The relationship between the type of amputation and the configuration of prosthetic limbs.

2018 / 02 / 05

In recent years, with the biomechanics of the basic theory research, the development of biological engineering, new material, new technology applications, the prosthetic the improvement of production technology, especially the new prosthesis to accept the application of cavity, the end of the tradit

In recent years, with the biomechanics of the basic theory research, the development of biological engineering, new material, new technology applications, the prosthetic the improvement of production technology, especially the new prosthesis to accept the application of cavity, the end of the traditional open accept for closed cavity change, contact, overall bearing type cavity. Therefore, it has the advantages of reasonable wear, comfortable wearing, strong suspension and no influence on the blood circulation of the residual limb. Lower leg in the past, especially the leg prosthesis, open at the end of the residual limb is tightly inserted into the cavity, in order to adapt to insert assembly, the traditional method of amputation is cutting the muscle ring as its retraction, bone cutting end only covered by skin, due to the retraction muscle disuse atrophy and bone cutting end is outstanding, to form the conical limbs, this conical limbs amputation method has clearly not adapt to the requirement of modern prosthetic wear. The condition of residual limb directly affects the installation and wear of prosthesis, and plays a key role in the function of prosthesis compensation. To fit the modern artificial limbs of good wear and play the best compensatory function, the residual limb condition put forward the following requirements: residual limb for cylindrical shape, the proper length, good condition of skin and soft tissue, skin feel normal, no deformity, joint activities not restricted, muscle strength is normal, no residual limb pain or phantom limb pain, etc. Postoperative hard bandage technology, especially immediately after the operation to install temporary prosthesis, the development of technology has greatly promoted the amputation of improvement, also has also had a great effect on the bone tumors amputation. As a result, the surgeon must change the traditional concept of amputation, is not only destructive amputation surgery, and shall be deemed to be heavy To build and repair surgery, amputation is actually for the patients with bone tumor regression to family and society for the first step to recovery. Therefore, the operation should be planned, requiring careful attention, the skilled technique of plastic surgery and reconstructive surgery, the postoperative rehabilitation should be supervised and supervised by the professional staff. Amputation to prepare for the prosthetic, surgeons for artificial limbs and amputation of rehabilitation knowledge, create good conditions for residual limb, ideal prosthetic installation, play better compensatory function, to the patients to live and work to actively compensate.

Type of bone tumor amputation.

Orthopaedic to threat of life in patients with limb malignant tumor treatment developed very fast in recent years, the local perfusion, a variety of anti-cancer drugs chemotherapy, radiation therapy, and the application of immunotherapy and other comprehensive measures taken various limb-salvage surgery method, both saved the lives of patients and save the limb. However, about 15 to 25 percent of osteosarcoma patients still need to be amputated. For some visits late, with wider range of tumor has been infringed or recurrence after limb-salvage surgery and cannot take limb-salvage surgery, or not caused by tumor body function, amputation is still an effective treatment method. And many of the patients who underwent amputation have survived and can be fitted with prosthetic limbs for good compensation. In 1977, Enneking proposed the stage system of tumor surgery in musculoskeletal system, and the surgical stagingsystem (SSS), formed by g-t-m, was an effective method for comprehensive assessment of benign and malignant tumor invasion. The main objective is to determine the scope of operation, type of operation and surgical method. Make the classification of the tumor than ever simplified, the operation standard is more reasonable, for clinical doctors choose treatment, provide the scientific basis for the analysis of curative effect and prognosis, has been recognized and accepted orthopaedic industry.

Amputations are also classified into four types:

1. Massive amputation of amputation, palliative operation.

2. Marginal amputation. The operation was carried out in the reaction area, outside the pseudomonas.

3. Extensive bone amputation. The operation was performed within 3 ~ 5cm outside the reaction area, but it was still in the room.

4. Radical joint dissection and hyperjoint amputation. To remove the entire compartment of the tumor, including the entire bone or muscle.

According to Enneking tumor surgical staging system, the indications of amputation are as follows :1. Imaging examination is clear about the scope of tumor invasion, and there is no metastasis in the distance. The surgical staging is Ⅱ and Ⅱ B period. There were no tumor invasion, no pathological fracture and no tumor invasion. Massive excision of amputation, a palliative operation. Pelvic bone resection; Such as femoral malignant tumor and the rotor of tumor invasion, and the calf is normal, can, rotor under all the femur and the diseased tissue resection crus flip up edge keratoplasty, calf rotation plasty or amputation. 2. It is suitable for patients to visit the hospital late, and the local area has been extensively invaded, even the nerve and blood vessels have been invaded by the tumor, unable to retain limbs or distant metastases. According to the tumor surgical staging Ⅲ, Ⅲ B period. It is widely used in bone amputation or radical joint dissection. 3. Although surgical staging the Ⅰ tumor, Ⅰ B period but tumor encroach blood vessels, nerves or limb-salvage surgery after repeated recurrence, appropriate lines widely by bone amputation or radical joint surgery.

Ii. Selection of amputation site.

According to the indications and principles of bone tumor amputation, the amputation part was selected from the Angle of fitting the prosthesis. The length of the stump should be kept as long as possible in accordance with the principle of bone tumor amputation and conditions permitting. Choose amputation site factors to consider are: patient's age, sex, occupation, living habits, the environment, the nature of the tumor, soft tissue condition, chemotherapy and scope, etc., in addition to think of patients can install what kind of type of prosthesis. First of all should be made to the recovery ability after amputation patients compared with the actual evaluation, from the aspects such as age and systemic state to consider, namely the amputation after whether can wear a prosthesis, whether after wearing prosthetic rehabilitation training, can return to independent self-care activities and life. When choosing the amputation level must be from two aspects of the cause and the function, the cause is to total removal of the tumor in the soft tissue condition is good, can achieve satisfactory healing skin parts, namely the farthest parts of amputation; The functional level is that amputation in this area can achieve optimal function. In the past, for the installation of suitable prosthesis, need amputation in special area, and in recent years, with the prosthesis asfar to accept the application of cavity and sophisticated prosthesis assembly technology, makes the amputation site selection and past there has been a significant change, so the amputation level mainly surgery need to consider to decide, the condition is amputation site organization should be able to achieve satisfactory healing, and tumor tissue can be removed completely. The general principle is to keep the length of the stump as long as possible, so as to maximize the function of the amputation. Amputation site for prosthesis assembly, compensatory function of energy consumption, lower limb amputation wearing prosthetic walking ability, operation ability, employment ability, patient life, there is a direct relationship, so the surgeon to choose amputation level must be very carefully.

(1) selection of upper limb amputation: the principle should be to preserve the length of the stump.

Amputation: 1. Shoulder to retain the humerus head can be beneficial to the prosthetic wear, humerus head can maintain the normal shape of shoulder joint, also need to tell from the beautiful, round shoulder joint appearance of prosthesis were adapted, suspension and stability, help prosthetic wear; From the point of view, the prosthesis while retain the humerus head, but still need to be installed and shoulder joint from off the shoulder of the same from broken limbs, but from the viewpoint of biomechanics, humerus head keep help prosthetic elbow and hand hook.

2. Upper arm amputation: to keep the length as long as possible, because the function of upper arm prosthesis depends on the lever arm length, muscle strength and shoulder range of the stump. Long residual limb is beneficial to the suspension and control of the prosthesis, so the length of the stump should be kept as far as possible. It should be noted, however, that the prosthesis of the amputee must include an internal elbow joint and a rotating disc of the elbow. The purpose of the elbow joint is to stabilize the joint in a position with full extension, full flexion or in the extensional flexion. The rotating disc device is used to replace the humerus rotation. Elbow ground lock device located in the distal accept cavity, about 3.8 cm long, in order to beautiful and for the purpose of elbow prosthesis should with the contralateral elbow on the same level, therefore, in the elbow on cut limb bone cutting level should be at least in the elbow line near the end of 3.8 cm, keep enough space for installing the equipment. After the amputation of the humerus condyle prosthesis assembly and function with the elbow from the break is the same, so when condition allowed by humerus condyle level amputation is not on the humerus condyle parts undergo amputation, due to the elbow from broken limbs are better than that of the upper arm prosthesis in every respect.

3. Elbow amputation: if you can keep the distal humerus, the elbow is an ideal amputation area. In recent years, due to the design of elbow joint, the elbow joint has been used effectively. Humerus condyles of peng, inside and outside the distal humerus is broad, is advantageous for suspension and control ability of the prosthesis, and the rotation of the humerus can be directly passed to the prosthesis, and elbow over parts of amputation, the rotation of the humerus can not directly passed to the prosthetic limbs, which is accomplished by rotating disc prosthesis elbow, elbow from off the amputation of is a good place, is preferable to elbow amputation.

4. Forearm amputation: keep the length as long as possible, even if it is very short. Through at the bottom of the forearm amputation, retain only very short forearm stump, even if only 4 ~ 5 cm long, also than the elbow from broken or knee amputation preferable, from a functional point of view, it is very important to keep the patient's own elbow. An improved prosthetic assembly technique, such as a separate receiving chamber with a double strand, can provide a better function than the elbow joint. The longer the stump, the greater the lever arm, and the more the rotation function remains. When the residual limb length retain 80%, the residual limb rotation Angle is 100 °; Retain 55% residual limb length, residual limb rotation activity is only 60 °; Retain 35% residual limb length, residual limb activity rotation Angle for 0 °. The forearm is elliptical at the far end of the forearm, which is conducive to the rotation function of the prosthetic hand. The more muscle retained by the residual limb, the easier it is to obtain good electromyography, which is very beneficial to the emg.

5. The wrist amputation: after wrist amputation or wrist is broken, do better than the forearm amputation, because retained the forearm distal ulnar radial joints, can keep the rotation of the forearm all functions, while only 50% of pronation and supination movement is passed to the prosthesis, but these movements to patients is very important and valuable. It can now be fitted with a good and beautiful wrist amputated prosthesis or wrist amputated prosthesis. Therefore, the amputation of the wrist joint or the amputation of the wrist is an ideal part of the amputation, which can maximize the function of the residual limb.

6. The wrist joint is broken: the flexion motion of the radial wrist is retained, the movement of these wrist joints can be applied by the prosthesis, and the wrist joint is an optional part of the amputation.

Hand and finger amputation: keep the length as long as possible, especially if the thumb should try to retain the length. The <

2) selection of lower limb amputation: in recent years, it is the same as upper limb amputation to retain the longer residual limb as its basic trend, except for lower leg amputation.

1. The total excision: prosthesis suspension function is poor, walking accept cavity pump activity is larger, the crest is very important to accept cavity adaptation and suspension, due to the lack of ischial tuberosity is very adverse to load, reason should be according to the condition managed to retain the iliac crest and sitting bone nodules.

2. Hip amputation: if there is a condition, the femoral head and neck should be retained, and the lower part of the lower trochanter should be amputated, without the dislocation of the hip joint. From the point of view of the prosthesis, it belongs to the hip joint, but it is helpful for the adaptation and suspension of the cavity, which increases the lateral stability and bearing area of the prosthesis.

3. Leg amputation: the length of the stump should be kept as far as possible, even the extremely short stump should be retained.

4. The distal thigh amputation: should try to retain the residual limb length, due to the application of modern four link structure of knee joint prosthesis, any thigh length can be used without difficulty to stump, achieve good function and gait. The amputation of the knee joint can be applied to the amputation of the knee joint within 5cm of the femoral condyle.

5. The knee is broken, is the ideal amputation site, knee joint from broken provides an excellent residual limb end load, it is the residual limb end bearing of the femoral condyle, rather than the ischial tuberosity bearing, femoral condyle of peng help prosthesis suspension, residual limb length control ability of limbs, and the residual limb skin is by a hard and soft inner sleeve prosthesis were isolated, and thigh amputation stump skin is direct contact with prosthetic accept cavity phase. The main weight bearing area of the thigh prosthesis is in the ischial tubercle, and the body gravity line is the front lateral of the ischial tubercle, which causes the pelvis to tilt forward, accompanied by lumbar protuberance. When the femoral condyle is loaded, the force line is close to normal, so it does not increase the lumbar protuberance. Again due to the end of the residual limb weight, when standing or walking the information transfer is directly, rather than after accepting cavity indirect transfer, reaction force at the ends of the residual limb, easy access to the prosthetic knee joint stability, good for prosthesis control. And because the thigh cut limb part of adduction muscle resection, and abate the adduction of the thigh strength, can't keep the prosthetic side separate loading thighs in the normal position, the body to the prosthetic side tilt, is caused by different degree of swaying gait. Therefore, the compensatory function of the knee joint is obviously superior to that of the thigh prosthesis. < P >

6. The proximal leg amputation: as long as you can keep the patellar ligament attachment point, can be installed under the tibial tubercle amputation crus prosthesis, the knee joint of reserve is extremely important to lower extremity function, its function is better than knee broken limbs. Therefore, it is necessary to keep the knee joint as much as possible, especially in children with lower limb amputation, which is more necessary to preserve the epiphysis of the proximal tibia.

7. Lower leg amputation: with the lower 1/3 border, it can be used to install the ideal prosthesis. The lower leg is not suitable for amputation here because of the lack of soft tissue and poor blood transport.

8. Samuel amputation: for ideal amputation site, although the amputation level is equivalent to the ankle is broken, but the residual is complete, the good foot is covered with skin, its stability, wear-resisting, not easy to burst, so the residual limb end has the good bearing capacity, the ability to walk is good, is advantageous to the daily life activities, its function is superior to crus prosthesis, ankle is broken, however, is not desirable.

9. The foot amputation: also want to keep the length of the foot as far as possible, is to keep the length of the lever arm front feet as far as possible, this in the gait cycle before the end of a resting phase after enough thrust is very important. The current length of the lever arm is shortened, causing great obstacles to walking, running and jumping.

The foot is mostly operated by Boyd (it is about to be removed from the bone and removed from the bone, with the lower tibia and bone fusion). The Pirogoff operation is no longer in use. Chopart joint from broken technique (boat joints, with roll joints from broken), Lisfranc joint is broken (plantar hocks from broken), long-term follow-up after observation found that the residual horseshoe varus deformity, reason should be careful, if the operation need to simultaneously tendon transposition muscle and tendon YanChangShu roughly in balance.

3. Improvement of amputation surgery.

For nearly 10 years, with the use of new prosthesis were caused by the traditional method of amputation conical limbs has clearly not suitable for modern prosthetic accept cavity assembly, it requires that the residual limb for a reasonable length, cylindrical shape, good strength and function. Therefore, the amputation technique also has a great improvement.

(a) the skin treatment: no matter at what level amputation, residual to have good skin skin cover is the main, good residual limb skin proper activity, scalability and normal sense. For bone tumor amputation, do not shorten the limb in order to seek the requirement of skin incision for routine amputation, and often use atypical skin incision and skin flap. It is not so important for the modern comprehensive contact to accept the position of the scar on the stump.

1. Treatment of upper limb amputation skin: the anterior and posterior side flap of the stump. However, the flaps of the flexor side are longer than the dorsal side of the forearm long stump or wrist joint, in order to move the lobes to the dorsal side.

2. Processing: lower limb amputation skin leg amputation, short before long after the fish's beak skin flap has been widely used at present is no longer, and more applications need to lengthen the rear flap, the flap with a calf, is actually with inside and outside the head of the gastrocnemius muscle skin flap. From broken knee surgery is now behind the claim application extension of gastrocnemius myocutaneous flap forward flip cover the femoral condyle, practice proves that application reduced the incidence of wound does not heal long rear myocutaneous flap, flap not only good blood supply, and provides a good and durable stump load-bearing parts in the soft tissue of pad.

(2) neural processing: attention should be paid to the prevention of neuroma formation and vascular bleeding. Now advocates the nerve stumps ligation with a thread of silk, or will, epineurium longitudinally cut the nerve bundle, then epineurium ligation, make nerve fiber bundle epineurium pipe buried in the atresia, cut off the nerve stumps will not grow outward.

(3) treatment of bone: the normal bone and periosteum are cut off at the same level, and the edge of the osteotomy is blunt. It is also argued that the open bone marrow cavity is closed with periosteum. Leg amputation, in order to obtain the residual good weight, avoid secondary outreach fibula deformity and increase the stability of the residual limb lateral side, bone end processing method is tibiofibula isometric, with reserves of tibiofibula periosteal flap suture, each other the best periosteum with a thin layer of bone cortex, the periosteal flap bridging between the tibiofibula stumps, make tibiofibula residual fusion called osteoplasty (osteoplasty).

(4) muscle: the processing of the traditional processing method is cutting the muscle ring, losing muscle attachment points, muscle tension is abate, can't exert the function of the original, muscle atrophy, further local circulation loss and degradation, even form a conical limbs. To fit the modern comprehensive contact and comprehensive bearing type of prosthesis were assembled, requires that the residual limb is a cylindrical shape, implementing the muscles fixation and muscle into shape can meet the above requirements, specific methods are as follows:

1. Muscle fixation (myodesis) : the distal muscle in bone cutting end party at least 3 cm is cut off, the formation of muscle flap, while maintaining muscle tension of the original case, through the bone ends, drilling through the muscle flap and bone adjacent to the bone hole suture fixation, make muscle gain new attachment point, prevent muscle in extremities sliding and continue to bounce back.

Keratoplasty (myoplastic) : 2. Muscle group corresponding muscle flap suture to end, each section in the extremities were completely covered the embedding, maintain good conditions of the muscles in the normal physiological function, to form a cylindrical limbs, can fully meet the full contact bearing prosthesis accept cavity assembly requirements. The knee joint from the patellar ligament and is broken? The cord tendon is sutured with the cruciate ligament. Thigh amputation? Rope and adductor muscle was cut off after hip adduction and stretch ability is abate, sciatic inclusive type of prosthesis were trying to control the femur in a more physical adduction, by weight of X-ray examination found that accept the shape of the cavity of the residual limb femoral prosthesis position don't affect, accept cavity can't maintain the femoral prosthesis adduction of axis position in raw material, its power mainly depends on the surgical techniques to the line, need to fix the adductor muscle on the residual of the lateral femoral, maintain the femoral muscle tension in adduction, can reduce those found in general via femoral amputees to lateral tilt gait. Muscles of the processing method is to adduction muscle under the tension suture fixation Decided to cut bone stump of the lateral side hole, put the femur in adduction, the quadriceps tendon suture fixation to the residue of bone cutting back side hole, keep straight hip in place, be careful not to form iatrogenic hip flexion contracture, then the rear and the lateral muscles and stitch the two groups of muscles, adduction position over the femur biomechanics axis, the play of limb function and improving the walking gait is very beneficial.

Elbow from cutting is the humerus head tendon and head of biceps tendon suture, brachial muscle residual end, outside the humerus condyles of extensor muscle membrane flap repair flexor and humeral epicondyle residues after break at suture, covering the humerus distal. It is believed that this technique of muscle fixation and muscle forming will improve the function and circulation of the residual limb, which is beneficial to prevent phantom limb pain. In order to obtain a good cylindrical shape and a less bulky residual limb, the muscles of the stump may be modified when necessary, such as the stump of the muscle may be excised.

(5) hard bandage application: hard bandage is on the table after amputation as its main materials with plaster bandage wrapped around the used dressing bandage good on the residual limb, a general method is to use "U" type plaster cast.

It can effectively prevent hematoma and reduce swelling, and promote the venous return, a fixed limb body, to ensure that the correct body position, to impose muscle fixation and molding performer will be good for muscle tissue healing, the residual limb shape as soon as possible, create conditions for installation as soon as possible formal prosthesis. The "U" plaster of the leg amputation should be in the front and rear of the stump, and the plaster splint exceeds the knee joint, and the knee joint is fixed in the straightening position. "U" type plaster thigh amputation should be in inside and outside of the residual limb, lateral plaster splint should upset and more than hip, keep straight hip and femoral in 15 ° of adduction, avoid hip flexion abduction contracture deformity. The time of hard bandage dressing is related to the method of amputation, and it is not used in the application of residual muscle fixation and muscle forming. In the application of residual muscle fixation and muscle forming, the stump is usually bandaged for 3 weeks in order to achieve healing. When the leg amputation is done, the stump of the distal tibiofibular bone is generally applied for 5 ~ 6 weeks to ensure the healing of the bone. Experience has shown that this method improves the rehabilitation effect of amputees, because this method is relatively simple, and the general surgeon can practice it, which is a good method that is widely promoted and applied at present.

(6) install namely postoperative prosthesis: in the 80 s, the installation of temporary prosthetic taking a more positive and effective method, the installation of temporary prosthesis is completed on the operating table, called amputation surgery where temporary prosthesis. Due to the compression of the cavity, the swelling of the residual limb was limited, the residual limb was accelerated, the phantom limb pain was reduced, and the early separation from the bed was also an inspiration to the patient's psychology. However, whether the amputation of malignant bone tumors adopts this method must be determined according to the patient's specific situation.

Four, several special bone tumor amputation operation.

It is suitable for benign invasive bone tumor and low-grade malignant bone tumor. Surgery is performed to remove the tumor from the periosteum, along with the invasive soft tissue, and the range of osteotomy is generally suitable for 3 ~ 5cm of normal bone, including X-ray film and CT scan.

(1) of the calf flip up keratoplasty (turn - up plasty of the legs) in some cases femoral or leg soft tissue tumor, normal hip, the rotor area, the calf is normal, and the lower part of the femur rotor widely femoral need excision, can be widely in femoral line and soft tissue tumor resection and calf flip up keratoplasty, and avoids the hip joint is broken. When the entire femur needs to be resected, the lower leg is reversed and the lateral malleolus can be placed into the acetabulum to form the joint. The principle of surgery is to protect all the large blood vessels and nerves, and to preserve the muscles of the hip, especially the hip flexure, extension and abduction. Crus flip could be a sagittal plane, can also be coronal, little legs turn over direction choice depends on the part of the skin and muscle resection, if full reverse forming, must choose coronal reverse it.

1. To retain the crus of the femur rotors: to apply a tourniquet, the method is to insert a needle at the upper end of the large rotor, and then to bypass the vaginal area with a rubber tourniquet. Patients healthy side lies, in lower limb lateral removal of 12 ~ 15 cm wide strip of leather skin, from lower part of big rotor to the ankle, according to the need of subcutaneous tissue removal, if is a malignant tumor, should will be part of the soft tissue around the tumor resection, and the most important thing is to keep large blood vessels and sciatic nerve in the thigh, from the femoral resection under the rotor, try to keep the rotor under the appropriate length of the femur, for leg up in turn and tibia relative to create conditions and internal fixation, distal femur

The knee joint is broken, in order to be able to accept the calf upturn, should have good vascular bed soft tissue wound surface. The muscle of the lateral crus area outside and rear compartment to appropriate resection, avoid bloated, calf flip when too much soft tissue removed fibula, but keep blood vessels between bone, lower leg and foot according to the needs of the residual limb length to be cut, can be applied to fibula as far in the proximal femur and tibia intramedullary nail fixed. Remove a tourniquet, earnest thorough hemostasis, lower leg on coronary oriented flip to the big leg soft tissue bed has been prepared, nearly at the distal tibia and the femur involution, given the strong internal fixation, placing drainage tube, close the incision, postoperative hip "people" word a plaster cast.

2. All the femoral resection of crus flip keratoplasty: when all need the femoral resection can be made false external ankle insert acetabulum joint, when adult femoral resection and proximal tibia to remove 4 ~ 5 cm, in children in order to retain tibiofibula proximal epiphyseal, without causing crus to flip the residual limb distal skin tension increased, there can be shin backbone of shortening osteotomy. Can apply the method of total hip replacement, keep the ankle joint capsule, and the residual suture of the hip joint capsule, can with the medial malleolus of middle phase of the deltoid ligament suture, the shank of the ankle joint keep.

If ahead of the lower limbs are large skin scar, can use sagittal calf ZhuanShu, turned up in front of the thigh of scar can be removed, the corresponding calf skin and soft tissue is also according to the design, must be removed from the femoral resection ahead.

(2) rotary plasty (borggreve-van ness)

Lower middle section (above and below the knee joint section) is amputated, distal limb rotation crus bone cutting, rotation Angle is 180 °, the toe posteriorly, according to the need to be cut at the same time, the length of the retained distal crus proper, in order to keep the ankle with the contralateral knee joint at the same level shall prevail, postoperative limb ankle to exercise the function of knee joint, the general procedure used for distal femoral tumor resection, and proximal femur is normal.

Surgical indications: (1) the distal femur can total removal of tumor, (2) the vascular nerve normal, (3) the calf rotation ankle with the contralateral knee after bone cutting at the same level, (4) preoperative ankle to good flexing and stretching function actively, (5) the ankle joint muscle were nearly normal; (6) fibula dysplasia or defect is not a surgical contraindication, (7) the toe should be complete, and (8) the general operator is over 12 years old. < operation method: total removal of distal femoral tumor, skin incision design requirement is to remove a rhomboid skin, removed the rhomboid skin range than the original design of the resection of longitudinal incision length required more than 5 cm, in the diamond cut skin mouth Angle on the far side of the extended down 8 cm, show phil total nerve, and along the nerve proximally, until the bifurcation of sciatic nerve, tibial nerve, and? The blood vessels. Cut off the blood vessels that enter the tumor area. In tibia bone cutting levels will all muscle transection, in proximal femoral bone cutting 5 cm above the level of the thigh muscle transection, with two gram respectively parallel needle insertion in the femur and distant period of the tibia, have good design truncation in femoral and tibial tumors were total removal of the lesion site, and only between end gap are connected by nerves, blood vessels. Crus distal rotated 180 °, the femur and tibia involution is good, or with a steel screws with interlocking intramedullary nail fixation. The neurovascular bundle relaxes and bends. The quadriceps and the triceps of the calf are sutured, and the extensor muscles of the toe? When the rope muscle is sutured, it is necessary to pay attention to the blood transport of the foot, remove the kirschner's needle, completely stop the bleeding, put the silicone rubber drainage tube, and close the incision. The ankle joint of the postoperative limb replaced the knee joint, and the foot replaced the function of the calf, creating a good condition for the installation of the special leg prosthesis.

Surgical complications :(1) the lower leg was ischemia, (2) the osteotomy was not healed, and (3) the rerotation of the lower limb caused the new knee joint to be defective.

5. Characteristics of children amputation.

Children with malignant tumors are second only to traumatic amputations, while malignant tumor amputations account for more than 50 percent of all other diseases and congenital malformations. Children amputation, the operation technology although there isn't much difference in adults, but for children body anatomy and growth factors must be considered, then the principle of amputation vary, the ideal of amputation level without regular limit, but children should take a more conservative than the adult method, should as far as possible keep the length of the residual limb. It is preferable to retain the amputation of the joint and proximal bone epiphyseal. The amputation of the joint has preserved the epiphysis of the distal limb, so the stump can continue to grow at a normal rate, and the dislocation of the joint prevents overgrowth of the bone end that has occurred through the backbone amputation. In one case, a 5-year-old patient had an amputation of the middle leg of the thigh, which was amputated at the distal end of the femur and became a short thigh limb at the age of 14. However, 1 case of 5 children with short legs amputated limbs, because the calf proximal epiphyseal growth, to the age of 14, may form a calf residual limb length compared with meaning, can wear appropriate crus prosthesis.

Long bone growth that the amputation because of new bone with a generation, and has nothing to do with the epiphyseal growth at the bottom, the length of the excessive growth of bone in children with each amputation of difference is very big, about 8% ~ 12% of the children to one or more stumps Finishing operation, try to use epiphyseal block method to prevent the overgrowth on bone will never succeed, and should be strictly prohibited. This complication occurs most often in the humerus and fibula, and in sequential order is the tibia, femur, radius, and ulnar bone.

Because of children's growth and metabolism, amputation stump after pressure and friction resistance ability of the skin is much better than adults, and in children in adult cannot tolerate often can survive, children's skin and subcutaneous tissue more tolerance under tension suture closed wound, free skin graft in thick skin more easily than adults to provide permanent skin cover, even the skin of the prosthetic graft compression performance is stronger. In addition, the complications after children amputation are generally not as severe as that of adults, and can even tolerate large areas of scar, and children have few psychological problems after amputation. Muscle should be dealt with line keratoplasty broken end, used to cover the extremities, rather than the muscle fixation, fixation of bone distal muscle injury, excess may cause the bone growth, this is due to a growth in the supportive tissue of the extremities, it results in extremities in spikes, may wear out the skin and cause infection. The method of covering the bone with periosteal cortical flap can limit the excessive growth of bone end. If the nerve of children amputation is not treated, it is a neuroma, but it rarely causes discomfort and rarely needs surgical treatment for neuroma. Phantom limb sensation after amputation of children is often present, however, there are few problems. When the amputation age is less than an hour, the phantom limb is blurred and the phantom limb pain is rare. Children's leg amputation stump tibiofibula don't osteoplasty, namely the fusion of tibiofibula end, due to the length of proximal fibula epiphyseal growth than the proportion of proximal tibial epiphyseal growth length proportion is large, if the merger of tibiofibula end line, due to the fibula long is longer than the tibia, the terminal can be made into tibial varus deformity or fibular head proximally dislocation.

Children better application of prosthetic limbs than adults, on the application of the prosthetic proficiency increases with the age, because the activity ability of children, coupled with growth factors, so often prosthesis may need to repair and adjust, accept cavity will replace or install new prosthesis.