Salter, Textbook of Disorders and Injuries of the Musculoskeletal System BAB VI General
Principles. Page 109
For certain serious limb conditions- such as an extensive radioresistant malignant neoplasm,
irreparable injury, gangrene, or a severe congenital deformity that cannot be corrected by
reconstructive operations – it may be necessary to remove part (or all) of the limb through bone
(amputation) or through a joint (disarticulation) and to provide the patient with an artificial lmb
(prosthesis).
In recent decades, amputation for malignant neoplasms of the extremities has been replaced
to a large extent by operations that achive wide resection of the neoplasm and immediate
reconstruction of the resultant defect, thereby sparing the remaider of the extremity (limb sparing or
limb salvage operations).
Apley, A. G., & Solomon, L. 2018. Apley's system of orthopaedics and fractures 10th Ed. London:
Arnold. BAB GENERAL ORTHOPAEDICS Pages 340-343
INDICATIONS
Alan Apley, in characteristic style, encapsulated the indications for amputation in the never-
to-be for- gotten ‘three Ds’: (1) Dead, (2) Dangerous and (3) Damned nuisance.
Dead (or dying) Peripheral vascular disease accounts for almost 90% of all amputations. Other
causes of limb death are severe trauma, burns and frostbite.
Dangerous ‘Dangerous’ disorders are malignant tumours, potentially lethal sepsis and crush
injury. In crush injury, releasing the compression may result in renal failure (the crush syndrome).
Damned nuisance In some cases retaining the limb may be worse than having no limb at all.
This may be because of: (1) pain; (2) gross malformation; (3) recurrent sepsis or (4) severe loss of
function. The combination of deformity and loss of sensation is particularly trying, and in the lower
limb it is likely to result in pressure ulceration.
VARIETIES
A provisional amputation may be necessary because primary healing is unlikely. The limb is
amputated as distal as the causal conditions will allow. Skin flaps sufficient to cover the deep tissues
are cut and sutured loosely over a pack. Reamputation is performed when the stump condition is
favourable.
A definitive end-bearing amputation is performed when pressure or weight is to be borne
through the end of a stump. Therefore the scar must not be terminal, and the bone end must be solid,
not hollow, which means it must be cut through or near a joint. Examples are through-knee and Syme’s
amputations.
A definitive non-end-bearing amputation is the commonest variety. All upper-limb and most
lower-limb amputations come into this category. Because weight is not to be taken at the end of the
stump, the scar can be terminal.
AMPUTATIONS AT SITES OF ELECTION
Most lower-limb amputations are for ischaemic disease and are performed through the site
of election below the most distal palpable pulse. The selection of amputation level can be aided by
Doppler indices; if the ankle/brachial index is greater than 0.5, or if the occlusion pressure at the calf
and thigh are greater than 65 mmHg and 50 mmHg respectively, then there is a greater likelihood the
below-knee amputation will succeed. An alternative means is by using transcutaneous oxygen tension
as a guide, but the level that assures wound healing and avoids unnecessary above-knee amputations
has not been confidently determined. The knee joint should be preserved if clinical examination and
investigations suggest this is at all feasible – energy expenditure for a transtibial amputee is 10–30%
greater as compared to a 40–67% increase in transfemoral cases. The sites of election are determined
also by the demands of prosthetic design and local function. Too short a stump may tend to slip out
of the prosthesis. Too long a stump may have inadequate circulation and can become painful, or
ulcerate; moreover, it complicates the incorporation of a joint in the prosthesis (Figure 12.20).
Discussion with the prosthetist before amputation will ensure an optimal level especially if a
specialized prosthesis is available (e.g. a cosmetic fingertip or a myoelectric forearm).
AMPUTATIONS OTHER THAN AT SITES OF ELECTION
Interscapulo-thoracic (forequarter) amputation This mutilating operation should be done only
for traumatic avulsion of the upper limb (a rare event), when it offers the hope of eradicating a
malignant tumour, or as palliation for otherwise intractable sepsis or pain.
Disarticulation at the shoulder This is rarely indicated, and if the head of the humerus can be
left, the appearance is much better. If 2.5 cm of humerus can be left below the anterior axillary fold,
it is possible to hold the stump in a prosthesis.
Amputation in the forearm The shortest forearm stump that will stay in a prosthesis is 2.5 cm,
measured from the front of the flexed elbow. However, if a shorter stump is required because of the
injury or pathology, it still may be useful as a hook to hang things from.
Amputations in the hand These are discussed in Chapter 16.
Hemipelvectomy (hindquarter amputation) This operation is performed rarely. The
indications include malignancy and intractable sepsis.
Disarticulation through the hip This is rarely indicated and prosthetic fitting is difficult. If the
femoral head, neck and trochanters can be left, it is possible to fit a tilting-table prosthesis in which
the upper femur sits flexed; if, however, a good prosthetic service is available, a disarticulation and
moulding of the torso is preferable.
Transfemoral amputations A longer stump offers the patient better control of the prosthesis
and it is usual to leave at least 12 cm below the stump for the knee mechanism. However, recent gait
studies suggest some latitude is present as long as the amputated femur is at least 57% of the length
of the contralateral femur.
Around the knee The Gritti–Stokes operation (in which the trimmed patella is apposed to the
trimmed femoral condyle) is rarely performed because the bone may not unite securely; the end-
bearing stump is rarely satisfactory and there is no room for a sophisticated knee mechanism.
Amputation through the knee is used at times but is often associated with poorer functional
and psychological outcomes to above-knee amputees. Fitting a modern knee mechanism is
troublesome and the sitting position reveals the knees to be grossly unequal in level. The main
indication for this procedure is in children because the lower femoral physis is preserved, effectively
permitting a stump length equivalent to an above-knee amputation to be reached when the child is
mature.
Transtibial (below-knee) amputations Healthy below-knee stumps can be fitted with excellent
prostheses allowing good function and nearly normal gait. Even a 5–6 cm stump may be fitted with a
prosthesis in a thin patient; greater length makes fitting easier, but there is no advantage in prolonging
the stump beyond the conventional 14 cm.
Above the ankle Syme’s amputation This is sometimes very satisfactory, provided the
circulation of the limb is good. It gives excellent function in children, and shares the same advantage
as a through-knee amputation in that the distal physis is preserved. In adults it is well accepted by
men, but women find it cosmetically undesirable. The indications are few and the operation is difficult
to do well. Because the stump is designed to be end-bearing, the scar is brought away from the end
by cutting a long posterior flap. The flap must contain not only the skin of the heel but the fibrofatty
heel pad so as to provide a good surface for weight-bearing. The bones are divided just above the
malleoli to provide a broad area of cancellous bone, to which the flap should stick firmly; otherwise
the soft tissues tend to wobble about.
Pirogoff’s amputation This amputation is similar in principle to Syme’s but it is rarely
performed. The back of the os calcis is fixed onto the cut end of the tibia and fibula.
Partial foot amputation The problem here is that the tendo Achillis tends to pull the foot into
equinus; this can be prevented by splintage, tenotomy or tendon transfers. The foot may be
amputated at any convenient level; for example, through the mid-tarsal joints (Chopart), through the
tarsometatarsal joints (Lisfranc), through the metatarsal bones or through the metatarsophalangeal
joints. It is best to disregard the classic descriptions and to leave as long a foot as possible provided it
is plantigrade and that an adequate flap of plantar skin can be obtained. The only prosthesis needed
is a specially moulded slipper worn inside a normal shoe.
In the foot Where feasible, it is better to amputate through the base of the proximal phalanx
than through the metatarsophalangeal joint. With diabetic gangrene, septic arthritis of the joint is not
uncommon; the entire ray (toe plus metatarsal bone) should be amputated.
COMPLICATIONS OF AMPUTATION STUMPS
EARLY COMPLICATIONS
In addition to the complications of any operation (especially secondary haemorrhage), there
are two special hazards: breakdown of skin flaps and gas gangrene.
Breakdown of skin flaps This may be due to ischaemia, suturing under excess tension or (in
below-knee amputations) an unduly long tibia pressing against the flap.
Gas gangrene Clostridia and spores from the perineum may infect a high above-knee
amputation (or reamputation), especially if performed through ischaemic tissue.
LATE COMPLICATIONS
Skin Eczema is common, and tender purulent lumps may develop in the groin. A rest from the
prosthesis is indicated.
Ulceration is usually due to poor circulation, and reamputation at a higher level is then
necessary. If, however, the circulation is satisfactory and the skin around an ulcer is healthy, it may be
sufficient to excise 2.5 cm of bone and resuture.
Muscle If too much muscle is left at the end of the stump, the resulting unstable ‘cushion’
induces a feeling of insecurity that may prevent proper use of a prosthesis; if so, the excess soft tissue
must be excised.
Blood supply Poor circulation gives a cold, blue stump that is liable to ulcerate. This problem
chiefly arises with below-knee amputations and often reamputation is necessary.
Nerve A cut nerve always forms a neuroma and occasionally this is painful and tender. Excising
3 cm of the nerve above the neuroma sometimes succeeds. Alternatively, the epineural sleeve of the
nerve stump is freed from nerve fascicles for 5 mm and then sealed with a synthetic tissue adhesive
or buried within muscle or bone away from pressure points.
‘Phantom limb’ This term is used to describe the feeling that the amputated limb is still
present. In contrast, residual limb pain exists in the area of the stump. Both features are prevalent in
amputees to a varying extent, and they appear to have greater significance in those who also have
features of depressive symptoms. The patient should be warned of the possibility; eventually the
feeling recedes or disappears but, in some, long-term medication may be needed. A painful phantom
limb is very difficult to treat.
Joint The joint above an amputation may be stiff or deformed. A common deformity is fixed
flexion and fixed abduction at the hip in above-knee stumps (because the adductors and hamstring
muscles have been divided). It should be prevented by exercises. If it becomes established,
subtrochanteric osteotomy may be necessary. Fixed flexion at the knee makes it difficult to walk
properly and should also be prevented.
Bone A spur often forms at the end of the bone, but is usually painless. If there has been
infection, however, the spur may be large and painful and it may be necessary to excise the end of the
bone with the spur.
If the bone is transmitting little weight, it becomes osteoporotic and liable to fracture. Such
fractures are best treated by internal fixation.
Crush Injury[1]
[1] D. R, Correlations Between Degree of Limb Ischemia in MESS (Mangled Extremity Severity
Score) Score in Predicting Amputation or Limb Salvage in Crush Injury at Hasan Sadikin
Hospital, Bandung`, Biomed. J. Sci. Tech. Res. 1 (2017) 1695–1697.
doi:10.26717/bjstr.2017.01.000515.
Criteria established by Apley mainly rely on the subjective assessment of the physician,
therefore, Helfet, Howey, Sanders and Johansen makes an objective scoring system to assess crush
injury at the affected lower limb, what it can still be saved or to be amputated. The scoring system
called the mangled Extremity Severity Score (MESS), which is now widely used around the world. MESS
wa first introduced to the public in the journal “Limb Salvage Versus Amputation: Preliminary Results
of the Mangled Extremity Severity Score”, published in 1990. Helfet stated that the scoring system is
a predictor and not a absolute procedure. However, because of the accuracy and the ease of
application, MESS is a scoring system that is most widely used around the world to assess the viability
of the lower extremities after crush injury
MANGLED EXTREMITY SEVERITY SCORE (MESS)
FACTOR SCORE
Skeletal / soft tissue injury
Low energy (stab, fracture, civilian gunshot wound) 1
Medium energy (open or multiple fractures) 2
High energy (shotgun or military gunshot wound, crush) 3
Very-high energy (above plus gross contamination) 4
Limb ischemia
Pulse reduced or absent but perfusion normal 1*
Pulseless diminished capillary refill 2*
Patient is cool, paralyzed, insensate, numb 3*
Shock
Systolic blood pressure always >90 mmHg 0
Systolic blood pressure transiently <90 mmHg 1
Systolic blood pressure persistently <90 mmHg 2
Age, yr
<30 0
30-50 1
>50 2
