Exarticulation is the process of removal of distal phalanx of the finger at the joint level. The operation is performed with formation of flaps that are used to cover the heads of metacarpal bones. The flaps are made in such a way that they won't be found on the working surface of the palm.

For I, III and IV fingers the working working surface is the palmar, for the II finger –radial and palmar, for the V finger- humeral and palmar.

Removal of the III and IV fingers is performed by Luppy incision. The circular incision is made up to the boneon the level of the palmar-digital fold. On the dorsal surface of the proximal phalanx the additional medial slit incision is made starting from the head of a metacarpal bone ending with the circular one. The flaps are separated. The scalpel reaches metacarpophalangeal joint and dissecting articulate capsule with lateral ligament, separate the finger. Digital arteries are ligatured. Flexor and extensor tendons are sutured above the head of the metacarpal bone.

Removal of II and V fingers is performed using Farabef incision. On the II finger the bow-shaped incision is done along the dorsal surface from metacarpophalangeal joint line to the middle length of radial of the proximal phalanx. From here the incision is run through the palmar surface of the proximal phalanx to the humeral edge of the finger, not reaching the interdigital folds by 2mm. The initial and the final points of the incision are connected by an additional incision. Palmar-radial skin flap is separated. The finger is removed, and then the scalpel is used to cut the lateral ligament and joint capsule. Digital arteries are ligatured. The flap is attached with silk stitches to the free skin edge on the surface of the removed finger. For the removal of the V finger, the flap is formed on the palmar-humeral surface of the proximal phalanx of the little finger.

To remove the thumb, the Malgeni incision is made. It is run on the palmar surface of the finger 0,5cm proximally interphalanx fold and on the the dorsal surface of the finger 0,3cm distally metacarpophalangeal joint. After dissecting the soft tissues along the ellipse line the dermal flap formed on the on the palmar surface is separated. The finger is removed trying to save the front wall of the articular bursa with sesamoid bone where the bones are attached that controls the movement of remaining metacarpal bone. The vessels are ligatured, the wound is sutured. 

Fig 33. Exarticulations of hand fingers.

1. Thumb - Malgeni incision.

2. Of the II and V fingers is performed using Farabef incision.

3. Of the III and IV fingers is performed by Luppy incision or in the form of tennis rackets.

RESECTION OF JOINTS

The indication for arthrectomy is gun shots wounds of articular ends, tuberculosis of joints, and purulent arthritis with epiphysises involvement.

The operation includes partial or complete removal of bone ends together with cartilages and the synovial membrane. After complete resection the adhesion of the osteal ends and the stiffness of the joint follow (ankylosis). In these cases the plane bone saw is used for resection. Bone saw-lines are brought together and fixed in the best position for reserve the extremity function. The resection may be performed without the opening of the articular cavity (extra-articular resection).

Knee replacement.

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability. It is most commonly performed for osteoarthritis,[1] and also for other knee diseases such as rheumatoid arthritis and psoriatic arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation and is not a reason to perform knee replacement.

Fig 34. Knee replacement.