Amputations II – 1

AMPUTATIONS 1
AMPUTATIONS

“Amputation is a mutilation attended by not only physical and functional loss but often severe psychological trauma with the body image altered and distorted. Whether by accident or design, the more proximal the loss is, the more there is a progressive reduction in the ability to move, work, and play and even, in some circumstances, to survive. Our first responsibility must be to avoid amputation; all possible alternatives must be explored, evaluated, and rejected only when the evidence points to amputation as the best solution for the patient’s plight.”

G. Murdoch, General Principles of Amputation, in Amputation,
Surgical Practice and Patient Management, 1996

HISTORY

Oldest known artificial limb is a copper and wood leg found in Capri Italy in 1858, supposedly made in 300 BC.

484 BC – Herodotus reports on a Persian soldier, Hegesistratus who escaped from stocks by cutting off his foot and replacing it with a wooden one.

Ambroise Pare, 1529 – the “founder of modern principles of amputation”. Used ligatures to control bleeding, allowing for fashioning of stumps for prosthesis. (survival improved from the old practice of crushing the stump or immersing it in boiling oil to control bleeding).

Morel, 1674 – introduces the tourniquet, making bleeding control much easier. Amputations become more common in Europe for the treatment of open fractures, limbs with vascular injury, and severe joint injury.

James Syme, 1843 – disarticulation of the ankle; developed from his recognition of the fact that Chopart amputations (midtarsal disarticulations) were less likely to get “hospital disease” (infection).

Lister, 1867 – antiseptic technique; a true milestone in amputation surgery.

Civil War

World War I Throughout history, war remains the most significant
impetus to the advancement of amputation surgery.
World War II

Radcliffe and Foort, 1961 – developed the rationale and techniques of fabrication for the patellar-tendon-bearing prosthesis

Weiss, 1963 – myoplasty technique revisited.

International Society for Prosthetics and Orthotics – Denmark, 1970
GENERAL PRINCIPLES

In general, there are two goals of amputation surgery:
1. Ablation: Remove all that is necessary to eliminate the pathologic
state and provide primary or secondary wound healing.
2. Reconstruction: Create the optimum motor and sensory end-organ
for prosthetic substitution and restoration of function.

LEVEL
� The most distal level of amputation consistent with the disease state and a well-healed, non-tender, physiological residual limb – ie. a balance between limb length and wound healing.

SKIN
� Gentle handling and eventual tension-less (but not redundant) closure is critical.
� Broad-based skin flaps with minimal elevation to avoid compromising blood supply.
� Split and full-thickness skin grafts are permissible with modern prosthetic fitting and technology – resistance to shear and pressure is comparable to normal skin over time

MUSCLE
� Functioning muscle provides the limb with strength, size, shape, circulation, metabolic exchange, and proprioception.
� Distal muscle stabilization allows resistance to contraction; lessens weakness and atrophy
� When anatomical circumstances permit, distal attachment of tendons and aponeuroses to the periosteum and/or bone (myodesis) should be performed, ideally under physiological tension.

NERVE
� Neuroma formation is inevitable.
� The nerve should be gently pulled down, ligated, divided cleanly, and allowed to retract proximally into healthy muscle. (Dellon et al., 1984). This allows the neuroma to lie well away from incision scar, cushioned by muscle from traction or pressure from the prosthesis wall. Excess traction when cutting should be avoided.

BONE
� Sectioning of bone should be at a length consistent with soft-tissue coverage and closure.
� Bone edges must be smoothly contoured.
� Power saws cause thermal necrosis and should be cooled with saline.
� If possible, close periosteum over the end of cut diaphysis; otherwise, resect it circumferentially. WOUND CLOSURE
� Physiologic tension is ideal.
� Avoid running sutures. Some authors close only the skin with a combination of interrupted sutures and steri-stips.
� Closed suction drainage, if necessary, is preferable to Penrose drains (infection).