Amputation

When amputation (Latin amputatio ) the separation of a body part is called. The amputation is carried out for various reasons:

  • Is surgically if the patient's life is threatened or not expected to cure the affected body part
  • As a consequence of an accident ( traumatic)
  • As punishment, which in many regions was usual and today still takes place in some Islamic countries (Iran, Saudi Arabia, Sudan)
  • Rarely in the womb ( connatally ) by Schnürringe ( amniotic band syndrome).
  • 2.1 in Islamic law
  • 2.2 with the Japanese Mafia

Amputation as a surgical procedure

Definitions

Acute or chronic arterial circulatory disorders are in addition to injuries and infections, the most common causes of amputation represents the overwhelming cause of chronic arterial circulatory disorder is a generalized arteriosclerosis. According to the distribution pattern of vascular occlusion, the lower extremity is the most common amputation risk. Therefore, the following definitions apply to the lower limb, but also apply mutatis mutandis for the upper extremity.

Major amputation is an amputation above the ankle. In the DRG reimbursement system of health insurance, the major amputation begins due to the higher material consumption already at the transmetatarsalen forefoot amputation.

Minor amputation means a "small amputation " to below the ankle region (ie up to and including the Chopart amputation). In the DRG system, it includes only toe amputations or Strahlresektionen.

The border zone amputation is a limited to the German-speaking collective term for the combination of minor amputation in the border of the vital tissue, necrectomy or debridement.

Depending on the indication, a distinction is made between the scheduled and emergency amputation amputation.

Indications for amputation

Most scheduled amputations of limbs must be performed as a result of arterial occlusive disease (PAOD ). The indication is provided in most cases in stage IV when extensive tissue necrosis, or an infected gangrene are present, with impending sepsis and vascular surgical procedures have been exhausted or do not qualify. Exceptionally, the indication is also provided in stage III, when the present here persistent pain can not be controlled and limit the quality of life of the patient so highly that the amputation is the "lesser evil". The level of amputation is determined by the quality of the blood flow, which is determined by angiography, and after the most sensible way of the prosthetic restoration. In the leg, usually the knee amputation is about a hand's breadth above the knee ( in PAD from the basin type ) or the lower leg amputation about a hand's breadth below the knee ( at AVK from the thigh type ) are used. The amputation of the arms due to arterial occlusive disease is a rarity.

The second most common indication is diabetic gangrene. In contrast to the AVK so amputation is here usually the so-called " border zone amputation " aimed distally as possible, in just the healthy range. Therefore, these are often amputations of the toes, the forefoot ( amputation or disarticulation of the Chopart or Lisfranc joint) or the hindfoot ( Pirogov - stub). This procedure, formerly known as " salami tactics " rather frowned upon, has gained widespread acceptance due to improvements in wound management, systemic antibiotic therapy and diabetes - setting since the 1990s. Nevertheless, many sub - or thigh amputations must still be performed as a " last resort ".

Amputations as a result of accidental injuries are rare compared to the first two indications. The aim is always the limbs receipt in good conditions, greater traumatic severed limbs Shares may even be replanted more often. Failure of the severed section, however, can often be carried out only the residual limb. Unmanageable wound infections after injury, an extensive Compartmentsyndrom as well as open fractures grade IV, in which the nerves or blood vessels are irreversibly destroyed forcing the amputation. The level of amputation is here - to follow without a schema - chosen as far distally as possible. The modern prosthetics can to supply nearly every stump.

Very rare malignant tumors forcing the amputation of a limb. These are usually bone or soft tissue tumors ( sarcomas). Primarily here the local tumor resection and restoring continuity of bone will be achieved by special stents.

For the number of amputations are no statistics available for Germany. According to estimates by the Scientific Institute of the AOK more than 55,000 surgical amputations of the lower extremities with more than 41,000 hospital cases were made in 2002. According to other data are currently available in Germany about 60,000 amputations per year. By European standards, that's a high number. 70 percent of amputations involve diabetics in Germany. This would allow a 10 - to 15 - fold higher risk of amputation.

Performing an amputation

The outcome of rehabilitation after amputation depends essentially on the possibility of prosthetic fitting. Therefore, a planned amputation must be performed so that a possible well -sufficient stump is created. Decisive here is the soft tissue covering the bony stump. Therefore, the incision is placed so that it is sufficient, but not too far below the planned bony amputation level in order to ensure ( " frog mouth cut" ) as a muscle flap of skin along with the underlying muscles a safe coverage of the bone end. After transection of the or of the bones ( osteotomy ), the bone edges must be smoothed and possibly beveled. Particularly in the lower leg amputation front of the tibia it is necessary, there is a wedge of bone is usually removed ( de Farabœuf triangle ).

The muscle is then severed that surrounds them as a " cushion" the bony stump. For secure fixation of the muscles are connected to each other ( myoplasty ) or via holes connected directly to the bone stump ( Myodese ). The skin scar should be placed away from the loading zone of the cone.

The main nerves are exposed far proximally and there is severed, so that the nerve terminal is located deep in the soft tissue outside the load zone. This is an intergrowth with skin scar, a neuroma formation and phantom pain can be prevented.

In the first phase of the treatment it is necessary at first to achieve a good healing. Wound complications or infections are mainly engaged in the two most common reasons for amputations, vascular disease and diabetes, not rare. To form the cone, which should be as cylindrical for a good prosthetic supply, which is the day of surgery to the system frequently, a special bandage. For healing of the wound and reduction of the initial swelling of the stump is usually provided with a liner of a resilient sheath, which further shapes the die and is applied over the later of the prosthesis stem.

Besides the actual amputation, there are other ways of reconstruction or techniques that increase the functionality of the truncated particularly at arm amputations:

  • Kineplastik by Sauerbruch: Due to a muscle belly above the stump skin a channel is formed through which a pin can be performed, which is connected to the prosthesis and thus enables active movements such as the prosthetic hand. This was often used after the First World War, mostly on the biceps brachii muscle in forearm amputees.
  • Krukenberg Gripping Pliers: For amputation at the forearm and ulna can be separated so that a gripping function between the two bones is possible. This is similar also possible with metacarpal amputations.
  • Winkelosteotomie the humerus after Marquardt: Occasionally can not achieve rotational stability of the prosthesis in the upper arm amputation above the condyles. Then, an osteotomy of the humeral shaft with angled enable the distal segment forward a rotationally secure supply.
  • Extension extremely short stumps by means of callus distraction when there is sufficient skin flap, also mainly on the arms.

In some cases, specific surgical techniques have emerged:

  • Pirogov amputation amputation of the foot than with partial preservation of the heel bone and the underlying sole and arthrodesis between calcaneus and tibia after removal of the talus.
  • Gritti -Stokes amputation refers to a transfemoral amputation, which is performed very kniegelenknah, just above the Kniekondylen ( suprakondylär ), where the kneecap is obtained is brought under about 15 ° to the front - bottom pointed stump and fixed by transosseous sutures. The patellar tendon is sutured with the knee flexor tendons, there is no muscle transection necessary. With a slightly longer anterior lobe of the seam is usually located at the back. The advantage is a fast endbelastungsfähiger very long stump with a good arm and largely full force of the adductors and hip extensors. The technique offers beside trauma patients even with circulatory disorders. Thanks to the resulting upper knee arteries supplying the anterior lobe of wound healing disorders are rarely observed. Patients go in comparison to a standard thigh amputation with a prosthesis faster with better balance and less additional walking aids
  • Ertl modification at lower leg amputations with creating a solid bone bridge between the tibia and fibula at the stump end especially in traumatic amputations. First described in 1949 by Janos Ertl, they will create a more stable and stress-resistant lower leg stump. However, studies have proven no advantage of this technique

For specific indications, particularly in malignant bone or soft tissue tumors, also part of amputations are occasionally performed, in which only a portion of the limb is removed and is then reconnected to, for example, the foot with the remaining stump, partly under rotation of the foot by 90 °, as occurs for example in the conversion graft to Borg Greve.

In addition, stump revisions are often necessary, including for scar correction, joint mobilization, removing protruding parts of the bone or axis corrections.

Notamputation

In desperate accident situations, it may be required that the emergency physician at the scene carrying out an amputation. This relates primarily Verschüttungsunfälle ( quarry, mining, earthquakes, gas explosions ) when a limb is clamped and the injured, in danger of floating, otherwise can not be saved. In traffic accidents this approach by the far-reaching possibilities for technical rescue only in extremely rare cases is required.

Is in desperate, life-threatening accident situations no help available, one can save the life of a self- amputation. Gained international recognition of American mountaineer Aron Ralston, who freed in 2003 by self- amputation of his trapped hand from a canyon.

First aid and medical care for accident-related amputations

In the emergency of a traumatic complete ( total ) or partial ( subtotal ) amputation vessels are injured, which can have life-threatening haemorrhage. A restriction of these bleeding is the primary goal of care of the injured. Is clamped the injured, acutely threatened and not befreibar in a reasonable time, shall be made in the extreme case, a Notamputation by the attending emergency physician. Depending on the situation of the injured measures to stabilize the vital signs taken ( recovery position in case of unconsciousness, the ventilation in respiratory arrest and resuscitation in a cardiovascular arrest) are also carried out. In addition, a possibly occurring shock is treated accordingly and carry out an adequate pain therapy with highly potent painkillers.

To secure the severed body part, the Amputats, made ​​by the first responders a temporary storage in germ-free materials such associations. In order to favor a possible accident- surgical reconstruction of the injury, in addition to the aseptic and dry storage, also a cool possible transport is necessary. The wrapped amputated part is to put in a clean plastic bag, which is fixed after closure in a second filled with cold water or ice bag. It is important to make sure that the amputated part does not come into contact with ice to prevent frostbite and related tissue damage. After handing over the Amputats the cleaning is done in the hospital. The amputated part should not be cleaned by the first responders themselves, because it may cause by improper handling significant injuries that make reconstruction impossible.

At a subtotal amputation of an extremity the existing skin bridge should not be removed, since it can ensure a minimal blood supply.

Amputation as punishment

In many cultures and eras amputations were performed as stricter form of corporal punishment do so. For example, in Christian Europe of the Middle Ages ( chopping off the hands as punishment for grand larceny ).

In Islamic law

In Islamic law, there are some offenses that are punishable under the hadd punishments with amputation. So, for example, male and female thieves by the Koran (Sura 5:38 ), the hand will be cut off " as compensation for what they have done, and as a warning of God." The cross- cut by hand and foot is in the Koran (Sura 5:33 ) mentioned as a possible punishment for the fight against God and His Messenger and for highway robbery. The enforcement of such penalties, however, was subject to strict conditions in the Islamic jurisprudence. For example, must a theft ( sariqa ), which aims to take such punishment to be done secretly, the stolen goods have a certain minimum value ( nisab ), the thief may have no property in it and he has it from a detention ( Hirz ) have taken away. Amputation may also be performed only by state authorities.

In reality, there have been incidents in the early modern period in most Islamic countries, only very rarely to such criminal amputations. Occasionally, cross- amputations were, however, used as a punishment for spies, such as the end of the 19th century in the Sudanese Mahdi Empire ( see figure). Between the late 19th century and early 20th century, the hadd punishments were abolished in almost all Islamic countries. Saudi Arabia is the only Muslim country in which the application of the amputation sentence was until today never interrupted. Here, however, judicial amputations are relatively rare. Between 1981 and 1992 there were a total of 45 cases.

As part of the re-Islamization was codified after 1972 Islamic criminal law in different states and introduced in this framework, the amputation as punishment for theft again. Examples include Libya, Pakistan, Iran, Sudan and northern Nigeria. In Sudan, these resulted in an alarming expansion of occupied with amputation offense. So were dropped in Article 320 of the stealth and the removal of a custody as prerequisites for theft in the Sudanese Criminal Act of 1983. Again, the enforcement of the amputation sentence was enforced with great energy. In time alone, from September 1983, April 1985, 96-120 amputations were carried out until the fall of the Nimeiry regime. Although after the government implemented the amputation of, but were again completed adoption penalties after the coup of 1989 and sent executioners to study in Saudi Arabia. In January 2001, the cross amputation was performed on five men for highway robbery.

With the Japanese Mafia

In the Japanese mafia, a member can make up for gross failure by self- amputation of a single phalanx.

History of amputation surgery

As early as the Paleolithic surgical procedures were carried out which patients survived. This art was not only restricted to Homo sapiens: A 50,000 year-old skeleton of a male Neanderthal discovery in a cave in Iraq is a clean separation of a forearm. Later successful amputations, for example, from the French Buthiers - Boulancourt the Neolithic period (around 4900 BC) underline the successful amputation of the left forearm of an older man. Further evidence of Neolithic amputations there from Germany and the Czech Republic. Amputations were performed in Egypt 3000 years ago. However, researchers also discovered already on cave paintings depictions of amputations of fingers. These images are from the Mesolithic period (8000-6000 BC). It is unknown whether the amputations took place due to medical or ritual reasons.

The surgeon Hans von Gersdorff described in his 1517 published " Field Book of Wundarzney " the first time the tourniquet binding system and the cauterization to control bleeding, the French surgeon Ambroise Paré led mid-16th century again artery ligature in amputation surgery one as before already by Hippocrates were described by Kos .. Paré also described as the first phantom pain.

The first successful midfoot amputation level of the tarsometatarsal joints was carried out in 1815 by the French surgeon Jacques Lisfranc, after this amputation level and at the same time the joint line continues to be identified. The first disarticulation at the ankle led by the Scottish surgeon James Syme in 1842, while the Russian surgeon Nikolay Ivanovich Pirogov at the Pirogov amputation was the heel bone and merged with the tibial resection under the hocks. Both, however, were given the endbelastungsfähige heel skin. On the trial of the Italian surgeons Giuliano Vanghetti to attach muscles directly to the prosthesis, which subsequent development is due in particular by Ferdinand Sauerbruch, the muscle channels it has established to control kineplastischer prostheses.

Only after the Second World War, the myoplasty was introduced by R. Dederich and popularized by E. Burgess. The muscle flap are sutured over the bone stump each other to get a stress-resistant stump tip. Later M. Weiss recommended the addition Myodese, in which the muscles are anchored directly into the bone.

The transtibial amputation developed in the 1960s thanks to myoplasty and long posterior muscle flap particularly in the art for E. Burgess to a safe and successful procedure, so they replaced the until the 1970s standard transfemoral amputation in vascular disease as a new standard, with corresponding benefit to patients by obtaining a active knee joint.

Congenital amputation

From congenital amputation occurs when form during a pregnancy is tearing of the amniotic protein bands, the fetal limbs cut off, so that at birth all limbs missing, but they were originally created. It is the extreme form of the amniotic band syndrome.

Congenital absence of a limb or part is also referred to as dysmelia.

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