tissue breakdown associated with the normal pistoning that occurs between the residual limb and the prosthetic socket during normal walking. An extended posterior flap appears to prevent these potential morbidities by providing improved cushioning and comfort even for individuals who are capable of only limited activity. The encouraging results of this relatively simple modification support the well-accepted notion that an optimal residual limb should be composed of a sufficient osseous plat- form and a durable and cushioned soft- tissue envelope.
当残肢大的骨表面区域覆盖有缓冲作用好的可移动肌肉团和全厚皮肤组成的耐久软组织包封时,经胫骨截肢术后荷重转移似乎增强了。通过长的后面的肌皮瓣的使用可以很好地实现这个渴望的结果。尽管事实是经胫骨截肢术中的标准的后面的皮瓣令大多数病人感到满意,但是皮瓣随时间的回缩可以导致残余胫骨远端部分的前面部分产生麻烦的压觉点。标准的经胫骨截肢技术,被Burges等推广,其手术切口经常直接位于残余胫骨以上。这增加了那部分胫骨皮肤产生粘连性疤痕的可能,或增加了承重期间该区域的不适当缓冲。当残余胫骨远端部分的前面没有被充分填补的时候,正常行走时残余肢体和假肢接受腔之间的正常活塞相关的局部不适感、起泡或组织破坏的可能性会增加。延伸的后面皮瓣似乎可以通过提供改善的缓冲来防止这些可能并发症和增加仅有有限活动病人的舒适感。这个相对简单的修改的令人鼓舞的结果支持了公认结果:理想假肢应当由一个有效的骨质平台和耐久的缓冲性软组织包封组成。The extended posterior flap is created by increasing the length of the standard posterior flap by several centi-meters (Figs. 5-A and 5-. The posterior myocutaneous flap is created and the osseous cuts are performed in the
traditional manner. The myocutaneous flap is generally created from the gastrocnemius muscle and overlying skin, with removal of the soleus muscle belly in all but very thin patients. Care is taken in the handling of the transected
nerves to avoid the development of sensitive, painful neuromas. It is advised to avoid clamping of the nerves prior to transection in order to avoid the pain so frequently encountered following crushing injuries. The nerves should be dissected proximal to the level of the bone transection, with use of gentle traction with a sponge, and then they
are transected with a fresh scalpel blade. This allows the inevitable terminal neuroma to be cushioned within bulky muscle. To avoid a bulbous stump, the posterior and lateral compartment muscles (except the gastrocnemius) should be transected at the level of the transected tibia. Anterior skin is re- moved to allow proximal attachment of the muscle flap and proximal placement of the wound scar. A myodesis of the posterior muscle flap to the tibia can be performed through drill holes. The posterior gastrocnemius fascia is secured to the transected anterior compartment fascia and tibial periosteum with horizontal mattress sutures (Figs. 6-A and6-. A rigid plaster dressing is applied, and prosthetic fitting is initiated when the residual limb appears capable of weight-bearing.
延伸的后面皮瓣通过将标准后面皮瓣的长度增加几公分得到。后面的肌皮瓣和骨截断采用传统方式操作。肌皮瓣一般从腓肠肌和上面的皮肤来构建,除了非常瘦的病人外要移除比目鱼肌。谨慎处理切断的神经以避免敏感性的疼痛性神经瘤的发生。建议避免在横断神经前钳夹神经以避免压碎性损伤后如此常见的疼痛。神经应该在骨截断水平的近端横断,用海绵轻柔牵引,然后用新的手术刀片切断。这允许不可避免的末端神经瘤的产生,可在肌肉内缓冲。为了避免球根状残端,后面的和侧面的肌肉(除了腓肠肌)应该在胫骨横断水平横断。移除前面的皮肤从而允许肌肉瓣的近端附着和伤口疤痕的近端固定。后面的肌肉瓣的肌肉固可通过钻孔固定于胫骨。后面的腓肠肌筋膜水平褥式缝合于横断的前隔膜和胫骨骨外膜上。应用坚硬的石膏包扎,当残肢看起来能够承受重量时开始假肢的装配。

Transfemoral (Above-the-Knee) Amputation经股(膝上)截肢术Transfemoral amputation is performed less frequently than in the past, but it is still necessary in some patients with severe vascular disease, a neoplasm, infection, or trauma in whom reconstruction at a more distal level is not feasible15,16. The energy expenditure for walking, even on a level surface, by an individual with a transfemoral amputation has been shown to be as much as 65% greater than that for similar, able-bodied individuals17,18. Energy expenditure can be minimized by a properly performed above-the-knee amputation.
经股截肢术不如过去进行得频繁,但是它在一些患严重血管疾病、新生物、感染或创伤的病人中远端水平的重建不可行时仍是必需的。经股截肢术病人的行走甚至水准面的能量消耗已表明要比类似的健壮病人高65%之多。能量消耗可通过恰当的膝上截肢术最小化。

The anatomical alignment of the lower limb has been well defined. The mechanical axis lies on a line from the
center of the femoral head through the center of the knee to the center of the ankle. In normal two-limbed stance,
this axis measures 3° from the vertical axis and the femoral shaft axis measures 9° from the vertical axis19. The femur is normally oriented in relative adduction, which allows the hip stabilizers (the gluteus medius and minimus) and abductors (the gluteus medius and the tensor fasciae latae) to act on it to reduce the lateral motion of the center of mass of the body, producing an energy- efficient gait (Fig. 7).
下肢的解剖学排列已经被很好的确定。力轴位于从股骨头中心通过膝中心再到踝中心的线上。正常两腿姿态情况下,这个轴与垂直轴成3度角,股骨颈轴与垂直轴成9度角。股骨正常情况下定位于相对内收状态,这允许髋的稳定(臀中肌和臀小肌)和此基础之上的外展以减少身体质心的外侧移动,产生节能姿态。In most individuals who have undergone a transfemoral amputation, the mechanical and anatomical alignment is altered as a result of disruption of the adductor magnus insertion at the adductor tubercle and the distal part of the linea aspera. This allows the residual femur to drift into abduction as a result of the unopposed action of the hip abductors. Many patients who have undergone a transfemoral amputation encounter difficulties with prosthetic fitting due to inadequate muscle stabilization at the time of the amputation21. The unstable femur disrupts the relationship between the anatomical and mechanical axes of the limb. The abductor lurch, so common after transfemoral amputation, is a consequence of the unopposed action of the intact hip abductors. This dynamic deformity overcomes the capacity of even modern prostheses to compensate.
大多进行经股截肢术的个体,由于收肌结节和粗线远端大收肌插入的中断导致了力学和解剖学排列的改变。这允许残余的股骨由于髋展肌的无抵抗作用而漂移外展。许多进行经股截肢术的病人由于截肢时没有足够的肌肉稳定导致在假肢安装时遇到了困难。不稳定的股骨使肢体的解剖学和力学轴间的关系被打破。外展肌倾斜在经股截肢术后如此常见,这是完整的髋外展肌的无抵抗作用的后果。这种动态畸形甚至超过了现代假肢所能代偿的能力。Traditional transfemoral amputation is done by suturing the femur flexors to the extensors—i.e., creating a myoplasty—while ignoring the adductors that contribute to stability of the residual femur22. When the adductors are not anchored to bone, the hip abductors are able to act unopposed, producing a dynamic flexion-abduction deformity. This deformity prepositions the femur in an orientation that is not conducive to efficient walking. The retracted adductor muscles lead to a poorly cushioning soft-tissue envelope, further complicating
prosthetic fitting.
传统的经股截肢术中是将股骨屈肌缝合到伸肌上-即构建肌成形术-而忽略对有助于残存股骨稳定性的内收肌。当内收肌没有锚定于骨时,髋外展肌能够无对抗地作用,产生动态的弯曲-外展畸形。这种畸形使得股骨向一种不利于有效行走的方向发展。内收肌群导致了缓冲作用差的软组织包封,进一步使得假肢的安装复杂化。

The cross-sectional area of the adductor magnus is three to four times larger than that of the adductor longus and brevis combined. It has a moment arm with the best mechanical advantage. Transection of the adductor magnus at the time of amputation leads to substantial loss of cross-sectional area, a reduction in the effective moment arm, and loss of up to 70% of the adductor pull20,25. This results in overall weakness of the adductor force of the thigh and subsequent abduction of the residual femur (Fig. 7). The decrease in overall limb strength is due to (1) a reduction in muscle mass at the time of the amputation, (2) inadequate mechanical fixation of the remaining muscles, and (3) and atrophy of the remaining muscles.

大收肌的横断面积比长收肌和短收肌联合起来还要大3-4倍。它有着最好机械效益的力臂。截肢术时大收肌的横断导致了横断面积丢失,有效力臂减小,内收肌拉力丢失高达70%。这导致了大腿内收肌力量的总体减弱和随后的残存股骨的外展。总的肢体力量的降低是由于:1)截肢时肌肉块的减少;2)剩余肌肉的不充分机械固定;3)剩余肌肉的萎缩。Magnetic resonance imaging has demonstrated a 40% to 60% decrease in muscle bulk after a traumatic transfemoral amputation. Most of the atrophy is in the adductor and hamstring muscles, whereas the intact hip abductors and flexors show smaller changes, ranging from 0% to 30%28,29. As much as 70% atrophy of the adductor magnus has been found. The amount of atrophy correlates with the length of the residual limb, and this atrophy is most likely due to loss of the muscle insertion.
磁共振成像发现在创伤性经股截肢术后肌肉容量下降了40%-60%。大部分萎缩是在内收肌和腿后肌,而完整的髋外展肌和屈肌显示出改变较小,变化范围从0%-30%不等。大收肌被发现有高达70%的萎缩。萎缩的数量和残肢的长度相关,这种萎缩很大可能是由于肌肉插入的丢失。Electromyographic studies of residual limbs following transfemoral amputation have revealed normal muscle phasic activity; however, the active period of the retained muscles appears to be prolonged29. The electrical activity of sectioned muscles varies, depending on whether the muscles have been reanchored and on the length
of the residual femur. Furthermore, asymmetric gait has been related to residual limb length, and lateral bending of the trunk has been correlated directly with atrophy of the hip stabilizing muscles.
经股截肢术后残肢的肌电图描记研究揭示了正常肌肉形势活性;然而,保留的肌肉的活跃周期似乎延长了。切开的肌肉的电活性不同,取决于肌肉是否被重新锚定和残存股骨的长度。此外,不对称步态也和残肢长度相关,躯体的侧弯和髋的稳定性肌肉直接相关。All of these findings indicate the need to preserve the hip adductors and hamstrings. Preservation of a functional adductor magnus helps to maintain the muscle balance between the adductors and abductors by allowing the adductor magnus to maintain its power and retain the mechanical advantage for positioning the femur. Preservation is best accomplished with a myodesis. The patient is positioned supine with a sandbag under the buttocks to avoid performing the myodesis with the hip in a flexed position thus producing an iatrogenic hip flexion contracture. A tourniquet is generally not necessary for patients with peripheral vascular disease. Depending on the size of the patient, a standard, or a sterile, tourniquet can be used when the transfemoral amputation is being performed because of a traumatic injury or a tumor and normal femoral vessels can be expected.
所有这些发现都表明了需要保留髋内收肌和腘绳肌腱。功能性大收肌的保留可通过允许大收肌维持它的力量和保持定位股骨的机械效益来帮助维持内收肌和外展肌之间的肌肉平衡。通过肌固定术可很好的实现保留。病人仰卧,臀下垫沙袋,这样可以避免在髋屈曲位时进行肌固定术并进而产生医源性髋屈曲性挛缩。对外周血管基本能够的病人来说止血带通常是必须的。进行经股截肢术时需根据病人的大小使用标准的无菌止血带,因为可能会碰到创伤性损伤或肿瘤和正常股血管。

Equal anterior and posterior flaps should be avoided, as such flaps place the suture line under the end of the residual limb, making prosthetic fitting more difficult and adequate muscular padding less likely. A long medial-based myofasciocutaneous flap is dependent on the vascular supply from the obturator artery, which generally has less severe vascular disease and is thus preferred (Figs. 8-A and 8-31. The flap configuration may need to be modified, in order to preserve residual limb length, when an amputation is done after trauma or because of neoplastic disease. The tendon of the adductor magnus is detached. The femoral vessels are identified in Hunter’s canal and are ligated. The major nerves should be dissected 2 to 4 cm proximal to the proposed bone cut, gently retracted, and sectioned with a new sharp blade. The quadriceps is detached just proximal to the patella, with retention of some of its tendinous portion. The smaller muscles, including the sartorius and gracilis and the more posterior group of hamstrings (biceps femoris, semitendinosus, and semimembranosus) should be transected 2 to 2.5 cm longer than the proposed bone cut to facilitate the anchoring of those muscles in bone.
应该避免前后皮瓣相等,因为这样的皮瓣将缝线固定在残肢末端下面,会使得假肢的安装更困难,并使足够的肌肉填充的可能性更小。长的内侧为基础的肌筋膜皮瓣,其血供依赖于闭孔动脉,通常有不严重的血管疾病,因此可更愿选择。当创伤后进行截肢或因为肿瘤性疾病时,皮瓣的形态可能需要修整,以便维持残肢长度。大收肌肌腱被离断。识别出Hunter’s管里的股血管并结扎。主要的神经应该在计划的骨切口近端2-4cm处切断,轻柔的牵引并用新的锋利刀片切断。在髌骨近端切断四头肌,保留一些肌腱部分。较小的肌肉包括缝匠肌和股薄肌和更后面的腘绳肌腱群(股二头肌,半腱肌和半膜肌)应该比计划的骨切口长2-2.5cm,以使这些肌肉易于锚定于骨头上。The femur is then transected with an oscillating power saw 12 to 14 cm proximal to the knee joint to allow sufficient space for the prosthetic knee joint. Drill-holes are made in the distal end of the femur to anchor the transected muscles. The adductor magnus is attached to the lateral cortex of the femur while the femur is held in maximum adduction. This allows appropriate tensioning of the anchored muscle. The hip is positioned in extension for reattachment of the quadriceps to the posterior part of the femur, and the remaining hamstrings are anchored to the posterior area of the adductor magnus or the quadriceps.
然后用震荡的动力锯在膝关节近端12-14cm处横断股骨,以使得假膝关节有足够的空间。在股骨远端钻孔以锚定横断的肌肉。在股骨处于最大内收情况下将大收肌附着于股骨的外侧皮质。这是的锚定的肌肉能够进行适当的张力调整。髋置于伸展位,将四头肌附着于股骨后面部分,剩余的腘绳肌腱锚定于大收肌或四头肌的后面区域。Postoperative Care术后护理
A soft compression dressing with a “mini-spica” wrap above the pelvis is used in the early postoperative period. Because the residual limb is relatively short, it is difficult to maintain a rigid plaster dressing. Range-of-motion exercises and early walking are encouraged. Preparatory prosthetic fitting can be initiated as soon as the residual
limb appears capable of accepting the load associated with weight-bearing.This varies with individual patients and the experience of the rehabilitation team.
术后早期采用迷你人字形围巾软加压包扎骨盆以上。因为残肢相对较短,很难维持住坚硬的石膏包扎。鼓励活动锻炼和早期行走。当残肢能够接受承重相关的荷重时即可开始准备安装假肢。这随不同的个体病人和康复综合小组的经验而不同。Overview概述In conclusion, an amputation should be considered the first step in the rehabilitation of a patient for whom reconstruction of a functional limb is not possible. Care should be taken to create a residual limb that can optimally interact with a prosthetic socket to create a residual limb-prosthetic socket relationship capable of substituting for the highly adaptive end organ of weight-bearing. A well-motivated patient in whom the amputation is done well and who is taught how to use the prosthesis will be able to return to most activities.
总之,对于功能性肢体重建不可能的病人进行康复治疗,应当首先考虑截肢术。应当注意创建能够和假肢接受腔理想地作用的残肢,来创建能够替代承重终末器官的高度适合的残肢-假肢接受腔关系。对于很好的诱导的病人,如果截肢术做的漂亮,并教会其如何使用假肢,那么病人将能够回到大多数活动中来。
您的位置:医学教育网 >> 医学资料