1. The main indications for amputation are:

2. Major upper limb amputations are rarely required (only 3% of the total).

1. If you are in any doubt about the necessity for amputation, obtain a second opinion from a senior colleague.

2. Operate using general anaesthesia whenever possible.

3. The level of amputation and type of prosthesis are influenced by:

4. Energy conservation is an important consideration when planning lower-limb amputation and the chosen level is crucial. Energy expenditure following bilateral below-knee amputation is still less than that of a unilateral above-knee amputation. Plan to preserve every possible dynamic structure, including the knee joint and the epiphysis in children.

5. Appraise the blood supply of the limb clinically by looking for skin colour changes, shiny atrophic appearance and lack of hair growth. Feel for skin temperature changes. Be willing to order transcutaneous Doppler recordings and measurement of the ankle-brachial index, thermography, radioactive xenon clearance and transcutaneous PO₂ measurements.

6. Assess the bone by taking plain radiographs in two planes, tomograms or a radioisotope bone scan. In the presence of bone or soft-tissue malignancy, ensure that the diagnosis has been confirmed with a biopsy. Computed tomography (CT) and magnetic resonance imaging (MRI) are essential in fully staging the lesion and assessing the necessity for amputation. Limb-sparing surgery has recently become more feasible, provided the correct indications are followed under guidance from expert tumour surgeons.

1. As the surgeon performing the operation it is your personal responsibility to obtain consent and explain possible complications. Fully inform the patient of the proposed operation. Obtain consent to amputate, if necessary, more proximally than you intend.

2. Give prophylactic antibiotics: penicillin (or erythromycin) plus one other broad-spectrum antibiotic. Swab and culture any wounds preoperatively.

3. Clean the limb and seal off the infected or necrotic areas.

4. Arrange for the disposal of the limb after amputation to the pathology department or straight to the incinerator.

5. Clearly mark the limb with indelible marker.

General techniques

1. Apply a well-padded compressible but not crushing dressing, using either cotton wool or latex foam. Hold this in place with crepe bandage taking care to avoid fixed flexion or other deformity of neighbouring joints.

2. Except in cases with infection or doubtful flap viability, apply a light shell, maximum four layers, of plaster of Paris over the dressing. This makes the patient more comfortable and able to be more mobile in bed. In specialist centres a prosthetist can apply a rigid dressing to which a temporary pylon can be attached, allowing early ambulation.

3. Leave the dressing undisturbed if possible for 10 days.

4. Order regular physiotherapy to prevent joint contractures.

5. Encourage mobilization and use of the stump as soon as the patient is comfortable.

6. When the wound has healed and sutures have been removed, apply regular stump bandaging to maintain the shape of the stump.

7. As soon as possible refer the patient to the local limb-fitting centre if you had not already done so before operation.

Amputations in children

Children’s amputations present their own special problems:

Decision making for amputations in major trauma

Haematoma

Infection

Flap necrosis

Joint contractures

Neuroma

Phantom limb sensation

Phantom pain

Failure to use a prosthesis

1. This radical operation is usually performed for malignant disease of bone or soft tissue of the pelvis or upper thigh. It is beyond the scope of anyone except a skilled and especially experienced expert.

2. It is included to demonstrate the principles if you are an assistant. The detailed steps were described by Gordon-Taylor and Monro.¹

3. The incision is shown in Figure 29.1. The external iliac, deep epigastric and internal iliac branch vessels are divided, as are the femoral, obturator and sciatic nerves. The pelvis is sectioned at the symphysis pubis and upwards from the greater sciatic notch to the iliac rim. The anterior portion of the pelvis is freed and removed with the hindquarter, and the wound is closed.

 The longer the femoral stump the better the control of the prosthesis.

 Do not transect the femur lower than 15 cm above the knee joint; this allows room for the hinge mechanism of the prosthesis. If the stump is longer, the artificial knee joint is lower than on the normal leg. This is most marked when the patient sits.

 Always perform a myodesis (Greek: desis = a binding together), anchoring a muscle group to the femur. This prevents the femur from migrating through the stump, resulting in skin necrosis; it also makes it difficult for the patient to control the prosthesis during walking.

 If there is fixed flexion deformity at the hip, fashion a shorter stump in order to fit into a prosthesis.

 If the patient is unlikely to walk after amputation, leave a short stump if the hip is stiff.

1. Place the patient supine with a sandbag beneath the buttock.

2. Use a tourniquet if there is room for it without interfering with the operative area.

3. Mark out equal anterior and posterior flaps, their bases sited at the proposed level of bone section.

4. Deepen the incision to the deep fascia, allowing the skin to retract slightly. From this level divide the anterior muscles with a raking cut aimed at the level of bone section.

5. Identify the femoral vessels beneath the sartorius muscle and doubly ligate them. Pull down the femoral nerve, ligate it with a fine suture and then cut it cleanly, allowing it to retract.

6. Divide the periosteum around the whole femur at the level of proposed section. Cut through the bone with a Gigli or amputation saw, protecting the soft tissues as previously described.

7. Now retract the distal femoral fragment and locate the profunda femoris vessels in the tissues behind the femur. Ligate them, then identify the sciatic nerve. Pull it down gently, ligate it and then divide it cleanly, allowing it to retract.

8. Complete the division of the posterior muscles using a raking cut to match the anterior flap.

9. Remove the limb.

10. Secure haemostasis.

1. Round off the end of the bone with a rasp.

2. Now turn your attention to the flaps, which should be roughly equal in size and thickness. They are composed of muscle and skin and are called myoplastic flaps. Perform a myodesis after drilling a small hole in the posterior cortex of the femoral stump. Draw and fix the quadriceps muscle over the end of the bone with absorbable sutures. Suture the remaining muscles to the quadriceps, attempting to retain roughly equal tension in all the muscle groups.

3. Insert a suction drain.

4. Close the skin with interrupted nylon sutures plus adhesive such as Steri-Strip tapes.

5. Apply a well-padded compression dressing and hold it in place by taking two or three turns of crepe bandage round the waist. Be careful, however, to avoid pulling the stump into a position of flexion with the dressing.

1. Remove the drain at 48 hours.

2. Encourage maximum mobility as soon as the patient is comfortable. Ensure regular physiotherapy is given, including prone lying to prevent a flexion contracture at the hip.

3. Inspect the wound at 10 days and remove the sutures when healed.

4. Apply a firm stump bandage daily thereafter to mould the stump into a roughly conical shape.

5. Arrange for the fitting of a temporary pylon by the third or fourth week and plan for definitive limb-fitting between the sixth and twelfth week.

1. Carefully assess the viability of the soft tissues of the lower leg when considering amputation at this level, looking for evidence of peripheral vascular disease, diabetic gangrene or trauma.

2. Do not consider this amputation in the non-ambulant patient but otherwise always try to preserve the knee.

3. The optimal level for tibial section is a third of its length. Do not make it longer than this or the resulting flaps will not contain sufficient muscle to maintain its viability. The minimum length is 6 cm. If there is a fixed flexion deformity of the knee then the required tibial lengths are as indicated in Table 29.1.

1. Seal off any infected, gangrenous areas by enclosing them in a polyethylene bag.

2. Employ general or epidural anaesthesia.

3. Apply a tourniquet to the thigh unless the amputation is for peripheral vascular disease.

4. Place the patient supine on the operating table with a padded, inverted bowl underneath the proximal tibia.

5. Mark the skin flaps (Fig. 29.2).

1. Start the anterior incision at the base of proposed bone section, cutting transversely round each side of the leg to a point two-thirds of the way down each side. Then take the incisions distally on each side, passing slightly anteriorly to a point well below the length that is likely to be required.

2. Join the two incisions posteriorly.

3. Deepen the longitudinal incisions down to deep fascia. Anteriorly incise straight down to bone and then on to the interosseous membrane. Ligate the anterior tibial vessels at this point.

4. Elevate the periosteum of the tibia for 1 cm proximal to the level of section. Divide the tibia using a Gigli or amputation saw. Bevel the anterior half of the tibial stump with the saw and a rasp. Divide the fibula 1 cm proximally and bevel the bone laterally.

5. Use a bone hook to distract the distal part of the tibia. Divide the deep posterior muscles of the calf at the same level as the tibia. At this stage identify and ligate the posterior tibial and peroneal vessels. Cleanly divide the posterior tibial nerve, allowing it to retract.

6. Use a raking cut through the soleus and gastrocnemius muscles down to the end of the posterior flap. Remove the limb.

1. Complete the smoothing and bevelling of the tibia and fibula using bone nibblers and a rasp.

2. Bevel the gastrocnemius and soleus medially and laterally, and trim the excess skin to fashion a rounded, slightly bulbous stump.

3. Release the tourniquet and secure haemostasis.

4. Insert a suction drain brought out medially through the wound.

5. Bring the posterior flap forwards over the bone and suture it anteriorly to the deep fascia of the anterolateral group of muscles, using a strong absorbable suture.

6. Close the skin, preferably with closely placed staples, or with interrupted nylon sutures and adhesive strips such as Steri-Strip tapes. Do not leave any ‘dog-ears’ laterally.

7. Apply a dressing of gauze and sterile plaster wool, then apply gentle compression of the stump with a crepe bandage. Apply a further layer of plaster wool and then a light plaster cast to mid-thigh level. Mould the plaster over the femoral condyles to prevent it from slipping down. Do not use plaster if there is any infection.

1. Elevate the leg.

2. Remove the drain at 48 hours by gently pulling it out of the top of the plaster cast.

3. Mobilize the patient early but retain the plaster cast undisturbed for at least 10 days.

4. Remove the sutures at 14 days.

5. Apply a daily stump bandage.

6. Arrange for daily hip and knee physiotherapy.

7. As soon as the wound has fully healed arrange for the fitting of a temporary pylon, either patellar-tendon-bearing or ischial-bearing, depending on the quality of the stump. Now arrange for definitive limb-fitting.

1. This was described by James Syme (1799–1870), Professor of Surgery in Edinburgh, in 1842, as an alternative to below-knee amputation. Transmetatarsal and tarsometatarsal amputation is occasionally required for severe trauma. For elective amputation, Syme’s amputation is functionally superior.

2. Ensure that there is adequate circulation in the foot. The posterior tibial pulse must be palpable. The skin of the heel must be of good quality.

3. Carry out a Syme’s or through ankle amputation, if possible, in preference to a below-knee amputation where there has been an associated amputation of the ipsilateral arm. It is possible to weight bear directly on the Syme’s stump, for instance in the night, obviating the need to attach the BK prosthesis, which is difficult to achieve with one arm.

1. Place the patient supine with the foot extending beyond the end of the table.

2. Apply a tourniquet to the thigh.

3. With the foot and ankle in a neutral position, mark the skin flaps (Fig. 29.3). The plantar flap runs from the tip of the lateral malleolus across the sole (curving slightly forward) to a point just below the medial malleolus. The dorsal flap joins the ends of the plantar incision at an angle of 45° from the line of the tibia.

4. Deepen the incision in the plantar flap down to the bone. On the dorsum, divide the extensor retinaculum and pull down the extensor tendons, dividing them as high as possible.

5. Open the ankle joint, plantar-flex the foot and divide the medial and lateral collateral ligaments from within. Take care to avoid the posterior tibial nerve and artery on the medial side.

6. Dislocate the talus downwards and open the posterior capsule of the ankle, exposing the posterosuperior surface of the os calcis and the anterior surface of the tendo achilles.

7. With a periosteal elevator, reflect periosteum and soft tissue from the medial and lateral sides of the os calcis down to the inferior surface of the bone. Continue this dissection so as to free the inferior surface.

8. Detach the long plantar ligament from the tuberosity of the os calcis and continue until you reach the plantar incision. The proximal end of the bone is now free except for the insertion of the tendo achilles. Carefully divide this from above downwards, keeping close to the bone. Avoid buttonholing the skin flap behind the tendon.

9. Now remove the foot.

1. Turn the heel flap backwards and upwards and free the malleoli and distal centimetre of tibia. Remove the malleoli and a thin slice of tibia with a saw.

2. Round off the bone edges.

3. Release the tourniquet and secure haemostasis.

4. Insert a suction drain.

5. Suture the heel flap to the margin of the dorsal incision in two layers with subcutaneous synthetic absorbable material such as polyglycolic acid (Dexon) and interrupted nylon to skin. Begin skin closure in the middle and continue to each end.

6. Ensure that the heel flap remains centred over the cut end of the tibia. The flap may be secured with adhesive such as Steri-Strip tapes.

7. If the heel flap is very unstable, transfix it percutaneously with a Kirschner wire or Steinmann pin passed up into the tibia.

    Ensure that the Kirschner wire is bent to 90 degrees outside the stump to prevent its proximal migration into the skin of the flap, so becoming buried.

8. Apply a well-padded pressure dressing and retain this either with adhesive strapping to the upper calf or a lightweight above-knee plaster cast.

1. Elevate the leg.

2. Remove the drain at 48 hours but do not disturb the dressing.

3. If you have not transfixed the heel flap, inspect the wound at 5 days to check the position of the flap. Otherwise, inspect the wound at 14 days, when the sutures and the percutaneous pin may be removed.

4. Carefully apply a stump bandage thereafter and arrange the fitting of a prosthesis as soon as the swelling has subsided, usually at 2–4 weeks.

1. Indications for ray amputation are:

1. Use a tourniquet.

2. In the case of gigantism:

3. Congenital additional rays. If the ray is buried between normal MTs expose it through a dorsal longitudinal incision and excise it. Approximate the adjacent MTs.

4. Diabetic ulcers:

1. Avoid amputating single toes if possible. Neighbouring toes tend to develop secondary deformity and take more weight.

2. Remove all the toes (nicknamed the ‘Pobble’ operation, from a poem by the English humourist Edward Lear, 1812–1888) if there are multiple painful, fixed deformities or if several toes are gangrenous.

3. Ray resection of toes may be required for gangrene or diabetes.

4. If you need to amputate the great toe, try to preserve the attachments of the short flexor and extensor tendons on the proximal phalanx.

1. Use a tourniquet after exsanguination.

2. Mark out a racquet incision for amputation of individual toes. For amputation of all the toes use a transverse incision, passing across the root of the toes on the plantar aspect, that is overlying the proximal phalanx, and across the MTPJ on the dorsum. The eventual scar should lie dorsally.

3. Take the flaps straight down to bone and dissect off the proximal phalanx.

4. Preserve the base of the proximal phalanx if possible, dividing the bone just distal to the insertion of the capsule. This creates a small wound cavity, which heals quickly, and the amputation does not damage the transverse MT ligaments. Alternatively, perform a careful disarticulation.

5. Secure haemostasis.

6. Close the skin with interrupted nylon sutures.

7. Apply a bulky compression dressing, passing a few turns of crepe bandage round the ankle to hold the dressing in position.

1. Elevate the leg.

2. Remove the sutures at 10 days and mobilize the patient.

3. Where individual toes have been amputated, ask the chiropodist to supply a toe spacer.

4. Where all the toes have been amputated, order a special insole that incorporates a combined MT and cavus support, together with a cork toe-block faced with sponge rubber.

1. Use an exsanguinating tourniquet.

2. Place the arm on a side table.

3. Mark the incision, which should be placed so that the scar will lie on the dorsal aspect and the stump will be covered by volar skin.

4. Do not suture together the ends of the extensor and flexor tendons over the end of the bone.

5. Identify the digital nerves and isolate them from the vessels before dividing them cleanly, 1 cm proximal to the stump.

6. Round off the end of the bone and remove the articular cartilage and prominent condyles when performing a disarticulation.

7. Reduce the bulk of the fibrofatty subcutaneous tissue to allow the skin edges to be brought together without difficulty.

8. Release the tourniquet and secure haemostasis before closure.

9. Avoid tight skin closure, otherwise painful and ischaemic torsion may develop as a result of postoperative swelling. Some soft tissue retraction occurs during the first 2 months but do not, on this account, leave excessive slackness of the stump; this causes an unsightly, unsupported soft-tissue mass.

10. Apply a compression dressing of gauze and narrow crepe bandage.

1. As a rule, employ this operation only for the middle and ring fingers. It is particularly suitable for the hand of a man doing manual labour, since a powerful grip can be retained.

2. The two disadvantages are the obvious deformity and a gap between the fingers through which small objects in the hand may fall.

3. Disarticulation of the index or little fingers at this level leaves the metarcarpal head projecting and unprotected. Oblique amputation through the metacarpal shaft is preferable.

1. Mark the skin incisions, which should lie over the proximal part of the proximal phalanx on each side, leaving sufficient skin to permit full abduction of the other fingers without tension in the cleft.

2. Join the incisions anteriorly just distal to the flexor crease and posteriorly over the metacarpal head with an extension along the line of the metacarpal (Fig. 29.5).

3. Complete the amputation as described above.

1. Use the same skin incision as for a disarticulation in the middle and ring fingers.

2. For the index and little finger use an incision along the midlateral aspect of the radial, or ulnar, border of the hand from the junction of the proximal and middle thirds of the metacarpal to the metacarpophalangeal joint (Fig. 29.5). Fashion a larger palmar flap and a smaller dorsal flap and joint the incisions in the cleft at the level of the web.

3. Amputate the middle and ring fingers by dividing the metacarpal cleanly through the neck, taking care not to splinter the bone.

4. Amputate the index and little fingers by exposing the middle third of the metacarpal, stripping the muscular attachments and dividing the bone obliquely with a power saw. Smooth the edges of the bone and allow the muscles to fall back over the stump. Divide the digital nerves to the radial border of the index or the ulnar border of the little finger in the proximal part of the wound.

1. Whenever possible operate using general anaesthesia and an exsanguinating tourniquet.

2. Place the patient supine with the arm on a side table.

3. Rest the arm on an inverted bowl just proximal to the site of the amputation.

1. Remove the drain at 48 hours.

2. Start physiotherapy to the remaining joints in the limb at 48 hours.

3. Remove the sutures at 10 days.

4. Refer to the local limb-fitting centre as soon as the wound has healed.

1. This is beyond the scope of all but the highly skilled, especially experienced surgeons. It is included merely to demonstrate the extent of the excision, usually for extensive tumour, if you are an assistant. There are two methods available: the posterior approach described by Littlewood (Fig. 29.6) and the anterior approach of Berger (1887), which is preferred.

2. The clavicle is divided, the vessels including the subclavian artery and axillary vein are divided, as are the trunks of the brachial plexus. The attaching muscles are divided, including pectoralis major and minor, trapezius, latissimus dorsi, levator scapula rhomboids and serratus anterior.

3. The forequarter, including the scapula, is removed and the wound closed.