During these weeks, the site is monitored to verify that proper healing is taking place. Prescription painkillers are administered as necessary during the recovery period. As soon as sufficient healing has taken place, the patient begins physical therapy to learn how to perform the day-to-day tasks that involved the amputated limb. In many cases, the patient, when sufficiently healed, is fitted with a prosthesis, a device that replaces the amputated limb, and then given therapeutic instruction on how to use it.
In rare instances, it may be possible for an amputee to have a limb transplanted from a donor's body. This involves extremely complex surgery and rehabilitation, but can be highly successful. If a limb is successfully transplanted, anti-rejection medications must be taken for the remainder of the recipient's life. There are also unusual cases in which a patient's own digits are transplanted to another part of the body where they will be more useful. Unfortunately, there is no test that can predict in every patient whether healing will take place and it is a matter of surgical judgement and experience whether a wound is likely to heal or not.
In general the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below knee amputation when compared with an above knee amputation, because the chances of successfully walking after the operation are much better.
Unfortunately, not everyone is suitable for this operation and many people need to have an above knee amputation. This may be because the blood supply to the lower leg is too poor and a below knee amputation would not heal properly.
If the knee cannot straighten out properly before the surgery fixed flexion deformity , it will be impossible to walk with an artificial leg after the operation.
In these circumstances it may be better to undergo an above knee amputation. Once an amputation stump is created it is a potentially vulnerable area that will require lifelong care and attention.
A major amputation wound is almost always closed with stitches or staples. A major amputation will take approximately minutes to perform. Small plastic tubes are often inserted into the stumps before the end of the operation. These are drains which are used to take away any excess fluid that accumulates in the wounds. Tiny plastic tubing may also be inserted into the nerves at the back of the leg to reduce post operative pain and these tubes are generally removed within a few days.
This operation can be performed using 2 major techniques. The most common technique is the posterior myoplastic flap Burgess technique where the skin and muscle from the calf are brought forward to cover the shin bones after they have been divided see below left. The other main technique is the skew flap Kingsley Robinson technique in which the muscles of the calf are brought forward in the same way as in the posterior technique but the skin flaps are skewed in relation to the muscle.
There is no proven advantage for one technique, but sometimes it is easier to perform a skew flap amputation if there has been significant skin damage above the ankle. Initially the skin is incised after marking the line of the incision and the incision is then deepened through the subcutaneous fatty tissue to the muscles. Bleeding from superficial veins is controlled and then the muscles are divided initially at the front to expose the two bones of the lower leg — the tibia and fibula.
While doing this the major blood vessels in the calf are ligated. The bone in the lower leg tibia is divided about cms below the knee joint, the fibula is divided a little higher so that it is well recessed away from the end of the stump.
The muscles and skin at the back are then divided low down after separation from the tibia and fibula so that they can be brought forward over the end of the bones to provide cover. To facilitate this coverage much of the calf muscle bulk must be thinned down so that the muscle flap is not too bulky. Other blood vessels at the back must also be controlled. The skin edges are then approximated.
This produces a good size stump to which a prosthesis can be fitted. In this operation the bone in the thigh femur is divided about cms above the knee joint and the muscle and skin closed over the end of the bone in a similar way the below knee amputation.
Amputation of a limb or limbs will affect people in different ways. It is a very personal loss and in many patients can feel like a bereavement. The emotional loss can be like losing a relative and it will take time to adapt to such a loss. Physically your body will be permanently altered and can affect all areas of your life. How much your amputation affects your life will to some degree depend on the extent of your physical recovery. There are virtually no activities that a person with an amputation cannot perform with the right help, training and equipment.
However, the most important rehabilitation objective for the majority of elderly patients with a lower limb amputation is to walk again. It is important to remember that rehabilitation from an amputation in an elderly person is a much more difficult process than in a young person. Regaining the ability to walk will be a major achievement. All amputees have a greater energy and oxygen requirement when walking which is one of the reasons it can be so difficult in the elderly.
It is therefore crucial that people who may require a major amputation continue regular exercise to maintain muscle strength in other parts of the body. This will allow a smoother transition to walking with a prosthetic leg.
Access through your institution. Add or change institution. Save Preferences. Privacy Policy Terms of Use. Access your subscriptions. Free access to newly published articles. Purchase access. If the muscle groups themselves are attached directly and securely to the periosteum or the bone, it is called myodesis.
In myodesis, the deepest layers of muscle are typically secured directly to the bone, while the more superficial layers of muscle are sewn to each other as a myoplasty. The myofascial envelope is then closed over the top of this muscular reconstruction.
A final muscle stabilization technique, tenodesis, is very secure but frequently anatomically impossible. Tenodesis involves the firm distal attachment of the severed tendon down to the bone, and is the most physiologic and effective means of muscle stabilization. It is possible only when the muscle belly itself is not transected and the tendon is intact.
Tenodesis is most commonly used in disarticulations, and is the primary method in knee disarticulations in which the patellar tendon is secured to the origin of the cruciate ligaments on the distal femur.
Whenever anatomical circumstances permit, distal attachment of the muscles, tendon, fascia or aponeurosis directly to the bone should be performed. To optimize effective residual limb muscle activity, the muscle should be stabilized under near physiologic tension.
Correct muscle tension varies from case to case, and the primary determinants of appropriate tension level remain somewhat amorphous. There is no set of hard and fast rules. Studied clinical judgement and adherence to the principles of muscle tension provide the best results. Determining correct muscle tension in an amputation is similar to determining the tension of tendon transfers in the hand or foot.
In general, most surgeons err on the side of too lax rather than too tight. Unfortunately, it is entirely possible that when stabilizing muscle groups the surgeon can apply excessive or unbalanced tension, causing sever pain to the patient. One example of accidental implementation of excessive tension occurs if a surgeon advances the quadriceps under too far, a scenario that leads to hip-flexion contracture. Though it is difficult to establish a solid set of guidelines when performing muscle stabilization, stabilization is an essential element of amputation surgery and the reconstructive process.
The management of sectioned nerves remains a controversial aspect of amputation surgery. The free end of a divided nerve heals by forming a neuroma. This intertwined mass of scar and nerve tissue can be painful to pressure, stretching and other types of physical manipulation.
Even when completely undisturbed, electrical potentials may arise within the mass, causing negative local and distant sensory and motor phenomena. These sensations can be bothersome and painful to the amputee. While numerous techniques have been devised in order to minimize neuroma formation, none have proven uniformly successful.
Some methods have included cauterizing the nerve ends using chemicals or heat, burying the nerve in bone, encasing the nerve in impervious material, ligating the nerve or injecting the nerve with a variety of chemicals. Other methods include sewing the sectioned nerves to other nerves or sewing them back onto themselves, thereby creating a nerve loop.
Others methods entail simply dividing the nerve and allowing it to retract. Since neuroma formation is to some degree inevitable, the generally accepted management procedure is drawing the nerve distally, sectioning it and allowing it to retract away from areas of pressure, scarring and pulsating vessels. Ligation of a nerve is indicated if the nerve is likely to bleed, as is the case with the sciatic nerve.
There it will not be irritated by traction, pressure from the prosthetic socket or any other potential sources of contact. Neuromas in very scarred and adherent areas are the most symptomatic.
When working in these areas the surgeon should apply moderate tension to the nerve and section it cleanly, allowing it to retract away from the site of amputation and into the proximal soft tissues.
This circumvents the distal end of the nerve scarring to the surgical site where traction and pressure are more likely. Traction on the nerve at the time of sectioning should not be excessive, as too much tension can lead to proximal pain and neuropathy. Care should be taken to avoid disturbing the nerve fibers enervating the remaining limb structures, particularly those enervating the muscles and skin.
The theory that proximity between nerves and blood vessels causes symptoms is undergoing renewed interest. In the transtibial amputation, the two most common nerves ligated with a vessel are the deep peroneal nerve and the tibial nerve. This happens if the deep peroneal nerve is not separated off the anterior tibial vessels, or the tibial nerve is not separated off the posterior tibial vessels.
At revision surgery, the separation and division of the nerve away from the re-ligatated vessels can relieve the throbbing. Extra caution concerning the nerves should always be exercised in the high-level upper extremity amputations. Unfortunately, particularly in surgeries involving the brachial plexus, nerves are often accidentally included in the ligatures with the axillary vessels.
Adequate hemostasis and the management of blood vessels and bleeding sites is of utmost importance in amputation surgery. Major arteries and veins should be isolated and ligated securely. Double ligation of large arteries should be standard, especially when the amputation is carried out in the presence of normal blood supply. Cauterization should be reserved for smaller bleeding points only. The central artery of a large nerve such as the sciatic nerve can be a troublesome source of bleeding.
Excessive bleeding in this instance can be avoided by ligation with absorbable suture. Bleeding from the sectioned bone end is best controlled by pressure. Occasionally critical intra-osseous vessels will require cauterization or a small amount of bone wax. However, bone wax is in actuality only very rarely required. Bone wax should be used as infrequently as possible because it remains as a foreign body within the surgical site and can lead to potential complications.
Adequate blood supply to the distal tissues and to the wound margins facilitates proper healing. For appropriate blood supply, the surgeon should avoid dissection of the subcutaneous tissue and keep the muscular investing fascia with the skin whenever possible. Dissection should not damage the proximal blood vessels. Skin or preferably fasciocutaneous flaps, even when broad based, should be developed with careful attention to blood supply.
This is especially important for patients suffering from vascular disease and diabetes. Careful attention to hemostasis and managing the vascular supply to the flaps can make the difference between healing and failure, particularly when blood supply is marginal. Amputation sites are usually drained surgically with suction drainage, as sectioned muscle and bone can often result in a surgical site that is not, and cannot be perfectly dry.
A post-operative hematoma can be a major complication that predisposes the patient to infection. In worst case scenarios, hematomas result in delayed wound healing or complete failure.
If a large post-operative hematoma is identified the patient should be returned to the operating room for evacuation, irrigation and debridement. Complete hemostasis should be attained before leaving the operating room the second time. Revision surgery and higher-level amputation have been necessitated due to hematoma formation. The surgeon should do his utmost to avoid this, but if a hematoma does form, it must be identified early and treated quickly.
The forces traveling between prosthesis, residual limb and the remaining body are in large part transmitted through the retained bone in the amputated limb.
Diaphyseal bone should be sectioned at the length consistent with reconstructive soft tissue closure. Managing the edges of severed bone is essential to pain-free healing, and the sharp cortical bone edges and irregularities should be carefully contoured and rounded. In each amputation case, bone transection and shaping should take into account the available prosthetic devices for that particular level of amputation.
Preoperatively, the surgeon must be sufficiently familiar with the most frequent bone related problems at each level in order to minimize future woes. For example, in transtibial amputations, anterior beveling to remove the distal corner of the tibia is one method of proactive management. Removing the distal plantar corner of the calcaneous in a hindfoot amputation is another example of a preemptive strike against future complications.
Proper foresight and attention to bone preparation eliminates potential areas of high pressure at the bone socket interface. Under normal circumstances there are no sharp, angular surfaces in the palm of the hand or the sole of the foot, and retained distal bone in these areas should come as close to this natural state as possible.
Occasionally in disarticulations, it is a good idea to narrow the distal metaphyseal flare of the bone to prevent an overly bulbous and enlarged distal stump. For example, in the Syme ankle disarticulation surgical contouring of the distal tibia and fibula are mandatory, as a bulbous, and non-contoured distal stump will cause increased difficulties in prosthetic fitting.
However, in general bone resection is kept to the minimum in most disarticulations. Protocol for the successful management of the periosteum is less concretely defined. In instances of diaphyseal amputation, children tend to form new bone with periosteal and endosteal bone overgrowth at the end of the amputation. Capping the end of a diaphyseal amputation with osteochondral bone surface often obtained from part of the amputation specimen itself , has been shown to minimize bony overgrowth.
These specific techniques are addressed in the pediatric chapters. Diaphyseal bone does not exist without an outer cover of cortex in its natural state.
Thus it is intuitively physiologic to seal the end of the bone following amputation, and techniques have been refined for performing an osteo-periosteal bone cap over the end of diaphyseal bone.
However, even without a surgical osteo-periosteal flap, the end of the bone naturally heals by formation of bone callous and fibrous tissue. When a periosteum cuff is available it may be sutured over the end of the bone, but excessive use of periosteal strips can cause problems. As occasionally seen in traumatic amputations or when the periosteum is circumventially peeled off the bone before sectioning, the residual periosteal strips can slowly form irregular bone spikes.
These spikes or bone spurs can cause painful pressure points for the amputee. The surgeon should be aware of this potential problem in order to minimize its occurrence. The standard protocols for skin closure in any other surgery also apply to closing the wound following an amputation. Dead space should be eliminated and drain systems used when necessary.
When closing the wound, opposing tissue layers are sewn under physiologic tension, and care must be taken so that the final closure is neither too light nor too loose. As with all surgery, careful judgement is necessary in the selection of suture and closure technique, and the amputation surgeon must be aware of the options and differences between various techniques.
Many patients have only marginal blood supply and the utmost surgical care and technique is required to maximize their wound healing potential.
If primary closure of the wound is not advisable, amputation should be carried out in two or more stages. An initial amputation may be done to provide adequate drainage of infection.
This is the recommended course for a preliminary open ankle disarticulation involving a septic patient with a severely infected, non-salvagable diabetic foot.
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