AMPUTATIONS

LAYOUT

GENERAL CONSIDERATION.
UPPER LIMB AMPUTATIONS.
LOWER LIMB AMPUTATIONS.

MORE THAN 90% OF AMPUTATIONS PERFORMED IN THE WESTERN

WORLD ARE SECONDARY TO PERIPHERAL VASCULAR DISEASE.

IN YOUNGER PATIENTS, TRAUMA IS THE LEADING CAUSE, FOLLOWED BY

MALIGNANCY.
THE ONLY ABSOLUTE INDICATION FOR AMPUTATION IS IRREVERSIBLE
ISCHEMIA IN A DISEASED OR TRAUMATIZED LIMB.

AMPUTATIONS

PERIPHERAL VASCULAR DISEASE

TRAUMA
BURNS
FROSTBITE
INFECTION
TUMORS

TRAUMATIC AMPUTATIONS

SALVAGE VS AMPUTION
THE MOST IMPORTANT FACTOR REGARDING LIMB SALVAGE VERSUS
AMPUTATION WILL
BE THE SEVERITY OF THE SOFT TISSUE INJURY.

DUPLEX DOPPLER EXAMINATION OF THE ARTERIAL SYSTEM TO

CHARACTERIZE THE ARTERIAL ANATOMY.
TCPO 2 MEASUREMENTS WILL AID IN DETERMINING THE HEALING
POTENTIAL OF SURGICAL WOUNDS.
CPO 2 VALUES BELOW 20 MM HG ARE INDICATIVE OF NONHEALING AND
VALUES OF 40 MM HG OR GREATER ARE INDICATIVE OF HEALING. BETWEEN
THESE VALUES, THE SURGEON SHOULD TAKE INTO ACCOUNT THE PATIENTS
PRE-EXISTING COMORBIDITIES, ARTERIAL ANATOMY, AND NUTRITIONAL
STATUS.

ABI

INDICATIONS

SUBJECTIVE
TYPE III-C OPEN TIBIAL FRACTURES, WHICH INCLUDE COMPLETE DISRUPTION
OF THE TIBIAL NERVE OR A CRUSH INJURY WITH WARM ISCHEMIA TIME OF
MORE THAN 6 HOURS, ARE AN ABSOLUTE INDICATION FOR AMPUTATION.
RELATIVE INDICATIONS INCLUDE: SERIOUS ASSOCIATED INJURIES, SEVERE
IPSILATERAL FOOT INJURIES AND ANTICIPATED PROTRACTED COURSE TO
OBTAIN SOFT TISSUE COVERAGE AND TIBIAL RECONTRUCTION.

INDICATIONS, OBJECTIVE

TO PREDICT WHICH LIMBS WILL BE SALVAGEABLE, AVAILABLE SCORING

SYSTEMS INCLUDE THE
PREDICTIVE SALVAGE INDEX, PSI
LIMB INJURY SCORE, LIS
LIMB SALVAGE INDEX, LSI
MANGLED EXTREMITY SYNDROME INDEX, MESI

MANGLED EXTREMITY SEVERITY SCORE, MESS

 DO NOT STRICTLY FOLLOW THESE GUIDELINES IN ALL PATIENTS, DO CALCULATE AND

DOCUMENT A MANGLED EXTREMITY SEVERITY SCORE IN THE CHART WHENEVER WE
ARE CONSIDERING PRIMARY AMPUTATION VERSUS A COMPLICATED LIMB SALVAGE.
NO SCORING SYSTEM CAN REPLACE EXPERIENCE AND GOOD CLINICAL JUDGMENT,
ATTEMPTS TO SALVAGE A SEVERELY INJURED LIMB MAY LEAD TO METABOLIC
OVERLOAD AND SECONDARY ORGAN FAILURE.
BOSSE ET AL. (THE LEAP GROUP) PROSPECTIVELY EVALUATED THE UTILITY OF
MULTIPLE SCORING SYSTEMS: MESS, LSI, PSI, NISSA, AND HFS-97. THE OVERALL
ANALYSIS SHOWED THAT LOWER SCORES HAD SPECIFICITY FOR LIMB SALVAGE
POTENTIAL BUT THE LOW SENSITIVITY OF THESE SCORING SYSTEMS DID NOT
VALIDATE THEM AS PREDICTORS OF AMPUTATION.

IF A LIMB CAN BE SAVED, SHOULD IT BE?

PATIENT CENTERED PLAN
EARLY AMPUTATION AND PROSTHETIC FITTING ARE ASSOCIATED WITH
DECREASED MORBIDITY
FEWER OPERATIONS
A SHORTER HOSPITAL COURSE
DECREASED HOSPITAL COSTS

SHORTER REHABILITATION

EARLIER RETURN TO WORK

OFTEN PROVIDE BETTER FUNCTION THAN MANY SUCCESSFULLY SALVAGED LIMBS

 SEVERAL RECENT COMPARISONS OF LIMB RECONSTRUCTION AND LIMB

AMPUTATION HAVE COME TO DIFFERING CONCLUSIONS WITH REGARD TO
COST AND FUNCTION
A BIG STUDY CONCLUDED LIFETIME HEALTH CARE COSTS TO BE 3X HIGHER
FOR PATIENTS WITH AMPUTATIONS THAN FOR THOSE WITH
RECONSTRUCTION.
A META-ANALYSIS, ON THE OTHER HAND, CONCLUDED THAT LENGTH OF
REHABILITATION AND TOTAL COSTS ARE HIGHER FOR PATIENTS WHO HAVE
UNDERGONE LIMB SALVAGE PROCEDURES.
ONE STUDY REPORTING A 64% RETURN TO-WORK RATE AFTER LIMB SALVAGE
COMPARED WITH 73% AFTER AMPUTATION AND ANOTHER STUDY REPORTING
THAT LONG-TERM FUNCTIONAL OUTCOMES WERE EQUIVALENT BETWEEN
LIMB SALVAGE AND PRIMARY AMPUTATION.

SURGICAL PRINCIPLES
OF AMPUTATIONS

DETERMINATION OF AMPUTATION LEVEL

MORE DISTAL BETTER FUNCTION
MORE PROXIMAL LESS COMPLICATIONS
OVERALL WELL-BEING, GENERAL MEDICAL CONDITION, AND
REHABILITATION ALL ARE IMPORTANT FACTORS

 IT BECOMES APPARENT THAT AMPUTATION SHOULD BE PERFORMED AT

THE MOST DISTAL LEVEL POSSIBLE IF AMBULATION IS THE CHIEF
CONCERN.
IF A PATIENT HAS NO AMBULATORY POTENTIAL, WOUND HEALING WITH
DECREASED PERIOPERATIVE MORBIDITY SHOULD BE THE CHIEF
CONCERN.

PRINICIPLES
SKIN AND MUSCLE FLAPS
FLAPS SHOULD BE KEPT THICK. UNNECESSARY DISSECTION SHOULD BE
AVOIDED TO PREVENT FURTHER DEVASCULARIZATION OF ALREADY
COMPROMISED TISSUE
MUSCLES USUALLY ARE DIVIDED AT LEAST 5 CM DISTAL TO THE INTENDED
BONE RESECTION.

MYODESIS (SUTURING MUSCLE OR TENDON TO

BONE) OR BY MYOPLASTY (SUTURING MUSCLE TO PERIOSTEUM OR TO

MAY BE STABILIZED BY

FASCIA OF OPPOSING MUSCULATURE).

F POSSIBLE, MYODESIS SHOULD BE PERFORMED TO PROVIDE A STRONGER
INSERTION, HELP MAXIMIZE STRENGTH, AND MINIMIZE ATROPHY

 HEMOSTASIS
USE TOURNIQUET,, EXCEPT IN SEVERELY ISCHEMIC LIMB
MAJOR BLOOD VESSELS SHOULD BE ISOLATED AND INDIVIDUALLY LIGATED.
THE TOURNIQUET SHOULD BE DEFLATED BEFORE CLOSURE, AND
METICULOUS HEMOSTASIS SHOULD BE OBTAINED.
A DRAIN SHOULD BE USED IN MOST CASES FOR 48 TO 72 HOURS.

NERVES
THE NEREVE SHOULD BE ISOLATED, GENTLY PULLED DISTALLY INTO THE
WOUND, AND DIVIDED CLEANLY WITH A SHARP KNIFE SO THAT THE CUT
END RETRACTS WELL PROXIMAL TO THE LEVEL OF BONE RESECTION.
NEUROMA ALWAYS FORMS AFTER A NERVE HAS BEEN DIVIDED. A
NEUROMA BECOMES PAINFUL IF IT FORMS IN A POSITION WHERE IT
WOULD BE SUBJECTED TO REPEATED TRAUMA

 BONE
EXCESSIVE PERIOSTEAL STRIPPING IS CONTRAINDICATED
BONY PROMINENCES THAT WOULD NOT BE WELL PADDED BY SOFTISSUE
ALWAYS SHOULD BE RESECTED.
THE REMAINING BONE SHOULD BE RASPED TO FORM A SMOOTH CONTOUR.

POST OP CARE
MULTIDISPLINARY APPROACH
RIGID DRESSINGS CASTING
PREVENT EDEMA AT THE SURGICAL SITE, PROTECT THE WOUND FROM BED
TRAUMA, ENHANCE WOUND HEALING AND EARLY MATURATION OF THE STUMP,
AND DECREASE POSTOPERATIVE PAIN.

PATIENTS SHOULD BE MOBILIZED FROM BED TO CHAIR ON THE FIRST

POSTOPERATIVE DAY. PATIENTS WITH LOWER EXTREMITY AMPUTATIONS
SHOULD BEGIN PHYSICAL THERAPY WITHIN THE FIRST SEVERAL DAYS AND
BEGIN AMBULATING USING THE PARALLEL BARS. THIS IS FOLLOWED SHORTLY
BY AMBULATION WITH A WALKER ORCRUTCHES

TRANSTIBIAL (BELOW-KNEE)
AMPUTATIONS
THE MOST COMMON AMPUTATION LEVEL.
AMPUTATIONS IN NONISCHEMIC LIMBS RESULT FROM
TUMOR, TRAUMA, INFECTION, OR CONGENITAL
ANOMALY. IN EACH, THE UNDERLYING LESION DICTATES
THE LEVEL OF AMPUTATION AND CHOICE OF SKIN
FLAPS.
ISCHEMIC VS NON ISCHEMIC.
IN NONISHEMIC LIMBS SKIN FLAPS OF VARIOUS DESIGN
AND MUSCLE STABILIZATION TECHNIQUES, SUCH AS
TENSION MYODESIS AND MYOPLASTY, FREQUENTLY ARE
USED.
IN ISCHEMIC LIMBS, TENSION MYODESIS IS
CONTRAINDICATED AND A SHORT OR EVEN ABSENT
ANTERIOR FLAP IS RECOMMENDED.

TRANSTIBIAL AMPUTATION USING

POSTERIOR MYOCUTANEOUS FLAP
BURGESS
POSITION THE PATIENT SUPINE ON THE OPERATING TABLE; DO NOT APPLY
A TOURNIQUET. PREPARE AND DRAPE THE LIMB SO THAT AN ABOVE-KNEE
AMPUTATION CAN BE PERFORMED IF BLEEDING AND TISSUE VIABILITY ARE
INSUFFICIENT TO PERMIT A SUCCESSFUL TRANSTIBIAL AMPUTATION. FOR
ISCHEMIC LIMBS, BURGESS RECOMMENDED AMPUTATION 8.8 TO 12.5 CM
DISTAL TO THE LINEOF THE KNEE JOINT.

 ERTL APPLIED THE CONCEPT OF OSTEOPERIOSTEAL FLAPS TO THE

AMPUTATION SURGERY, COMBINING BONY RECONSTRUCTION
(OSTEOPLASTY CREATING A SYNOSTOSIS BETWEEN THE TIBIA AND THE
FIBULA DISTALLY) WITH SOFT TISSUE RECONSTRUCTION (MYOPLASTY)
OSTEOMYOPLASTIC AMPUTATION.
THE TIBIA IS TRANSECTED AND THE FIBULA SHOULD BE TRANSECTED NO
HIGHER THAN 1.5 TO 2 CM PROXIMAL TO THE CUT EDGE OF THE TIBIA.
THIS WILL ASSURE MAINTENANCE OF A CYLINDRICAL RESIDUAL LIMB. A
FIBULA WHICH IS TOO SHORT IN RELATION TO THE TIBIA WILL RESULT IN
A CONICAL LIMB, AND ONE WHICH IS TOO LONG WILL RESULT IN DISTAL
IRRITATION SOFT TISSUE ENVELOPE AND DISCOMFORT WITH THE
PROSTHESIS.

CLASSIC TRANSTIBIAL AMPUTATION USING

EQUAL ANTERIOR AND
POSTERIOR FLAPS

TRANSFEMORAL (ABOVE-KNEE)
AMPUTATIONS
SECOND IN FREQUENCY ONLY TO TRANSTIBIAL AMPUTATION.
EXTREMELY IMPORTANT FOR THE STUMP TO BE AS LONG AS POSSIBLE TO
PROVIDE A STRONG LEVER ARM FOR CONTROL OF THE PROSTHESIS
THE KNEE JOINT USED IN MOST ABOVE-KNEE PROSTHESES EXTENDS 9
TO 10 CM DISTAL TO THE END OF THE PROSTHETIC SOCKET
AMPUTATION SHOULD BE THIS FAR PROXIMAL TO THE KNEE, TO HAVE
THE JOINT OF THE PROSTHESIS AT THE SA
MUSCLE STABILIZATION BY MYODESIS OR MYOPLASTY IS IMPORTANT
WHEN CONSTRUCTING A STRONG AND STURDY AMPUTATION STUMP ME
LEVEL OF THE CONTRALETRAL KNEE.

 A LONG MEDIAL FLAP OR EQUAL ANTERIOR/POSTERIOR FLAPS CAN BE UTILIZED.

IN THE TRAUMA SETTING, THE SURGEON MAY HAVE TO UTILIZE ANY VIABLE
RESIDUAL SOFT TISSUE UNIQUELY FOR WOUND CLOSURE
THE THREE MUSCLE GROUPS (ADDUCTORS, QUADRICEPS, AND HAMSTRINGS) ARE
EACH ISOLATED AND REFLECTED PROXIMALLY TO EXPOSE THE DISTAL FEMUR.
VASCULAR STRUCTURES ARE ISOLATED AND TIED OFF WITH SUTURE LIGATURES,
PREFERABLY DOUBLE SUTURE LIGATURES.
THE SCIATIC AND OBTURATOR NERVES SHOULD BE ISOLATED, TRANSECTED
PROXIMALLY, AND ALLOWED TO RETRACT INTO THE SOFT TISSUE BED.

SOFT TISSUE RECONSTRUCTION BEGINS WITH SECURING THE ADDUCTOR

MUSCULATURE TO THE DISTAL END OF THE FEMUR, TYPICALLY WITH SUTURE
PASSED THROUGH DRILL HOLES, THUS RESTORING PROPER ANATOMIC AND
MECHANICAL ALIGNMENT OF THE RESIDUAL LIMB. THE QUADRICEPS CAN
ALSO BE SECURED DISTALLY TO THE END OF THE FEMUR WITH THE HIP IN
EXTENSION WITH SUTURES PASSED THROUGH ADDITIONAL DRILL HOLES.
FINALLY, THE HAMSTRINGS ARE SECURED POSTERIORLY.
ERTL SUGGESTED CLOSING THE MEDULLARY CANAL VIA OSTEOPERIOSTEAL
FLAP SEWN OVER THE END OF THE FEMUR

SYME AND BOYD PROCEDURES

THE TWO MOST COMMON RECONSTRUCTIVE AMPUTATIONS PERFORMED
FOR THESE CHILDREN ARE THE SYME AND BOYD PROCEDURES.
THE SYME AMPUTATION IS A MODIFIED ANKLE DISARTICULATION. THE
BOYD PROCEDURE AMPUTATES ALL OF THE FOOT BONES EXCEPT THE
CALCANEUS AND FUSES THE CALCANEUS TO THE DISTAL TIBIA.
STUDIES HAVE DOCUMENTED EXCELLENT RESULTS WITH BOTH
PROCEDURES, YET THE LITERATURE SEEMS TO FAVOR A WELL
PERFORMED BOYD AMPUTATION OVER A SYME AMPUTATION.

SYME AMPUTATION

BOYD AMPUTATION

 DISADAVANTAGES OF SYME AMPUTATION

OVERGROWTH OF RETAINED CALCANEUS APOPHYSES, HEEL PAD
MIGRATION, AND FORMATION OF EXOSTOSES.

THE ADVANTAGES OF THE BOYD OPERATION ARE

THE ADDITIONAL LENGTH GAINED AND THE PREVENTION OF THE POSTERIOR

DISPLACEMENT OF THE HEEL PAD, WHICHOCCURS IN MANY PATIENTS WITH
SYME AMPUTATIONS.

BELOW ELBOW AMPUTATION

A FUNCTIONAL ELBOW JOINT IS VITAL AS THIS JOINT SERVES TO
POSITION THE HAND IN SPAC
PRESERVING THE PRONATOR QUADRATUS ALLOWS THE PATIENT TO
MAINTAIN TWO-THIRDS OF ACTIVE FOREARM ROTATION, AND THUS A
BODY-POWERED PROSTHESIS CAN BE APPLIED TO THIS LEVEL.
MYOELECTRIC PROSTHESIS IN UTILIZED, THE OPTIMUM LENGTH WILL BE
AT THE JUNCTION OF MID- AND DISTAL THIRDS OF THE FOREARM

 THE SOFT TISSUE RECONSTRUCTION MUST BE STABLE AND CAN BE

ACCOMPLISHED WITH MYODESIS (MUSCLE SUTURED TO BONE) OR A
COMBINATION OF A MYODESIS OF THE DEEPER LAYER AND MYOPLASTY
OF THE SUPERFICIAL LAYER (USING A OF THE SUPERFICIAL LAYER (USING
A PANTS-OVER-VEST TECHNIQUE) TECHNIQUE).
THIS WILL PROVIDE ADEQUATE SOFT TISSUE COVERAGE DISTALLY WITH
VOLAR AND DORSAL FLAPS AND ALLOWTHE RESIDUAL MUSCULATURE TO
BE ACTIVE AND DYNAMIC, PROVIDING A STRONG MYOELECTRIC SIGNAL

 THE END OF THE STUMP IS NOT AT LEAST DISTAL TO THE INSERTION OF

THE BICEPS TENDON, RESECT THE DISTAL 2.5 CM OF THIS TENDON
ACCORDING TO THE TECHNIQUE OF BLAIR AND MORRIS. THIS
LENGTHENS THE STUMP FUNCTIONALLY AND ENHANCES PROSTHETIC
FITTING. EVEN WITHOUT BICEPS FUNCTION, THE ELBOW CAN BE FLEXED
SATISFACTORILY BY THE BRACHIALISMUSCLE.

 FROM THE SUPRACONDYLAR REGION OF THE HUMERUS DISTALLY TO

THE LEVEL OF THE AXILLARY FOLD PROXIMALLY.
DIFFICULT LEVEL BOTH FOR PROSTHETIC FITTING AND APPEARANCE AS
THE PROSTHETIC ELBOW WILL BE MORE DISTAL THAN THE
CONTRALATERAL NATIVE ELBOW, THEREFORE THIS AMPUTATION LEVEL
IS RARELY SELECTED.
IDEAL LEVEL FOR A BODY-POWERED PROSTHESIS IS JUST PROXIMAL TO
THE DISTAL METAPHYSEALDIAPHYSEAL JUNCTION. HOWEVER, FOR A
MYOELECTRIC PROSTHESIS THE HUMERUS WILL NEED TO BE
TRANSECTED AT THE MIDSHAFT TO ALLOW FOR ADEQUATE FITTING OF
THIS PROSTHESIS.
SOFT TISSURE STABILIZATION

COMPLICATIONS
PAIN
RESIDUAL LIMB PAIN; POORLY FITTING PROSTHESIS. THE STUMP SHOULD BE EVALUATED
FOR AREAS OF ABNORMAL PRESSURE, ESPECIALLY OVER BONY PROMINENCES. DISTAL
STUMP EDEMA, OFTEN CALLED CHOKING, MAY RESULT IF THE END IS NOT COMPLETELY
SEATED IN THE PROSTHESIS, AND ULCERATION OR GANGRENE COULD RESULT. THESE
PROBLEMS CAN BE AVOIDED WITH SOCKET MODIFICATIONS.
PHANTOM LIMB SENSATIONS; COMMON AFTER AN AMPUTATION THAT THEY SHOULD BE
CONSIDERED NORMAL. EDUCATE THE PATIENT REGARDING THESE SENSATIONS SO THAT
THEY ARE NOT SURPRISED BY THEIR PRESENCE. SOME MAY DESCRIBE TELESCOPING,
WHEREBY THE PHANTOM LIMB GRADUALLY SHORTENS TO THE END OF THE RESIDUAL
LIMB.

 PHANTOM LIMB PAIN

FAR LESS COMMON.
THE EXACT INCIDENCE IS DIFFICULT TO DETERMINE BECAUSE MANY AUTHORS FAIL TO
DIFFERENTIATE BETWEEN PHANTOM LIMB PAIN AND PHANTOM LIMB SENSATIONS.
MOST AUTHORS WOULD AGREE THAT TRULY BOTHERSOME PHANTOM LIMB PAIN IS MUCH LESS
COMMON AND IS PROBABLY PRESENT IN LESS THAN 10% OF AMPUTEES.
IF ESTABLISHED ITS VERY DIFFICULT TO TREAT.
MAY BENEFIT FROM SUCH
DIVERSE MEASURES AS MASSAGE, ICE, HEAT, INCREASED PROSTHETIC USE, RELAXATION TRAINING,
BIOFEEDBACK, SYMPATHETIC BLOCKADE, LOCAL NERVE BLOCKS, EPIDURAL BLOCKS, ULTRASOUND,
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION, AND PLACEMENT OF A DORSAL COLUMN
STIMULATOR

 HEMATOMA
METICULOUS HEMOSTASIS BEFORE CLOSURE, THE USE OF A DRAIN, AND A
RIGID DRESSING.
DELAY WOUND HEALING AND SERVE AS A CULTURE MEDIUM FOR BACTERIAL
INFECTION
IF ASSOCIATED WITH DELAYED WOUND HEALING WITH OR WITHOUT
INFECTION, IT SHOULD BE EVACUATED IN THE OPERATING ROOM.

INFECTION
CONSIDERABLY MORE COMMON IN AMPUTATIONS FOR PERIPHERAL VASCULAR
DISEASE, ESPECIALLY DM

 WOUND NECROSIS
REEVALUATE THE PREOPERATIVE SELECTION OF THE AMPUTATION LEVEL.
A SERUM ALBUMIN LEVEL AND A TOTAL LYMPHOCYTE COUNT SHOULD BE
OBTAINED (ALBUMIN LEVELS LESS THAN 3.5 G/DL OR TOTAL LYMPHOCYTE
COUNTS LESS THAN 1500 CELLS/ML)
NUTRITIONAL SUPPLEMENTS
SMOKING CESSATION
LOCAL DEBRIDMENTS
NPWT

 CONTRACTURES
PREVENT BY PROPER POSITIONING OF THE STUMP, GENTLE PASSIVE
STRETCHING, AND HAVING THE PATIENT ENGAGE IN EXERCISES TO
STRENGTHEN THE MUSCLES CONTROLLING THE JOINT.
SEVERE FIXED CONTRACTURES MAY REQUIRE TREATMENT BY WEDGING
CASTS OR BY SURGICAL RELEASE OF THE CONTRACTED STRUCTURES.