Principios de Las Amputaciones

CHAPTER 14
GENERAL PRINCIPLES OF AMPUTATIONS

Patrick C. Toy
INCIDENCE AND SURGICAL PRINCIPLES OF COMPLICATIONS 690

INDICATIONS 680 AMPUTATIONS 686 Hematoma 691
Peripheral vascular disease 681 Determination of amputation level 686 Infection 691
Trauma 681 Technical aspects 687 Wound necrosis 691
Burns 683 Skin and muscle flaps 687 Contractures 691
Frostbite 683 Hemostasis 688 Pain 691
Infection 684 Nerves 688 Dermatologic problems 693
Tumors 685 Bone 688 AMPUTATIONS IN CHILDREN 693
Open amputations 688
Postoperative care 689
Amputation is the most ancient of surgical procedures. biomechanics and materials has greatly improved prosthetic
Advancements in surgical technique and prosthetic design design. Patients with amputations now can enjoy higher levels
historically were stimulated by the aftermath of war. Early of activity. Older patients, who previously would have been
surgical amputation was a crude procedure by which a limb wheelchair dependent, are now more likely to regain ambula-
was rapidly severed from an unanesthetized patient. The tory ability. Younger patients now have access to specialized
open stump was crushed or dipped in boiling oil to obtain prostheses that allow them to resume recreational activities
hemostasis. The procedure was associated with high compli- such as running, golfing, skiing, hiking, swimming, and other
cation and mortality rates due to hemorrhage and infection. competitive sports.
Surgeons during that time could rely only on their efficiency Now, more than ever, it is important that amputations be
and technique to affect outcome and minimize pain. For performed by surgeons who have a complete understanding
patients who survived, the resulting stump was poorly suited of amputation surgical principles, postoperative rehabilita-
for prosthetic fitting. tion, and prosthetic design. Improved prosthetic design does
Hippocrates was the first to use ligatures; this technique not compensate for a poorly performed surgical procedure.
was lost during the Dark Ages but was reintroduced in 1529 Amputation should not be viewed as a failure of treatment
by Ambroise Paré, a French military surgeon. Paré also intro- but rather as the first step toward a patient’s return to a more
duced the “artery forceps.” He was able to reduce the mortal- comfortable and productive life. The operative procedure
ity rate significantly while creating a more functional stump. should be planned and performed with the same care and
He also designed relatively sophisticated prostheses. Further skill used in any other reconstructive procedure.
advances were made possible by Morel’s introduction of the
tourniquet in 1674 and Lister’s introduction of antiseptic
technique in 1867. Based on the microbial theory of infec- INCIDENCE AND INDICATIONS
tion, Lister instituted treating the patient’s skin, the surgeon’s The National Center for Health Statistics estimated that
hands, surgical instrumentation, and the surrounding operat- more than two million patients with amputations live in the
ing theater air with phenol. As a result, the incidence of surgi- United States. The number (∼185,000) of amputations per-
cal sepsis and associated mortality fell dramatically. With the formed each year is increasing, mainly because of an aging
use of chloroform and ether for general anesthesia in the late population. More than 90% of amputations performed in the
19th century, surgeons for the first time could fashion reason- Western world are secondary to peripheral vascular disease.
ably sturdy and functional stumps. In younger patients, trauma is the leading cause, followed by
During the 1940s in the United States, veterans began malignancy.
to voice their concerns over the poor performance of their The only absolute indication for amputation is irreversible
artificial limbs, which prompted the Surgeon General of the ischemia in a diseased or traumatized limb. Amputation also
Army, Norman T. Kirk, to turn to the National Academy may be necessary to preserve life in patients with uncontrol-
of Sciences. This led to the formation of the Advisory lable infections and may be the best option in some patients
Committee on Artificial Limbs, later the Prosthetics Research with tumors, although advances in orthopaedic oncology
Board, and finally the Committee on Prosthetics Research now allow limb salvage in most cases. Injury not affecting
and Development. circulation may result in a limb that it is not as functional
Today, federally funded prosthetic research continues as a prosthesis. Similarly, certain congenital anomalies of the
through university programs. With better understanding of lower extremity are best treated with amputation and pros-
biology and physiology, surgical technique and postoperative thetic fitting. Each of these indications is discussed in further
rehabilitation have improved. New information regarding detail.
680
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CHAPTER 14 GENERAL PRINCIPLES OF AMPUTATIONS 681
PERIPHERAL VASCULAR DISEASE in men because of vocational and avocational hazards. These
Peripheral vascular disease with or without diabetes, which patients are often otherwise healthy and productive, and such
most frequently occurs in individuals aged 50 to 75 years, is injuries may have profound effects on their lives. The only
the most common indication for amputation. The treating absolute indication for primary amputation is an irreparable
physician should keep in mind that if vascular disease has pro- vascular injury in an ischemic limb. With improvements in
gressed to the point of requiring amputation, it is not limited prehospital care, acute resuscitation, microvascular tech-
to the involved extremity. Most patients also have concomi- niques, and bone transport techniques, orthopaedic surgeons
tant disease processes in the cerebral vasculature, coronary more often are faced with situations in which a severely trau-
arteries, and kidneys. In addition to obtaining a vascular sur- matized limb can be preserved, although this involves sub-
gery consultation to evaluate the diseased limb, appropriate stantial compromises.
consultation is indicated to evaluate these other systems. Several studies have suggested guidelines to help decide
Approximately half of amputations for peripheral vascular which limbs are salvageable. Most of these studies have con-
disease are performed on patients with diabetes. The most sig- centrated on severe injuries of the lower extremity. Most
nificant predictor of amputation in diabetics is peripheral neu- authors would agree that type III-C open tibial fractures,
ropathy, as measured by insensitivity to the Semmes-Weinstein which include complete disruption of the tibial nerve, or a
5.07 monofilament. Other documented risk factors include crush injury with warm ischemia time of more than 6 hours,
prior stroke, prior major amputation, decreased transcutane- are an absolute indication for amputation (Fig. 14.1). Relative
ous oxygen levels, and decreased ankle-brachial blood pres- indications for primary amputation include serious associated
sure index. Diabetics must be instructed on the importance of injuries, severe ipsilateral foot injuries, and anticipated pro-
proper foot care and footwear and must examine their feet fre- tracted course to obtain soft-tissue coverage and tibial recon-
quently. Ulcers should be treated aggressively with appropri- struction. Although these relative indications are subject to
ate pressure relief, orthoses, total-contact casting, wound care, various interpretations, they serve as reasonable guidelines.
and antibiotics when indicated. Other risk factors, including Other authors have attempted to remove subjectivity from
smoking and poor glucose control, should be minimized. the decision-making process. To predict which limbs will be
Before performing an amputation for peripheral vascular salvageable, available scoring systems include the predictive
disease, a vascular surgery consultation is almost always indi- salvage index, the limb injury score, the limb salvage index,
cated. Improved techniques currently allow for revasculariza- the mangled extremity syndrome index, and the mangled
tion of limbs that previously would have been unsalvageable. extremity severity score. Of these, we have found the mangled
However, revascularization is not without risk. Although extremity severity score to be most useful (Table 14.1). This
there is no conclusive evidence in the literature that peripheral system, which is easy to apply, grades the injury based on the
bypass surgery compromises wound healing of a future trans- energy that caused the injury, limb ischemia, shock, and the
tibial amputation, our experience seems to indicate otherwise.
If amputation becomes necessary, all effort must be
expended to optimize surgical conditions. All medical prob-
lems should be treated individually. Infection should be con-
trolled as effectively as possible, and nutrition and immune
status should be evaluated with simple screening tests. It has
been shown that the risk for wound complications is greatly
increased in patients whose serum albumin is less than 3.5 g/
dL or whose total lymphocyte count is less than 1500 cells/
mL. Perioperative mortality rates for amputation in periph-
eral vascular disease have been reported to be 30%, and 40%
of patients die within 2 years. Critical ischemia develops in the
remaining lower extremity in 30% of the remaining patients.
Determining the appropriate level of amputation is dis-
cussed later in this chapter. The energy required for walking
is inversely proportionate to the length of the remaining limb.
In an elderly patient with multiple medical problems, energy
reserves may not allow for ambulation if the amputation is
at a proximal level. If a patient’s cognitive function, balance,
strength, and motivation level are sufficient for ambulatory
rehabilitation to be a reasonable goal, amputation should be
performed at the most distal level that offers a reasonable
chance of healing to maximize function. Conversely, a non-
ambulatory patient with a knee flexion contracture should
not undergo a transtibial amputation because a transfemoral
amputation or knee disarticulation provides better function
and less risk.
TRAUMA
Trauma is the leading indication for amputations in younger FIGURE 14.1 Lengthy warm ischemia time generally is an
patients. Amputations caused by trauma are more common absolute indication for amputation.
682 PART VI AMPUTATIONS
TABLE 14.1
Mangled Extremity Severity Score
TYPE CHARACTERISTICS INJURIES POINTS

1 Low energy Stab wounds, simple closed fractures, small-caliber gunshot wounds 1
2 Medium energy Open or multiple-level fractures, dislocations, moderate crush injuries 2
3 High energy Shotgun blast (close range), high-velocity gunshot wounds 3
4 Massive crush Logging, railroad, oil rig accidents 4
SHOCK GROUP
1 Normotensive hemodynamics Stable blood pressure in field and in operating room 0
2 Transiently hypotensive Unstable blood pressure in field but responsive to intravenous fluids 1
3 Prolonged hypotension Systolic blood pressure <90 mm Hg in field and responsive to 2
intravenous fluid only in operating room
ISCHEMIA GROUP
1 None Pulsatile limb without signs of ischemia 0*
2 Mild Diminished pulses without signs of ischemia 1*
3 Moderate No pulse on Doppler imaging, sluggish capillary refill, paresthesia, dimin- 2*
ished motor activity
4 Advanced Pulseless, cool, paralyzed, and numb without capillary refill 3*
AGE GROUP
1 <30 years 0
2 >30 to <50 years 1
3 >50 years 2
*Points ×2 if ischemic time exceeds 6 hours.

From Helfet DL, Howey T, Sanders R, et al: Limb salvage versus amputation: preliminary results of the mangled extremity severity score, Clin Orthop Relat Res
256:80, 1990.
patient’s age. The system was subjected to retrospective and or loss of a muscle flap, may occur. Chronic pain and drug
prospective studies, with a score of 6 or less consistent with addiction also are common problems of limb salvage because
a salvageable limb. With a score of 7 or greater, amputation patients endure multiple hospital admissions and surgery, iso-
was the eventual result. Although we do not strictly follow lation from their family and friends, and unemployment. In the
these guidelines in all patients, we do calculate and document end, despite heroic efforts, the limb ultimately could require
a mangled extremity severity score in the chart whenever we amputation, or a “successfully” salvaged limb may be chroni-
are considering primary amputation versus a complicated cally painful or functionless.
limb salvage. Patients also need to understand that the advances made
No scoring system can replace experience and good clini- in limb salvage surgery have been paralleled by advances
cal judgment. Amputation of an injured extremity might made in the amputation surgery and prosthetic design.
be necessary to preserve life. Attempts to salvage a severely Early amputation and prosthetic fitting are associated with
injured limb may lead to metabolic overload and secondary decreased morbidity, fewer operations, shorter hospital stay,
organ failure. This is more common in patients with multiple decreased hospital costs, shorter rehabilitation, and earlier
injuries and in the elderly. It has been suggested that an injury return to work. The treatment course and outcome are more
severity score of greater than 50 is a contraindication to heroic predictable. Modern prosthetics often provide better function
attempts at limb salvage. Concomitant injuries and comorbid than many “successfully” salvaged limbs. A young, healthy
medical conditions must be considered before heading down patient with a transtibial prosthesis is often able to resume all
a long road of multiple operations to save a limb. previous activities with few restrictions. In long-term studies,
After determining that a limb can be saved, the surgeon patients who have undergone amputation and prosthetic fit-
must decide whether it should be saved, and this decision must ting are more likely to remain working and are far less likely
be made in concert with the patient. The surgeon must educate to consider themselves to be “severely disabled” than patients
the patient regarding the tradeoffs involved with a protracted who have endured an extensive limb salvage.
treatment course of limb salvage versus immediate amputation Several comparisons of limb reconstruction and limb
and prosthetic fitting. On entering the hospital, most patients amputation have come to differing conclusions, with one large
are concerned only with saving the limb; they must be made study of 545 patients projecting lifetime health care costs to be
to understand that this often comes at a great cost. They may three times higher for patients with amputations than for those
have to face multiple operations to obtain bony union and with reconstruction. A meta-analysis, on the other hand, con-
soft-tissue coverage and multiple operations on other areas to cluded that length of rehabilitation and total costs are higher
obtain donor tissue. External fixation may be necessary for sev- for patients who have undergone limb salvage procedures.
eral years, and complications, including infection, nonunion, Reports of functional results have been equally varied, with
one study reporting a 64% return-to-work rate after limb sal-

vage compared with 73% after amputation, and another study
reporting that long-term functional outcomes were equivalent
between limb salvage and primary amputation.
The worst-case scenario occurs when a limb must be
amputated after the patient has endured multiple operations
of an unsuccessful salvage or after years of pain following a
“successful” salvage. After realizing the function that is pos-
sible with a prosthesis, many patients ask why the amputa-
tion was not performed initially. It is important to present all
information from the very beginning so that the patient can
make educated decisions regarding which course to follow.
The physician cannot understand the importance each patient
places on cosmesis, function, or body image without specifi-
cally asking these questions. Other important issues include
the patient’s ability to handle uncertainty, deal with prolonged
immobilization, accept social isolation, and bear the finan-
cial burden. Without discussing all these issues, a physician
would not be able to help patients make the “correct” deci-
sions. The “correct” decisions are based on the patient as a
whole, not solely on the extent of the limb injury.
When an amputation is performed in the setting of acute
trauma, the surgeon must follow all the standard principles
of wound management. Contaminated tissue must undergo
debridement and irrigation followed by open wound man-
agement. Although all devitalized tissue must be removed,
any questionable areas should be retained to preserve future
FIGURE 14.2 Electrical burn of the hand and forearm that
reconstructive options and reevaluated at a repeat debride-
necessitated an above-elbow amputation.
ment in 24 to 48 hours. This time will not only allow the wound
to further declare its course but also allow the patient to com-
prehend the severity of the problem. Functional stump length inadequate debridements with the unrealistic hope of saving a
should be maintained whenever possible; this may require limb may put the patient in undue danger. Debridements must
using nonstandard flaps or free muscle flaps for closure. be aggressive and must include amputation when necessary.
Traction neurectomy for all named nerves and large cutane-
ous nerves should be performed proximal to the end of the FROSTBITE
residual limb to avoid sympathetic neuromas. Vascularized Frostbite denotes the actual freezing of tissue in the extremi-
or nonvascularized tissue may be harvested from the ampu- ties, with or without central hypothermia. Historically, frost-
tated part to aid in this endeavor. If adequate length cannot bite was most prevalent in wartime; however, anyone exposed
be maintained acutely, the stump may be revised later using to subfreezing temperatures is at risk. This is a common prob-
tissue expanders and the Ilizarov technique for bone length- lem for high-altitude climbers, skiers, and hunters. Also at
ening. Negative pressure wound therapy is a useful adju- risk are homeless, alcoholic, and schizophrenic individuals.
vant until the time of revision surgery. Controlled localized When heat loss exceeds the body’s ability to maintain
negative pressure promotes healing by promoting wound homeostasis, blood flow to the extremities is decreased to
contraction, decreasing extracellular fluid, increasing tissue maintain central body temperature. The problem is exac-
oxygenation, and stimulating formation of granulation tissue. erbated by exposure to wind or water. Actual tissue injury
A multidisciplinary approach involving other subspecialties occurs through two mechanisms: (1) direct tissue injury
(e.g., general surgery, vascular surgery) is recommended in through the formation of ice crystals in the extracellular fluid
the acute setting when patients are unable to be involved in and (2) ischemic injury resulting from damage to vascular
the decision process secondary to their other injuries. endothelium, clot formation, and increased sympathetic tone.
The first step in treatment is restoration of core body tem-
BURNS perature. Treatment of the affected extremity begins with rapid
Thermal or electrical injury to an extremity may necessitate rewarming in a water bath at 40°C to 44°C. This requires paren-
amputation (Fig. 14.2). The full extent of tissue damage may teral pain management and sedation. After initial rewarming,
not be apparent at initial presentation, especially with electri- if digital blood flow is still not apparent, treatment with tissue
cal injury. Treatment involves early debridement of devitalized plasminogen activator or regional sympathetic blockade may
tissue, fasciotomies when indicated, and aggressive wound be indicated. Tetanus prophylaxis is mandatory; however, pro-
care, including repeat debridements in the operating room. phylactic systemic antibiotics are controversial. Blebs should
Compared with early amputation, delayed amputation of an be left intact. Closed blebs should be treated with aloe vera.
unsalvageable limb has been associated with increased risk of Silver sulfadiazine (Silvadene) should be applied regularly
local infection, systemic infection, myoglobin-induced renal to open blebs. Low doses of aspirin or ibuprofen also should
failure, and death. In addition, length of hospital stay and cost be instituted. Oral antiinflammatory medication and topical
are greatly increased with delayed amputation. Performing aloe vera help stop progressive dermal ischemia mediated by
TABLE 14.2
Differential Diagnosis of Infection With Gas-Forming Organisms
FACTOR ANAEROBIC CELLULITIS CLOSTRIDIAL MYONECROSIS STREPTOCOCCAL MYONECROSIS

Incubation >3 days <3 days 3–4 days
Onset Gradual Acute Subacute
Toxemia Slight Severe Severe (late)
Pain Absent Severe Variable
Swelling Slight Severe Severe
Skin Little change Tense, white Tense, copper colored
Exudate Slight Serous hemorrhagic Seropurulent
Gas Abundant Rarely abundant Slight
Smell Foul Variable, “mousy” Slight
Muscle involvement No change Severe Moderate
From DeHaven KE, Evarts CM: The continuing problem of gas gangrene: a review and report of illustrative cases, J Trauma 11(12):983–991, 1971.
vasoconstricting metabolites of arachidonic acid in frostbite Three distinct gas-forming infections must be differ-
wounds. Physical therapy should be started early to maintain entiated (Table 14.2). The first is clostridial myonecrosis,
range of motion. which typically develops within 24 hours of closure of a
In stark contrast to traumatic, thermal, or electri- deep contaminated wound. The patient has an acute onset
cal injury, amputation for frostbite routinely should be of pain, swelling, and toxemia, often associated with a men-
delayed 2 to 6 months. Clear demarcation of viable tissue tal awareness of impending death. The wound develops a
may take this long. Even after demarcation appears to be bronze discoloration with a serosanguineous exudate and a
complete on the surface, deep tissues still may be recover- musty odor. Gram stain of the exudates shows gram-positive
ing. Despite the presence of mummified tissue, infection rods occasionally accompanied by other flora. Treatment
is rare if local wound management is maintained. Triple- consists of immediate radical debridement of involved tis-
phase technetium bone scan has helped delineate deep tissue, high doses of intravenous penicillin (clindamycin may
sue viability. Performing surgery prematurely often results be used if the patient is allergic to penicillin), and hyper-
in greater tissue loss and increased risk of infection. An baric oxygen. Emergency open amputation one joint above
exception to this rule is the removal of a circumferentially the affected compartments often is needed as a lifesav-
constricting eschar. ing measure but may be avoided if treatment is initiated
early.
INFECTION Streptococcal myonecrosis usually develops over 3 to 4
Amputation may be necessary for acute or chronic infection days. The onset is not as rapid, and patients do not appear as
that is unresponsive to antibiotics and surgical debridement. sick as patients with clostridial infections. Swelling may be
Open amputation is indicated in this setting and may be per- severe, but the pain is typically not as severe as that experi-
formed using one of two methods. A guillotine amputation enced in clostridial myonecrosis. Abundant seropurulent
may be performed with later revision to a more proximal level discharge may be seen with only small amounts of gas forma-
after the infection is under control. Alternatively, an open tion. Debridement of involved muscle compartments, open
amputation may be performed at the definitive level by ini- wound management, and penicillin treatment usually allow
tially inverting the flaps and packing the wound open with for preservation of the limb.
secondary closure at 10 to 14 days. The third entity that must be distinguished is anaerobic
Partial foot amputation with primary closure has been cellulitis or necrotizing fasciitis. Onset usually occurs several
described for patients with active infection; the wound is days after closure of a contaminated wound. Subcutaneous
closed loosely over a catheter through which an antibiotic emphysema may spread rapidly, although pain, swelling, and
irrigant is infused. The constant infusion is continued for toxemia usually remain minimal. Gas production may be
5 days. The wound must be closed loosely enough to allow abundant with a foul smell, but muscle compartments are not
the fluid to escape into the dressings. The dressings must be involved. Causative organisms include clostridia, anaerobic
changed frequently until the catheter is removed on post- streptococci, Bacteroides, and gram-negative rods. Treatment
operative day 5. This method may allow for primary wound includes debridement and broad-spectrum antibiotics.
healing, while avoiding a protracted course of wound healing Amputation rarely is indicated.
by secondary intention. Indications for amputation of a chronically infected limb
In the acute setting, the most worrisome infections are must be defined on an individual basis. The systemic effects
those produced by gas-forming organisms. Typically associ- of a refractory infection may justify amputation. Disability
ated with battlefield injuries, gas-forming infections also may from a nonhealing trophic ulcer, chronic osteomyelitis, or
result from farm injuries, motor vehicle accidents, or civil- infected nonunion may reach a point at which the patient is
ian gunshot wounds. Any contaminated wound that is closed better served by an amputation and prosthetic fitting. Rarely,
without appropriate debridement is at high risk for the devel- a chronic draining sinus is the site of development of a squa-
opment of gas gangrene. mous cell carcinoma, which necessitates amputation.
TUMORS
Advances in diagnostic imaging, chemotherapy, radiation
therapy, and surgical techniques for reconstruction now
make limb salvage a reasonable option for most patients with
bone or soft-tissue sarcomas. Four issues must be considered
when contemplating limb salvage instead of amputation:
1. Would survival be affected by the treatment choice?
2. How do short-term and long-term morbidity compare?
3. How would the function of a salvaged limb compare with
that of a prosthesis?
4. Are there any psychosocial consequences?
Several studies have discussed the first question with
regard to osteosarcoma. With the use of multimodal treat-
ment, including surgery and chemotherapy, long-term sur-
vival for osteosarcoma patients has improved from 20% to
70% in most series. For osteosarcoma of the distal femur, the
rate of local recurrence after wide resection and limb salvage
is 5% to 10%, which is equivalent to the local recurrence rate
after a transfemoral amputation for osteosarcoma. Although
the rate of local recurrence of a tumor after hip disarticulation
is extremely low, no study has shown a survival advantage for
this technique. In general, provided that wide surgical mar- A
gins are obtained, no study has proved a survival advantage of
one technique over the other.
Amputation for malignancy may be technically demand-
ing, often requiring nonstandard flaps, bone graft, or pros-
thetic augmentation to obtain a more functional residual limb
(Fig. 14.3). Limb salvage is associated with greater periopera-
tive morbidity, however, compared with amputation. Limb
salvage involves a more extensive surgical procedure and is
associated with greater risk of infection, wound dehiscence,
flap necrosis, blood loss, and deep venous thrombosis. Long-
term complications vary depending on the type of recon-
struction. These include periprosthetic fractures, prosthetic
loosening or dislocation, nonunion of the graft-host junction,
allograft fracture, leg-length discrepancy, and late infection. B
A patient with a salvaged limb is more likely to need multiple
subsequent operations for treatment of complications. After FIGURE 14.3 Hip disarticulation secondary to osteosarcoma.
initial successful limb salvage surgery, one third of long-term A, Proximal femoral replacement is constructed using hip hemiar-
survivors ultimately may require an amputation. throplasty component and bone cement. B, Anterior and posterior
Regarding function, the location of the tumor is the most flaps are repaired over prosthesis. Patient can function as trans-
important factor. Resection of an upper extremity lesion with femoral amputee.
limb salvage, even with sacrifice of a major nerve, generally
provides better function than amputation and subsequent which results in decreased endurance. The problem in many
prosthetic fitting. Similarly, resection of a proximal femoral of these patients is compounded by decreased cardiac func-
or pelvic lesion with local reconstruction generally provides tion from doxorubicin-induced cardiomyopathy.
better function than hip disarticulation or hemipelvectomy. In a comparison of the long-term function of amputa-
Sarcomas around the ankle and foot are frequently treated tion, arthrodesis, or arthroplasty for the treatment of tumors
with amputation followed by prosthetic fitting. Treatment for around the knee, patients with an amputation had difficulty
sarcomas around the knee must be individualized. walking on steep, rough, or slippery surfaces but were very
Most patients with osteosarcoma around the knee are active and were the least worried about damaging the affected
treated with one of three surgical procedures, which include limb. Patients with an arthrodesis performed the most
either wide resection with prosthetic knee replacement, demanding physical work and recreational activities, but they
wide resection with allograft arthrodesis, or a transfemoral had difficulty with sitting, especially in the back seat of cars,
amputation. In one study of osteosarcoma patients, patients theaters, or sports arenas. Patients who had arthroplasty gen-
who had undergone resection and prosthetic knee replace- erally led more sedentary lives and were more protective of
ment showed higher self-selected walking velocities and a the limb, but they had little difficulty with activities of daily
more efficient gait with regard to oxygen consumption than living. These patients also were the least self-conscious about
patients with transfemoral amputations. Individuals with the limb.
a transfemoral amputation functioned at more than 50% of No study has shown a significant difference between
their maximal aerobic capacity at free walking speeds, requir- amputation and limb salvage with regard to psychologic
ing anaerobic mechanisms to sustain muscle metabolism, outcome or quality of life in long-term sarcoma survivors.
The decision of limb salvage versus amputation involves more

than the question of whether the lesion can be resected with
wide margins. The patient ultimately must make the final
decision based on long-term goals and lifestyle decisions.
Rarely, amputation may be indicated as a palliative mea-
sure for a patient with metastatic disease and pain that has
been refractory to standard surgical treatment, radiation, che-
motherapy, and narcotic pain management. Amputation may
be indicated for treatment of a recurrent pathologic fracture
in which stabilization is impossible. It also may be indicated if
the malignancy has caused massive necrosis, fungation, infec-
tion, or vascular compromise (Fig. 14.4). Although cure is
not the goal, amputation may dramatically improve the func-
tional status and pain relief for the remaining months in some
patients. The surgeon must remember, however, that survival
is not always predictable. One such “palliative” hemipelvec-
tomy was performed at this institution on a patient who sub-
sequently lived comfortably for an additional 20 years.
SURGICAL PRINCIPLES OF
AMPUTATIONS
DETERMINATION OF AMPUTATION LEVEL FIGURE 14.4 Fungating tumor required transhumeral ampu-
Determining the appropriate level of amputation requires an tation.
understanding of the tradeoffs between increased function
with a more distal level of amputation and a decreased com- capacity even for minimal ambulation. In this state, as already
plication rate with a more proximal level of amputation (Fig. mentioned, anaerobic mechanisms are summoned to sustain
14.5). The patient’s overall well-being, general medical condi- muscle function, and endurance is greatly compromised. As
tion, and rehabilitation all are important factors. a result, fewer vascular transfemoral amputees regain func-
A vascular surgery consultation is almost always appro- tional ambulatory ability. It becomes apparent that amputa-
priate. Even if revascularization would not allow for salvage tion should be performed at the most distal level possible if
of the entire limb, it may allow for healing of a partial foot or ambulation is the chief concern.
ankle amputation instead of a transtibial amputation. As pre- If a patient has no ambulatory potential, wound heal-
viously stated, however, peripheral bypass surgery may com- ing with decreased perioperative morbidity should be the
promise wound healing of a future transtibial amputation. chief concern. A transtibial amputation in this setting is not
Simple screening tests for nutritional status and immu- a reasonable option because of the increased risk of wound
nocompetence should be performed. Use of tobacco products problems and increased skin problems from knee flexion
should be discouraged. Medical illness, infection, and major contractures. A knee disarticulation often provides the best
operations all induce a hypermetabolic state. Multiple stud- function for these patients. Compared with transfemoral
ies have confirmed that malnourished or immunocompro- amputation, knee disarticulation provides a longer lever arm
mised patients have markedly increased rates of perioperative with balanced musculature to help with bed mobility and
complications. transfers. In addition, muscles are not divided and do not
Waters et al. studied the energy cost of walking for atrophy and contract over the femur as they often do after
patients with amputations at the transfemoral, transtibial, transfemoral amputation. Finally, better sitting stability and
and Syme levels secondary to trauma or chronic limb isch- comfort are provided with a through-knee amputation.
emia. Compared with controls without amputations, the Determining the most distal level for amputation with a
self-selected walking velocity for vascular amputees was reasonable chance of healing can be challenging. Preoperatively,
66% at the Syme level, 59% at the transtibial level, and 44% clinical assessment of skin color, hair growth, and skin tem-
at the transfemoral level. For traumatic amputees, generally perature provides valuable initial information. Preoperative
younger patients, the rates were 87% at the transtibial level arteriograms, although already obtained for vascular surgery
and 63% at the transfemoral level. At self-selected walking consultation, are of little help in determining potential for
velocities, the slower rates for amputees seem to be a com- wound healing. Segmental systolic blood pressures likewise
pensatory mechanism to conserve energy per unit time. offer little useful information because they are often falsely
Except for transfemoral amputations secondary to vascular elevated owing to the noncompliant walls of arteriosclerotic
insufficiency, all patients tended to ambulate at similar per- vessels. Measurements of skin perfusion pressures may be
centages of their maximal aerobic capacity compared with of some benefit, however. Some authors have recommended
age-matched controls. Patients tended to decrease their thermography or laser Doppler flowmetry as methods to test
velocities to keep their relative energy costs per minute within skin flap perfusion. Others recommend determining the tis-
normal limits. Patients with transfemoral amputations sec- sue uptake of intravenously injected fluorescein or the tissue
ondary to vascular insufficiency were unable to accomplish clearance of intradermally injected xenon-133. We have found
this, however, often exceeding 50% of their maximal aerobic transcutaneous oxygen measurements to be most beneficial.
Forequarter
Hemipelvectomy
Shoulder
disarticulation
Hip disarticulation
Very short
above knee
Transhumeral
Short above
knee
Medium above
knee
Elbow Long above

disarticulation knee
Knee
disarticulation
Transradial
Short below
knee
Wrist
disarticulation Standard below
knee
Transcarpal
Chopart
Transmetacarpal Lisfranc Symes

Hindfoot,
Transphalangeal such as Boyd
Metatarsal
Toe disarticulation or amputation
FIGURE 14.5 Levels of amputation: more distal levels are associated with increased function,
more proximal levels are associated with a decreased complication rate.
Transcutaneous oxygen measurements can be deter- zone. A decrease of greater than 15 mm Hg after 3 minutes of
mined at multiple sites along the limb. The test is performed by elevation of the involved limb is a poor prognostic indicator
inserting a probe that is heated to 45°C for 10 minutes before for healing. This information must be used in light of other
oxygen tension is measured. This allows for a maximum vaso- patient variables, including age, concomitant medical prob-
dilatory response and a more accurate determination of per- lems, and ambulatory potential.
fusion potential. Various studies have recommended different
cutoff levels, ranging from 20 to 40 mm Hg, for “good” heal- TECHNICAL ASPECTS
ing potential. There is, however, no absolute cutoff because Meticulous attention to detail and gentle handling of soft tissues
some studies have shown healing rates of 50% even when are important for creating a well-healed and highly functional
the transcutaneous oxygen level is less than 10 mm Hg. The amputation stump. The tissues often are poorly vascularized or
measurement can be falsely decreased in circumstances that traumatized, and the risk for complications is high.
decrease the diffusion of oxygen, such as cellulitis or edema.
The test can be improved by comparing the transcutaneous SKIN AND MUSCLE FLAPS
oxygen level before and after the inhalation of 100% oxygen. Flaps should be kept thick. Unnecessary dissection should be
An increase of 10 mm Hg at a particular level is a good indi- avoided to prevent further devascularization of already com-
cator for healing potential. Accuracy also can be improved promised tissues. Covering the end of the stump with a sturdy
by comparing supine and elevation of the extremity mea- soft-tissue envelope is crucial. Past studies have determined
surements in patients who fall into the 20 to 40 mm Hg gray the best type of flaps for each level of amputation, but atypical
flaps are always preferable to amputation at a more proximal

level. With modern total-contact prosthetic sockets, the loca-
tion of the scar is rarely important, but the scar should not
be adherent to the underlying bone. An adherent scar makes
prosthetic fitting extremely difficult, and this type of scar
often breaks down after prolonged prosthetic use. Redundant
soft tissues or large “dog ears” also create problems in pros-
thetic fitting and may prevent maximal function of an other-
wise well-constructed stump (Fig. 14.6).
Muscles usually are divided at least 5 cm distal to the
intended bone resection. They may be stabilized by myodesis
(suturing muscle or tendon to bone) or by myoplasty (sutur-
ing muscle to the periosteum or the fascia of opposing muscu-
lature). Jaegers et al. showed that transected muscles atrophy FIGURE 14.6 Redundant soft tissue or large “dog ears” can
40% to 60% in 2 years if they are not securely fixed. If possible, create problems in prosthetic fitting.
myodesis should be performed to provide a stronger insertion,
help maximize strength, and minimize atrophy (Fig. 14.7).
Myodesed muscles continue to counterbalance their antago-
nists, preventing contractures and maximizing residual limb
function. However, myodesis may be contraindicated in severe
ischemia because of the increased risk of wound breakdown.
HEMOSTASIS
Except in severely ischemic limbs, the use of a tourniquet is
highly desirable and makes the amputation easier. The limb
may be exsanguinated by wrapping it with an Esmarch ban-
dage before the tourniquet is inflated. However, in amputa-
tions for infections or malignancy, expressing blood from the
limbs in this manner is inadvisable. In such instances, infla-
tion of the tourniquet should be preceded by elevation of the
limb for 5 minutes.
Major blood vessels should be isolated and individually FIGURE 14.7 Myodesis in transfemoral amputation. Adductor
ligated. Arteries and veins should be ligated separately, and magnus tendon (arrow) is pulled into cut end of distal femur and
larger vessels should be doubly ligated. The tourniquet should secured through drill hole in lateral cortex.
be deflated before closure, and meticulous hemostasis should
be obtained. A drain should be used in most cases for 48 to Bony prominences that would not be well padded by soft tis-
72 hours. sue always should be resected, and the remaining bone should
be rasped to form a smooth contour. This is especially impor-
NERVES tant in locations such as the anterior aspect of the tibia, lateral
A neuroma formation is inevitable after transection as the aspect of the femur, and radial styloid.
axons are unable to locate the distal nerve stump. A neuroma
becomes painful if it forms in a position where it would be OPEN AMPUTATIONS
subjected to repeated trauma. Normal physiologic stimuli An open amputation is one in which the skin is not closed
such as stretching, pressure, and vascular pulsations may be over the end of the stump. The operation is the first of at least
painful and, thus, limit prosthetic usage. Special techniques two operations required to construct a satisfactory stump. It
have been tried in the hopes of preventing the formation of always must be followed by secondary closure, reamputation,
painful neuromas. These include end-loop anastomosis, peri- revision, or plastic repair. The purpose of this type of amputa-
neural closure, Silastic capping, sealing the epineurial tube tion is to prevent or eliminate infection so that final closure
with butyl-cyanoacrylate, ligation, cauterization, and meth- of the stump may be done without breakdown of the wound.
ods to bury the nerve ends in bone or muscle. Most surgeons Open amputations are indicated in infections and in severe
currently agree that nerves should be isolated, gently pulled traumatic wounds with extensive destruction of tissue and
distally into the wound, and divided cleanly with a sharp knife gross contamination by foreign material. Appropriate antibi-
so that the cut end retracts well proximal to the level of bone otics are given until the stump is finally healed (Fig. 14.8).
resection. Strong tension on the nerve should be avoided dur- Previous editions of this book have described the tech-
ing this maneuver; otherwise, the amputation stump may niques for open amputations with inverted skin flaps and
be painful even after the wound has healed. Crushing also circular open amputations with postoperative skin traction.
should be avoided. Large nerves, such as the sciatic nerve, More recently, in the setting of tissue contamination or severe
often contain relatively large arteries and should be ligated. trauma at the amputation site, we have employed the tech-
nique of vacuum-assisted closure. A wound vacuum-assisted
BONE closure is applied to the open stump immediately after the ini-
Excessive periosteal stripping is contraindicated and may tial debridement. Subsequent debridements are scheduled at
result in the formation of ring sequestra or bony overgrowth. 48-hour intervals. The vacuum-assisted closure is reapplied
FIGURE 14.8 Open amputation. First stage, without skin

closure, is aimed at preventing or eliminating infection before
the second stage (closure, reamputation, revision, plastic repair).
after each debridement until the wound is ready for closure

(Fig. 14.9). B
FIGURE 14.9 Postoperative below-knee amputation stump
POSTOPERATIVE CARE
before (A) and after (B) negative-pressure wound therapy dressing.
Postoperative care of amputations often requires a multi-
(From Sumpio B, Thakor P, Mahler D, Blume P: Negative pressure wound
disciplinary team approach. In addition to the surgeon, this
therapy as postoperative dressing in below knee amputation stump closure
team may include a physical medicine specialist, a physical
of patients with chronic venous insufficiency, Wounds 23[10]:301–308,
therapist, an occupational therapist, a psychologist, and a
2011.)
social worker. An internist often is required to help manage
postoperative medical problems. All the same precautions
are followed as for any major orthopaedic surgery, including period, the rigid dressing may be applied by the surgeon,
perioperative antibiotics, deep venous thrombosis prophy- observing standard cast application precautions, includ-
laxis, and pulmonary hygiene. Pain management includes the ing appropriate padding of all bony prominences, avoiding
brief use of intravenous narcotics followed by oral pain medi- proximal constriction of the limb, and use of dependable
cine that is tapered as soon as can be tolerated. Several stud- cast suspension methods. If weight-bearing ambulation in
ies have noted decreased narcotic usage with improved pain the immediate postoperative period is anticipated, a true
management using an oral multimodal pain medication regi- prosthetic cast should be applied, preferably by a certi-
men (Table 14.3) and/or continuous postoperative perineural fied prosthetist, with appropriate use of stump socks, con-
infusional anesthesia for several days. toured felt padding over all bony prominences, and special
Treatment of the stump from the time the amputation suspension techniques. A metal pylon with a prosthetic
is completed until the definitive prosthesis is fitted is cru- foot is attached to the cast and properly aligned for ambu-
cial if a strong and functional amputation stump capable lation. Specific details of such prosthetic cast applications
of maximum prosthetic use is to be obtained. Since the for the major levels of amputation are provided after each
mid-1970s, there has been a gradual shift from the use of discussion of surgical technique. Rigid stump dressings
“conventional” soft dressings to the use of rigid dressings, may be employed successfully and beneficially at essen-
especially in centers that perform significant numbers of tially all levels of amputation in the lower and upper limbs
amputations. The rigid dressing consists of a plaster of and are applicable to all age groups.
Paris cast that is applied to the stump at the conclusion Rigid dressings offer several advantages over soft dress-
of surgery. Early weight bearing is not an essential part of ings. Rigid dressings prevent edema at the surgical site, pro-
the postoperative management program. If weight-bearing tect the wound from bed trauma, enhance wound healing and
ambulation is not planned in the immediate postoperative early maturation of the stump, and decrease postoperative
TABLE 14.3
Multimodal Analgesia: Pharmacologic Components
TYPE EXAMPLES
Principal Regional anesthesia Central neuraxial or peripheral nerve block
Single-shot or continuous catheter
± Local infiltration analgesia
Opioid analgesics Oxycodone, morphine, fentanyl, hydromorphone
Systemic nonopioid analgesics Acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs)
Adjuvants Gabapentinoids Gabapentin, pregabalin
N-methyl D-aspartate (NMDA) Ketamine, memantine, dextromethor phan, magnesium
receptor antagonists
Alpha-2 adrenergic agents Clonidine
Glucocorticoids Dexamethasone
Other Antidepressant, calcitonin, nicotine, capsaicin, cannabinoid, lidocaine
pain, allowing earlier mobilization from bed to chair and or delayed wound healing. Any weight bearing before the
ambulation with support. For transtibial amputations, rigid stump has healed should be strictly supervised. Advancement
dressings prevent the formation of knee flexion contractures. of weight-bearing status should be individualized. A young
The physiologic benefits of upright posture to the respira- patient with a traumatic amputation above the zone of injury
tory, cardiovascular, urinary, and gastrointestinal systems are probably could begin 25-lb partial weight bearing immedi-
easily recognizable, but the psychologic benefits sometimes ately postoperatively. A patient with a traumatic amputation
are more subtle. In most instances, the hospital stay can be through the zone of injury, or a patient with an amputation
decreased and the cost of care reduced accordingly. Finally, performed secondary to ischemia probably should wait until
earlier definitive prosthetic fitting is possible and a higher early wound healing is documented before gradually begin-
percentage of patients are successfully rehabilitated. ning partial weight bearing. Weight-bearing status should be
Drains usually are removed at 48 hours. The patient is reevaluated with each subsequent cast change. If the wound
instructed on how to position the stump properly while in is progressing well, weight bearing can progress in 25-lb
bed, while sitting, and while standing. The stump is elevated increments each week. Supervision is especially important in
by raising the foot of the bed, which helps manage edema patients with peripheral neuropathy who may have difficulty
and postoperative pain. The patient is cautioned against leav- judging how much weight they are placing on their stumps.
ing the stump in a dependent position. With transfemoral Juvenile amputees also require close supervision because they
amputations, the patient is cautioned against placing a pil- are usually quite comfortable in a temporary prosthesis and
low between the thighs or beneath the stump or otherwise often attempt to walk without support.
keeping the stump flexed or abducted. These precautions are Regardless of when prosthetic ambulation is begun, the
necessary to help prevent flexion or abduction contractures. rigid dressing should be removed and the wound inspected
Exercises for the stump are started under the supervision of in 7 to 10 days. Cast loosening, fever, excessive drainage,
a physical therapist the day after surgery or as soon thereaf- or systemic symptoms of wound infection are indications
ter as tolerated. These should consist of muscle-setting exer- for earlier cast removal. If the wound is healing well, a new
cises followed by exercises to mobilize the joints. Patients rigid dressing is applied, and ambulation with or without
should be mobilized from bed to chair on the first postop- a pylon and prosthetic foot is continued. The cast should
erative day. Patients with lower extremity amputations should be changed weekly until the wound has healed. After the
begin physical therapy within the first several days and begin wound is well healed, the rigid dressing may be removed
ambulating using the parallel bars. This is followed shortly by for bathing and stump hygiene, and, if desired, an elastic
ambulation with a walker or crutches when patients can con- stump shrinker may be used at night in lieu of the rigid
trol the limb and are comfortable enough. dressing. As stump shrinkage occurs, continued gentle
The optimal time to begin prosthetic ambulation with compression of the stump is maintained by applying an
protected weight bearing depends on many factors, includ- additional stump sock before donning the plaster socket;
ing the age, strength, and agility of the patient as well as the this minimizes the need for repeated cast changes. Use of
patient’s ability to protect the amputation stump from injury the rigid dressing is continued until the volume appears
as a result of excessive weight bearing. The availability of a unchanged from the previous week. At that time, the pros-
well-trained team of nurses, therapists, and prosthetists who thetist may apply the first prosthesis. One or more socket
can carry out a well-integrated prosthetic treatment program changes frequently are required over the first 18 months;
consistently and the desire and willingness of the surgeon to therefore, many prosthetists prefer to make the initial
meticulously supervise such a treatment program are impor- prosthesis in a modular fashion.
tant factors.
The gradual application of functional mechanical stress
in the appropriate distribution can enhance wound healing; COMPLICATIONS
however, shearing forces can lead to wound breakdown. Early In a review of 5732 patients with transmetatarsal, below-knee,
unprotected weight bearing can result in sloughing of the skin or above-knee amputations, the overall complication rate was
FIGURE 14.10 Partial closure of infected transtibial amputation.

FIGURE 14.11 Tissue necrosis on stump wound.
43%, most of which consisted of wound-related complica-
tions. Independent predictors of readmission after ampu- flow, lowering tissue oxygen pressure. In a study by Lind et al.,
tation were chronic nursing-home residence, nonelective the risk of infection and reamputation was 2.5 times higher in
surgery, previous revascularization or amputation, preopera- smokers than in nonsmokers.
tive congestive heart failure, and preoperative dialysis. Necrosis of the skin edges less than 1 cm can be treated
conservatively with open wound management (Fig. 14.11).
HEMATOMA There are several alternatives for management of more severe
Meticulous hemostasis before closure, the use of a drain, and wound necrosis. The wound can be treated conservatively
a rigid dressing should minimize the frequency of hematoma with local debridements combined with nutritional supple-
formation. A hematoma can delay wound healing and serve mentation. In patients who are better rehabilitation candi-
as a culture medium for bacterial infection. If a hematoma dates, some authors recommend total-contact casting with
does form, it should be treated with a compressive dressing. If continued progression of weight bearing and rehabilitation.
the hematoma is associated with delayed wound healing with These authors state that weight bearing in a properly fitted
or without infection, it should be evacuated in the operating total-contact cast stimulates wound healing and stump matu-
room. ration. We prefer to postpone prosthetic use until the wound
has healed. We have made extensive use of vacuum-assisted
INFECTION closure in this setting.
Infection is considerably more common in amputations for In cases of severe necrosis with poor coverage of the
peripheral vascular disease, especially in diabetic patients, bone end, wedge resection may be indicated. The basic
than in amputations secondary to trauma or tumor. Any deep principle of wedge resection is to regard the end of the
wound infection should be treated with immediate debride- amputation stump as a hemisphere. Although local resec-
ment and irrigation in the operating room and open wound tion increases local tension on already compromised tissues,
management. Antibiotics should be tailored according to the resection of a wedge incorporating the full diameter of the
results of intraoperative cultures. Delayed closure may be dif- stump would allow for reformation of the hemisphere while
ficult because of edema and retraction of the flaps. Smith and minimizing local pressures (Fig. 14.12). Finally, hyperbaric
Burgess described a method whereby the central one third oxygen therapy and transcutaneous electrical nerve stimu-
of the wound is closed and the remainder of the wound is lation have been shown in some studies to promote wound
packed open (Fig. 14.10). This method allows for continued healing.
open wound management while maintaining adequate flaps
for distal bone coverage. CONTRACTURES
Mild or moderate contractures of the joints of an amputa-
WOUND NECROSIS tion stump should be prevented by proper positioning of
The first step in evaluating significant wound necrosis is to the stump, gentle passive stretching, and having the patient
reevaluate the preoperative selection of the amputation level. engage in exercises to strengthen the muscles controlling the
If transcutaneous oxygen studies were not obtained preopera- joint. At the knee, increased ambulation tends to reduce a
tively, they should be obtained at this point to evaluate wound contracture. In some patients, prosthetic modification may
healing potential. A serum albumin level and a total lympho- be necessary to adapt to the contracture. Rarely, severe fixed
cyte count should be obtained. Many authors have reported contractures may require treatment by wedging casts or by
significantly more problems with wound healing in patients surgical release of the contracted structures.
with serum albumin levels less than 3.5 g/dL or total lym-
phocyte counts less than 1500 cells/mL. Nutritional supple- PAIN
mentation has been shown to promote wound healing in this Because pain is complex and mediated by multiple pathways,
setting. Patients who smoke tobacco should quit immediately Kehlet and Dahl introduced the concept of multimodal anal-
because smoking severely compromises cutaneous blood gesia for the management of acute postoperative pain. This
Local
resection
Wedge
resection
FIGURE 14.12 Diagrams of end-on and side views of amputation stumps. Local resection
produces uneven tension; this is reduced and evenly distributed after wedge resection.
algorithm has proven to be valuable at our institution, and Other possible causes of residual limb pain may be unre-
examples are shown in Table 14.3. Effectively treating postop- lated to the amputation stump. Osteoarthritis of the hip in a
erative pain will promote function, enhance psychologic well- patient with an amputation should be treated the same way
being, and potentially minimize the risk of developing chronic as with any other patient. If conservative measures fail to
pain. relieve symptoms, total hip arthroplasty should be offered as
After the immediate postoperative pain has been resolved, a reasonable option. Pain from osteoarthritis of the knee in a
some patients continue to feel chronic pain as a result of vari- patient with a transtibial amputation, although rare, may be
ous causes. The first step in management is to diagnose the cause partially relieved by adding a knee joint and thigh corset to
accurately. Phantom limb pain must be differentiated from resid- the prosthesis to allow load sharing with the thigh.
ual limb pain, and both must be distinguished from pain arising Phantom limb sensations are common after an amputation
from a distant site, such as from a herniated lumbar disc. and they should be considered normal. Most patients do not
Mechanical lower back pain has been shown to be more find these to be bothersome. The most important part of man-
prevalent in amputees than in the general population. In a agement is simply to educate the patient regarding these sensa-
study of 92 patients with amputations, back pain was rated tions so that they are not surprised by their presence. During
more bothersome than phantom limb pain or residual limb the first year after amputation, many patients experience a phe-
pain. In addition to other accepted treatments for back pain, nomenon referred to as “telescoping,” whereby the phantom
patients must be instructed on proper prosthetic ambulation limb gradually shortens to the end of the residual limb.
to minimize abnormal stresses on the lumbar spine. Phantom limb pain is far less common. The exact inci-
Residual limb pain is often caused by a poorly fitting pros- dence is difficult to determine because many authors fail to
thesis. Pressure is placed on tissues of the remaining leg or arm differentiate between phantom limb pain and phantom limb
that were not designed to be pressure bearing. An intimate fit is sensations. Other authors fail to distinguish between the
required to provide maximal function and avoid focal pressure mere presence of phantom limb pain versus the presence of
points that can often be uncomfortable or painful. severe phantom limb pain, which has a significant effect on
The stump should be evaluated for areas of abnormal pres- the patient. Subsequently, some reports state that phantom
sure, especially over bony prominences. Distal stump edema, limb pain is present in 80% of amputees. Most authors would
often called “choking,” may result if the end is not completely agree that truly bothersome phantom limb pain is much less
seated in the prosthesis, and ulceration or gangrene could result. common and is probably present in less than 10% of ampu-
These problems can be avoided with socket modifications. tees. In our experience, phantom limb pain is more often
A neuroma always forms after division of a nerve. A pain- present with proximal amputations, such as forequarter and
ful neuroma occurs when the nerve end is subjected to pres- hindquarter amputations. Phantom pain also appears to be
sure or repeated irritation. A painful neuroma usually can be more common in patients who felt pain in the limb before
prevented by gentle traction on the nerve followed by sharp amputation. Subsequently, some investigators claim that
proximal division, allowing the nerve end to retract deep into phantom limb pain can be prevented with the use of epidural
the soft tissue. A painful neuroma usually is easily palpable anesthesia beginning the day before surgery. Other investiga-
and often has a positive Tinel sign. Treatment initially con- tors have failed to substantiate these claims. When significant
sists of socket modification. If this fails to relieve symptoms, pain is established, however, it can be extremely difficult to
simple neuroma excision or a more proximal neurectomy treat. Although no one specific method is universally benefi-
may be required. Some authors recommend neuroma exci- cial, some patients may benefit from such diverse measures as
sion combined with centrocentral anastomosis of the proxi- massage, ice, heat, increased prosthetic use, relaxation train-
mal stump or a procedure to seal the epineurial sleeve. Rarely, ing, biofeedback, sympathetic blockade, oral medications,
it may be difficult to distinguish a neuroma from a possible local nerve blocks, epidural blocks, ultrasound, transcuta-
recurrent tumor. Provost et al. have provided some helpful neous electrical nerve stimulation, and placement of a dor-
descriptions of the ultrasound features of a neuroma. sal column stimulator. Other general treatment guidelines
have been suggested to be helpful. These include control- general body growth and stump growth are significant fac-
ling stump edema, decreasing anxiety and stress, establish- tors. Krajbich summarized the general principles of child-
ing good sleep hygiene patterns, decreasing depression, hood amputation surgery as follows: (1) preserve length, (2)
and encouraging smoking cessation. Treatment algorithms preserve important growth plates, (3) perform disarticulation
have been developed for both residual limb pain and phan- rather than transosseous amputation whenever possible, (4)
tom limb pain (Figs. 14.13 and 14.14). preserve the knee joint whenever possible, (5) stabilize and
normalize the proximal portion of the limb, and (6) be pre-
DERMATOLOGIC PROBLEMS pared to deal with issues in addition to limb deficiency in
Patients should be instructed to wash their stumps with a children with other clinically important conditions.
mild antimicrobial soap at least once a day. The stump should Preserving length is crucial. Seventy-five percent of
be thoroughly rinsed and dried before donning the prosthe- the growth of the femur occurs at the distal growth plate.
sis. Likewise, the prosthesis should be kept clean and should Consequently, any transfemoral amputation performed in a
be thoroughly dried before donning. young child would result in a very short stump as an adult.
Contact dermatitis is common and may be confused with Conversely, even a very short transtibial stump in a young
infection. Skin inflammation is associated with intense itch- child may result in a functional stump as an adult if the
ing and burning when wearing the socket. The most common growth plate is preserved.
cause is failure to rinse detergents from stump socks thor- Disarticulation can provide a child with a well-balanced,
oughly. Other sensitizers include nickel, chromates used in sturdy stump capable of end weight bearing. Length and phy-
leathers, skin creams, antioxidants in rubber, topical antibiot- ses are preserved without the risks of terminal overgrowth.
ics, and topical anesthetics. Treatment consists of removal of Additionally, prosthetic suspension is improved with a disar-
the irritant, soaks, steroid cream, and compression. ticulation secondary to preservation of the metaphyseal flares.
Bacterial folliculitis may occur in areas of hairy, oily skin. This is important because of the high mechanical demands
The problem may be exacerbated by shaving and by poor that children often place on their prostheses.
hygiene. Treatment initially consists of improved hygiene and Terminal bone overgrowth is a significant problem in a
possibly socket modifications to relieve areas of abnormal child amputee with a transosseous amputation. The problem
pressure. Occasionally, cellulitis develops that requires antibi- does not occur after disarticulation. The overgrowth is caused
otic treatment or an abscess forms that requires incision and by appositional new bone formation and is unrelated to the
drainage. growth of the physis. The resulting bone is elongated and
Epidermoid cysts may develop at the socket brim. These often pencil shaped. It may cause swelling, edema, pain, and
frequently occur late and are best treated with socket modifi- bursa formation, and in severe cases may penetrate the skin.
cation. Excision may be required. Overgrowth is more common after traumatic amputations
Verrucous hyperplasia refers to a wart-like overgrowth than after amputations performed for other indications. It is
of the skin at the end of the stump. It is caused by proximal also more common in younger children than in older chil-
constriction that prevents the stump from fully seating in the dren and occurs most often in the humerus and fibula and
prosthesis. This “choking,” as previously mentioned, causes dis- less often in the tibia, femur, radius, and ulna, in that order.
tal stump edema followed by thickening of the skin, fissuring, The exact incidence is difficult to determine because of vari-
ulceration, and possibly subsequent infection. Treatment ini- ables in the definition of significant overgrowth and variations
tially is directed toward treating the infection. The skin should in the age cutoff of different studies. In one study, 27% of child
be treated with soaks and salicylic acid to soften the keratin. amputees experienced overgrowth severe enough to require
Socket modification is mandatory because pressure on the distal revision surgery.
skin is essential to treat the problem and to prevent recurrences. Terminal overgrowth is treated effectively with surgi-
cal resection of the excess bone. Epiphysiodesis has been
unsuccessful and is contraindicated. Capping the bone with
AMPUTATIONS IN CHILDREN a synthetic device has had only limited success and has been
Amputations in children may be divided into two general complicated by infection or fracture of the implant or bone.
categories: congenital and acquired. Surveys of specialized Improved results have been obtained by capping the bone
child amputee clinics have shown that approximately 60% with an epiphyseal graft harvested from the amputated limb
of childhood amputations are secondary to congenital limb at the index procedure (Fig. 14.15) or by capping with tricor-
deficiencies and 40% are secondary to acquired conditions. tical iliac crest graft at a revision operation.
Acquired amputations most often are secondary to trauma, Because of growth issues and increased body metabolism,
followed by neoplasm and infection. Motor vehicle acci- children often can tolerate procedures on amputation stumps
dents, gunshot wounds, and power tool injuries are the most that are not tolerated by adults, including more forceful skin
common causes of limb loss from injury in older children; traction, the application of extensive skin grafts, and the closure
in young children, accidents with power tools, such as lawn- of skin flaps under moderate tension. In addition, complications
mowers, and other household accidents are the most com- after surgery tend to be less severe in children. Painful phantom
mon causes. Dysvascular amputations in children are rare, sensations do not develop, and neuromas rarely are trouble-
but when they do occur, they usually are secondary to throm- some enough to require surgery. Even extensive scars usually
botic or embolic events caused by another underlying prob- are tolerated well. One or more spurs usually develop on the
lem. Congenital amputations are discussed in Chapter 29; end of the bone, but, in contrast to terminal overgrowth, almost
only acquired amputations in children are considered here. never require resection. Psychologic problems after amputation
Most of the techniques of amputation described for are rare in children until they reach adolescence, at which time
adults also are useful for children, but in pediatric patients, they may become severe enough to require treatment.
Is pain in the
residual limb?
Phantom No Yes
limb pain
Residual limb pain
Are there psychologic Yes

factors? (Depression, Psychologic
anxiety, anger) evaluation/treatment
No Pain unresolved Pain resolved
Are there sleep Yes Medications/

disturbances? sleep lab
Is the pain worse Pain unresolved Pain resolved

Prosthetic evaluation for
with use of prosthesis?
fit and alignment
Yes
No
Pain unresolved Pain resolved
Are there signs
of infection? Antibiotics/
Yes wound care
No

Is edema present?
Yes Shrinkage treatments/
comorbidity (CHF, CRF)
No
Are there skin Pain unresolved Pain resolved

abrasions present?
Yes
No Dermatologic
treatments
With palpation, is
there any tenderness Pain unresolved Pain resolved
Yes
No Yes Bursa, ligament, tendon
Etiology
Tx: NSAID, PT, injections
Yes
Muscle (trigger points)
Tx: NSAID, PT, injections
Are there signs of Yes
autonomic dysfunction? Nerve (neuroma, nerve
Yes entrapment) Tx: padding,
medications, injections, surgery
No
Bone (bone spur, heterotopic
ossification, bone cyst)
Other potential pain generators: Tx: padding, surgery, radiotherapy
radiculopathy, vascular claudication,
cardiac, brachial plexus injury, Complex regional pain syndrome/RSD
Yes
thoracic outlet syndrome Tx: desensitization, medications,
injections, neuromodulation
FIGURE 14.13 Residual limb pain algorithm. CHF, Chronic heart failure; CRF, chronic renal
failure; NSAID, nonsteroidal antiinflammatory drugs; PT, physical therapy; RSD, reflex sympathetic
dystrophy. (From Hompland S: Pain management for upper extremity amputation. In: Meier RH, Atkins DJ,
editors: Functional restoration of adults and children with upper extremity amputation, New York, Demos,
2004.)
Is pain in the
residual limb?
No
Phantom limb pain
Are there psychologic Yes

factors? (Depression, Psychologic
anxiety, anger) evaluation/treatment
Are there sleep Yes Medications/

disturbances? sleep lab
Rule out all etiologies of

residual limb pain that may
contribute to phantom
pain (see Fig. 14.13)
Medications
Physical therapies • Tricyclic antidepressants
• Desensitization • SSRIs
• Massage • Antiarrhythmics
• Vibration therapy Level 1 • Anticonvulsants
• Percussion therapy management • Antihypertensives
• Ultrasound • Calcitonin
• TENS therapy • Opioids
• Heat/cold therapy • NSAIDs
• Antispastics
Pain unresolved • Dronabinol
Neuromodulation
Level 2 • Peripheral nerve stimulation
Electroconvulsive therapy management • Spinal cord stimulation
• Thalamic stimulation
• Deep brain stimulation
Neurodestructive procedures:
• Neuroma excision
• Rhizotomy
• Dorsal Root Entry Zone (DREZ) ablation
• Cordotomy
• Thalamic ablation
FIGURE 14.14 Phantom limb pain algorithm. NSAIDs, Nonsteroidal antiinflammatory drugs;
SSRIs, selective serotonin reuptake inhibitors; TENS, transcutaneous electrical nerve stimulation.
(From Hompland S: Pain management for upper extremity amputation. In: Meier RH, Atkins DJ, editors:
Functional restoration of adults and children with upper extremity amputation, New York, Demos, 2004.)
activities. Because of their activity level and growth, children

with amputations must be observed closely for prosthetic
repair, for frequent changes in the socket, and for fitting with
new prostheses.
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Principios de Las Amputaciones

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Principios de Las Amputaciones

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CHAPTER 14

GENERAL PRINCIPLES OF AMPUTATIONS

INCIDENCE AND SURGICAL PRINCIPLES OF COMPLICATIONS 690

TYPE CHARACTERISTICS INJURIES POINTS

*Points ×2 if ischemic time exceeds 6 hours.

one study reporting a 64% return-to-work rate after limb sal-

FACTOR ANAEROBIC CELLULITIS CLOSTRIDIAL MYONECROSIS STREPTOCOCCAL MYONECROSIS

The decision of limb salvage versus amputation involves more

Elbow Long above

Transmetacarpal Lisfranc Symes

flaps are always preferable to amputation at a more proximal

FIGURE 14.8 Open amputation. First stage, without skin

after each debridement until the wound is ready for closure

FIGURE 14.10 Partial closure of infected transtibial amputation.

Residual limb pain

Are there psychologic Yes

No Pain unresolved Pain resolved

Are there sleep Yes Medications/

Is the pain worse Pain unresolved Pain resolved

Pain unresolved Pain resolved

Are there skin Pain unresolved Pain resolved

Phantom limb pain

Are there psychologic Yes

Pain unresolved Pain resolved

Are there sleep Yes Medications/

Pain unresolved Pain resolved

Rule out all etiologies of

activities. Because of their activity level and growth, children

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