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It can be: Malignant haemangioendothelioma; Malignant
haemangiopericytoma.
SYNOVIAL SARCOMA (7%)
SRB’s Manual of Surgery
Fig. 1.572: Synovial sarcoma.
It is the 4th commonest type. It occurs at 15–40 years of age.
Origin need not be from synovium.
85–90% occurs in lower limb; head, neck and shoulder are
the next common site.
It is common in thigh, leg, shoulder, hand and foot.
Occasionally it can occur in the abdominal wall and
retroperitoneum.
It is common in young individuals.
It occurs adjacent to joint but uncommon to involve the
synovial sheath of the joint.
It spreads both through blood as well as through lymph
nodes (20%).
It is very aggressive soft tissue sarcoma (High grade).
Calcification with or without ossification is common—10%.
Synovial sarcoma may be biphasic or monophasic.
It possess specific chromosomal translocation (96–100%)
– t(X; 18)(p11.2; q11.2).
MALIGNANT PERIPHERAL NERVE SHEATH
TUMOUR (MPNST) (3%)
It arises from peripheral nerves.
It shows differentiation along nerve elements.
MPNST replaced older terms—malignant schwannoma,
neurofibrosarcoma, neurogenic sarcoma, malignant
neurilemmoma.
20–50% arises from neurofibromatosis type 1 (latent period
15–20 years). MPNST is an exception to sarcoma will not
arise from benign precursor.
Common sites are major/proximal nerve trunks.
KAPOSI’S SARCOMA
It is malignant blood vessel tumour of multicentric origin
arising from vascular smooth muscle or pericytes.
It is seen commonly in HIV patients due to immuno suppression.
Primary tumour commonly occurs in skin, mucous
membrane, lymph nodes or viscera.
It is linked with Human Herpes Virus 8 (HHV8) as causative
agent.
TYPES
B
1. European Kaposi‘s sarcoma: Common in old age. It is first
described by Kaposi in 1862. It mainly involves skin especially
lower extremity. Visceral involvement is rare.
2.
African Kaposi‘s sarcoma: It occurs commonly in children and
young individual. It involves skin and lymph nodes commonly. It
resembles lymphoma.
Transplant associated Kaposi‘s sarcoma: It is due to drug- induced
3.
immunosuppression. It involves mainly skin and often regresses
once immuno
AIDS associated Kaposi‘s sarcoma: It occurs in 30–40% of AIDS
4.
patients. It is common in homo
nated involvement with metastases. It is very aggressive. It is often
associated with lymphoma and other malignancies.
suppression is discontinued.
sexuals. It has got wide, dissemi-
Note:
Kaposi’s sarcoma is not found in transfusion related AIDS.
Clinical Features
Multiple reddish-blue nodules in the skin with ulceration
over the nodule.
Lymph node enlargement.
Koebner phenomenon is common in areas of trauma.
Differential diagnosis:
Mycobacterial infection of skin.
Investigations:
infection.
Treatment:
¾
Irradiation.
¾
Chemotherapy. Drugs used are adriamycin, bleomycin
and vinblastine.
¾
Antiretroviral therapy.
¾
Interferons.
SARCOMAS WHICH ALSO SPREAD TO LYMPH NODES
B
1. Synovial sarcoma
2. Lymphangiosarcoma
3. Rhabdomyosarcoma—alveolar type
4. Ewing‘s sarcoma
5. Angiosarcoma
6. Epithelioid sarcoma
Carcinosarcoma of uterus
7.
Lymphomas; Cutaneous angiomatoses;
Biopsy from the skin lesion; Tests for HIV
T. Amputations
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“Amputation is one of the meanest yet one of the greatest operations in surgery, i.e. mean—when resorted to where better may
be done. Great—as the only step to give comfort and prolong life.”
—Sir William Ferguson
C hapter Outline
·
Amputation
·
Complications of
·
Prosthesis
Amputations
AMPUTATION
Indications
Gangrene due to atherosclerosis, embolism, TAO, diabetes,
ergots.
Trauma: To save life in crush injuries.
Neoplasms: Osteosarcomas, Marjolin’s ulcer, melanomas.
Gas gangrene.
Severe sepsis.
Occasionally severe elephantiasis, madura foot, when all other
methods have failed to help.
Dead, dying, devitalised tissues.
Severe deformity congenital or acquired.
Types of Amputation
It can be:
¾
Non-end bearing/side bearing—Weight is taken up by
the joint.
¾
End bearing/cone bearing—Weight is taken up by the body.
It can be: Weight bearing; Non-weight bearing.
It can be:
¾
Provisional amputation with flap—later final formal
amputation my be required.
¾
Guillotine amputation which always requires revision
formal amputation.
¾
Formal amputation—is definitive one.
A
Figs. 1.573A and B: Different levels of amputation in
upper limb and lower limb.
B
Types of Flaps
Long posterior flap in below-knee amputation.
Equal flaps in above-knee amputation.
Ideal Stump
Should heal adequately by 1st intention.
Should have rounded, gentle contour, with ade quate muscle
padding.
Fig. 1.574: Little toe amputation for gangrene. Wound has healed well.
Peace is so hard to nd because it is under your nose.
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CONICAL BEARING
B
x Here healing is by primary intention
x Bone should not be projecting
x Myoplastic; No neuroma
x Scar should not be tender; Proximal joint should be supple
Evaluation of the Patients who need Amputation
Haematocrit, control of anaemia by transfusing blood/packed
cells.
Control of infection using antibiotics.
SRB’s Manual of Surgery
Fig. 1.575: Forefoot amputation.
Decision of level of amputation by skin temperature, arterial
Doppler.
Informed consent should be taken.
Plan for prosthesis and rehabilitation by physio therapist and
rehabilitation team.
DIFFERENT INCISIONS FOR AMPUTATION
B
x Circular incision amputation—skin and muscles are divided
circularly at a lower level than that of bone
x Elliptical/oval incision amputation
x Racquet incision amputation—for digital disarticulation
x Amputation using flaps—it may be of equal flap (above-knee
amputation) or with long posterior single flap (below-knee
amputation). Total length of single flap or combined length of
two flaps should be equal to 11/2 times the diameter of the limb
at the line of amputation. Flap should be semicircular to get a
conical stump, not rectangular
Fig. 1.576: Above-knee amputation done for osteosarcoma of the
upper end of the tibia. Here equal flaps are used.
Should have sufficient length to bear prosthesis.
¾
For B-K 7.5 (minimum) to 12.5 cm from tibial tuberosity.
¾
For above and below elbow 20 cm stump.
¾
For A-K 23 cm from greater trochanter.
Should have thin scar which does not interfere with prosthetic
function.
Should have adequate adjacent joint movement.
Should have adequate blood supply.
Scar should be in a place where it is not exposed to pressure.
Scar should be freely mobile over underlying tissues. Skin and
scar should be freely mobile over the underlying bone. It is
achieved only if deep fascia is closed properly. Scar and skin
should be free to achieve free movement of the prosthesis.
Socket of prosthesis with mobile skin creates a piston to bone
to move like a joint.
Skin should not be infolded.
Redundant soft tissue should not be there.
Stump should be free from tenderness and conical.
Principles in Amputation
Adequate blood supply of the flap should be maintained.
Proper marking of the skin incision is essential.
Tourniquet should not be used if amputation is done for
vascular diseases.
Proximal part of the flap contains muscle component but
distal part should contain only skin and deep fascia.
Flap length should be adequate; not short. It should be ideally
semicircular not rectangular to get a conical stump.
Nerve should be pulled down and cut using a sharp knife and
allowed to retract into the soft tissue otherwise neuromas
may develop.
In crush injury/entrapment injury/sepsis—guillotine amputa-
tion is done. Later skin is pulled down by using skin traction,
eventually to have better skin coverage.
Bone should be cut with beveling and all sharp margins
should be rounded.
Postoperatively regular dressings are done. Patient is mobi-
lised using axillary crutches. After 3 months, once scar has
matured and stump has become supple, proper prosthesis is
fitted. Berlamont first started immediate postoperative fitting
of prosthesis to leg for early mobilisation. Plaster pylon is
applied to the stump and a prosthetic extension is fit to facilitate
partial weight bearing immediately after surgery. It has got
more stump complications and so it has not become popular.
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CHAPTER 1T General Surgery: Amputations
Fig. 1.577: Pylon is plaster cast with walking component used for
immediate mobilisation after below-knee amputation.
Stumps can be side bearing (sutures are on the side); end
bearing/conical (sutures are on the end) or cylindrical.
Postoperatively active exercise should be given to the
proximal joint so that prosthesis can be fit to it properly.
If there is sepsis especially in gangrene limb, flaps should
be left open or loose suture applied otherwise flap necrosis
occurs.
Proper anatomy of muscles and neurovascular bundle around
should be known in all amputations.
Different Amputations
Ray amputation
Amputation of toe with head of metatarsal or metacarpals.
Transmetatarsal amputation (Gillies’)
Here amputation is done proximal to the neck of the meta-
tarsals, distal to the base.
Fig. 1.579: Ray amputation for toes—racquet incision.
Fig. 1.580: Ray’s amputation done for gangrene of great toe.
It is usually not sutured.
Fig. 1.578: Different levels of amputation in lower limb.
Fig. 1.581: Forefoot amputation.
Lisfranc‘s amputation (Tarsometatarsal amputation)
Here tarsometatarsal joint is disarticulated with a long volar
flap. It needs a surgical boot. But there is inevitable develop-
Asking for help is strength, not weakness.
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ment of equinovarus deformity. So stabilisation of midtarsal
and ankle joints is needed. In Hey’s modification, 2nd metatarsal is cut at base instead of disarticulation.
Chopart‘s amputation (Midtarsal amputation)
Here talonavicular joint and calcaneo-cuboid joints are disar-
ticulated. Tibialis anterior muscle is sutured to drilled talus
bone. A long volar flap is used and immobilised for 6 weeks
after surgery.
Syme’s amputation
¾
It is removal of the foot with calcaneum and cutting of
tibia and fibula just above the ankle joint with retaining
SRB’s Manual of Surgery
heel flap (dividing both malleoli). Heel flap is supplied
by medial and lateral calcaneal vessels (branches of
posterior tibial artery). Elephant boot is used for the
limb after Syme’s which is inexpensive. Many patients
walk well with Syme’s stump without difficulty. It is
presently mainly used in trauma (crush injury) and
malignancies in distal part of the foot. In vascular
diseases, calcaneal vessels may not be adequate to
maintain the viability of the flap. While raising the flap,
knife should be very close to the calcaneum so as to
avoid injury to calcaneal vessels and to maintain the
viability of the flap.
¾
In Wagner’s method deep fascia of heel is sutured to
drill holes made on the anterior edge of tibia and fibula.
Above-knee cast is essential.
¾
Advantages are—it is an end-bearing stump having good
proprioception. Patient can walk without prosthesis. Low
energy consumption ambulation is possible.
¾
Disadvantages—posterior displacement of heel pad;
poor cosmesis.
¾
Boyd’s amputation—anterior part of the calcaneum is
excised (osteotomy) just distal to the peroneal tuberosity
and calcaneotibial arthrodesis is created. It is done to
prevent posterior migration of heel pad.
Fig. 1.583: Incision for Syme’s amputation.
Fig. 1.584: Elephant boot used after Syme’s amputation.
Modified Syme‘s amputation
Here heel flap is elliptical. Tibia and fibula are divided slightly
higher. But variation here is the elliptical flap.
Fig. 1.582: Syme’s incision and level of amputation.
Fig. 1.585: Modified Syme’s incision is elliptical one.
Pirogoff‘s amputation
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It is like Syme’s amputation except posterior part of the
calcaneum is retained along with heel flap. It provides longer
stump than Syme’s amputation.
Fig. 1.586: Pirogoff’s amputation.
Below-knee amputation
Here we use a long-posterior flap with scar placed over ante-
rior aspect. Prosthesis placement is better here with greater
range of movements without limp and without support. It is
also called as Burgess amputation. Fibula should be divided
first, higher than the proposed site of cut of tibia otherwise
its sharp end will press on the skin flap. Tibial stump should
be beveled anteriorly. Posterior muscles are sutured across
the bone end, to the periosteum in front. In more proximal
type of below-knee amputation, fibula often is removed to
allow the proper use of flap. Length of the flap should be
11/2 times the circumference of the site (around 12 cm).
Stump length is 14–17 cm from knee joint. Minimum length
required for prosthesis is 8 cm. If there is need to extend more
proximally, it is better to do above-knee amputation. Modern
artificial limbs like suction socket prosthesis are used now.
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CHAPTER 1T General Surgery: Amputations
Fig. 1.588: Below-knee amputation—long posterior flap.
Note the placing of the drain.
Fig. 1.589: Below-knee amputation flap necrosis has occurred which
eventually granulated with repeated dressings. Area is ready for skin
grafting.
Fig. 1.587: Below-knee amputation technique—incision, flap and
levels of cutting bones.
Fig. 1.590: Bilateral below-knee amputations done for vascular
causes with diabetes.
Imagination is the highest kite one can y.
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‘Peg-leg’ amputation
¾
It is amputation 5 cm below the knee level—proximal
most below-knee amputation. It is not practiced nowa-
rehabilitation is difficult, and fitting of prosthesis is not
proper, patient needs a third support for walk with often
a limp.
days. Here anterior flap is rotated posteriorly like a
hood and patient kneels and bears weight which is wellaccustomed to pressure. It is done whenever prosthesis
cannot be used probably due to economic causes (in
developing countries).
SRB’s Manual of Surgery
Fig. 1.592: Above-knee amputation, incision and approach.
Fig. 1.591: ‘Peg-leg’ amputation is below-knee amputation done close
to the knee joint (5 cm stump) with folding flap and metallic support
down. It is not used now.
Transcondylar-Gritti-Stokes amputation with long posterior
flap.
¾
Femur is divided just above the articular surface and
patella is anchored to the divided femur. There is risk of
nonunion between patella and femur. This procedure is
no longer performed.
Above-knee amputation
¾
Usually equal anterior and posterior flaps are used.
Lower third and middle third level amputations are done.
Ideally the required length of the femur as stump is
25 cm from the tip of the trochanter. Femur length lesser
than 10 cm is not possible and here one needs to do
hip disarticulation. In children as growing epiphysis of
femur is in lower end, it is essential to preserve as much
length of femur as possible. It is done in ischaemia,
trauma, sepsis, gangrene which is spreading above.
Often patient might earlier have undergone below-knee
amputation but now as indicated need above-knee
amputation. It is usually contraindicated in children
(done only in undue definitive indication) or if stump
is less than 7.5 cm.
¾
Advantages are technically easy, healing chances are
better and faster. Disadvantages are cosmetically poor,
Fig. 1.593: Above-knee amputation wound which is infected in a
diabetic patient.
Hip disarticulation
It is done whenever it is not possible to save the minimum 10
cm length of the femur. Incision used is either single posterior
flap—Solcum’s approach (better) or anterior racquet incision—Boyd’s approach.
Hind quarter amputation
Inter-innominate abdominal amputation (Sir Gordon Taylor’s
amputation): Removal of one side pelvis with innominate
bone, pubis, muscles and vessels. Original ligation of
common iliac artery is modified to individual ligations of
external and internal iliac vessels. Internal iliac artery is
ligated beyond the origin of the superior gluteal artery to
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keep the large posterior flap viable. Now hind quarter name
is replaced by hemipelvectomy. It may be standard hemipelvectomy with classic gluteal flap; extended hemipelvectomy
with removal of posterior part of the sacrum; conservative
hemipelvectomy with retaining part of the pubis, ilium bones
on that side. Internal hemipelvectomy is new method wherein
hemipelvectomy is done with preserving the limb.
It is removal of entire upper limb with scapula and lateral
2/3rd of the clavicle and muscles attached to it. It is done
in malignancies involving scapula, upper part of humerus
and near shoulder joint.
In emergency conditions like severe sepsis, gas gangrene
and machinery entrapment, Guillotine amputation is done
without suturing. Suturing is done at later period. All tissues
are divided at same level.
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CHAPTER 1T General Surgery: Amputations
Fig. 1.594: Hindquarter amputation done for run over of vehicle over
pelvis, right thigh. Patient also underwent colostomy. Patient survived
with severe morbidity.
Krukenberg’s amputation
Done in upper limb following any trauma. Here forearm
amputation is done in such a way that it creates a gap between
radius and ulna like a claw to have a hold or grip.
Interscapulothoracic amputation (Forequarter amputation)
(Littlewood’s posterior approach or Berger’s anterior approach):
Fig. 1.596: Upper limb Guillotine amputation—above elbow done for
trauma induced gas gangrene.
Postoperative Period
Physiotherapy is advised.
Regular dressings are done.
Crutch is used initially, after 3 months prosthesis is placed.
Rehabilitation is important.
A
Figs. 1.595A and B: (A) Forequarter amputation done for electric
burn which caused extensive damage to upper limb, (B) Forequarter
amputation done for sarcoma proximal to shoulder joint.
B
Fig. 1.597: Patient with axillary crutches.
Love the life you live; Live the life you love.
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COMPLICATIONS OF AMPUTATIONS
Early
Haemorrhage, haematoma, infection.
Late
Pain, ulceration of stump, ring sequestrum formation, flap
necrosis, painful scar, Phantom limb—feeling of amputated part
in toto or partially with pain over it.
Haematoma
SRB’s Manual of Surgery
It is identified by pain, swelling over the stump underneath the
flap. It is aspirated using a wide bore needle. Haematoma may
delay healing; may precipitate infection or flap necrosis due
to pressure. After aspiration, pressure dressing is needed. If
haematoma reforms after 2–3 aspirations, it should be drained
by opening the wound on one corner and inserting haemostat
into the wound.
Infection of the Stump
It may cause abscess formation, delay in wound healing, flap
necrosis, giving way of the wound. Removing few or all sutures
to relieve pressure and draining the pus underneath is needed.
Infection may also lead into poor scar, adherent scar which
causes difficulty in placing the prosthesis.
Stump Neuroma
It can occur due to proliferation of the nerve fibrils beyond the
point of nerve division and is usually due to failure of cutting of
the nerve more proximal to the level of division of the bone. It
causes pain and tenderness over the stump. It is usually relieved
by analgesics, re-assurance and prosthesis. Occasionally, it may
require re-exploration of the wound, excision of end neuroma
and also cutting nerve more proximally.
A
Figs. 1.599A and B: (A) Below-knee amputation stump infected. (B)
B
tibia is exposed.
Stump Pain after Amputation
Fig. 1.598: Above-knee amputation stump having small sinus.
Flap Necrosis
It is a common complication. Main causes for flap necrosis are
poor blood supply, infection, haematoma underneath, inadequate length of the flap causing stretching of flap. Small area
of necrosis can be excised. Wider area needs laying opening
of the wound or revision of the stump or higher level amputation. Anaemia, poor nutrition, nutritional deficiencies, diabetes
mellitus, immunosuppression, smoking, old age are other
factors causing flap necrosis.
It is a common problem. Causes are—infection, poor blood
supply, causalgia, stump neuroma, phantom pain/limb, deep vein
thrombosis, adherent scar, formation of spurs and osteophytes
at amputated bone end. Scar adhesion to bone is prevented by
keeping adequate length of deep fascia underneath intact. Spurs
and osteophytes are confirmed by X-ray and needs removal
using bone nibbler after appropriate skin incision.
Phantom Limb
It is typical awareness of sensation that as if amputated part is
still exists partly or in toto; often such part may be painful or
disturbing or hyperaesthetic. Exact cause is not known; but it
is probably due to severe pain at the amputated part just prior
to amputation making brain area for that part in alert situation
causing phantom limb. Reassurance, prosthesis, analgesics
help to control the condition. It is said that it can be prevented
by proper pain control for 24 hours prior to amputation; but it
is often difficult. It is common in upper limb.
Ulceration over the stump
It is not uncommon. It is due to necrosis, infection, lengthy
bone stump pressing on the summit of the flap, prosthesis,
nutritional deficiencies, diabetes mellitus, ischaemia. Ulcer
may be small/large; superficial/deep. Callous chronic ulcer at
the end of the stump is called as Douglas ulcer. Small ulcer
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is later treated by regular dressings and suturing. Large ulcer
needs flap to cover the defect. Osteomyelitis of the stump
should be ruled out in chronic stump ulcer. Ring sequestrum
may be typical in such situation. Revision amputation is needed
for the stump.
Contracture of the joint
Contracture of the joint proximal to the amputated stump is
common. It is mainly due improper positioning after amputation
due to pain, poor exercise and occasionally due to inflammation of surrounding soft tissues. Contracture interferes with
proper fitting and functioning of the prosthesis and delays
rehabilitation. Proper positioning, passive stretching and exercises, strengthening exercises with help to correct it. Rarely
needs surgical release of the contracture.
Other Complications
Scar hypertrophy, skin thickening, hyperkeratosis, papilloma,
eczema,lymphoedema, boils, bursae over bony point can
occur which are treated accordingly.
Spur, osteophyte formation, causalgia, jactitation of the
stump, stump aneurysm, stump fracture— are other complications.
PROSTHESIS
It is the substitution to a part of the body to achieve its optimum
function.
(Orthroses are supplement for limb function.)
In Lower Limb
Syme’s amputation: Elephant boot, Canadian Syme’s prosthesis.
Below-knee amputation: Patellar-tendon bearing (PTB) pros-
thesis and solid ankle cushion heel (SACH).
Above-knee amputation: Suction type prosthesis. It is placed
above the stump. It is better and well-tolerated.
Nonsuction type prosthesis: It is placed at the ends. It
requires additional support.
Hind-quarter amputation: Tilting table prosthesis (TTP) or
Canadian prosthesis is used here.
Patellar tendon-bearing prosthesis (PTB prosthesis): Here
all the weight bearing is done below knee; movement is
controlled by his own knee joint. Patellar tendon is the main
key weight-bearing area within the socket; stump posteriorly
up to the popliteal fossa is also important to provide counter
pressure so that patellar tendon is kept in place. Medial and
lateral paratibial areas and medial condylar flare also bear
significant weight. Head of the fibula, tibial tubercle, cut
ends of tibia and fibula are pressure intolerant areas. Socket
should have proper relief areas to these intolerant parts.
Computer-assisted designing and computer-assisted manu-
facturing (CAD – CAM) socket is an automated processing
method which fulfills all above criteria accurately with modifications. It is more comfortable and is made up of thermoplastic
or laminated plastic with closed cell polyethylene foam.
Suspension for below knee amputation prosthesis is leather
cuff strap above femoral condyles. Exo- or endoskeleton is
used. For athletics endoskeleton is preferable.
SACH (Solid Ankle Cushion Heel) foot is used. It is multiaxial,
optimizes gait, and facilitates walking on rough ground. It
needs minimal maintenance. It is preferred in old people.
Energy storing foot is often used wherein ankle joint is
replaced by a plastic spring.
In Upper Limb
1. Above-elbow prosthesis is a high technology prosthesis. It is
sophisticated device with harness, socket, elbow joint unit,
control cable, forearm and wrist device.
Below-elbow prosthesis.
2.
Krukenberg’s amputation does not require any prosthesis.
ADVANTAGES OF PROSTHESIS
B
x Cosmetic
x Function of the part relatively can be got
x Ambulation in lower limb prosthesis
DISADVANTAGES OF PROSTHESIS
B
x Infection
x Pressure ulcers
x Joint disability
Prosthesis Types
Exoskeletal prosthesis.
Endoskeletal prosthesis with modular system.
Internal prostheses are one used inside. They are placed by
open surgery. They are nonreactive, long-durable materials, e.g.
hip prosthesis in total hip replacement.
A
Figs. 1.600A to C: Below-knee amputee with prosthesis. It gives good
range of movements, normal walk and comfort. Note: Most popular
jaipur foot is designed by PK Sethi.
B
C
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CHAPTER 1T General Surgery: Amputations
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