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AMPUTATION

DEFINATION:

Amputation is the removal of a body extremity by trauma or surgery. As asurgical measure, it is used to control pain or a disease process in theaffected limb, such as malignancy or gangrene.Amputated fingerapprox 1 in 13,066 or 0.01% or 20,816 people in USAINCIDENCE :20,816 349 annual cases in Victoria

Amputated thumb approx 1 in 11,573 or 0.01% or 23,500 people in USA23,500 394 annual cases in Victoria

Amputated arm approx 1 in 506,683 or 0.00% or 536 people in USA 536 9annual cases in Victoria

Amputated toe approx 1 in 111,223 or 0.00% or 2,445 people in USA 2,44541 annual cases in Victoria

ETIOLOGY AND RISK FACTOR

Amputations are caused by:

Accidents

Disease

Congenital Disorders

The accidents most likely to result in amputation are traffic accidents,followed by farm and industrial accidents.

Amputations in the case of disease are performed as a lifesaving measure.The diseases that cause the most amputations are peripheral vascular disease

(poor circulation of the blood) and cancer.

Congenital disorders or defective limbs present at birth are not amputations,but rather are a lack of part or all of a limb. A person with a limb deficiencycan usually be helped by use of an artificial limb. Sometimes amputation of

part of a deformed limb or some other type of surgery may be desirablebefore the application of an artificial limb.

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TYPES OF AMPUTATION

The list of types of Amputation mentioned in various sources includes:

Amputated finger

Amputated thumb

Amputated arm

Amputated toe

Amputated leg

Amputated lower leg

Amputated finger:

Conditions that may require amputation of the finger include infection,gangrene, frostbite, atherosclerosis, bone infection and cancer

Amputated thumb:

Conditions that may require amputation of the thumb include infection,gangrene, frostbite, atherosclerosis, bone infection and cancer

.

Amputated arm:

Conditions that may require amputation of the toe include infection,gangrene, frostbite, atherosclerosis, bone infection and cancer. Prosthetics

are often worn following an arm amputation.

Amputated toe:. Conditions that may require amputation of the toeinclude infection, gangrene, frostbite, atherosclerosis, bone infection

DIAGONOSTIC STUDIES

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History and physical examinationPhysical appearance of soft tissueSkin temperatureSensory functionArteriography

VenographyTranscutaneous ultrasonic Doppler studies

Amputation of lower limbAbove-knee amputations may be performed through the distal femur(supracondylar), the midfemur(diaphyseal), or just below the lessertrochanter (highabove-knee amputation) ( Above-kneeamputations

performed for tumors of the distal femuror sarcomas of the distal thigh tendto be performed ata higher level than standard above-knee amputationThereare more "below-knee" (trans-tibial) amputees than any other type. Surgeons

preserve the knee joint whenever it is practical to do so and will fashion thestump at the lowest practical level. Very short stumps make fitting extremelydifficult and very long below-knee stumps are prone to circulation problems.

Level of AmputationAbove-knee amputations may be performed through thedistal femur(supracondylar), the midfemur(diaphyseal), orlessertrochanter (highabove-knee amputation) . Above-kneeamputationsperformed for tumors of the distal femur or sarcomas of the

distal thigh tend to be performed at a higher level thanstandard above-knee amputations. By contrast, tumors ofthe leg are treated with thestandard above-knee amputation.As a rule, any lengthof femur makes prosthetic fitting easierthan none. Evenamputations at the subtrochanteric level are preferred to hipdisarticulation; if 35 cm of bone distal to the lessertrochanter remain, the patient can be fitted with a prosthesisin a manner used for above-knee amputation.The main

factors that determine the type of flaps to be constructed arethe soft-tissue extent of the tumor, areas of prior irradiation,and previous scars.Level of osteotomy and cross-sectional anatomy for

supracondylar,diaphyseal, and high above-knee amputation.Higher above-knee amputations are generally used forprimary bone sarcomas of the distal femur. Low above-knee

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amputations are used for bone sarcomas of the leg,especially those involving the popliteal fossa or arterialtrifurcation. High above-knee amputation is preferable to hipdisarticulation, even though the osteotomy is only a few

centimeters below the greater trochanter. With the hip jointintact, movement of the prosthesis is greatly facilitated.toavoid local recurrence and no attempt is made toadhere tostandard flaps. At this level a skin or muscle flap of almostany length will heal in the young patient. Furthermore, it isnot necessary to use equal flaps; longposterior, anterior, ormedial flaps will all heal rapidly.

SURGICAL TECHNIQUE

Emphasis is on flap design and meticulous dissection,use ofcontinuous epineural analgesia, myodesis of themajormuscle groups to the distal femur, meticulouswound closure,and application of a rigid dressing.The patient is supine, andthe operated extremityshould be abducted and flexed .Mostamputations are performed without compressive tourniquetbecause it is easier to locate the bleeding edges ofbloodvessels and perform an adequate hemostasisundersuch circumstances. The most common type of flap is

the anterior and posterior fish-mouth flap, and theskinincision should be planned accordingly. It is recommendedto draw the incision line priorto surgery.Transection of muscle and bone is shown in. Majormusclegroups should be carefully dissectedand tacked fortheir further use in soft-tissue reconstruction.The femoraledge should be beveled and smooth. Cytologic examination and a frozen sectionof the proximalmarrow canal must be performed toascertain that there is nooccult medullary extension ofthe tumor. A frozen section of any questionable siteshould beperformed.Sciatic and Femoral Nerves

The cut ends of the nerves may form neuromata, which canbe extremely painful when exposed to pressure fromtheprosthesis or direct trauma. Therefore, the nerveendings

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must be positioned, and even sutured, withmuscles. Malawer et al.2 described the use of continuousinfusion of bupivacaine into the epineural space tocontrolpostoperative pain. That method was found tosignificantly

reduce the need for intravenous and oralnarcotics, and it is now routinely used in limb-sparingresections and amputations.the epineural catheter is placedunder the nerve sheath,in the epineural space. The catheteris sutured to the nerve sheath,pulled through a muscle flap,andsecured to the skin. A bolus of 10 ml of bupivacaine 0.25% isinjected into the epineural space, and an additional 10 ml aregiven before the patient leaves the operating room. This isfollowed by a continuous infusion of 4ml/h. Boluses of 10 ml

can be given as required. The epineural catheter is generallyremoved after 5 days of treatment, following gradualweaning.

Muscle ReconstructionMuscle reconstruction around the femur is essential toensure a functional extremity. In addition, the bone end mustbe adequately covered and padded with muscles in order toavoid pressure from the prosthesis. The quadriceps and the

hamstrings are tenodesed to each other by covering thebone end . The hip flexors are stronger than the extensors;thus, the hamstrings should be cut longer than thequadriceps and

Above-knee Amputation

Position. The patient is supine; the operated extremity is inflexion and abduction. attached to one another, with thehamstrings somewhattighter. In addition, the adductors should be tenodesed tothese muscles and the femoral stump using drillholes and 3mm Dacron tapes. This is especially important in the shortproximal femoral stump, which has a tendency to go intoflexion and abduction. Closed suction drains are brought outof the medial and lateral aspects of the incision, and the

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superficialascia is tightly closed .Special attention should be given towound closure; it is important to avoid large folds of skin.Skin sutures must be positioned

by halving the incision, especially if unusual skin flaps havebeen utilized.As soon as the surgery is completed, a rigid dressing isapplied it is used to reduce the swelling and, if positionedproximally enough, prevent flexion contracture around thehip joint. Contractures are more common with short stumps;to prevent this problem the cast should be continued up tothe groinand held in place with a belt. With early ambulation,patientstend to have less pain and experience fewer psychological

difficulties. Patients with a rigid cast invariably mobilizeearlier than those who have a standard soft dressing.Preoperative or early postoperative chemotherapy is not acontraindication to a rigid dressing and early ambulation.Drains are usuallyremoved on the third or fourth day after the surgery or wheneach drains less than 50 ml/day. The patient should keepcompression on the stump at all times; this is bestaccomplished with an elastic stump shrinker. As

soon as the wound is healed and the stump is notsignificantly swollen (usually around 4 weeks after surgery),the patient can have the first prosthetic fitting.MEDICAL MANAGEMENT

The objective of treatment is to achieved heeling of theamputation wound. The result brings a nontender residuellimbs.(stump)with healthy skin for prosthesis used. Heelingenhanced by gentle handling of residual limb ,control ofresidual edema through rigid or soft compression dressingand use of aseptic technique in wound care to avoid infection

A closed rigid cast dressing is frequently is used toprovede uniform compression to support soft tissue , tocontrol pain to prevent joint contracture

Residual limb is immediately is applied with sterile limbshock and felt pad are over pressure sensitive area

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The residual limb is wrapped with elastic plaster of parisbandage while firm pressure is maintained ,care istaken not constrict the circulation

For the patient with lower extremities amputation

plaster cast may equipped to attach a temporallyprosthetic extension (pylon )and artificial foot this rigiddressing technique is to created a socket for immediatepost operative prosthetic fitting .the length prosthetic istailored individual patient . Early minimal weightbearing on the residual limb with rigid cast dressingand pylon attached produced little discomfort .The castis changed in about 10 to 14 days .Elevated bodytemperature ,severe pain ,or loose fitting cast maynecessitate earlier replacement

A removable rigid dressing may be placed over softdressing to control edema ,to prevent joint flexioncontracture and to protect residual limb fromunintentional trauma during during transfer activities

This rigid dressing is removed several days aftersurgery wound inspection and is then replaced tocontrol edema .The dressing facilitate shaping of theresidual limb

A soft dressing with or without compression may be

used if there is significant wound drainage and frequentresidual is desired . An immobilizing splint mayincorporated in dressing stump,wound haemotoma arecontrolled with wound drainage device to minimize theinfection

REHABILITATION

Successful rehabilitation of the patient who has undergonean above-knee amputation requires a coordinated effort thatshould start at the time of the staging studies. The health-care team must develop an honestrelationship with the patient and family and include them inthe decision-making process from the very beginning.Building upon this basis the patient will be better able toaccept the amputation and set realistic goals for recovery.

The patient should be told that phantom limb sensations

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might occur following surgery. These sensations should bepresented as a normal part of the recovery process. Phantomlimb pain is generally controlled by the judicious use ofanalgesics and the passage of time. The requirements of

above-knee amputees are somewhat different from those ofbelow-knee amputees.Their energy requirements are almost 100% greater, and it isnot unusual for the above-knee amputee to require anassistive device (i.e. a cane) for community ambulation, andbe less able to participate in sports thana patient who has undergone below-knee amputation.

Younger and motivated patients can have a good functionaloutcome, but older patients can find the energy cost difficultto overcome. The first stage of recovery is dedicated to

proper wound healing and conditioning of the stump.Prevention of flexion contracture of the hip can beachievedwith rigid dressing, prone positioning, a physical therapyprogram and, in most cases, a combination of all threemodalities. The use of immediatepostoperative prosthesis is more practical and better

Musculoskeletal Cancer Surgery

Incision. The skin flaps are marked. The main factors thatdetermine the type of flaps are the extent of the soft-tissuetumor, areas of prior radiation, and previous scars. Thegreatest priority is to avoid local recurrence and no attemptis made to adhere to standard flaps; at this level a skin ormuscle flap of almost any length will heal primarily in ayoung patient. It is not necessary to utilize equal flaps; longposterior, anterior, and medial flaps will heal. tolerated bythese patients than by below-knee amputees. A temporaryprosthesis provides the patient the advantage of trainingwith a simple and adaptabledevice. It also becomes a backup to the permanentprosthesis, which is fabricated when the residual limb hasstabilized in volume and matured to allow full-time wear. Twocritical elements are selection of the knee joint mechanismand suspension system. Many designs, with varying degrees

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of durability, gait parameters, weight, and stability, areavailable. Selection of an appropriate product is dependenton patient-specific factors such as age, weight, type of dailyactivities, and desired sports activities, and requires close

consultation with the prosthesist.The Immediate

Postsurgical Period

Nearly every amputee feelsquite depressed immediatelyafter the surgery, except

possibly those who havesuffered intense pain for a

period just prior to the

amputation. This depression isusually replaced early by awill to resume an active life.

The dressing applied by thesurgeon is either "rigid,"usually made of plaster-of-Paris, or "soft," using ordinarycotton bandaging techniques.

When the rigid dressing is

used it is left in place for 10 to14 days during which timemost of the healing takes

place. Sometimes a simplealuminum tube, or "pylon",and an artificial foot areattached to the rigid dressingso that walking, or gait,training can begin even beforethe healing period is complete.

When the soft dressing is used, elastic bandages are used soon after surgeryto aid circulation. The bandages are removed and reapplied throughout theday. (Instructions for application of elastic bandages are given in the nextsection.)

Regardless of the type of dressing used, exercises are extremely important toprevent contractures (tightening of the muscles) which, when present,

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prevent efficient use of a prosthesis. Some "Don'ts" that will help preventmuscle tightening, or contractures, are shown above.

It is most important that the prescribed exercises be carried out regularly,and the positions shown above be avoided if the greatest benefit is to be

obtained from the prosthesis.

Musculoskeletal Complications in Amputees: Their Preventionand Management

John H. Bovvker, M.D.Robert D. Keagy, M.D.Pradip D. Poonekar, M.B., B.S., M.S. (Gen. Surg.)

One of the primary aims of any surgical procedure, apart from obtaining primary healingat the operative site, is the prevention of complications due to that procedure. Amputeemanagement has the added dimension of complications related to the amputation-prosthesis interface. The complications of amputation surgery can therefore be dividedinto preprosthetic and post-prosthetic problems.

In general, the frequency and degree of complications decrease remarkably when thesurgeon is keenly interested in the challenge presented by properly designed andexecuted amputation procedures and keeps abreast of innovations. A casual or defeatistattitude toward amputation surgery engenders many of the problems to be discussed.

PREPROSTHETIC COMPLICATIONS

Delayed Healing

Delayed healing may be related to several factors that can be operative singly or incombination. These include inappropriate amputation-level selection, sub-optimaloperative technique, inadequate postoperative management, and infection.

A common cause of delayed healing is inappropriate amputation-level selection. Thiscan, to a large extent, be obviated by proper use of the vascular laboratory as an aid inlevel selection. Noninvasive techniques such as segmental Doppler studies andtranscutaneous oximetry mapping can yield valuable information. Delayed healing canalso be due to suboptimal operative technique. Handling dysvascular skin with forceps,

attempting to close the skin under tension, or placing excessive closure tension on muscleof questionable vascularity can result in ischemic changes leading to dehiscence. Evenwith minimal closure tension, skin edges may be made ischemic by the placing of toomany sutures, especially mattress sutures . It is better to place a few widely spacedsutures and reinforce the wound with adhesive paper strips . There is also little need forsubcutaneous sutures in most amputations if good myofascial and fascial closures aredone. Removal of skin sutures prior to firm initial healing of the amputation wound mayalso lead to dehiscence, especially in the immunocompromised or dysvascular patient.

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Prior to any definitive treatment of dehiscence other than debridement, the patient shouldbe thoroughly reevaluated to determine the reason for wound failure. The preoperativevascular studies should be reassessed to be sure that the level previously selected wascorrect. If the patient's wound healing potential was not evaluated preoperatively, itshould be done at this point. This would include a determination of serum albumin levelto ascertain nutritional status and a total lymphocyte count to assess immunocompetency.If these are deficient, further surgery should be delayed until nutrition is normalized. Inchronic renal failure, this may not be possible, and one may be forced to proceed withoutthis assurance. Although it is good practice for patients to permanently discontinue theuse of nicotine or at least delay resumption until the wound is well healed, it is commonto find them smoking within a day or two of surgery. Rather than have anotherimmediate failure due to smoking, the surgeon has the option to refuse surgical treatmentbeyond debridement on these patients if they fail to comply with this request, so long aslife is not threatened. If vascular studies and nutritional parameters are normal and thepatient stops the use of nicotine, treatment should proceed with the most appropriatetechnique.

Treatment is determined by the length and depth of the dehiscence. If skin separation isminor, the residual limb may be allowed to heal by secondary intention followingconservative debridement under adequate antibiotic coverage. Often a temporaryfiberglass or plaster of paris cast helps in the healing of such cases. If wound edgeseparation due to necrosis is confined to the skin, local debridement that avoids trauma toskin of marginal viability is called for. This may be followed by split-thickness skingrafting once adequate granulation tissue forms. Dehiscence with moderate woundseparation can be managed by adequate debridement and secondary closure withouttension by utilizing a minor wedge excision with minimal bone shortening .

If infection is the sole cause of dehiscence, the wound should be widely opened fordrainage and appropriate antibiotics given. Once the wound is clean and granulating well,

the decision can be made to allow healing by secondary intention, with delayed split-skingrafting coverage of granulating areas, or to revise proximally and maintain the sameanatomic level if an adequate soft-tissue envelope for the bone can be constructed. In thepresence of gross necrosis or failure of the wound to produce adequate granulation tissue,the choice is limited to a revision amputation.

If peripheral vascular parameters are poor, before proceeding to a higher anatomic level,for instance, from transtibial to transfemoral, transcutaneous oximetry can be utilized todetermine the potential for skin healing slightly more proximally in the same limbsegment. Evaluation should begin with baseline transcutaneous oxygen pressure (Tcp02)determinations on room air at the site of proposed revision. If less than 40 mm Hg, the

measurements may be repeated after the patient has been breathing 100% 02 at 1 atm for20 minutes. If Tcp02 values then meet or exceed 40 mm Hg, postoperative hyperbaricoxygen (HBO) therapy may be considered. In selected cases, readings can be taken in thehyperbaric chamber while the patient is breathing 100% 02 at 2.4 atm. If Tcp02 levels arestill borderline, consideration should be given to amputation at the next higher anatomiclevel, followed by HBO therapy if Tcp02 readings are borderline at that level.

On occasion, repeated attempts at healing a trans-femoral amputation in cases of severedysvascularity result in wound dehiscence due to necrosis at a higher level. The next

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proximal level is a hip disarticulation, with no assurance that this level will heal. Ifnecrosis then recurs, the patient is at great risk of death due to the difficulty ofcontrolling a wound at that level without involving the pelvic structures. It is sometimesbest to merely debride high transfemoral wounds in a manner so as to avoid trauma towound edges of marginal viability. This is done by leaving a residual rim of necrotictissue approximately 2 to 3 mm in width. In this way, the marginally viable skin beyondthe necrosis is not traumatized by the scalpel. This will often stop the inexorable spreadof necrosis attendant upon repeated aggressive debridement. This small rim of necrotictissue should separate spontaneously. Gauze dressings applied moist and removed drythree times daily will encourage the formation of granulation tissue, which will lead toeither healing by secondary intention or the production of a suitable bed for a split-skingraft. This is, of course, combined with improvement of nutrition and cessation ofsmoking. HBO treatments are again a useful adjunct in management if pretreatment testresults are favorable.

In older dysvascular patients, falls in the early postoperative period are common due toproblems with balance, coordination, and weakness during crutch or walker ambulation.

Direct falls on a partially healed amputation wound can result in massive dehiscence andleave the bone exposed. Cleansing, debridement, and closure should be done on anemergency basis to prevent infection, flap shrinkage, and prolonged delay in prostheticfitting . This complication is usually prevented by application of a cast to the midthighwith the knee in full extension each week for 3 weeks. This will also allow woundinspection at weekly intervals and afford an opportunity for a full range of motion of theknee prior to application of each cast.

Skin Adherence to Bone of the Residual Limb

The ideal closure of an amputation includes the construction of an adequate soft-tissue

envelope for the enclosed bone or bones. Myodesis or myoplasty are the two besttechniques available to provide both distal padding and to prevent adherence of theincisional scar to the underlying bone. If the skin cannot slide over the underlying bone,it will not be able to comfortably tolerate shear forces applied by the prosthesis at theinterface with the residual limb.

If wound closure is to involve split-thickness skin grafting, this should be applied onlyover deeper soft tissues such as muscle and not directly on bone because the graft is verylikely to ulcerate as soon as use of a prosthesis is begun. Exceptions occur in upper-limbamputations, which are not weight bearing, and in children, who do surprisingly wellwith split-skin grafts once they have matured.

Problems in Shaping of the Residual Limb

Much can be done at the time of surgery to create an amputation stump that, by itsconfiguration, will assist in early prosthetic fitting. On the other hand, many problemsthat lead to delayed application of a definitive prosthesis are a direct result of suboptimaloperative technique. While it is axiomatic that wound closure tension should beminimized by designing ample myofasciocutaneous flaps, it is equally true thatredundant skin and muscle can lead to slow stump shrinkage with persistent distal edema

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despite adequate attempts at shrinkage .

In order to ensure optimal configuration, proper shaping of the bone end and adequatesoft-tissue coverage are important. Here the role of myodesis/myoplasty cannot beoveremphasized. The most structurally stable residual limbs are achieved with myodesisin which the surrounding muscles and their fasciae are sutured directly to the bone

through drill holes . In the case of transfemoral amputation, the additional advantages ofmyodesis are stabilization of the femur in adduction by the adductor magnus, enhancedhip flexion by the rectus femoris, and enhanced hip extension by the biceps femoris, allthree being muscles that cross the hip joint.

In myoplasty, on the other hand, opposing muscle groups are simply joined to each otherby sutures through the myofascia and investing fascia over the end of the bone. In aseverely dysvascular residual limb with marginal muscle viability, myoplasty is probablythe preferable method but should be done with little closure tension. In either case,tapering of the muscle mass avoids excessive distal bulk .

Following amputation surgery, there is a tendency for terminal swelling to occur. Controlof this edema will greatly reduce the tendency for wound complications and thusfacilitate early healing. This is a major benefit of rigid circumferential dressings ofplaster of paris or fiberglass. As postoperative swelling decreases, the rigid dressing mayslip distally and produce a circumferential constriction with distal choking andaggravation of distal swelling. If the cast is changed promptly on loosening, this problemwill not occur.

Whenever removal of a limb for malignancy is to be followed by chemotherapy, it isrecommended that nonabsorbable sutures be used to oppose the fascia and other deepstructures. Fascia and other soft tissues tend to heal poorly in the presence ofchemotherapeu-tic agents, and soft-tissue retraction occurs if absorbable sutures are used.

The overall conformation of the residual limb will then be altered, possibly leading todifficulties in fitting.

The Syme ankle disarticulation presents a special case. If the heel pad is secure and wellcentered, the patient will be able to tolerate a great deal of end bearing. If it is notproperly anchored to the end of the tibia, it may migrate posteriorly or to one side in thesocket . If passively correctable, however, it can be held in the proper weight-bearingposition by a carefully fabricated prosthesis. On the other hand, if the heel pad becomesfixed off center by contracture of the triceps surae, other muscle groups, or a scar, itshould be surgically repositioned by division of the contracted tendons or scar andremoval of an ellipse of excess skin, including the incisional scar, opposite the originalcontracture. It may also be necessary to remove a wafer of distal tibia and fibula to allow

reduction of the heel pad. The plantar fascia of the heel pad may then be firmly suturedto the distal-anterior portions of the tibia and fibula through drill holes.

Prior vascular surgery may have resulted in a longitudinal scar beginning on the lowerportion of the abdomen and crossing the inguinal crease into the thigh . This presents twopossible problems for the transfemoral amputee. One is scar irritation by the socket brim.The other is maintaining suction suspension, especially if the scar is depressed. Anotherincisional approach that results in a scar that will not cross the socket brim begins in the

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proximomedial portion of the thigh and extends laterally, parallel and just distal to theinguinal crease.

Repeated application of an elastic bandage has been the time-honored method ofshrinking and shaping a residual limb. Unfortunately, less-than-expert application of thebandage will produce a poorly shaped residual limb, generally with distal edema . The

bandages are meant to be applied on the bias with gradually decreasing pressure as thewrapping proceeds proximally. Since layers of bandage tend to shift with movement,frequent rewrapping is necessary to avoid circumferential constriction and distal edemaformation. As a result, many surgeons and prosthetists now recommend the use of anelastic shrinker sock. This sock not only is easy to don and doff but also results in theproper pressure gradient. When first fitted, it should be snug. A tuck may be sewn in thesides of the sock every 7 to 14 days to keep it snug as the residual limb decreases involume (.). Depending on limb configuration and activity level, the sock may need to befitted with a waist belt to keep it in place. The sock is briefly removed daily for skin care.Two socks should be supplied so that a clean one can be worn each day to assist inhygienic care of the residual limb. Very muscular or obese amputees may show virtually

no shrinkage of their residual limbs by wrapping or shrinker sock usage. In these cases, atemporary prosthesis or weight-bearing rigid dressing fitted as soon as the wound issound will cause both the bulky calf and the obese thigh to shrink most rapidly. Thistechnique may also be applied to the standard residual limb as well. This shrinkageincludes the removal of edema as well as atrophy of all the soft tissues of the residuallimb. Shrinkage is the greatest during the first 6 weeks of compression by prosthesis usebut continues for approximately 1 year after amputation, at which time a new socket willprobably be required. Shrinkage may be further enhanced by applying a snug elasticshrinker sock when the preparatory socket is removed each night. When a definiteplateau in shrinkage has been reached, as determined by no further need for shrinker socktightening or by stable weekly circumferential measurements of the residual limb, a

definitive prosthesis may be fitted.

Contractures

The joint immediately proximal to an amputation site tends to develop contractures if fullrange of motion is not initiated early in the postoperative phase. Contractures most oftenoccur as a result of the patient keeping the residual limb in a comfortable flexed position.In lower-limb amputees, a variety of contractures may occur. These are seriouscomplications that will interfere with proper prosthetic gait and increase the energyrequirements of ambulation.

Patients with partial-foot amputations between the transmetatarsal and Syme ankle

disarticulation levels are likely to develop an equinus deformity due to the relativelyunopposed action of the triceps surae. This may be prevented during tarsometatarsal(Lisfranc) and midtarsal (Chopart) amputations by reattaching the extrinsic muscle-tendon units of the foot to more proximal bony structures in a balanced fashion and bylengthening the Achilles tendon percutaneously. A postoperative cast applied with thepartial foot in a plantigrade position will prevent contractures until a definitive prosthesisis made. A plastic ankle-foot orthosis fitted with an anterior ankle strap can be similarlyused. If, despite these precautions, a contracture later develops, a second percutaneous

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Achilles tendon lengthening or revision to the Syme ankle disarticulation level may berequired.

Transtibial amputees, especially those with a short tibial segment, are prone to developknee flexion contractures in the first or second week postoperatively . For this reason, acircumferential rigid dressing of plaster of paris or fiberglass with the knee in full

extension is advised until the wound heals sufficiently to allow the removal of sutures.This is replaced weekly for 3 weeks with a full range of knee motion at each change. Thepatella should be well padded to prevent pressure necrosis of the prepatellar skin. Evenwith a cast in place, pillows should not be placed under the residual limb, or a hip flexioncontracture may be encouraged.

Severe knee flexion contractures are virtually impossible to reduce by exercise once theybecome fixed. In amputations notdone for vascular insufficiency, hamstring lengtheningand release of the posterior knee joint capsule should be considered. The dysvascularamputee with a short contracted residual limb may be fitted with a bent-knee prosthesis,which is functionally no better and cosmetically inferior to that for a knee

disarticulation . Occasionally, moderate knee contracture in a proximal-third amputationmay be improved by fitting a prosthesis with the foot in slight equinus to provide a kneeextension moment on foot contact.

At the transfemoral level of amputation, a hip flexion-abduction contracture can bedevastating because the already high energy requirement for ambulation at this level isfurther increased by contracture. Again, prevention is the key. During transfemoralamputations, flexion-abduction contracture can be discouraged by a balanced myodesis,including reattachment of the adductor magnus tendon to the lateral aspect of the femuras it is held in adduction and extension . Postoperatively, pillows under the thigh areforbidden. Within a few days of surgery, the patient should be taught to lie prone for 15minutes three times a day to stretch out any early flexion contracture and to actively

adduct the residual limb to prevent abduction contracture. Active extension of theresidual limb while flexing the opposite thigh to the chest is also effective. Excessivewheelchair use, which encourages contractures, is discouraged by early walking withcrutches or a walker.

An alternative approach may be used in anticipation of prosthetic use by vigoroustransfemoral amputees. A unilateral hip spica is applied in the operating roomimmediately following wound closure. Application is easily done by lifting the patient bythe opposite leg. The benefits are analogous to those achieved by postoperative casting oftranstibial amputees. The hip is aligned to discourage contractures, distal constrictionedema from bandaging is avoided, and the wound is protected from shear and directpressure, thereby reducing pain. At the first cast change, a pylon and foot may be addedto convert it to a preparatory prosthesis.

At the short transfemoral level, flexion contracture of up to 25 degrees may beaccommodated by prosthetic alignment, but hip extensor power, needed for goodprosthetic knee stability, is compromised. As one progresses distally to the midthighlevel, it is increasingly difficult to compensate prosthetically for a hip flexioncontracture. Even then, the resulting cosmesis of the prosthesis will leave something tobe desired. More than 15 degrees of hip flexion contracture will require a marked

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compensatory increase in lumbar lordosis that, even if available, may lead to low backpain.

When prescribing a prosthesis in cases with significant flexion contracture of the hip orknee, the patient and family must be forewarned of the relatively grotesque appearanceof the prosthesis. Otherwise, if the patient and family do not understand the rationale for

this initial fitting in the hope that prosthesis usage will tend to decrease the contracture,they may be very dissatisfied with the prosthesis and reject it.

In children, knee and hip flexion contractures can be stretched out by ignoring theirpresence and fitting the patient with conventional alignment techniques. Spontaneous usewill usually stretch the contractures without other special treatment.

Contractures also occur in upper-limb amputations. Limitation of glenohumeralabduction and forward flexion is common in short transhumeral amputations. Elbowflexion contracture occurs readily in a short transradial case. Either can be easilyprevented by instituting range-of-motion exercises as soon as postoperative pain hassubsided at 5 to 7 days. Gentle muscle-strengthening exercises begun at 2 to 3 weekspostoperatively are also helpful. If contractures become fixed, even an extensive programof stretching may be ineffective and require selective release of contracted muscles toallow fitting of a prosthesis.

Chronic Wound Sinus

The patient who appears with a small adhesive bandage on his wound with minimaldrainage has a problem that may or may not be related to one of the many conditionsmentioned above. This small opening may only lead to a superficial suture abscess, or itmay be a sinus related to a bone spur or low-grade, localized osteomyelitis. Since a sinusis likely to become inflamed or infected, it is useful to know that it is present. A good

way to determine this is to probe the opening with a malleable metal probe or a flexiblepolyethylene intravenous catheter after antiseptic skin preparation. Radiographs will helpto determine bone involvement. A sinus is best managed surgically during a benign,nonacute interval. A sinogram followed by excisional surgery can be curative.

POSTPROSTHETIC COMPLICATIONS

Painful Residual Limb

In this section we will be dealing with causes of residual-limb pain other than phantompain. Pain in a residual limb can have as many causes as pain in an intact limb. Taking an

adequate history and performing a physical examination continue to be appropriate, withinspection, palpation, performance tests, radiography, and other imaging studies used asnecessary. Since all persons with acquired amputations have phantom-limb sensation,there is a tendency for patients, families, and physicians not familiar with amputees toconsider all pain in the residual limb to be phantom pain. In fact, chronic phantom pain isvery rare and presents a specific syndrome of a totally preoccupying pain in a stocking-glove distribution. Another equally poor presumption is that all pain problems are relatedto a poorly fitting prosthesis, and this results in the making of many unnecessary newlimbs.

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Preamputation traumatic disruption of the interos-seus membrane and proximaltibiofibular joint, with resultant hypermobility of the fibula, can be a cause of pain in thetranstibial amputee. Ertl has recommended distal tibiofibular synostosis to prevent ortreat this hypermobility. Fusion of the proximal tibiofibular joint is a much simplerprocedure that does not require shortening of the residual limb or disturbance of theotherwise satisfactory distal tissues.

A common site of discomfort and skin breakdown in a transtibial amputation is over thedistal-anterior part of the tibia. This is commonly due to inadequate contouring(beveling) of the tibia at the time of amputation. Although this can often be corrected bylocal socket relief, with or without injection of the local bursa with steroids, surgicalrevision may be required.

Symptomatic spurs from ectopic bone formation of the transected bone may be generatedin one of two ways. One is by surgical extension of periosteal stripping onto bone that isto be retained . The periosteum should therefore be disturbed as little as possible on anybone that one anticipates keeping. In addition, the approach to the fibula should be extra-

periosteal to avoid fibular regeneration. Widespread ectopic bone formation also occurswhen the trauma leading to amputation has resulted in wide stripping of periosteum fromthe bone that is to be retained. This can be quite massive and may lead to considerablediscomfort in the residual limb. Before proceeding to revision, the surgeon shoulddetermine exactly those portions that are contributing to discomfort and not disturb allectopic bone just because it is present. Following any bone transection, the soft tissuesshould be copiously washed to remove minute bone fragments.

If the fibula is inadvertently left longer than the tibia, the resulting distal bonyprominence may be weight bearing and tender. Socket modification should be attempted,but surgical revision is often necessary. In very short transtibial residual limbs, if thefibular head and shaft are unduly prominent or hypermobile, the fibular remnant may

require complete secondary resection . This complication is prevented by routine primaryexcision of the fibular remnant if amputation is close to the tibial tubercle. In thetranstibial amputee, torn knee ligaments may result in painful instability while wearingthe standard patellar tendon-bearing (PTB) prosthesis. Depending on the degree ofinstability, it may be controlled by using a supracondylar-suprapatellar or supracondylarprosthesis or a PTB prosthesis with a thigh corset.

In transfemoral amputations, if a dynamically balanced myodesis has not beenperformed, the femur may drift anterolaterally through the soft tissue to present its distalend subcutaneously . This will produce local tenderness and even ulceration with orwithout use of a prosthesis. In the absence of ulceration, prosthetic modificationsincluding socket relief over the bony prominence or anterior filling-in of the socket justabove the prominence may be effective. If simple socket adjustments do not producerelief, surgical revision, including myodesis, may be necessary. Pain-producing bonespurs may develop at the cut end of the femur and require similar socket relief orexcision . Adventitious bursae develop over bony prominences and occasionally needtreatment beyond socket relief.

Transfemoral amputees may complain of a burning sensation in the ischial weight-bearing area, particularly in the early phases of using a quadrilateral socket. With the

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increasing utilization of ischial containment sockets and the advent of flexible socketmaterials, pressure discomfort over the ischium is less common. Nonetheless, theresidual limb should be carefully examined at each visit for areas of local inflammationsecondary to excessive pressure.

Neuroma formation is a natural consequence of nerve section, and all amputees will

therefore have several neuromas. If nerves are divided at a level that avoids bothinclusion in the wound scar and weight-bearing or other significant pressure from theprosthesis, they will rarely be symptomatic. If a symptomatic mass is suspected of beinga neuroma, direct manipulation should produce a Tinel's sign with a tingling discomfortin the peripheral nerve patterns of the missing portion of the limb. If a neuroma isincidentally found by palpation in an asymptomatic residual limb, the amputee should bereassured that it is a normal finding and does not require corrective surgery. Firm fibrousnodules that are only locally sensitive are probably not neuromas. The treatment ofneuromas should usually begin with socket accommodation. If this approach isunsuccessful after several attempts, the neuroma should be moved to a deeper site, eitherby proximal division under moderate tension or by placing the nerve end in bone. This is

certainly the case when the neuroma is directly over bony prominences where pressurefrom use with or without a prosthesis is unavoidable, such as in the hand at themetacarpal heads or at the neck of the fibula. In the case of a very short transtibial limbwith a symptomatic peroneal neuroma, the neuroma can be easily deafferented byremoval of peroneal nerve proximal to the knee through an incision posterior to the distalportion of the biceps femoris muscle.

In some transtibial amputees who have had traumatic disruption of the interosseusmembrane and subluxation of the proximal tibiofibular joint, there may be ill-definedpain related to fibular hypermobility producing pressure on the peroneal, tibial, and suralneuromas. Ertl advocated a distal tibial fibular fusion to correct this problem and providean "end-bearing" bone. It is easier to simply fuse the proximal tibiofibular joint and not

shorten the residual limb or disturb its distal soft tissues.

In dysvascular patients, a healed skin wound may be associated with considerableischemia of the underlying muscles and result in intermittent claudication duringwalking. In these cases, there will be no signs of inordinate prosthetic pressures, and thepain will occur regularly when the patient walks a specific distance. Medication may beprescribed, but the amputee should be assured that refabricating the prosthesis will nothelp.

Whenever late pain occurs in a limb amputated because of tumor, local recurrence is apossibility. The proper course of action depends upon the type of tumor and may rangefrom radiation or chemotherapy to amputation at a higher level. Consultation with anoncologist is essential before proceeding.

Adherence of Skin to Bone

In any residual limb, but especially at the transtibial level, the adherence of skin to boneor the application of split-thickness skin grafts directly to bone may rapidly lead to painand ulceration when a prosthesis is used. This occurs because skin without underlyingsoft tissue has little resistance to direct or shear forces imposed by the prosthesis. In an

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attempt to avoid revision, the amputee can be taught to mobilize tissue by gentlepersistent fingertip massage on a daily basis over several weeks as a routine part of self-care. A gel socket may be useful. A nylon sheath should be provided to reduce shearforces. If a transtibial amputation stump continues to show skin breakdown despitecompetent socket adjustments, other methods may be helpful. The addition of a rotatorunit will decrease rotational shear forces. Partial unloading of the transtibial level by theaddition of knee joints and a long thigh corset or the use of ischial weight bearing may benecessary to allow continued ambulation.

Surgical revision is done as a last resort and will usually require only a local wedgeexcision, including a small length of bone. In the case of adherent split-thickness skingrafts, often a relatively small area of adherent split graft can be excised, with primaryclosure effected by advancement of surrounding skin and subcutaneous tissue oncemuscle atrophy has resulted in relative skin redundancy at 10 to 12 months . Amputationto a higher anatomic level is rarely indicated.

Other sites where split-thickness skin grafts may not stand up to prosthetic use is over the

adductor longus tendon in the groin, at socket brims over the biceps tendon in theantecubital fossa, and in the anterior axillary fold in relation to transhumeral sockets.

Skin stretching, either by traction or by tissue expanders, is probably the best way todevelop enough normal skin to eliminate large areas of split-skin grafts. To cover theadductor tendon region in the groin, however, it is usually sufficient to swing a small flapdistally from the abdomen downward or proximally from the thigh.

Insensitive Skin

Amputees with diminished sensation in the residual limb are seen quite commonly. Thelargest group are diabetics, but other neurologic disorders such as my-elomenigocele,

Hansen's disease, and alcoholic neuropathy are also seen. These patients are not deterredby pain from continuing to walk on a locally ischemic or ulcerated residual limb andmust be taught to remove their prostheses at regular intervals for skin inspection,especially during the early phases of prosthetic use. Areas of skin blanching and/orerythema should be noted by the prosthetics team for prompt corrective action. Multipleshort periods of daily ambulation will usually allow gradual skin adaptation. Thepresence of insensate but otherwise normal skin on the residual limb should not beconsidered an indication for more proximal amputation. It does, however, demandprecise prosthetic fitting and attentive follow-up care.

Poor Fit

After a variable period of use, most amputees find that prosthetic fit can no longer beeffectively adjusted by further socket padding and additional stump socks. With anexcessive number of sock plies, usually 10 to 15, the socket/residual-limb interface isdisturbed, as manifested by a reduction in rotational control and an increased tendency topiston. In these cases, the prosthesis no longer fits properly, and a new socket is neededpromptly if dangerous, costly skin breakdown is to be avoided. On the other hand, manyproblems are easily corrected with minor sock or socket adjustments. All team members

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should therefore be aware of the signs of both loose and tight socket fit, especially at thetranstibial level. Evaluation of a residual limb for prosthetic pressures is exactly the sameas evaluation of a foot for shoe fitting. One looks for areas of prolonged erythema afterwalking in the prosthesis, erythema in abnormal places, callus or bursa formation, andlocal tenderness under erythematous areas.

Relative socket looseness will commonly cause excessive direct and shear forces over thetibia and fibula, fibular head, tibial tubercle, and distal end of the patella as the residuallimb enters the socket too deeply. This problem is usually related to residual-limbvolume decrease by atrophy or weight loss. Relative socket tightness will cause directtibial tubercle pressure on the patellar tendon bar and verrucous hyperplasia of the limbend due to loss of distal contact. This problem is often related to wearing excessive sockplies or due to weight gain. Pressure and shear forces result in inflamed and/or ulceratedareas of skin in either case.

Another transtibial problem of fit related to distal circumferential shrinkage is usuallyassociated with ill-defined pain in the residual limb. In this case, the amputee has good

suspension at the socket inlet but relative freedom of motion distally so that the residuallimb moves inside the socket like a clapper in a bell and strikes the anterior socket walleach time the knee is extended during swing phase. There is no sign of inordinateprosthetic pressure, but it may be noted, during donning or doffing of the prosthesis, thatwhile there is a snug fit proximally, there is room distally for an examining finger or thata soft insert feels loose. A weight-bearing radiograph of the residual-limb/socketinterface is useful to confirm the presence of a distal void. Often, the same situation leadsto choking. This problem may sometimes be corrected by filling in the socketposteriorly.

Lower-limb edema resulting from renal and/or cardiac disease will adversely affectsocket fit. If these amputees are unable to use their prosthesis for any reason, such as any

sudden change in their health, it may be impossible to get the socket back on. It isextremely important that they have appropriate shrinker socks to wear in bed. If they areadmitted for treatment of their underlying condition, compression of the residual limbshould be started promptly while in the hospital rather than being neglected for a periodof several days. The edema can become relatively chronic, and resumption of ambulationcan be very difficult as one struggles to shrink the residual limb again.

Bony Overgrowth in Children

The traumatic transosseous child amputee may experience rapid growth in length of theresidual limb to the point where the bone grows through the skin. This is appositional

bone growth and is not related to physeal growth, even though bony overgrowth usuallyceases when physeal growth ceases. It is often seen in the humerus, fibula, tibia, andfemur in that order of relative frequency . This may occur several times during childhoodand is easily treated by resection of sufficient bone to allow coverage with an adequatesoft-tissue envelope. Caps, plugs, chemical cautery, or electrocautery have not proved tobe consistently useful in controlling overgrowth. Proximal epiphysiodesis is con-traindicated since this has no influence on distal appositional bony overgrowth and willlead to unnecessary shortening.

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Degenerative Arthritis

Since most people who sustain amputations are middle-aged to elderly, some will havearthritis of the joints proximal to the site of amputation. Superimposed ambulation with aprosthesis may put more strain on the proximal joints, thereby contributing to arthritispain. Arthritis of the hip joint in the transfemoral amputee may be alleviated to some

degree since the trans-femoral socket bypasses the hip joint by utilizing a portion of thepelvis for weight bearing. Also, the lightest-possible prosthesis should be fabricated torequire less forceful contractions of the muscles crossing the hip joint, thus reducing jointcompression forces. If pain is not relieved, a total-hip arthroplasty should be consideredto maintain function in a prosthesis user. Likewise, transtibial amputees with significantsymptomatic hip joint arthritis should not be denied the benefits of hip joint arthroplastyif it is otherwise indicated. Weight-bearing pain in the knee secondary to femo-rotibialjoint arthritis may be partially relieved by the addition of knee joints and a thigh corset toallow shared weight bearing between the residual limb and the thigh. Patellofemoralarthritis has not proved to be a major concern. In cases of internal derangement of theknee joint, arthroscopic evaluation and surgery should be considered.

Fracture

Although uncommon, fracture in a residual limb following amputation does occursufficiently often to warrant a careful design of treatment methods to allow an early,effective return to prosthesis use. By applying current knowledge of the gait cycle andenergy expenditure in lower-limb amputees, certain goals in the treatment of lateresidual-limb fracture become clear. The general principles of fracture management,however, remain the same as in any other individual, but a different approach is alloweddue to the reduction in distal limb segment mass and lever arm length.

A combined American and Canadian study produced 90 cases with sufficient information

to provide both epidemiologic data and some specific recommendations for management.The average age at injury was 50 years, with a fall while wearing the prosthesis as theusual cause of injury. It was notable that knee joints and a thigh corset did not preventsupracondylar fractures in transtibial amputees, nor did a hip joint with a pelvic beltprevent fractures about the hip in transfem-oral amputees.

One important goal in the treatment of intertrochanteric fractures that applies to bothtranstibial and trans-femoral amputees is the restoration of a normal neck-shaft angle torestore hip abductor function. Although manipulation and casting often suffice in two-part intertrochanteric fractures, those amputees with unstable fractures are best served byopen reduction and internal fixation. Displaced femoral neck fractures in both groups

may be managed either by reduction and internal fixation or by endoprostheticreplacement. Excision of the femoral head alone will lead to an unstable gait. Instead,femoral endoprosthetic replacement or total-hip arthroplasty may be undertaken based onthe same criteria as in any patient with otherwise intact limbs.

Because of the small residual-limb mass and lever arm length in transfemoral amputees,most nondis-placed peritrochanteric fractures and shaft fractures can be successfullymanaged by non-weight bearing alone or minispica casts after appropriate manipulationof malaligned fractures.

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In transtibial amputees, preservation of knee motion and restoration of limb alignment,especially in more proximal femoral fractures, are paramount. Patients with stablesupracondylar femoral fractures can be mobilized rapidly by the use of the cast-bracetechnique . Unstable supracondylar fractures should be fixed primarily, if possible, topreserve knee motion. Severely comminuted supracondylar fractures unsuitable forfixation may be managed by casting with or without preliminary skeletal traction and/ormanipulation . Moderate malunion or loss of length at the transtibial level is easilycompensated by prosthetic adjustment, but an effort should be made to avoid flexioncontracture of the knee, which is much less compensable . In displaced intra-articu-larfractures of the knee, joint congruity should be restored as accurately as possible.

In this study, transtibial amputees were more likely to resume the use of their prosthesisthan were trans-femoral amputees due to lesser energy demands. Operative scars did notinterfere with the fitting or use of prostheses. Only 25% required a prosthesismodification following fracture, and all of these were transtibial amputees. Proximalrevision of amputations through the fracture site was not found to be necessary ordesirable.

Fractures of residual upper limbs are very rare. It is recommended that humeral fracturesbe treated by splinting. If delayed union or nonunion ensues, open reduction, internalfixation, and bone grafting should be considered, especially in transradial amputees.Fractures about the elbow may be managed by open or closed methods so long astreatment is designed to maintain elbow range of motion. In summary, good results in themanagement of fractures of residual limbs may be expected if they are treated with thesame care and expertise accorded fractures occurring in intact limbs.

NURSING INTERVENTATIONThe major goals of the patient may include relief of pain ,absence ofaltered sensory perception , wound healing , acceptance of altered

body image ,resolution of grieving process, independence in selfcare ,restoration of physical mobility ,and absence of complications .RELIEVING PAINSurgical pain can be controlled effectively with opoid analgesic ,nonpharmaceutical intervention or evacuation of haematoma oraccumulated fluid . Pain may be incisional or may be caused byinflammation ,infection and pressure on bony prominence orhematoma muscle spasm may add to the patient discomfort.