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Section 1: General Topics
century resulted, at least in part, from
this close collaboration between rehabilitation physicians, surgeons, prosthetists, therapists, and other professionals
who share a commitment to amputee
care. In recent years, changes in the economics of health care have reversed this
trend, as postoperative hospitalizations
have become increasingly brief and outpatient treatment became the norm for
new amputees. It is sometimes difficult
to replicate the fertile interchange of
ideas among team members that was inherent in the formal amputee clinic now
that these professionals often work in
geographic isolation from one another.
Summary
Historically, advances in amputation
surgery have been closely linked to
armed conflict, which spurred improvements in prosthetic technology
and postamputation care. These trends
have accelerated during postwar peri
ods whenever attention and resources
have been focused on amputee veterans. Advances in military rehabilitation
have, in turn, been incorporated into
civilian practice and developed further
when adequate funding has been established. Better surgery and prosthetic
sockets after World War II resulted in
demands for additional sophisticated
components, which were first developed
using government research funding and
later from commercial investment. The
level of education for prosthetists has
also gradually risen, along with the
technical sophistication of the materials, methods, and components used
while education in amputation surgery
has declined. Only time will determine
whether the fragmentation of the clinic team and the reduction in funding
for amputation surgery and prosthetic
education and training is a temporary
setback or the harbinger of a new era
in which the pace of advancement in
amputee care will diminish.
Acknowledgments
The authors wish to express their profound thanks to Thomas Burke, BSFA,
for his expert preparation of the illustrations; Alice M. Bowker, MA, OT, for her
diligent preparation of the manuscript;
and John W. Michael, MEd, CPO, for his
thoughtful critique of the manuscript.
Selected Readings
-
Paré A: On Gangrenes and Mortica-
tions, book VII in Ten Books of
Surgery With the Magazine of the
Instruments Necessary for It, 1563.
Translated from the French by RW
Linker and N Womack. Athens, GA,
University of Georgia Press, 1969.
Garrison FH: An Introduction to the His-
tory of Medicine, ed 4. Philadelphia,
PA, WB Saunders, 1929.
American Academy of Orthopaedic
Surgeons: Historical development
of articial limbs, in Orthopaedic
Appliances Atlas, Volume 2. Articial Limbs: A Consideration of Aids
Employed in the Practice of Orthopaedic Surgery. Ann Arbor, MI, JW
Edwards, 1960.
Furman B: Progress in Prosthetics. Wash-
ington, DC, US Government Printing
Oce, 1962.
Ellis H: Famous Operations. Media, PA,
Harwal Publishing, 1984.
Sanders GT: Lower Limb Amputations: A
Guide to Rehabilitation. Philadelphia,
PA, FA Davis, 1986.
Phillips G: Best Foot Forward: Chas. A.
Blatchford & Sons Ltd (Articial Limb
Specialists) 1890-1990. Cambridge,
England, Granta Editions, 1990.
Bennett WA Jr: History of amputation
surgery and prosthetics, in Bowker
JH, Michael JW, eds: Atlas of Limb
Prosthetics: Surgical, Prosthetic and
Rehabilitation Principles. St. Louis,
MO, Mosby Year Book, 1992.
van der Meij WKN: No Leg to Stand On:
Historical Relation Between Amputation Surgery and Prostheseology.
Gronigen, Netherlands, AE Brinkman, 1995.
Guyatt M: Better legs: Articial limbs for
British veterans of the First World
War. J Des Hist 2001;14(4):307-325.
urston AJ: Paré and prosthetics: e
early history of articial limbs. ANZ
J Surg 2007;77(12):1114-1119.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
22
Chapter 2
General Principles of Amputation Surgery
Michael S. Pinzur, MD
Abstract
Amputation should be viewed as the rst step in the rehabilitation process for a patient
with a limb that cannot be salvaged because of injury or disease. It is important for the
treating surgeon to understand how an individual is aected by limb loss, the diering
considerations in caring for those with upper versus lower limb amputations or amputations performed because of diering etiologies, and the nuances of treating children. Good
surgical planning and familiarity with methods of managing possible complications will
result in the best possible outcomes for patients.
Keywords: amputation; limb salvage versus amputation; principles
of amputation
Introduction
Experience gained during World War II
convinced Ernest Burgess to change the
perception of amputation from ablative
(failed) surgery to the current paradigm
of amputation as the first step in rehabilitation. Using a modern evidence-based
model for health care, it is necessary to
address the effect of the injury or disease
process on the affected individual and
determine the steps needed to return
the patient as fully as possible to his or
her preinjury or predisease state. The
goals of this chapter are to address the
components of limb loss that universally
affect the amputee population, discuss
the unique characteristics of upper versus lower limb amputations, compare
amputation in an adult to that in a child,
and review some of the nuances associated with amputation performed for
injury compared with amputation performed because of infection or disease.
Dr. Pinzur or an immediate family member is a member of a speakers’ bureau or has made paid
presentations on behalf of Wright Medical Technology (Biomimetic), Stryker, Smith & Nephew,
and KCI; serves as a paid consultant to or is an employee of Stryker and Wright Medical Technology (Biomimetic); has received research or institutional support from Wright Medical Technology
(Biomimetic); and serves as a board member, owner, ocer, or committee member of the American
Orthopaedic Foot & Ankle Society and the American Academy of Orthopaedic Surgeons.
Effect on Health-related
Quality of Life
The psychological effect of amputation
on health-related quality of life has been
best studied in trauma patients. The Lower Extremity Assessment Project (LEAP)
was an observational study of more than
600 civilian patients who sustained mu
tilating lower limb injuries; amputation
was performed in more than 150 of these
patients.1 Validated outcomes tools were
used to achieve longitudinal observation
of the effects of injury on the patients’
quality of life. One of the most important insights gained from this pivotal
investigation was the appreciation that
family support structure is one of the
most important factors for successful
rehabilitation after a traumatic amputation.1 Using understanding gained from
the LEAP study, the core investigators
used similar tactics to evaluate amputees from Operation Iraqi Freedom
and Operation Enduring Freedom. The
Military Extremity Trauma Amputation/
Limb Salvage (METALS) study provided
further insights about affected patients,
including the fact that traumatic amputees had a high probability of exhibiting
severe symptoms of depression or posttraumatic stress disorder.
This information provides evidence-based support that helps caregivers objectively appreciate the obvious
psychological effects of amputation
during both the acute phases of injury
and recovery and the prolonged period
of rehabilitation. The roles of depression and posttraumatic stress disorder
can be easily extrapolated for various
groups of amputees, whether it be the
stress of body image in a child who has
undergone an amputation because of a
-
congenital condition or a patient facing
limb loss because of tumor, infection,
or gangrene.
3
2
The Upper Limb: The
Hand as an Organ of
Sensation and Prehension
The hand is a unique organ of prehension and sensation that helps differentiate humans from much of the animal
kingdom. It is the special relationship
between sensory input and functional
prehension that makes amputation of
an upper limb much more disabling
than amputation of a lower limb. When
planning reconstruction of the upper
limb after a traumatic injury, the surgeon should consider the negative effect of a prosthesis or orthosis on the
residual limb, in both shielding the terminal residual limb from its important
role as a sensory probe and blocking
the sight lines necessary to optimally
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
23
Section 1: General Topics
Figure 1
A, Graph illustrates that walking spee d (velocity) is related to level of amputation. V1 is a measure of self-s elected walking sp eed, and V2 is a measure of
maximum walking speed. B, Grap h showing oxygen consumpti on per meter walked as rela ted to amputation level. No te that walking speed de creases
and the energy cost of walking increases with a more proximal amputation. (Reproduced with permission from Pinzur MS, Gold J, Schwartz D, Gross
N: Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopaedics 1992;15:1033-1037.)
manipulate objects with a terminal prosthetic device.
Experience has demonstrated that a
high percentage of patients reject even
high-tech, electronic-powered prostheses. Patients often perceive very sophisticated devices as being cumbersome
and slow to respond to task initiation.
Many patients become proficient with
an upper limb prosthesis but use it only
as a tool for performing a minimal number of necessary tasks. Because a prosthesis renders the upper limb insensate,
it shields the patient from proprioceptive
feedback and demands continual visual
monitoring to operate. Oftentimes, retention of a rudimentary post and palm
that allows simple prehension is functionally superior to the most sophisticated prosthetic device.
The Lower Limb: The
Foot as an Organ of
Weight Bearing
The normal human foot is composed of
more than 20 bones that have the dual
functions of acting as a shock absorber
at heel strike and a stable platform to
allow propulsion at push-off. The ligaments that connect the bones of the
foot are relaxed when the foot is loaded
at heel strike. This relaxed or unlocked
Bar graphs showing the metabolic cost of walking with an amputation. TT = transtibial, KD = knee disarticulation, TF = transfemoral.
position of the joints, combined with the
unique durable cushioned plantar skin
and subcutaneous fibrous connective
tissue, allows the foot to dampen the
impact of weight bearing. As the foot
transitions from the unlocked loadacceptance position of ankle dorsiflexion and foot supination at heel strike
to the locked position of ankle plantar
flexion and foot pronation at push-off, it
transitions from an organ that dampens
weight acceptance to a stable platform
for propulsion at push-off.
Unlike the adaptable weight-bearing
organ of the normal foot, an amputation
stump is generally composed of one or
two bones and a soft-tissue envelope
that must interface with a prosthesis to
mimic the organ functions of a normal
foot. When a residual limb is surgically
created, the surgeon must be cognizant
of these dual functions to create a terminal organ that will interface with a
prosthesis to provide pressure-dissipating cushioning at loading and stability
at push-off.
Metabolic Cost of Walking
After Amputation
The self-selected walking speed of an
individual is determined by multiple
factors that allow the optimization of
energy consumption during walking.
Most individuals exhibit the best metabolic efficiency when healthy and well
rested and decreased efficiency when
ill or injured.
From a bioengineering standpoint,
the joints of the lower limb act as
energy couples. Illness or injury to
the limb makes the mechanical construct less energy efficient and more
prone to activity-related discomfort.
Prosthetic joints are not as efficient as
native joints. Figure 1 demonstrates
the metabolic/energy cost of walking
with a prosthesis. The more proximal
the level of amputation, the greater the
negative effect on function. In a patient
with a transfemoral amputation, the
self-selected walking speed and the
maximal walking speed are very similar and energy consumption also is
similar. Therefore, during laboratory
testing, the energy expended by a patient with a transfemoral amputation
is comparable to the energy expended
by a nonamputee walking at maximal
speed at all times.
4-7
Amputees tend
to take a similar number of steps ever y day.4 This metabolic cost affects a
patient’s daily life and often causes an
amputee to ration the number of steps
8
taken.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
24
Chapter 2: General Principles of Amputation Surgery
Limb Salvage Versus
Amputation
Several important questions should be
addressed by the treating surgeon before
making the decision for limb salvage or
amputation. The best time to make this
decision is at the time of injury. It often
becomes difficult to convince a patient
of the need to amputate a nonfunctional
limb if substantial effort has been made
in attempting to salvage that limb. A
poorly conceived plan for limb reconstruction can result in a patient with
poor function and chronic neurogenic
regional pain.
Several questions should be addressed early in the patient’s treatment
(for example, in the trauma bay, the
diabetic foot clinic, or the oncology
clinic). Will limb salvage outperform
amputation and a prosthetic limb? The
surgeon should have a realistic expectation of the functional outcomes of limb
salvage and amputation. Not every patient will realize the optimal outcome.
Most surgeons will achieve a bell-shaped
curve of clinical outcomes for a given
set of clinical parameters, with most
outcomes placing in the middle of the
curve. When initiating a treatment plan,
the surgeon and the patient should have
realistic expectations regardless of the
treatment choice.
What is the cost of limb salvage?
Beyond the financial costs and the resources consumed during limb salvage
treatment, other costs include lost wages
from time away from work, depletion
of financial reserves, and the emotional
costs associated with the multiple
surgeries.
What are the risks of limb salvage?
When establishing a risk assessment
for limb salvage verus amputation, the
surgeon should consider factors beyond
a simple determination of morbidity
associated with surgery. The risks of
the multiple necessary surgeries and
anesthetics, the potential for sepsis,
the time necessary for rehabilitation,
and the potential for narcotic addiction
should be considered. When each of
these questions is considered before
initiating treatment, the decision may
become more straightforward.
Amputation Level Selection
In the current outcomes-oriented environment, it is clear that retention of limb
length is closely correlated with optimal
functional outcomes.9 When planning
amputation surgery, the goal is to retain
as many functional joints and as much
residual limb length as is compatible
with available tissue and the planned
prosthetic limb fitting. The most difficult decisions are those that require a
choice between a longer residual limb
length with a poor soft-tissue envelope
and a more proximal amputation level
with a more optimal residual limb. In
the LEAP study, results suggest that
the poor functional outcomes of the 17
evaluated knee disarticulations were the
result of suboptimal residual limbs as
opposed to the patients’ poor ability to
use prostheses.1 Careful evaluation of
the data from the LEAP study showed
that most of the knee disarticulations
were performed within the zone of injury and had a poor soft-tissue envelope. The patients in that study who
were treated with a knee disarticulation
would likely have fared better with an
optimally performed transfemoral
amputation.
1
Load Transfer and
Weight Bearing in Lower
Limb Amputation
In a lower limb amputation, weight
bearing can be viewed as the transfer
of load between the residual limb and
the prosthetic socket. The ground reaction force vector is applied directly to the
residual limb in disarticulations at the
knee or ankle levels and thorough total
surface bearing in transosseous (transfemoral or transtibial) amputation levels.
The terms direct load transfer or end
bearing are used when referring to disarticulations, and indirect load transfer
or total surface bearing are used when
referring to transosseous amputation
levels (Figure 2).
End-bearing load transfer in a disarticulation acts similarly to normal
weight transfer in a sound limb. Long
bones are expanded at the level of the
metaphysis to create a larger surface
area for distributing the weight-bearing
load and are composed of low elastic
modulus cancellous bone for dissipating the effect of loading. A cushioned
end pad substitutes for the dampening
and cushioning function of the durable
plantar tissue of the foot. Because actual
bony loading is similar to that which
occurs in normal conditions, the fit of
the prosthetic socket is less crucial than
the intimate fit needed in a transosseous
amputation. In patients with substantial
fluctuations in the volume of the residual limb (such as those with renal failure),
an adjustable socket can compensate for
volume changes
9,10
(Figure 3).
In prosthetic applications, the bioengineering concept of indirect load
transfer is better known as total surface bearing. This method of prosthetic socket construction is used in
transosseous amputation levels where
the surface area of the terminal bone
is small and the bone is composed of
higher stiffness cortical bone (Figure
2, B). The theoretic concept is to un
load the small surface of the stiff cortical
bone of the terminal tibia in a transtibial
amputation and the terminal femur in a
transfemoral amputation. By flexing the
knee 7° to 10° in a transtibial prosthesis
and adducting the femur in a transfemoral prosthesis, pressure can be directed
away from the distal end of the bone and
distributed over the entire surface area
of the residual limb.
11,12
To accomplish
this goal, the fit of the prosthetic socket
is crucial. If the patient loses as few as
5 lb (2.67 kg), the residual limb will
move too far distally into the prosthetic
socket (known as bottoming out) and
pain or ulceration will develop over the
prominent terminal cortical bone. If the
-
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
25
Section 1: General Topics
Figure 2
load transfer (total surface bearing) in transtibial (C) and transfemoral (D) amputation levels.
Figure 3
nal failure. Substantial residual limb volume uctuation would make transtibial prosthetic tting
very dicult. AP (B) and lateral (C) photographic views of a volume-adaptable knee disarticulation
end-bearing prosthesis.
patient gains weight, the residual limb
may not fit into the prosthetic socket
or the fit may be too tight and cause
discomfort.
In patients with a transosseous amputation, the residual bone normally
pistons (moves up and down) during
weight bearing. When the soft-tissue
envelope of the residual tibia or femur
Illustrations o f direct load transfe r (end bearing) in a Syme a nkle disarticulation ( A) and a knee disarticul ation (B). Illustrations of indirec t
A, Photograph of the residual limb in a morbidly obese diabetic patient with re-
is composed of mobile muscle and
full-thickness normal skin, the bone
will piston within the soft-tissue enve-
9,10
lope. If the soft-tissue envelope is adherent to the bone, the pistoning action
occurs between the skin and the prosthetic socket, creating shear forces that
lead to blisters and skin breakdown.
This condition is best treated surgically
by creating an optimal soft-tissue envelope. When the skin of the residual limb
adheres to the bone stump, the prosthetist will attempt to compensate for
the increased shearing forces by using
some form of silicone liner as an interface between the adherent skin and the
prosthetic socket.
The Soft-Tissue Envelope
The bone stump of the residual limb
serves as a platform for load transfer in
a lower limb amputation and as a lever
arm to drive an upper limb prosthesis.
The soft-tissue envelope serves as a
cushion to dampen the effect of weight
bearing and prevent tissue breakdown
over bony prominences during use of a
prosthesis. The optimal soft-tissue envelope is stable, robust, and composed of
mobile muscle and full-thickness skin
(Figure 4).
The first step in creating a terminal organ of weight bearing is the
removal of all nonviable tissue. This
process should be completed without
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
26
Chapter 2: General Principles of Amputation Surgery
Figure 4
B, The initial attempt at wound closure accomplished soft-tissue padding of the residual tibia with gastrocnemius muscle. Note that the skin was
degloved and eventually died. C, Prior to the availability of silicone gel prosthetic socket liners, the residual tibia would have been unable to tolerate
the shear forces associated with weight bearing. D, Photograph of the residual limb after split-thickness skin grafting at the time of the preparatory
prosthetic limb tting. E, Photograph at 1 year after the amputation. Note that the soft-tissue envelope has matured, allowing the patient to return
to running sports.
considering the reconstruction because
retaining marginal tissue leads to less
favorable outcomes; however, all viable
tissue should be retained to salvage as
much normal tissue as possible for the
reconstruction. When amputation is
performed for trauma or infection, the
reconstruction is often done as a second-stage surgical procedure to allow
the zone of injury to recover in trauma cases and to ensure infection-free
margins in cases involving infection or
gangrene.
A, Clinical photograph of a mutilated lower limb in a young man. The injury was initially managed with open transtibial amputation.
When staging amputation surgery
for trauma or infection, the safest option is open wound management with
a vacuum-assisted wound closure device or moist gauze dressings. If there
is redundant viable residual tissue, provisional loose wound closure without
tension is a reasonable wound management option. A planned staged return to surgery allows takedown of the
provisional wound closure, secondary
débridement, and formal creation of a
durable cushioned soft-tissue envelope.
Although historically popular, skin traction should be avoided because it adds
additional insult to the zone of injury.
Definitive wound closure in trauma is
delayed until the zone of injury recovers
from the crush and traction insults of
the injur y.
When performing amputation
for tumor, the first consideration is
the creation of adequate tumor margins, whether they are transverse or
compartment-based. Creation of the
soft-tissue envelope and the residual
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
27
Section 1: General Topics
Figure 5
the upper limb a fter fracture x ation, which allowed retentio n of sucient humeral length f or functional prost hetic limb tting. C, The humeral length
retention allowed sucient surface area to achieve prosthetic socket suspension and leverage to drive a prosthesis through space.
limb is determined after obtaining adequate tumor margins.
Socket Interface in Upper
Limb Amputation
Intimate prosthetic socket fit in the upper
limb is crucial. Although the patient will
not bear weight on an upper limb prosthesis, intimate fit is necessary to drive
the socket through space and establish
leverage for performing tasks (Figure 5).
As much limb length as possible should
be maintained based on the available
muscle that will be used to create the
soft-tissue envelope. Muscle groups
should be attached to the resid ual bone
at a relatively normal resting tension.
This allows the retained muscles to create an electromyographic signal that can
be used to drive a myoelectric prosthetic
motor and improves residual limb control for powering body-powered devices
because many of the pertinent muscle
groups cross the elbow or shoulder.
Tissue Management
Experience, rather than evidence, has
provided generally accepted amputation
principles for creating residual limbs.
The use of tourniquets has not been
A, Photograph of a transhumeral amputation performed after an injury in a young man who worked as a laborer. B, AP radiograph of
effectively studied in amputation surgery. Accepted practice is to avoid the
use of tourniquets in limbs that have
previously undergone vascular surgery
or angioplasty. When a tourniquet is
used, it should be deflated before wound
closure to obtain control of bleeding.
Arteries should be ligated with suture
ligatures (stick ties) to avoid late bleeding from a simple ligature that is extruded by the pulsations of the artery.
Venous bleeding can be controlled by
simple ligature, metal vascular clips, or
electrocautery.
In creating a transosseous residual
limb, soft-tissue stripping from bone
should be limited to the amount required to create the soft-tissue envelope.
Excessive periosteal stripping should be
avoided to prevent late prominent periosteal bone (bone spur) formation. Bone
necrosis from thermal burning with
power saws can generally be avoided by
cooling the bone with cool saline during
bony transection.
After muscles within the zone of injury have recovered from trauma, they
should be attached to bone at tension
that is as close to normal as possible.
Flexor muscle groups followed by
extensor muscle groups should be attached to the bone (radius and ulna for
transradial amputation and humerus
for transhumeral amputation) at normal
resting muscle tension. Attaching the
muscles to bone at normal resting tension creates a normal physiologic cushion, allows the muscles to drive the limb
through space in a pattern that most
closely mimics normal motion, and creates an optimal electromyographic signal to drive a myoelectric prosthesis.
6,7,13
Crushing injuries to nerves caused
by clamping should be avoided, even
when resection of the crushed section
of a nerve is planned. Crushed nerves
are likely a major factor in the development of phantom or residual limb pain
after amputation. The best practice is
to gently grasp a nerve with a gauze
sponge, apply gentle traction, and transect the nerve proximally with a fresh,
sharp scalpel blade. Although a neuroma will develop in every transected
nerve, a neuroma embedded in muscle
is less likely to cause late sensitivity and
symptomatic sensation or pain.
Native, full-thickness skin is more
durable than coverage obtained with
grafting or healing by secondary
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
28
Chapter 2: General Principles of Amputation Surgery
intention. All viable skin should be retained for use in the eventual construction of a functional residual limb. When
full-thickness skin is not available, options for healing by secondary intention
(with or without the use of a vacuumassisted wound closure, skin grafting,
or plastic and/or microsurgery for softtissue transfer) should be considered.
Amputation in Children
Several considerations make amputation
in children different from amputation
in adults. In a child, the epiphyseal
growth centers in amputated limbs
will generally achieve less limb length
than a contralateral normal limb. When
planned appropriately, temporizing
with provisional prostheses is often a
valuable component of a well-conceived
longitudinal treatment plan.
Because bony overgrowth is a common complication of transosseous amputation in growing children, surgery
to resect painful bony overgrowth is
often necessary in the management of
this patient population. Various surgical techniques that have attempted to
limit bony overgrowth have not been
universally successful in preventing this
complication.
Outcomes After
Amputation
The rehabilitative process should start
before surgery in an elective amputation
and as soon as possible in a traumatic
amputation. Peer counseling has proven extremely valuable in dealing with
posttraumatic stress disorder after amputation.
3,14 -16
Early transfer training and
ambulation with crutches or a walker
should be accomplished before prosthetic limb fitting. It is also important
that the patient’s progress be monitored
so that problems can be identified and
treated early.
Summary
Surgeons should consider amputation
surgery as construction surgery. It is
the first step in the rehabilitation of a
patient with a nonsalvageable limb. Preoperative planning methods should be
similar to those used by a fracture or
joint arthroplasty surgeon. To achieve
optimal outcomes for patients, each step
in the amputation process should be accomplished with a reasonable surgical
plan, including a plan to prevent complications and methods to aggressively
manage complications if they occur.
References
1. Bosse MJ, MacKenzie EJ, Kellam
JF, et al: An analysis of outcomes
of reconstruction or amputation
aer leg-threatening injuries. N
Engl J Med 2002;347(24):1924-1931.
Medline DOI
2. Doukas WC, Hayda RA, Frisch
HM, et al: e Military Extremity
Trauma Amputation/Limb Salvage
( METALS) study: Outcomes of amputation versus limb salvage following major lower-extremity trauma.
J Bone Joint Surg Am 2013;95(2):138-
145. Medline DOI
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sep_oct_09/evidence_based_care.
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Smith DG: Controversies in amputation surgery. Instr Course Lect
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11. Tucker CJ, Wilken JM, Stinner PD,
Kirk KL: A comparison of limbsocket kinematics of bone-bridging
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13. Gottschalk F, Kourosh S, Stills M:
Does socket conguration inuence
the position of the femur in aboveknee amputation? J Prosthet Orthot
1989;2:94-102. DOI
14. Support group and peer support.
Available at: http://www.
amputee-coalition.org/supportgroups-peer-support/certiedpeer-visitor-program/. Accessed
September 18, 2014.
15. Smith DG: Special challenges in
outcome studies for amputation
surgery and prosthetic rehabilitation.
J Prosthet Orthot 20 06;(suppl 1):
116-118. DOI
16. Smith DG, Berke GM: Post-operative management of the lower
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© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
29
Chapter 3
General Principles of Postoperative
Residual Limb Management
Frank Gottschalk, MD
Abstract
Various postoperative management protocols have been used over the years to care for
postoperative wounds and residual limbs aer amputation. e most successful protocols
have been those using modern so dressings, including negative-pressure incision and
wound dressings. Compression dressings and various types of rigid dressings, including
removable rigid dressings, are applied over the incision dressings and help reduce postoperative edema. Some of the newer postoperative dressings are impregnated with silver
ions. e goal of each type of dressing is to improve wound healing and shorten the time
to prosthesis tting.
Keywords: compressive dressing; hydrofiber dressings; incision and
wound dressings; negative-pressure dressing; protective dressing
Introduction
The management of immediate and early
postoperative wounds and residual limb
care is generally not well described in
surgical texts. The goal of such care is to
ensure uncomplicated healing in as short
a time as possible. Because many lower
limb amputations are a consequence of
diabetes mellitus and vascular disease,
wound healing problems are common
and may subsequently result in a more
proximal-level amputation. Traumatic
amputations may have unrecognized
tissue damage, and wound care is paramount to subsequent satisfactory healing. The minimization of wound healing
issues begins at the time of surgery by
removing dead, nonviable, and infected
tissues and ensuring the adequate viability of remaining tissues. Soft tissue
(muscle, fascia, and subcutaneous tissue) and skin closure without tension is
key to reducing the potential for wound
breakdown and failure to heal.
Dr. Gottschalk or an immediate family member is an employee of Biogen Idec and has stock or
stock options held in Pzer and Zimmer and is an employee of Biogen Idec.
In the past several years, scientific
articles have been published that document superiority of one method of
wound care over another. Several studies have noted that some form of rigid
or supportive dressing is better than
soft dressing alone.
postoperative management are currently
in use, with some incorporating modifications from older methods. Immediate
postoperative management encompasses the application of initial wound or
incision dressings and coverings and
more sophisticated applications of compressive, elastic support, and/or rigid
dressings. After the initial postoperative
care, various additional coverings are
used, all of which are intended to aid in
protecting the residual limb and assisting amputee mobility. The use of various soft-tissue dressings to “shape the
residual limb” has been invoked in the
past; however, the shape of the residual
limb is determined by the quality of the
1-4
Various types of
surgery and the length of the bone and
soft-tissue flaps, not by the bandages
and wrappings. The use of rigid dressings in the early postoperative period
helps to reduce trauma to the residual
limb and minimize tissue breakdown,
which may help in reducing edema. The
application of ice packs to the end of
the residual limb may also contribute
to edema reduction.
Incision and Wound
Dressings
In general, postoperative wound dressing of the amputated limb may be di
vided into the following categories: soft
dressings, negative-pressure wound
dressings, and hydrofiber dressings.
Soft Dressings
Soft dressings traditionally have been
used to cover the residual limb after
surgery. Their role is to cover the suture line and wrap the limb to hold the
incision dressings in place. Gauze wraps
do not reduce edema, nor do they affect
the shape of the residual limb. Residual
limb shape is determined at the time of
surgery and is affected by muscle, soft
tissue, skin flaps, and, in certain areas,
by the shape and length of the bones,
such as tibia and fibula or radius and
ulna.
Soft dressings include cotton or polyester gauze pads and wrapping with cotton gauze rolls or conforming polyester
rolls.1 These dressings are used to hold
wound and incision coverings in place,
but they do not provide support for the
residual limb. The dressings are permeable and help absorb drainage from
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© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
31
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