2005, vol.7, no.2, lower extremity amputations

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Volume 7, Number 2 June 2005

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Introduction

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his issue of Operative Techniques in General Surgery marksa changing of the editorial guard. As the new editor of

TIGS and after reviewing the past issues managed and over-een by my predecessors, I recognize the challenge of main-aining the journal’s quality and relevance that Drs. Vaneerden and Farley achieved during their tenures. The pub-

ishers and I thank them for their excellent past work and thene example they have set for our future issues.OTIGS is first and foremost a practical journal, published

or the operating general surgeon. In this regard, it has anmmediate relevancy for its readership and provides informa-ion and techniques that can be applied in a very practicalay. However, general surgery is changing, as are many other

hings in health care, and so must this journal. The generalurgeon of today increasingly needs to become more adeptnd competent in techniques and procedures that in previousears were usually delegated to the subspecialist. This is fa-ilitated by the subspecialist who, as he or she concentratesn evermore esoteric operations, passes the more commonlyerformed “specialist” techniques onto the general surgeon.TIGS will play its part in this educational process by pre-

enting, in a measured and practical fashion, subject matterhat reflects this increasing degree of operative sophisticationhat is taking place in general surgery. Subspecialists andurgeons with specialty interests will discuss and illustrateechniques that are increasingly becoming the responsibility
f the general surgeon.
524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1053/j.optechgensurg.2005.08.002

This issue, Lower Extremity Amputations, is an excellentxample of this “crossover” between specialist and generalurgeon. Despite the association of amputation proceduresith the vascular and orthopedic specialties, many amputa-

ions are still done by general surgeons. Besides arterial insuf-ciency, amputations are used for the treatment of malignan-ies, trauma, and extremity sepsis, all clearly the bailiwick of theeneral surgeon. The methods of amputation that result in theest possible long term functional and cosmetic outcome are ofritical importance to the patient and paramount concern to theurgeon, general or otherwise. In this issue, the subtleties in-olved in choice of amputation, flap construction, soft tissue/ony prominence cushioning, and wound healing are carefullyxplained and illustrated by specialists in vascular and orthope-ic surgery. General surgeons can certainly take advantage ofhese specialists’ technical advice to promote improved opera-ive outcomes and patients’ well being.

Walter A. Koltun, MDProfessor of Surgery,

Peter and Marshia Carlino Professorof Inflammatory Bowel Disease Chief,Section of Colon and Rectal Surgery,

Penn State College of Medicine,Milton S. Hershey Medical Center

Editor-in-Chief

61

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ntroduction and General Principlesobert G. Atnip, MD

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he feet and toes are surely among the most abused andleast appreciated regions of the human anatomy. There

re few structures in the body, indeed, even fewer man-madeevices or appliances, that are subjected to such intense re-etitive, relentless punishment in such an unforgiving envi-onment, yet expected to perform without flaws. Though nothe only animal species capable of mobility on two feet, theuman is, nonetheless, the only species that is exclusivelyipedal and cannot fly. With human girth and mass showingnprecedented increases of heretofore unimagined demo-raphic proportions, it appears that the human foot will beested in the future more than it has ever been tested in theast.Only those with bad feet can truly appreciate the bliss of

aving good feet. Yet bad feet and good feet alike are seldomfforded the attention and respect that should be their due.he good foot is expected to support a mass 200 to 300 times

ts own, on a surface area no more than 1% of the body as ahole, with such assumed performance and durability that

ts owner will likely give it no conscious regard. The bad foots expected to heal quickly and completely, and preferablyhile still in use. The inconvenience of a bad foot is onehich most persons tolerate poorly and with great impa-

ience. But rather than inspiring awe and reverence for theiracles that the foot routinely performs, such temporaryisabilities more often provoke vexation and resentment athe unwelcome interruption of mobility. So the host forcesis foot to function while dysfunctional, to heal while un-ealthy, and to again withstand the trauma and neglect thataused the original problem. It is the fate of the feet and toeso be taken for granted until catastrophe ensues, and eveneyond.Advances in modern podiatry, plastic surgery, orthope-

ics, and vascular surgery offer hope and relief for the myriadroblems that beset the modern foot. Most such problemsan either be prevented, or alleviated with orthotic appli-nces, or corrected with relatively minor surgery. Indeed,any body parts, including the hips and knees, are ulti-ately more likely than the foot to fail and require major

urgery. Unlike those structures, however, the foot cannot be

enn State Hershey Medical Center, College of Medicine of the PennsylvaniaState University, 500 University Drive, Hershey, PA.

ddress reprint requests to Dr. Robert G. Atnip, Professor of Surgery andRadiology, Chief of Vascular Surgery, Penn State Hershey Medical Cen-ter, College of Medicine of the Pennsylvania State University, 500 Uni-

uversity Drive, Hershey PA 17033-2390. E-mail: [email protected]

2 1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2005.07.001

eplaced. Irreversible disease or injury of the toes and feeteads to amputation. Amputation surgery itself has advancedn modern times, though perhaps not as dramatically as thecience of prosthetics. Fortunately, the end result for mostatients is a return to functional ambulation.1,2

The articles and illustrations in this journal present thessential considerations and techniques for successful lowerxtremity amputation, whether of a single toe or of the entireimb. The methods depicted herein represent standard andidely employed techniques for amputation surgery. As with

ny surgical procedure, individual surgeons will modify theirechnique as necessary to achieve optimal outcomes for eachndividual patient.

actors Leading to Amputationatients presenting for consideration of toe or partial footmputation typically have some combination of injury, ulcer-tion, tissue necrosis, and infection. A variety of conditionsnd factors exist that predispose to the occurrence of limb-hreatening tissue loss in the foot. In patients with diabetesellitus, the processes of infection, ischemia, and neuropa-

hy have been expressed as a combined “classic triad” of riskactors, and many similar groupings could be proposed foriabetics and nondiabetics alike. An alternate and helpfulay of organizing these many influences is to segregate them

nto local and systemic categories.

ocal Factorsumerous inherent characteristics of the foot itself are re-

ponsible for its vulnerability to injury and infection. Theery purposes of the foot are to bear the weight of the bodynd provide mobility, and the design of the foot is specific forhose purposes. The bony architecture provides surfaces thatolerate high pressures by spreading them over as much areas possible, while allowing the flexibility needed for all vari-ties of locomotion. Some loss of that architecture can beolerated, but more so on the dorsal surface than the plantar.eformities that cause pressure points on the plantar surfacere the cause of much dysfunction, disability, and limb loss.n the dorsal surface, weight bearing is less of an issue, but

n equally serious problem is the thinness of the skin and softissue and relative lack of protection of the underlying ten-ons, muscles, and joints. Full-thickness skin loss on theorsal surface can result in exposure and dessication of the
nderlying fascia and tendons, often with few reconstructive

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Introduction and general principles 63

ptions. Similar problems occur when ulcers develop overoints on the dorsum of the toes or sides of the foot.

Although well padded on the plantar aspect, the calcaneuss famously vulnerable on its posterior surface where softissue coverage is much thinner. Decubitus ulcerations in thisrea are typically full thickness, often down to the calcanealone itself, and highly resistant to healing unless pressureelief and optimal perfusion can be achieved.

In many patients, especially diabetics, limb loss is initiatedy seemingly trivial lesions on the toes. Ill-fitting footwear,ail care accidents, and other minor trauma are the mostommon causes, often in the setting of sensory loss and bonyeformity from diabetic polyneuropathy. Chronic fungal andermatophyte infections of the toes can act alone or withther factors to trigger local skin injury and subsequent ne-rotizing infections.

Patients and their physicians are equally culpable in failingo recognize minor foot problems, and in failing to treat themggressively in the early reversible stages. Though personsith normally innervated feet are exquisitely sensitive to pain

nd pressure, those with neuropathic feet may be completelynaware of even the worst noxious stimuli unless the injury isetected visually. Even when blisters, ulcers, lacerations,aronychiae and other warning signs are noticed and re-orted, all too many physicians do not recognize these small

esions for the great havoc that they can wreak, particularly inhe presence of ischemia and systemic disease.

ystemic Factorsiabetes mellitus is unquestionably the dominant systemicause of major limb loss in adults. The risk of limb loss inatients with this disease is many fold higher than in compa-able nondiabetic populations, owing to effects such as im-unosuppression, neuropathy, and accelerated vascular dis-

ase. Ischemia and neuropathy have a greater incidence inhe lower extremity compared with other anatomic regions,nd clearly act in concert with local factors to promote injury,nfection, and necrosis of the foot and toes. Much remainsnknown regarding specific mechanisms of interaction be-ween this disease and its host, perhaps in part because dia-etes is not a single disease entity. Much attention has beenocused on the question of whether complications of diabetesan be avoided or ameliorated by better glucose control. Yetven with dramatic progress toward understanding diabetes,ey questions remain unanswered and key misconceptionsersist, especially as concerns the interplay of diabetes anderipheral vascular disease.In the classic triad of infection, neuropathy, and ischemia,

he latter entity may well be the least understood. The gaps innowledge begin at the level of basic science, but are perva-ive in the clinical realm, where the difficulty lies not nearlyo much in a failure to know as in a failure to recognize andpply that which is known. Although reconstructible athero-clerosis of the named axial arteries of the lower extremity ishe primary cause of ischemia in diabetics and nondiabeticslike, a well-entrenched fallacy still circulates, even amongxperienced clinicians, that nonreconstructible “small vesselisease” of the foot is equally prevalent. Such a misperceptionnderlies a false belief that ischemia is untreatable, which in
urn allows it to go undiagnosed. In fact, the number of v
ffective treatment options for peripheral arterial disease hasever been greater, but there is much progress to be made inaking treatment available to those with limb-threatening

schemia in time to prevent major tissue loss.Other systemic factors that target the foot and toes are

ecoming increasingly prevalent. Though not widely dis-ussed in this particular context, obesity cannot be ignored asdisease whose wide-reaching effects certainly include enor-ous stress on feet that must support hundreds of pounds of

xcess body mass. Obesity leads to increased trauma to theeet, and promotes lipid disorders, hypertension and diabe-es. Obese patients are often physically unable to performdequate skin and nail care of the feet, and can developubstantial edema due to venous or lymphatic insufficiency.bese patients pose daunting technical challenges for arterial

econstructive surgery, but fare even worse with limb loss.Finally, and in addition to the immunosuppression asso-

iated with diabetes, there are numerous pharmacologicgents that inhibit the immune system and thereby enhancether processes that lead to skin breakdown and infection inhe feet. Corticosteroids, cyclosporin, methotrexate, plaque-il, and newer immune-targeted drugs not only lower resis-ance to infection but may also impair tissue integrity, inhibitealing, and even promote accelerated atherosclerosis.

eneral Principlesf Amputation

he desired end results of amputation are complete healing,nd restoration of function. An amputation is a reconstruc-ive procedure, and as such requires precise and exactingechnique. For most patients, there will be no second chanceor healing, short of a second higher amputation, an outcomeoth physically draining and emotionally devastating. Pa-ients facing limb loss are keenly aware of this possibility, andften fear it more than the primary procedure itself. Re-am-utation can never be entirely prevented or avoided, and its

ikelihood can only be minimized by the most rigorous sur-ical judgment and technique.

he Decision to Amputatelthough generally viewed as the “last resort,” amputation is,

ike all surgical procedures, one that will turn out best for theatient if it is done for the right patient and the right reason athe right time. Amputation must never be viewed as a defaultrocedure that is employed only after all other options haveeen explored. Such a perception fails to recognize the re-onstructive nature of amputation surgery, and thus resultsn grave disservice to the patient. Amputation must be amonghe options considered by any clinician, medical and surgicallike, called to treat the patient with serious infection, ulcer-tion, ischemia, or injury of the lower extremity. In selectedases, amputation should be the primary procedure. In allthers, the possibility of amputation should be incorporatedarly into the physician’s thinking, to ensure that the chosenreatment regimen does not needlessly compromise thehance of successful amputation should the need arise.

Amputation is generally indicated to control refractory in-ections, or to treat pathology of the foot that is either irre-
ersible or so far advanced that healing of a functional foot is

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ot feasible. Amputation is usually an elective procedure, butay become urgent in cases of aggressive local sepsis, espe-

ially if accompanied by systemic toxicity. In such cases, theatient may require open or guillotine amputation to limithe spread of infection or to avert life-threatening sepsis. Theevel and extent of amputation in these circumstances will beictated by both local and systemic factors, but must be cho-en to ensure swift and effective reversal of the septic process.horough drainage of deep space infections and debride-ent of wet gangrene are essential to halt propagation of the

nfection. Aggressive initial surgery in these patients will usu-lly preserve ultimate limb length and function rather thanompromise them.

In the more typical elective amputation, the surgeon’s goals to select the level of amputation that will optimize bothealing and function, with the recognition that in most cases,hese dual requirements are at cross purposes. In the pres-nce of normal perfusion to the foot, the patient will, as aule, obtain optimal function from an amputation that sparess much length and tissue as is technically possible. Contrari-ise, in the face of trauma, ischemia, or any other circum-

tance that compromises tissue perfusion, the surgeon mustace a fundamental dilemma: the chance of healing and thehance of function vary inversely with one another. Perfusionnd healing improve with higher amputations, while func-ion will steadily decline. In each such patient, therefore, theurgeon will need to carefully analyze the arterial flow to theimb, optimize it however possible, and then essentially pri-ritize between function and healing. Factors to be consid-red in this process include a detailed knowledge of the pa-ient’s psychosocial history, past and current functionaltatus, general medical condition, rehabilitation potential,nd an objective assessment of the healing potential of theelected amputation level(s).

Much has been written about choice of amputation level,ut as yet, no specific tool or technology has proven any moreccurate than the combination of physical examination andedside Doppler. Basic surgical principles dictate that ampu-ations are not likely to heal if performed through or nearones of active cellulitis, suppuration, severe ischemia, orrank necrosis. The severity of all these conditions can typi-ally be determined by careful physical examination. In thease of ischemia, however, additional useful information cane obtained with a portable continuous-wave Doppler, sup-lemented if necessary by simple noninvasive testing, such ashotoplethysmography (PPG) and transcutaneous oximetryTCpO2). Other more sophisticated studies such as laseroppler velocimetry and Xenon perfusion are much lessidely used, and do not appear to offer any greater accuracyf prediction.3

Bedside doppler examination includes quantitative (ankleystolic pressure, ASP) and qualitative (signal quality) infor-ation, which both complement and objectify the basic pal-ation of femoral, popliteal, and pedal pulses. A manualulse examination is essential, and can be surprisingly accu-ate in predicting healing. At any chosen level, the presencef a palpable pulse at the nearest proximal joint is associatedith healing rates of 90% or higher, whereas those rates drop

ignificantly if pulses are palpable only at two or more jointsemoved from the selected site. Studies have differed as to the
xact relationship between ankle pressure (or ankle-brachial a
ndex, ABI) and the success of healing, but most surgeonsould attempt a toe or partial foot amputation in a nondiabetic

f the ASP were greater than 80 mm Hg, and there were nother contraindications. As ASP is often inaccurate or noteasurable in diabetics with calcified tibial arteries, the cli-ician will often find toe systolic pressures or PPGs moreelpful. Toe pressures greater than 40 mm Hg correlate with

mproved healing, as do pulsatile PPG tracings. The useful-ess of transcutaneous oximetry is debatable, due to a ratheride range of indeterminate values.The possibility of limb amputation should enter early into

he thinking of those caring for the patient with a threatenedimb, but should only be enacted after the most thoughtfulnd deliberate analysis, a process which must include theatient and family. Uncertainty of outcome is a given. In thatontext, however, the surgeon’s efforts to ensure healing andreserve function must be based on as much objective infor-ation as possible, and on the exercise of consummate judg-ent and technical skill.

eneral Technical Principleseneral

mputation surgery has never been and is not likely to be-ome a popular pursuit among surgeons of any specialty. It iseither especially challenging nor sophisticated, and doesot require advanced technology. In the era of advancedndoscopic surgery, complex endovascular intervention,oint replacement, and nearly miraculous plastic reconstruc-ive surgery, amputation surgery seems to have changed littleince the 19th century. It is no exaggeration to argue that theersisting stereotype of major limb amputation is that of theivil War battlefield.4 Amputation surgery is distasteful andisturbing to many physicians (and quite a few surgeons),nd is abhorrent for most persons to contemplate. Yet, whenone successfully and well, amputation is not just recon-tructive, but also redemptive, capable of transforming recal-itrant suffering and incapacitation into healing and rehabil-tation, albeit, at a great and nonrefundable cost. To thisndeavor, the surgeon must apply every skill at his or herisposal.In performing an amputation, the surgeon must transect,

blate, cauterize, and sever, often with large instruments andold strokes. But in the same procedure, the surgeon mustebride, smooth, sculpt and re-shape, with movements bothrecise and delicate. It is essential not only to possess each setf skills, but to know when each is needed. Whether a step inhe procedure calls for strength or subtlety, every sequence ofction must be performed with control and clear intention. Inmputations, as in many types of surgery, there is a high priceor haste and carelessness. By long tradition, amputation sur-ery is often the first procedure performed by novice surgicalrainees, but there is no better time than the beginning forhese young surgeons to learn under close supervision thatmputation requires no less skill and no less attention thanhe more advanced procedures they will learn later in train-ng.

oft Tissuehe single most important technical aspect of amputation (at
ny level) is careful handling of tissue. Even the ablative

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Introduction and general principles 65

spects of the procedure must be done with as little injury tohe transected edges as possible. Virtually all patients whoequire amputation have impaired tissue integrity, to whichs added the unavoidable injury of the amputation itself. Yet,ith appropriate technique, the degree and extent of injury

an be controlled. Proper use of the proper tools will enablehe surgeon to divide tissues cleanly, rather than tearing,reaking, avulsing, or crushing. Particular attention is neces-ary to protect the skin edges from careless blunt or sharpnjury, which can lead to failure of primary healing. It istrongly recommended to avoid use of forceps on the skindges at any time during an amputation.

One of the more common technical and judgmental errorsn amputation surgery is attempted wound closure underension, an error usually culminating in stump breakdown.voiding this error requires forethought from the beginningf the case, and careful planning throughout. Flaps must beesigned to allow closure without tension. If there is seriousoubt that this can be accomplished, the surgeon shouldonsider a different method, or even a more proximal ampu-ation. Once committed, however, the surgeon should takehatever additional time is necessary to sculpt the flaps and

uccessfully close them. Helpful maneuvers may include fur-her shortening and recessing of bone stumps, and judiciousebulking of soft tissues, as long as blood supply is not com-romised.

onehe steps of dividing and shaping the bones must be handledifferently in each amputation, but some general conceptspply. Bones should be transected through the shaft, andmputations through joints should generally be avoided. Ar-icular cartilage receives its oxygen and nutrient supply fromhe synovial fluid, and is at high risk for necrosis if the artic-lar surface is left intact within an amputation wound. Al-hough this particular problem can be averted by removinghe exposed cartilage, an equally significant problem is thatony articular prominences generally do not make good am-utation stumps.Bones should be methodically stripped of their perios-

eum, and then transected cleanly with minimal splinteringnd fragmentation. Any bone fragements and splinters muste removed from the wound. Bone edges should be meticu-

ously smoothed, especially in those areas that will lie closesto the skin. In some cases, beveling of the bone stump isdvisable to avoid sharp edges and pressure points, such asn the plantar surface of the foot. At every step, the surgeonust be aware that orthopedic instruments (saws, drills, os-

eotomes, rongeurs, etc.) have great capacity to damage ad-acent soft tissues if used carelessly.

ound Closurehe meticulous technique employed in the performance ofn amputation must be carried through to placement of theery last suture. Whether due to trauma, ischemia, local in-ection and inflammation, age, or other factors, the skin of anmputation stump is seldom normal and healthy. Yet, theuccess of the entire procedure often depends on that skin’s
bility to heal. Careless and indiscriminate handling of the P
kin and soft tissues during closure can easily cause an oth-rwise successful amputation to fail.

The skin is, in fact, often the only tissue layer that can beeadily closed. When a digit or some part of the foot has beenmputated, the surgeon is typically confronted with one orore bone stumps surrounded by transected joint capsule,

endons, fascia, muscle, and subcutaneous fat. Depending onhe length of bone stump available, it may be possible toecess the stump deep enough to allow separate closure of theascia or muscle over the bone. The advantages of deep clo-ure—coverage of bone and elimination of dead space—areubstantial. Not infrequently, however, the level of resections such that the surgeon must be satisfied with a single layerkin closure, trusting that the deeper tissues will be coaptedy default.Specific techniques for closure of the skin vary widely and

re largely the province of personal preference. The authornds much to recommend in an interrupted nylon, eitherimple or vertical mattress, placed without use of forceps andeinforced by fine Steri-strips. Subcuticular closure or skintaples are popular in some quarters, although these methodsequire more handling of the skin. Whatever method is used,he goal should be precise alignment and apposition of skindges to create the best opportunity for primary healing.ailure of the skin and subcutaneous tissues to heal primarily

s an ominous development, usually resulting in wound de-iscence and portending greater tissue loss.The need may occasionally arise to place a wound drain in

n amputation stump, but only if clearly indicated. Standardeasures should be employed to obtain hemostasis, includ-

ng direct pressure, judicious use of the electrocautery, topi-al use of local anesthetics containing dilute epinephrine, andf course ligation of vessels. Even oozing wounds will usuallytop bleeding on re-approximation and closure of the tissues,articularly if a bulky dressing is applied for added tampon-de. If a drain is necessary, it should be inserted through aeparate stab wound, not through the suture line of thetump; it should be positioned to drain dependently, andhould be removed within 48 hours. Suction drains are pre-erred to passive drains. A temporary vacuum dressing withelayed primary closure may be considered in some circum-tances.

ressingshe dressing of amputation stumps is often a matter of reli-ion more than science. Practitioners adopt their favoriteressings through training and experience, and then adhereo them fervently. Dressings can be soft or rigid, small orarge, occlusive or open. A good dressing will pad and protecthe stump, inhibit seromas and hematomas, absorb drainage,mmobilize joints, serve as a barrier to contamination, and inll these ways, generally promote healing. Any given type ofressing can succeed or fail to accomplish these goals de-ending on how it is applied. The most common and costlyrror in dressing technique is to wrap the dressing too tightly,esulting in pressure necrosis of the stump or adjacent areas,hich at best will delay healing, and at worst may require

e-amputation. Areas at risk for this complication include theorsum of the foot, the malleoli, the heel, and the patella.
reventive measures include proper technique in applying

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he dressing, and early frequent dressing changes with skinnspection, especially if the patient complains of more painhan expected.

Open amputation stumps are generally handled differentlyrom closed stumps, with great variation in individual prac-ice. The method chosen may depend on whether the sur-eon’s intention is for early revision, delayed primary closure,r secondary closure. The use of vacuum-assisted closureechniques has become increasingly popular.

ostoperative Activityostoperative care routines are, again, very surgeon- and am-utation-specific. Patient positioning, allowed activity, com-encement of physical therapy and weight bearing, use of

ntibiotics, and prophylaxis of deep vein thrombosis are allatters of surgical judgment. A solemn reminder for all care-

ivers is that patients undergoing limb amputation arenown to be at high risk for eventual loss of the contralateral

imb due to the same factors that caused ipsilateral disease. Ofhese factors, one is nosocomial, insidious, and completelyreventable: the calcaneal decubitus ulcer. It is thus impera-
ive that patients who are at bedrest following amputation,
specially those with diabetic neuropathy, must be provided allvailable measures to protect their heel(s) from pressure ne-rosis. Although a panoply of soft mattresses and foot appli-nces are available to pad the heels, the only fully reliable wayo prevent decubitus ulceration is to avoid all contact andressure on the area in question. In the case of the heels, thisan be accomplished by placing pillows under the calf andnkle such that the heel is not in contact with any surface. Inombination with a well-padded appliance such as theooke® boot, and with attentive nursing care, this simpleeasure will effectively prevent serious decubitus lesions of

he heel.

eferences. Esquenazi A: Amputation rehabilitation and prosthetic restoration.

From surgery to community reintegration. Disabil Rehabil 26:831-836,2004

. Persson B: Lower limb amputation. Part 1: Amputation methods—a 10year literature review. Prosthet Orthot Int 25:7-13, 2001

. Smith DG: Amputation. Preoperative assessment and lower extremitysurgical techniques. Foot and Ankle Clinics 6:271-296, 2001

. Sachs M, Bojunga J, Encke A: Historical evolution of limb amputation.
World J Surg 23:1088-1093, 1999

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ormal ambulation is a complex process made possibleby the architecture of the foot and by the machinery of

he neuromuscular axis. Amputation of any portion of theoot will alter the process of ambulation in degrees rangingrom trivial to prohibitive, depending not simply on themount of tissue removed, but also on the existing health andunctional status of the patient. For any given patient, ambu-ation will be impaired in direct proportion to the amount ofissue removed. Further consideration of this concept will bencluded in the discussion of each amputation level in thensuing paragraphs.

The most commonly employed levels of amputation arehe phalangeal and transmetatarsal, each of which can beingle or multiple, and are sometimes performed in combi-ation. Less common are amputations performed throughhe midfoot (Chopart and Lisfranc), and hindfoot (Syme)Fig. 1).

natomy of the Foot and Toeshe complexity of the foot is illustrated by an accounting of

ts components: 26 bones, 33 joints, and over 100 muscles,igaments, and tendons, in addition to fatty tissue, vessels,nd nerves, and its investing envelope of skin. These struc-ures are somewhat artificially divided into three zones: theorefoot, including the phalanges, sesamoids, and metatarsalsf the five digits; the midfoot, composed of the five tarsalones, and the hindfoot, made up of the talus and calcaneus.The range of motion of the foot includes plantar flexion,

owered by the posterior compartment muscles (tibialis pos-erior and flexor digitorum), and innervated by the posterioribial nerve. Extension of the foot, also called dorsiflexion, isnabled by the anterior compartment muscles (tibialis ante-ior and extensor digitorum), innervated by the anterior tibialdeep peroneal) nerve. Eversion is performed by the pero-eus muscles and is rather limited in range. Inversion derives

rom the posterior muscles and is equally limited in range.he intrinsic muscles of the foot (lumbricals and interossei)omplement the extrinsic forces to maintain balance, allowor finer movements of the toes, and contribute signficantly


ddress reprint requests to Dr. Robert G. Atnip, Professor of Surgery andRadiology, Chief of Vascular Surgery, Penn State Hershey Medical Cen-ter, College of Medicine of the Pennsylvania State University, 500 Uni-

mversity Drive, Hershey, PA 17033-2390. E-mail: [email protected]

524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1053/j.optechgensurg.2005.07.002

o preserving the normal architecture. Multiple ligaments in-luding the large plantar fascia are essential to create andaintain joint stability.Sensory innervation is supplied by five nerves: the super-

cial peroneal for the dorsal surface; the deep peroneal for aery small area of the first web space; the sural for the poste-ior and lateral areas; the saphenous for the medial aspect;nd the posterior tibial for the plantar surface. Of theseerves, only the posterior tibial is crucial for normal function,s it provides protective sensation on the weight-bearing sur-ace.

Arterial supply derives from the posterior tibial artery, theorsalis pedis (a continuation of the anterior tibial), and theeroneal artery. The latter vessel ends in smaller branches athe ankle, but the two tibial vessels extend into the foot toorm the plantar arches and directly nourish the forefoot andoes. Each toe has medial and lateral digital arteries anderves.

halangeal Amputationhe hallux has two phalanges, and the other four digits have

hree, with the distal phalanx being the smallest. Beyond thisimple anatomic difference, the hallux overshadows thether digits in functional importance by virtue of its roles inalance of the forefoot and in push-off during ambulation.lthough the second toe can adapt to some extent in thebsence of the great toe, patients who have lost the halluxnvariably notice a substantial difference in the mechanics ofalking, especially after transmetatarsal amputation. Ampu-

ations of the great toe should be performed for only thetrictest and most carefully considered indications.

Although amputation of only the distal part of a toe isechnically possible, there is little functional advantage toaving half or two-thirds of a toe, even the great toe. Certainly

n any situation where perfusion is abnormal, digital ampu-ations are best performed through the base of the proximalhalanx, leaving a relatively short stump with a better likeli-ood of healing.Digital amputations are typically performed with a “fish-outh” technique, which is preferred to a circular incision in

ll cases intended for primary closure. Since the vesselsourse along the medial and lateral aspects of the toe, it isensible to orient the fishmouth in the anterior-posteriordorsal-plantar) direction, so that the bases of the flaps areedial and lateral, including the digital vessels. Nonetheless,
any surgeons obtain equally good results from the use of a
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edial-lateral fishmouth with anterior and posterior flaps. Inither case, the incisions are arc shaped and symmetric, eachncompassing a hemi-circumference of the toe. It is oftenecessary for the apex of the flap to extend rather close to theargin of necrosis, but the surgeon must visually verify that

he skin margins of the flap are viable and not grossly in-ected. If the surgeon has any doubt regarding the skin mar-ins, the wound might be better left open temporarily.

The soft tissue of the toes is sparse, consisting of skin,inimal subcutaneous fat with nerves and vessels, investing

ascia, and tendons within their sheaths. Flaps must thereforee incised perpendicular to the skin, full thickness down tohe bone, preserving all soft tissue with the flap. The flapshould initially be generously long (as the distal pathologyermits), with the intent of shortening them to optimal

ength for a tension-free closure. After stripping of the peri-steum, the bone should be amputated through the mid-haft, and then shortened and smoothed with a rongeurown to the base, taking care not to violate the metatarso-halangeal joint. The large flexor and extensor tendonshould be then be distracted, amputated sharply, and al-owed to retract into the deeper soft tissues. Any final de-

igure 1 The skeleton of the foot, showing the level of bony transec-ion for each of the four standard toe or partial foot amputations.reation of the soft-tissue flaps for each of these procedures is de-

cribed in more detail in the text.

ridement of the flaps can then be performed (Fig. 2). fl

The ideal flaps will be just long enough to coapt withoutension, but “too long” is always preferable to “too short.”

hen faced with inadequate soft tissue for closure, the sur-eon can use standard plastic techniques to mobilize the flapsurther, or can attempt to shorten the bone, even to the pointf excising the entire base of the phalanx. The options in thatase are to convert to a transmetatarsal amputation (see nextection), or to leave the metatarsal head intact. In the latterase, it is imperative to remove the articular cartilage to avoidecrosis and infection of this nonvascular tissue layer.As described in a previous section, closure of the skin can

e accomplished with the suture method and material ofhoice, provided that the technique is as gentle and atrau-atic as possible. A minimal number of sutures. combinedith interspersed thin adhesive strips, provide a secure clo-

ure with minimal tissue injury.

ransmetatarsalmputation (TMA)

his procedure consists of amputation of one or more toeslong with a portion of the corresponding metatarsal bone(s).he success of the procedure depends heavily on the healthnd integrity of the plantar skin and soft tissues that willrovide coverage of the bone stump and ultimately form theeight bearing surface. Transmetatarsal amputation is a veryseful and effective method for treating ischemic necrosis ofhe forefoot, and often represents the patient’s last hope foralvage of a functional foot. In cases where the plantar tissues

igure 2 A simple amputation through the proximal phalanx of theeft great toe. Symmetric medial and lateral flaps have been created,ased on the digital arteries. The stump of the phalanx is visible inhe base of the wound, along with the cut ends of the extensor and
exor tendons.

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Toe and partial foot amputations 69

f the forefoot are extensively compromised, however, TMAs unlikely to be a realistic option.

It is important to note that TMA includes resection of theetatarsal head. Although sometimes tempting, amputation

f a toe through the metatarso-phalangeal (MTP) joint shoulde avoided for several reasons. Leaving the metatarsal headoes not improve function, and instead creates a potentialressure point that may predispose to recurrent ulcerationnd infection. The bulk of the metatarsal head can make skinlosure more difficult. Since articular cartilage depends onynovial fluid for its nutrient supply, the cartilage may dience the joint has been disrupted. Removing the cartilage buteaving the bony head offers no advantage over amputation ofhe entire distal metatarsal.

Transmetatarsal amputation is indicated primarily in twoituations: necrosis or ulceration of the toe(s) at or proximalo the level of the MTP joint; and/or plantar pressure ulcer-tion over the metatarsal heads. The extent of the amputations dictated by the extent of necrosis, and can encompass aingle toe, two or three toes, or the entire forefoot. Theseariations will be considered separately in the following para-raphs.

ingle Outer-Toe TMAhe toe and its metatarsal are sometimes called a “ray,” and

he corresponding surgery can be called a “ray” amputation.he most commonly performed single ray amputations are

hose of the first or fifth toes. Each is performed by the use of“racket-handle” incision consisting of an elliptical cut

round the base of the affected toe, and a straight incisiontarting at the proximal end of the ellipse and continuinglong the outer edge of the metatarsal shaft (Fig. 3). The exactontour of the incision must often be modified by the patternf ulceration or necrosis of the toe, but must be designed toreserve as much plantar skin and soft tissue as possible. It isften convenient to use the elliptical incision to disarticulatehe toe at the MTP joint, and thus remove this ulcerated oread tissue from the surgical field before proceeding with theeeper dissection. This technique has the added advantagehat the metatarsal is easier to visualize and isolate after theoe itself has been removed (Fig. 4).

After disarticulation of the MTP joint, the joint capsuleust be sharply and completely separated from the metatar-

al head. Great care must be taken in avoiding entry into theTP joint of the adjacent ray, and in avoiding injury to the

lantar soft tissues abutting the shaft of the metatarsal. (Inhese tissues are located the arterial supply to the plantarap.) Once the head is free, one then proceeds with strippingf the periosteum of the metatarsal shaft to the desired levelsing a small elevator. The shaft is then divided with a boneutter and recessed with a rongeur so that the stump is bev-led with the shorter edge on the plantar surface (to avoid aressure point) (Fig. 5).The next step is to excise the remnants of the joint capsule,

hich in the case of the first toe, will include the sesamoidone. These structures are virtually avascular and healoorly. The dissection is best done with a very sharp #15calpel blade, taking only the ligamentous and bony compo-ents, and sparing the plantar fascia and other soft tissues.
Once the tissue resection has been completed, one must t
hen assess the closure potential of the dorsal and plantaraps. If at all possible, any redundancy should be trimmedrom the dorsal flap rather than the plantar, unless the plantarissue appears to be of poor quality. In cases where the flapsill not approximate without tension, the surgeon has the

hoices of resecting more bone, debulking the flaps, leavingart of the wound open, or amputating the adjacent ray toobilize more soft tissue. When all is satisfactory, closure is

hen performed as described in the preceding section.

ingle Inner-Toe TMAransmetatarsal amputation of an inner toe (toes 2, 3, or 4)an be a useful procedure, but requires modifications in tech-ique. Because of the constraints imposed by the adjacentays, it is more difficult to perform isolated TMA of an inneroe, and more difficult to obtain good closure. If the plantarissues are relatively normal, the amputation can be donesing the racket-handle technique, with the handle extend-

ng from the dorsal end of the ellipse along the dorsal surfacef the metatarsal shaft. Added difficulties occur when thelantar skin is ulcerated or ischemic, in which case, it is

mpossible to avoid an incision on the plantar weight-bearingurface. In either case, the operation proceeds best by disar-

igure 3 An example of the “racket-handle” type of incision used forransmetatarsal amputation of the great toe. The racket joins theandle over the medial aspect of the metatarso-phalangeal joint, andhe handle extends along the metatarsal shaft. This incision can beodified for combined amputations of the first and second toes, and

an also be used for amputation of the fifth toe, or of the fourth andfth toes together.

iculating and removing the toe at the MTP joint, freeing the

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ead from the joint capsule (while not entering the adjacentoints), stripping and resecting the desired length of shaft,nd excising the remnants of joint capsule before closing. Thessentially fixed position of the adjacent metatarsal rays canake it rather difficult to close an inner-toe TMA without

kin tension. The foot can be wrapped to compress the meta-arsals and reduce tension on the suture line, but only ifrecautions are taken to avoid pressure ulceration from theandage itself.

igure 5 Transmetatarsal amputationf the great toe. The metatarsal shaftas been cut on a posterior bevel, andhe plantar flap has been trimmed ofxcess soft tissue. The flexor tendonas been cut shorter than the bone.he joint capsule of the adjacent sec-nd MTP joint is intact, and has noteen entered or disrupted.

ultiple TMAlthough in theory any combination of toes could be ampu-

ated at the TMA level, such a decision should take intoccount the relative importance of the various toes in thetability of the foot and the mechanics of walking. Significanttability and function are lost with amputation of the greatoe, especially at the TMA level, and the loss is even greater ifhe second toe is also taken. To perform TMA of the first threeoes would likely be a disservice to the patient, leaving him/

Figure 4 Transmetatarsal amputationof the great toe. The specimen hasbeen removed after disarticulation ofthe metatarso-phalangeal joint. Thesesamoid bone has been carefully ex-cised from the plantar flap. Thetransected flexor hallucis longus ten-don can be seen posterior to the shaftof the metatarsal. The plantar flap isredundant, and will need to besculpted and trimmed before closure.

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er with a narrow, tapered, and dysfunctional forefoot. Sim-larly, the more toes removed from the lateral aspect of theoot, the greater the asymmetry and imbalance of forces onhe remaining rays.

The technique for multiple TMA is a simple modificationf that for first or fifth ray amputation. An ellipitical incisions created to encompass the base of the affected toes, modifieds needed to incorporate any areas of dorsal or plantar necro-is. The racket handle then extends along the outer aspect ofhe metatarsal shaft. Flaps are created in identical fashion totandard TMA. The MTP joints are disarticulated, the meta-arsal shafts amputated, recessed, and beveled appropriately.he flaps are then sculpted and closed without tension.Although preservation of the medial toes is more advanta-

eous than saving the lateral toes, it is questionable whetherMA of more than two adjacent rays should ever be per-

ormed. In patients with diabetic or other polyneuropathies,mputations that create gross asymmetry of the forefoot aressociated with a notoriously high incidence of subsequentreakdown and re-amputation. As a general rule, balance,unction, and stump integrity will be better with a completefull-foot) transmetatarsal amputation.

ull-Foot TMAmputation of the entire forefoot at the transmetatarsal level

s one of the most useful procedures in the surgical armamen-arium. When properly performed, full-foot TMA results in aymmetric stump with favorable weight distribution. Al-hough there is no question that patients with TMA mustearn to adapt their balance, gait, and stride after loss of theorefoot, most patients will be able to walk, either indepen-ently or with simple supportive devices. Foot orthoses orustom shoes can be useful to facilitate walking, but prosthe-es are not necessary.

If the plantar tissues are intact, the plantar incision forMA crosses the foot as close to the base of the toes as pos-ible. The dorsal incision is made across the mid- to distalevel of the metatarsal shafts, as dictated by the pattern oforefoot necrosis (Fig. 6). The dorsal and plantar incisions arehen connected by axial incisions made along the shafts of therst and fifth metatarsals. The result will be a plantar flap ofariable length. In developing the plantar flap, the incisionhould be carried down to the MTP joints, which should allhen be disarticulated. This allows the surgeon to find theroper plane along the plantar surface of the metatarsal headnd shaft. From the plantar approach, the metatarsal shaftsngle toward the dorsum of the foot as they traverse proxi-ally, and it is imperative that the surgeon adhere closely to

he shafts to preserve the muscles and vessels of the plantarap.The dorsal incision is carried directly down through the

oft tissues, extensor tendons, and dorsal vessels to the ante-ior surface of the metatarsal shafts. At the desired level, thesehafts are stripped of periosteum and divided with bone cut-er or rongeur. Working simultaneously from the plantarurface, the interosseus muscles are divided along with anyemaining ligaments and tendons, and the specimen re-oved. The metatarsal stumps should be recessed and bev-

led, shorter on the plantar aspect.
Remaining on the plantar flap at this point will be the T
esamoid bones and portions of the joint capsules, whichhould be carefully excised, leaving adjacent muscle and ves-els intact. All potentially viable skin and soft tissue of bothorsal and plantar flaps should be spared until the final stagef the procedure. Excess tissue can be removed and flapsrimmed during closure, once it is known how the flaps canest be re-approximated.In the presence of ulceration or necrosis on the plantar

urface, the placement of the plantar incision and the creationf the plantar flap will need to be individualized. In theommon case of a neuropathic ulcer penetrating to the meta-arsal head, the ulcer can be excised in elliptical or V-shapedashion, which in essence will create two plantar flaps andence require a final T-shaped suture line. If the plantarecrosis is more medial or lateral than central, the remaininglantar tissue can often be rotated to achieve final closure. Inuch situations, some of the metatarsal shafts may need to bemputated shorter than others to enable closure of the flapsithout tension. It is in these cases that the imagination and

econstructive skill of the surgeon become especially impor-ant.

Like most amputations below the ankle, a full-foot TMAends itself to only one layer of closure, the skin. In essence,he dorsal surface consists of skin, virtually no subcutaneousat, and a very thin layer of fascia. If the plantar flap is tooong, it should be shortened to eliminate redundancy andead space (and thereby minimize the chance of hematoma).

igure 6 Flaps outlined for a “full foot” transmetatarsal amputation.he plantar flap is long, and the plantar incision extends along thease of the toes. The dorsal incision crosses transversely over theid- to distal level of the metatarsal shafts. Either the dorsal orlantar incisions may need to be modified if there is ulceration orecrosis of the forefoot.

he optimal length is that which brings the plantar tissues up

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o abut and securely cover the bony stumps with minimalead space, while allowing the plantar and dorsal skin to beutured without tension (Fig. 7).

Given that the success and functionality of forefoot am-utation are much superior to that of mid- or hindfootmputations, there can be a role for a certain surgicallicense” in performing modified TMA for patients withxtensive forefoot necrosis. One option is to amputate theetatarsal shafts very short, provided that the surgeon is

ware of the dangers inherent in violating the tarso-meta-arsal joints. Removal of the first and/or fifth metatarsalases will result in loss of part of the insertion of theibialis posterior and peroneus tendons, respectively. Thensuing imbalance of forces on the TMA stump leads toeformity, pressure ulceration, and impaired walking.holesale entry into the tarso-metatarsal joints is tanta-ount to performing a Lisfranc amputation, which is dis-

ussed in the following section.If the bone and deeper tissues are viable but local coverage

s inadequate, vacuum-assisted closure and/or skin graftingay allow an “open” TMA to eventually heal. In rare cases,

he surgeon may wish to consider a free tissue transfer toalvage the foot, but an almost ideal set of conditions mustertain to justify such a complex undertaking. The indica-ions, techniques, risks, and outcomes of free-tissue transferre beyond the scope of this monograph.

idfoot AmputationsLisfranc and Chopart)hese two surgical procedures were introduced by French
urgeons in the 19th century, and they were supposedly first L
mployed in America by battlefield surgeons in the Civilar. They hold out the prospect of saving part of the foot in

atients who fail or are not eligible for TMA, but they areeldom used in modern amputation surgery. The chief dis-dvantage of the Lisfranc and Chopart procedures is that theyisrupt the tendinous attachments of the midfoot and predis-ose to stump deformities associated with dysfunctional am-ulation. The loss of foot length and loss of tendon insertions

eaves the plantar flexors almost unopposed, resulting in anquinus deformity, with a consequent shift of weight bearingrom the calcaneus onto the stump itself. Although technicalodifications have been introduced that partly compensate

or this imbalance of forces, midfoot amputation has still notained wide acceptance as an alternative to below-knee am-utation. Braces and prostheses are usually required foralking, and there is a relatively high incidence of conversion

o BKA.The Lisfranc amputation is essentially a disarticulation of

he tarso-metatarsal joints, using a plantar flap for coverageith a technique virtually identical to transmetatarsal ampu-

ation. The important technical point is to remove as muchrticular cartilage as possible from the cuneiform and cuboidurfaces to circumvent cartilaginous necrosis. Various ten-on transfers, reattachments, and tendo-Achilles lengtheningTAL) have been proposed to prevent equinus deformity, butesults are often suboptimal.

The Chopart amputation shortens the foot even furthery removing the entire mid- and forefoot through thealo-navicular and calcaneo-cuboid joints. Once again, alantar flap is used for coverage, but problems with stumpeformity tend to be even more common than with the

Figure 7 Closure of the transmetatar-sal amputation with simple inter-rupted sutures. The metatarsal shaftshave been cut with a posterior bevel,essentially flush with the dorsal inci-sion. The plantar flap has beensculpted to approximate the dorsaltissue without tension or redundancy.

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onclusionsocomotion is a fundamental human activity made possibley the structure and function of the foot. Most humans con-ider the potential loss of part or all of the foot as catastrophic,nd view amputation as a disfiguring and destructive proce-ure. Yet due to either trauma or disease, as many as 150,000atients per year are confronted with the necessity for ampu-ation surgery, virtually always with no realistic alternative.or these patients, properly performed amputation surgery isreconstructive procedure that rehabilitates and restores qual-

ty of life, albeit, a different life than the patient might desire.lthough many patients have such advanced disease that lossf the entire foot is inevitable, for some the goal of partial footalvage is achievable. This chapter has described a variety ofrocedures that preserve structure and function of the footufficient to enable ambulation without a limb prosthesis. To
chieve the best results for each patient, the surgeon perform-
ng amputations must approach each procedure with thenest exacting technique and attention to detail worthy of theraft.

uggested Readingttinger C, Cooper P, Blume P, Bulan E: The safest surgical incisions and

amputations applying the angiosome priciples and using the Doppler toassess the arterial-arterial connections of the foot and ankle. Foot andAnkle Clinics 6:745-799, 2001

rinnion J, Hicks D: Transmetatarsal amputation: an 8-year experience. AnnR Coll Surg Engl 84:291-295, 2002

unk C, Young G: Subtotal pedal amputations. Biomechanical and intraop-erative considerations. J Am Podiatr Med Assoc 91:6-12, 2001

inzur MS, Pinto MA, Schon LC, Smith DG: Controversies in amputationsurgery. Instr Course Lect 52:445-451, 2003

umenapf G: Borderline amputations in diabetics—open questions andcritical evaluation. Zentralblatt für Chirurgie 128:726-733, 2003

anders LJ: Transmetatarsal and midfoot amputations. Clin Podiatr MedSurg 14:741-762, 1997

mith DG: Principles of partial foot amputations in the diabetic. Instr Course
Lect 48:321-329, 1999

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riginally described in 1843 by James Syme, Professor ofSurgery in Edinburgh, Syme amputation continues to

enerate controversy and debate regarding its role in trau-atic injuries to the foot, peripheral vascular disease, andiabetes. Syme reported the successful outcome in a case ofuppurative disease of the tarsus by disarticulation of the foott the ankle and removal of the malleoli flush with the lowerrticular surface of the tibia.1 It is interesting to note that heescribed this procedure twenty-two years before Josephister, his son-in-law, first embarked on his experiments withntiseptic surgery.2 The procedure has remained popularith Canadian and Scottish surgeons, but has found less

avor elsewhere.The Syme amputation provides an end-bearing stump

ith excellent weight bearing characteristics that is coveredith tough and durable skin of the heel flap. From a technical

tandpoint, it is one of the most difficult amputations toerform, and meticulous attention to detail is essential tonsure a satisfactory outcome.

The primary disadvantages of Syme amputation are itsigh failure rate and cosmetically unappealing bulboustump. Over the years, various modifications to the originalechnique have been introduced to improve the cosmeticppearance and outcomes in patients with peripheral vascu-ar disease and diabetic foot infections. Wagner popularized awo-stage technique for use in diabetic patients with an in-ected or gangrenous foot lesion.3 Sarmiento, in 1972, intro-uced a modification that consisted of osteotomy of the tibialnd fibular malleoli to narrow the medio-lateral diameter ofhe distal end of the stump so that a more cosmetically ac-eptable prosthesis can be fitted.4

ndicationsne of the most important requirements for a positive out-

ome when performing Syme amputation is patient selection.he principal indications are congenital deformity of the footnd traumatic foot injuries in which a viable heel pad re-ains. It can also be performed in patients with peripheral

ascular disease and diabetic infections of the forefoot. A


ddress reprint requests to Dr. Sai Sajja, Fellow in Vascular Surgery, PennState Hershey Medical Center, College of Medicine of the PennsylvaniaState University, 500 University Drive, Hershey PA 17033-2390. E-mail:

[email protected]


wo-stage procedure is recommended in these patients. Dur-ng the first stage, the ankle joint is disarticulated, followedix to eight weeks later by osteotomies of the malleoli. Aalpable posterior tibial artery pulse is considered essentialor healing following Syme amputation. In the presence ofascular insufficiency, patient selection can be further refinedy Doppler studies and transcutaneous PO2 measurements.n ankle-brachial index of 0.35 to 0.4 or an absolute Doppleralue of 40 to 70 mm of Hg is often quoted as critical toound healing.5 An absolute reliance cannot be placed on

hese tests, as factors determining the ideal level of amputa-ion in vascular patients are many and complex. Syme ampu-ation should not be performed in the presence of ulcerationnvolving the heel pad, or when the viability of heel pad isuestionable. Although an insensate stump is generally con-idered a contraindication, Srinivasan reported good resultsn twenty Syme amputations in patients with anesthetictumps.6 Gaine and McCreath also reported no problems inhree patients with neuropathic stumps in a review of forty-ix cases of Syme amputation.7

echnical Principleshere are several important principles that must be observeduring the procedure to achieve successful outcome. Theseere emphasized in the initial report by Syme and later byarris.1,2 The posterior tibial artery must be preserved as itrovides the blood supply to the heel flap. It is at risk duringhe division of medial ligaments and malleolar transaction.he heel pad must be dissected subperiosteally from the cal-aneum. This ensures that the septae that run from the plan-ar aponeurosis to the periosteum of the calcaneum remainntact. These tight compartments contain adipose tissue thatrovides resilience and hydraulic resistance to the deformingorces of weight bearing. If the loculi are opened, the fat isxtruded by pressure because they are no longer closedpaces. Subperiostal dissection also protects the calcanealranches of the posterior tibial artery from injury. The heelap lined with periosteum adheres to the cut surface of tibiaore firmly and may allow new bone formation to ensurerm fixation of the heel flap. The heel flap will contain therigins of short muscles of the foot. Excessive debridement ofhe heel flap should be avoided, as this can lead to damage tohe plantar aponeurosis. Overzealous trimming of the cor-ers of the flap (“dog ears”) must be avoided, as it may com-romise the viability of heel flap. The heel flap must be firmly
ecured to the tibia.

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The Syme amputation 75

The tibia must be divided just above the dome of therticular surface to provide a wide area for optimal weightearing. The plane of the tibial osteotomy must be parallel tohe ground to prevent migration of the heel pad over the cuturface of tibia.

perative Techniqueingle-Stage Syme Amputationfter appropriate preparation and isolation of any forefoot

nfective process, the incision is placed as follows. It begins athe distal tip of the lateral malleolus and passes along thenterior aspect of the ankle joint at a point one-finger breadthnferior to the tip of the medial malleolus. The incision is thenxtended across the sole of the foot to the lateral aspect,nding at the lateral starting point (Fig. 1). All the soft tissuesre transected down to the bone.

The foot is then plantar flexed. The tendons crossing thenkle joint are sharply divided. Anterior tibial artery is ligatednd anterior capsule of the ankle joint is divided (Fig. 2). Thenife is then inserted into the joint space between the medialalleolus and talus and the deltoid ligament is divided taking

are to avoid injury to posterior tibial artery. The clacaneo-bular ligament on the lateral aspect of the joint is sectioned

n a similar maneuver. A bone hook is placed on the posteriorurface of the talus and foot is further plantar flexed. Theosterior capsule of the ankle joint is then divided. Thisrings the superior surface of calcaneus into view. Now be-ins the painstaking subperiostal dissection of calcaneus. Theissection is continued posteriorly along the superior surfacef the calcaneus (Fig. 3). Tendo-Achilles is identified at thistage and divided. The skin in this area is densely adherent toalcaneum and care must be taken to avoid buttonholing.sing a periosteal elevator or several sharp knives, the soft

issues are separated from the medial and lateral surfaces ofhe calcaneum. The foot is plantar flexed even more and theissection is continued along the inferior surface of the cal-aneus to the end of the plantar flap. The entire foot with the

igure 1 The incision begins at theistal tip of the lateral malleolus andasses along the anterior aspect of thenkle joint at a point one-fingerreadth inferior to the tip of the me-ial malleolus. It is further extendedcross the sole of the foot to the lat-ral aspect, ending at the lateral start-ng point.

xception of heel pad is then removed from the field. The t

osterior tibial artery is identified at the distal end of the heelad and ligated.The flap is retracted superiorly and the soft tissues are

eparated from the distal ends of tibia and fibula. The peri-steum is divided one-half centimeter proximal to the jointine so that the line of bone division is through the superior

ost part of the articular surface of tibia (Fig. 4). This osteot-my should be performed so that the surface will be parallelo the ground when the patient is standing. (The correctlane may not necessarily be perpendicular to the long axis ofhe tibia.) The sharp edges of the bone are rounded off. Onlyinimal debridement of the soft tissues in the heel pad flap iserformed (see preceding section). The wound is irrigatedith antibiotic solution.A variety of techniques are available to prevent heel padigration over the cut surface of the tibia. These include

aping the heel pad with adhesive tape, using a Kirshner wireo transfix the heel pad to the bone, or drilling holes in thenterior edge of tibia and fibula and suturing the plantarascia to the bone (Fig. 5). A suction drain is recommendednd can be brought out through a separate stab incision in theistal third of the leg. The skin of the heel pad is then suturedo the skin of the anterior flap using nonabsorbable sutures.edundant corners (“dog-ears”) are inevitable and should note sculpted or debrided. Finally, a padded rigid dressing ispplied to minimize swelling and to prevent heel pad slip-age.

wo-Stage Syme Amputationn the presence of gross infection of the forefoot in patientsho are not candidates for a more distal amputation and have

nsufficient vascularity, a two-stage Syme amputation is pref-rable. Wagner has demonstrated that, in a carefully selectedroup of patients, successful healing can be achieved ininety-five percent of patients using this approach.3

The first stage consists of disarticulation at the ankleoint. The incision is placed one cm distal to the incisionescribed for the one-stage procedure. No attempt is made
o resect the malleoli or the articular surface of the tibia.

76 S. Sajja

Figure 2 The soft tissues are transected down to the bone. Foot is then plantar flexed and the tendons crossing the ankle
joint are sharply divided.


Figure 3 Subperiosteal dissection of the calcaneus is the most pain staking part of the procedure. This is best performed
with a sharp knife.

78 S. Sajja

Figure 4 The periosteum is divided one-half centimeter proximal to the joint line so that the line of bone division isthrough the superior most part of the articular surface of tibia. This osteotomy should be performed so that the cut
surface will be parallel to the ground when the patient is standing.


Figure 5 To prevent heel pad migration over the cut surface of the tibia, holes are drilled in the anterior edge of tibia andfibula and plantar fascia is sutured to the bone. A suction drain is recommended and is brought out through a separatestab incision in the distal third of the leg. The skin of the heel pad is then sutured to the skin of the anterior flap using
nonabsorbable sutures.

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80 S. Sajja

Figure 6 Elliptical incisions aremade over each malleolus so as toexcise any redundant skin and theunderlying bone.

igure 7 The malleoli are dissectedubperiosteally and resected flushith the articular surface of tibia.

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mall incisions may need to be made on the sides of theeel pad to accommodate the malleoli. Suction irrigationrains may be placed to irrigate the wound with antibioticolution in the postoperative period. The skin is looselyeapproximated, and a soft compressive dressing applied.

plaster cast can be utilized at the discretion of the sur-eon once the signs of infection subside and the drains areemoved.

The second stage or definitive amputation is performedfter six to eight weeks. Elliptical incisions are madever each malleolus so as to excise any redundancy (Fig.). The malleoli are dissected subperiosteally and resectedush with the articular surface of tibia (Fig. 7). The me-ial and lateral flares of the tibial metaphysis are re-ected to decrease the bulk of the stump. Holes arerilled in the malleoli, and the plantar aponeurosis is su-ured to the bones. The skin is closed with nonabsorbableutures.

ost-Operative Care androsthetic Considerationswell-padded rigid dressing is applied in the operating room

o control excessive edema and to enhance the adherence ofhe heel flap to the under surface of the tibia. Weight bearings delayed until wound healing is assured. As the postopera-ive swelling decreases, the rigid dressing will need to refash-
oned to ensure proper stump molding. When weight-bear-
ng ambulation is to be instituted, an ambulatory cast shoulde constructed by an expert prosthetist.

onclusionhis chapter has discussed the historical aspects of and indica-

ions for Syme amputation. Particular emphasis is placed on theechnical aspects of the one-stage and two-stage Syme amputa-ion. The surgical principles essential for a successful outcomere outlined. While the role of Syme amputation is well estab-ished in congenital foot deformities and traumatic injuries ofhe foot, with appropriate patient selection utilizing segmentalimb perfusion pressures and transcutaneous PO2 measure-

ents, satisfactory results can also be obtained in patients withascular insufficiency and diabetic foot infections.

eferences. Syme J: Amputation at the ankle joint. Lond Edinb Month J Med Sci

3:93-96, 1873. Harris RI: Syme’s amputation; technical details essential for success.

J Bone Joint Surg [Br] 38:614-632, 1956. Wagner FW Jr: Amputations of the foot and ankle: current status. Clin

Orthop 122:62-69, 1977. Saramiento A: A modified surgical-prosthetic approach to the Syme’s

amputation: a follow-up report. Clin Orthop 85:11-15, 1972. Burgess EM: Amputations. Surg Clin North Am 63:749-770, 1983. Srinivasan H: Syme’s amputation in insensitive feet: a review of twenty

cases. J Bone Jont Surg [Am] 55-A:558-562, 1973. Gaine WJ, McCreath SW: Syme’s amputation revisited: a review of 46

cases. J Bone Joint Surg [Br] 78-B:461-467, 1996

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elow knee amputation (BKA) is the most commonly per-formed major limb amputation. With proper patient se-

ection, primary healing can be expected in more than 90% ofatients following BKA.1 Similarly, nearly 90% of patientsith BKA have a realistic chance to ambulate with a prosthe-

is, compared with only 25% of patients with above kneemputation.2 The advantages of BKA accrue primarily fromhe many benefits of preserving the patient’s own knee joint.

ndications andontraindications

KA is indicated in patients who have infection, gangrene,onhealing ulcers, or severe trauma of an extent that pre-ludes salvage of a functional foot by any of the methodsiscussed in prior chapters. It is also indicated in patientsith severe peripheral vascular disease who have failed arte-

ial reconstruction or have presented with unreconstructibleisease and intractable rest pain. BKA is also sometimes per-

ormed for cure or palliation of neoplastic disease, or for limbeformities that impair overall functional status.BKA is the procedure of choice for patients meeting the

bove indications and having a good prognosis for healingnd prosthetic ambulation. BKA (rather than AKA) can beonsidered in nonambulatory patients if there is a reasonablexpectation that preservation of the knee joint would im-rove functional status (for example, by providing better bal-nce and ability to transfer). In chronically ill, debilitated,nd/or institutionalized patients, BKA often leads to flexionontractures of the knee, which in turn impair sitting andransfer, and predispose to pressure ulceration. Similarly,KA should not be performed in patients with preexistingexion contracture of the knee exceeding 15°. It is also con-raindicated in the presence of anything more than minorlceration or skin necrosis proximal to the ankle joint. Spas-ic and rigid lower extremity following a stroke is also aontraindication for BKA, as muscle spasticity will produce axed flexion deformity.


ddress reprint requests to Dr. Sai Sajja, Fellow in Vascular Surgery, PennState Hershey Medical Center, College of Medicine of the PennsylvaniaState University, 500 University Drive, Hershey, PA 17033-2390. E-

tmail: [email protected]


echnical Principles ofelow Knee Amputationhen BKA is performed for nonischemic causes, the ideal

one length is 12.5 to 17.5 cm, depending on the patienteight. A general guideline is that 2.5 cm of bone length iseeded for each 30 cm of patient height.2 For ischemic limbs,ransection 10 to 12 cm below the joint line is recommended.t a recommended minimum, three finger-breadths of tibiaistal to the tibial tuberosity should be preserved to enablerosthetic fit and function. Amputation through the distalhird of the leg is not advisable, as fitting of the prosthesisecomes more difficult, soft tissue coverage is inadequate,nd the blood supply is tenuous.

A variety of techniques have been described in the con-truction of BKA skin flaps, including equal anterior andosterior flaps, long posterior flaps and medial and lateral orkew flaps.3,4 Whichever the technique employed, carehould be taken not to dissect skin and deep fascia from thenderlying muscle, at risk of compromising flap viability.hile factors such as location of previous incisions influ-

nce the choice of flap design, the long posterior flap (pos-erior myoplasty) and skew flap techniques are the mostidely applicable. The method of equal anterior and pos-

erior flaps can be used in patients with trauma or neo-lasm, but is inadvisable in the setting of ischemia oriabetic foot disease.The advantages of posterior myoplasty are the superb soft

issue coverage and the generally good perfusion afforded byhe calf musculature. Disadvantages include the bulboushape of the stump in obese or muscular limbs, and theendency to have redundant corners (“dog ears”) that mayead to delay in rehabilitation. The skew flap technique is anlternative that provides improved stump contour leading toarlier prosthetic fitting. In a multicenter randomized controlrial, Ruckley and coworkers found that both techniques areomparable in terms of healing, prosthetic limb fitting, andobility.5 Similar findings were confirmed in a recent Co-

hrane database systematic review.6 The choice of incision issually based on familiarity with a particular technique andersonal preference. The therapeutic goal of all the tech-iques is to produce a well-healed, pain free, and functionaltump that can be fitted with prosthesis. With the availabilityf modern prosthetic techniques, a successful prosthesis cane fitted to any well-healed BKA stump with a good func-
ional outcome.

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Below knee amputation 83

perative Techniqueethod of Equalnterior and Posterior Flapsfter appropriate anesthesia, the patient is positioned supinen the operating room table. A pneumatic tourniquet can besed to minimize blood loss. The desired length of tibia iseasured below the joint line and marked. The anteroposte-

ior diameter of the leg at this level is measured and equalnterior and posterior flaps are marked, each half the legiameter (Fig. 1). The skin and deep fascia are incised alonghe marked incisions. As the anterior incision is being carried

igure 1 Equal anterior and posterior flap method is commonly usedor nonischemic causes. The ideal bone length in this situation is2.5 to 17.5 cm. The anteroposterior diameter of the leg at this level

s measured and equal anterior and posterior flaps are marked, eachalf the diameter of the leg.

ver the anteromedial surface of tibia, the periosteum is in-

ised to provide a reference for the level of tibial division. Theevel of transection of the tibia is further marked with a boneaw.

The muscles of the anterior compartment are dividedlightly longer than the anticipated tibial stump length. Theuperficial peroneal nerve is identified coursing just beneathhe fascia of the lateral compartment and is sharply dividedfter gentle traction. The anterior tibial vessels are doublyigated and deep peroneal nerve is sharply divided after gen-le traction.

The tibia is then divided with a reciprocating saw, and thebula is divided 1 to 2 cm shorter, using either a saw, or aongeur and bone cutter. Using a bone hook, the distal tibias pulled anteriorly and deep posterior compartment musclesre divided 1 cm distal to the tibial section. The posterioribial and peroneal vessels are then identified, doubly ligatednd divided. Posterior tibial nerve is gently retracted andharply divided. The gastrocnemeus and soleus muscles areivided in a tangential fashion to form a myofascial flap longnough to reach the anterior fascia across the tibia (Fig. 2).he anterior crest of tibia is beveled 45 to 60°. Using a rasp orneumatic burr, all the sharp edges of the tibia and fibula aremoothed. The tourniquet is released and hemostasis is se-ured. The wound is irrigated with antibiotic solution. Alosed suction drain is placed deep to the muscle flap, andsing absorbable sutures, the deep fascia of the posterior flap

s sutured to the deep fascia and periosteum of the anteriorap. The skin is closed with interrupted nonabsorbable su-ures.

ethod of Long Posteriorlap (Posterior Myoplasty)he operative techniques most commonly used in patientsith ischemic limbs are the long posterior flap method pop-larized by Burgess and the skew flap technique reported byobinson.3,4 The posterior myoplasty method is well estab-

ished and is based on the principle of superior blood supplyf the posterior tissues.The patient is placed supine on the operating table. A

ourniquet is typically not used on the ischemia extremity.he anterior incision is marked at the chosen level (8.5 to2.5 cm below the joint line, or 6 to 10 cm distal to theuberosity), and should encompass the anterior hemi-cir-umference of the leg. Two methods are available for deter-ining the desired length of the posterior flap: either 2.5 cm

onger than the antero-posterior diameter of the leg at ante-ior incision line, or one-third the circumference of the leg athat level (Fig. 3) Once this length has been determined, theosterior incision is marked along the posterior hemi-cir-umference. The medial and lateral incisions connect thenterior and posterior ones.

The skin and deep fascia are incised, and the anterior andateral muscles are divided with cautery. The anterior tibialessels are ligated and the peroneal nerves divided sharply ashey are encountered. If not already done, the medial, lateral,nd posterior incisions are deepened through the fascia. Theosterior incision should include the tendo-calcaneus. Theibia is now sectioned with a reciprocating saw, and the fibulas divided one centimeter shorter.

An individual surgeon’s preferred method can be used for

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ividing the soft tissues of the posterior flap. The authorecommends the use of a long very sharp amputation knife.

ith the tibia distracted anteriorly with a bone hook, and thentire specimen on gentle caudal traction, the knife is in-erted just along the posterior edge of the fibula. With swiftlicing motions, the path of the knife should follow a gentleownward curve away from the fibula and toward the poste-ior incision. The result will be a beveled posterior myofascialap, with more muscle thickness proximally and less thick-ess distally (Fig. 4).With this technique the posterior tibial and peroneal ar-

eries are transected in “uncontrolled” fashion, but blood losss rarely significant, and the vessels can be promptly com-ressed once the specimen is removed. The posterior tibialerve will be visible on the flap, and should be distractedistally, crushed proximally to inhibit neuroma, ligated at therush site with a 2-0 or 0 ligature, and then divided sharply sohat the stump retracts into the muscle mass posterior to theibia. Likewise, the sural nerve is identified along the distalargin of the flap, distracted gently, ligated, and sharplyivided. The posterior flap is then sculpted to an optimalhape and thickness.

The anterior edge of the tibia will lie directly beneath thekin, covered only by subcutaneous fat and anterior fascia. Tovoid erosion and ulceration, the anterior one-fourth to one-hird of the tibial circumference should be re-cut with a bevelf 45 to 60°, and the new edge thoroughly smoothed with aasp or high-speed pneumatic burr. The posterior flap is thenrought over the tibia and the fascial edges approximatedith a suture of choice. Drains are not usually needed for

mputations in ischemic extremities, but can be employed ifecessary. Skin is closed using interrupted nonabsorbableutures.

kew Flap Methodhe skin flaps are of equal length, semicircular, and are basedn a line around the limb at right angles to the long axis. The

Figure 2 After the division of tibia and fibula, the musclethe tibial division. The gastrocnemeus and soleus muscllong enough to reach the anterior fascia across the tibia

ircumference of the leg is measured at the chosen level of fi

ibial division and skin flaps are one fourth this in length. Thenterior starting point of the incision is 2 cm lateral to thenterior border of the tibia, over the middle of the anteriorompartment. The posterior point is half way around theircumference. The incision is extended for about 2 cm an-eriorly to facilitate beveling of the tibia (Fig. 5). The skin andeep fascia are divided along the marked incisions. No at-empt is made to separate the deep fascia from the underlyinguscle.Division of the anterior and lateral compartment mus-

les and neurovascular structures is performed as de-cribed previously. Tibia is sectioned at the chosen levelnd fibula divided 2 cm proximally. It is beveled as de-cribed previously. A bone hook in the medullary cavityill help retract tibia anteriorly, and the soft tissues are

eparated from the tibia and fibula. The length of the gas-rocnemeus and soleus muscle flap should be at least equalo the diameter of the leg. The muscle bulk is thinned andome of the muscle from the medial and lateral aspects isemoved while leaving the deep fascia intact (Fig 6). Afteremostasis and irrigation, the muscle flap along with thettached deep fascia is brought anteriorly and sutured tohe deep fascia and periosteum. The skin flaps enclose theosterior muscle flap and are closed with interrupted non-bsorbable sutures (Fig. 7).

ostoperative Managementany experienced amputation surgeons employ rigid

ressings, applied in the operating room to help controlostoperative edema, protect the stump and prevent flex-

on contracture of the knee. Care should be taken to avoidroximal constriction of the thigh. As the swelling de-reases, a new rigid dressing may need to be applied. Arained therapist should closely supervise prosthetic am-ulation. After two to three weeks, elastic stump socks cane used to further shape the stump before final prosthetic

deep posterior compartment are divided 1 cm distal toivided in a tangential fashion to form a myofascial flap

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Figure 3 The incision is marked 8.5 to 12.5 cm below the joint line, or 6 to 10 cm distal to the tuberosity. It shouldencompass the anterior hemi-circumference of the leg. The length of the posterior flap should be 2.5 cm longer than the
antero-posterior diameter of the leg at anterior incision line.

86 S. Sajja

Figure 4 To create the posterior flap, the author recommends the use of a long very sharp amputation knife. With thetibia distracted anteriorly with a bone hook, and the entire specimen on gentle caudal traction, the knife is inserted justalong the posterior edge of the fibula. With swift slicing motions, the path of the knife should follow a gentle downwardcurve away from the fibula and toward the posterior incision. The result will be a beveled posterior myofascial flap, with
more muscle thickness proximally and less thickness distally.


Figure 5 The incision for skin flaps method is semicircular and is based on a line around the limb at right angles to thelong axis. The circumference of the leg is measured at the chosen level of tibial division and skin flaps are one fourththis in length. The anterior starting point of the incision is 2 cm lateral to the anterior border of the tibia, over the middleof the anterior compartment. The posterior point is half way around the circumference. The incision is extended for
about 2 cm anteriorly to facilitate beveling of the tibia.

88 S. Sajja

Figure 6 The length of the gastrocnemeus and soleus muscle flap should be at least equal to the diameter of the leg. The
muscle bulk is thinned and some of the muscle from the medial and lateral aspects may need to be removed.

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onclusionselow knee amputation is the most frequently performedajor extremity amputation. If loss of the foot is inevitable,

very attempt should be made to preserve the knee joint sohat patients may be afforded the best opportunity to ambu-ate with prosthesis. In dysvascular extremities, the posterior

yoplasty technique has long been established as a safe andeliable procedure with excellent functional results. Rigidtump dressings offer considerable advantages over tradi-ional soft dressings. An aggressive rehabilitation programhould be started early in the postoperative period with theelp of well-trained physical therapists and orthotists to

igure 7 The muscle flap along with thettached deep fascia is brought anteri-rly and sutured to the deep fascia anderiosteum. A suction drain is placed be-eath the muscle layer. The skin flapsnclose the posterior muscle flap and arelosed with interrupted nonabsorbableutures.

chieve functional independence.

eferences

. Smith DG: Amputation. Preoperative assessment and lower extremitysurgical techniques. Foot Ankle Clin 6:2, 271-296, 2001

. Carnesale PG: Amputations of the lower extremity, in Canale ST (ed):Cambell’s operative orthopaedics (10th ed). Philadelphia, PA, Mosby,2003, pp 575-586

. Burgess EM, Romano, RL et al: Amputations of the leg for peripheralvascular insufficiency. J Bone Joint Surg Am 53:5, 874-890, 1971

. Robinson KP, Hoile R, Coddington T: Skew flap myoplastic below-kneeamputation: a preliminary report. Br J Surg 69:9, 554-557, 1982

. Ruckley CV, Stonebridge PA, Prescott RJ: Skewflap versus long posterior flap inbelow-knee amputations: multicenter trial. J Vasc Surg 13:3, 423-427, 1991

. Tisi PV, Callam MJ: Type of incision for below knee amputation. Co-
chrane Database Syst Rev 1:CD003749 Review, 2004

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nee Disarticulation and Above-Knee Amputationarla M. Anderson, MD

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he previous two chapters have described a series of sur-gical procedures that illustrate priorities in the manage-

ent of limb-threatening injury and disease. Failing preven-ion or successful nonoperative management, the surgeonelects a level of amputation that minimizes tissue loss, en-bles healing, and preserves as much function as possible.

alking will almost always still be possible if only the fore-oot is lost. The functionality of mid- and hind-foot amputa-ions is highly variable, but may suffice for younger healthieratients. If no part of the foot can be salvaged, the surgeonill then typically be faced with a decision that has major

onsequences for the patient: whether to attempt salvage ofhe knee joint.

As previously emphasized, loss of the knee joint markedlyeduces the chance of community ambulation in all but theeartiest and most motivated patients. Yet all amputationurgeons are familiar with the circumstances that render theeg and knee unsalvageable: severe ischemia, infection, jointontractures, crush injuries, or other extensive trauma. Theurrent chapter will address techniques that again give pri-rity to healing and function, even when the knee joint can-ot be preserved.

natomy of the Knee and Thighneehe knee joint is the articulation between the femur and the

ibia, more specifically, between the condyles of the femurnd tibia. The knee is a hinge joint, stabilized by the anteriornd posterior cruciate ligaments, the tibial and fibular collat-ral ligaments, the quadriceps and patellar tendons, the ili-tibial tract, and the attachments of the biceps, gastrocne-ius, and adductor muscles. The articular surfaces are

ushioned by the medial and lateral mensici, also known ashe semilunar cartilages.

Aside from these musculoskeletal structures, the anatomyf the knee is notable for the popliteal artery and vein, whichass in the midline, directly posterior to the intercondylarotch, along with the tibial nerve. The common peronealerve branches from the sciatic nerve proximal to the knee


ddress reprint requests to Dr. Karla M. Anderson, Assistant Professor of Surgeryand Radiology, Division of Vascular Surgery, Penn State Hershey Medical Cen-ter, College of Medicine of the Pennsylvania State University, 500 University

tDrive, Hershey, PA 17033-2390. E-mail: [email protected]


oint, and courses more laterally behind the knee. The pop-iteal space consists of the vessels and connective tissue sur-ounding them, both above and below the knee.

highxtending from the inguinal crease to the knee, the thigh isomprised of the femur, vessels and nerves, connective tis-ue, and three groups of muscles. The anterior group in-ludes the quadriceps femoris and sartorius; the medialroup contains the adductor longus and magnus and theracilis; the posterior group is the biceps femoris, semitendi-osus, and semimembranosus.Differences in anatomy at different levels are important for

he surgeon to understand, particularly as regards the vascu-ar anatomy. The common femoral artery and vein are essen-ially subcutaneous, but both the profunda femoris and (su-erficial) femoral arteries quickly pass deep to fascia anduscle as they course distally from the femoral triangle. Therofunda passes medial to but toward the femur, while theemoral artery parallels the femur until the vessel emergesrom the adductor canal as the popliteal artery and passesosteriorly into the proximal popliteal space.The femoral nerve passes deep to the inguinal ligament

nd immediately divides into a series of both muscular andutaneous sensory branches. The saphenous nerve accompa-ies the femoral artery through the adductor canal, and thenurfaces to accompany the greater saphenous vein, from be-ind the sartorius tendon. The sciatic nerve, the largest and

ongest peripheral nerve in the body, enters the thighhrough the sciatic notch and courses deep to the bicepsemoris muscle until the nerve divides into the tibial andommon peroneal branches proximal to the knee joint.

nee Disarticulationeneral Considerations

ike the Syme amputation, the knee disarticulation has nevereen widely accepted by most amputation surgeons, but re-ains a loyal following among a minority of surgeons androsthetists. Its advantages are numerous. It preserves notnly the length of the limb, but also the function of the thighuscles, providing a “long and strong” lever arm for ambu-

ation. No muscles are cut in performing a knee disarticula-ion, and the tendons and ligaments around the knee can beeadily reattached to the femur. Because the function of all
high muscles is preserved, there is much less likelihood of

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Knee disarticulation and above-knee amputation 91

ontracture of the thigh, compared with AKA. Moreover, thend of the femur is a more suitable weight bearing surfacehan the ischium (for AKA).

Disadvantages of knee disarticulation cannot be ignored,nd account for its lack of popularity. Coverage of the bonytump requires use of the soft tissues of the upper calf, whichn some cases may be of dubious quality. The stump is some-hat bulky, requiring special considerations in prosthetictting. The prosthetic knee joint is located lower than theontralateral natural joint, a concern which may or may note problematic with walking.In general, knee disarticulation can be considered in

ounger patients, especially children, in whom it preserveshe growth plate of the femur. For young adults, opinionsiffer as to whether there is any significant advantage of kneeisarticulation versus distal AKA. Amputation through thenee should generally be avoided in older patients with vas-ular disease, who, if they are not suitable for a high BKA, areot likely to have adequate tissues to heal a knee disarticula-ion. In selected nonambulatory patients, this type of ampu-ation should be considered to avoid the development ofither knee or hip joint contractures.

echniquenee disarticulation is performed with the patient supine,nd with the thigh elevated on a soft roll. A pneumatic tour-iquet is preferred by some surgeons, but not mandatory.ncisions are made and flaps developed by one of severalethods. The classic approach is based on a longer anterior

Figure 1 Representative incisions for a knee-disarticul(dashed line below knee): A fish mouth configuration ipatella and patellar ligament. The corners are placed atabout 4 inches distal to the level. The posterior flap is thknee joint, as depicted. The underlying soft tissues areselves. The patellar ligament is divided from its insertioline above knee): The fish-mouth technique uses equal aflaps can be modified according to the presence of priorcorners should be at the desired level of bony amputati

ap, but the procedure can also be performed with a long t

osterior flap, or with equal fishmouth flaps, the latter ori-nted in either the sagittal or coronal planes. If fishmouthaps are used, each should have a length about 2/3 that of the

eg circumference at the site of incision.

lassic Approachsymmetric anterior curvilinear incision is made from the

evel of the joint line, extending to the distal aspect of theibial tuberosity (Fig. 1). The incision is taken perpindicularhrough the soft tissues down to bone, incising the fascia athe same length as the skin, which will ensure adequate cov-rage of the femoral condyles and add durability to thetump. Periosteum is taken with the flap, which is developeduperiorly, detaching the pes anserinus and patellar ligamentrom the tuberosity. The capsule of the knee joint is thenncised anteriorly, medially, and laterally along the marginsf the tibia, exposing the joint itself. Flexion of the knee to0° aids in exposure of the cruciate ligaments which are thenivided at their tibial insertion site. The posterior capsule ishen located and divided at the tibial attachments (Fig. 2).

At the completion of this sequence of steps, the surgeonill now be able to visualize the neurovascular bundle within

he popliteal fossa. The veins and artery should be individu-lly exposed, clamped, divided, and doubly ligated (nonab-orbable suture). The tibial nerve should be placed on mod-rate tension, ligated proximally, then sharply divided andllowed to retract into the depths of the stump. The neuro-ascular structures are in some few cases densely adherent tohe posterior capsule and cannot be readily mobilized until

nd for above-knee amputation. Knee-disarticulation, but the anterior flap is typically longer to include thel of the knee joint, and the anterior flap should extend

ised about two or two-and-one-half inches distal to thed with a gentle bevel corresponding to the flaps them-the tibial tuberosity. Above-knee amputation (dashedand posterior flaps, but the length and symmetry of the

ons, ulcers, or areas of necrosis. The medial and lateralthe length of the flaps should be about 3 inches.

ation as usedthe leveen incdividen ontonteriorincisi

hey have been transected. A pneumatic tourniquet is partic-

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larly useful in such circumstances to avert unexpectedroblems with vascular control. The next step is to identifyhe biceps tendon as it inserts onto the fibula, and transect itt that level. The surgeon can then visualize the commoneroneal nerve, which is distracted, ligated and divided inimilar fashion to the tibial nerve.

The amputation is then completed by developing the pos-erior flap, which in the classic approach has a length about/3 less than the anterior flap. The skin incision is againurvilinear, based at the joint line on each side, and carriedown perpendicular through the fascia. The gastrocnemiususcle must be bluntly separated from the underlying so-

eus, and is then divided far enough (several centimeters)eyond its origin to preserve the superior geniculate arteries.ith this step the specimen is free to be removed from the

eld.If a tourniquet is in use, it can now be deflated. The open

tump should be inspected, and hemostasis obtained. Anyharp margins of the femoral condyles are smoothed withonguer, rasp, file or burr. The femoral articular cartilage maye left undisturbed.

igure 2 A later stage in the knee disarticulation procedure. The flapsave been developed and the knee joint opened from the front. Theruciate ligaments, collateral ligaments, and menisci have beenransected. The origins of the gastrocnemius muscles, and the pop-iteal neurovascular bundle can now be visualized. Stepwise controlnd transection of these structures is accomplished. The vesselshould be securely suture ligated. The tibial nerve should be ligatednd divided well behind the femur. Finally, the posterior skin andascia are divided to complete the amputation.

The patella is left intact within its tendon. The patellar t

igament is placed on tension and sutured to the stump of theruciate ligaments at the intracondylar notch, thus stabilizinghe quadriceps mechanism and ensuring good muscle func-ion postoperatively (Fig. 3). The remaining biceps tendonnd hamstring tendons are also secured to the cruciate stumpn a similar fashion. Any excess tendon and ligament may beebrided.The flaps can now be assessed for length, and carefully

rimmed of redundant or devitalized soft tissues. Once theaps are deemed satisfactory, the anterior and posterior fasciare then closed with interrupted absorbable suture, over arain if necessary (see introductory chapter), which is bestrought out through a separate stab wound (Fig. 4). The skindges must come together without tension. The surgeon’shoice of dressing is then applied.

If appropriate preoperative evaluation has been per-ormed, the flaps will be adequately perfused, with no areasf infection or necrosis. Should there be major concern dur-ng the procedure about the viability or length of the flaps, aecision will be required to either modify the amputation asescribed in the next section, or convert to above-knee am-utation. A compression dressing is applied.

odified Knee Disarticulationeveral modifications of the classical knee disarticulationave been developed, primarily to equalize the level of therosthetic knee to that of the contralateral knee joint. Sec-ndary advantages include a reduction in the bulk of the

igure 3 Closing the completed knee disarticulation. The patellarendon is brought down into the intercondylar fossa and sutured tohe stump of the anterior cruciate ligament. The condyles are leftntact in this illustration, but some authors recommend removinghe convex surfaces of the condyles along with the articular cartilagesee text). Likewise, the patella is typically left intact within itsendon, but the technique can be modified to excise the patella,epending on the surgeon’s preference and the circumstances of the

ndividual case. The soft tissue flaps consist of relatively thin fascia,ubcutaneous tissue, and skin, and must be carefully closed without
ension.

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tump, and modifications of the flaps that are less problem-tic for the dysvascular limb. The primary disadvantage of theodified procedures is a moderate increase in technical dif-culty. Similar to the classic approach, each of the modifiedechniques can be performed with sagittal or coronal flaps ofariable length.

The four common eponymous modifications are as fol-ows:

1. Gritti-Stokes: removes condyles of femur leaving a bev-eled anterior femoral edge to which the patella is thenanchored.

2. Burgess: removes patella and portion of condyles.1

3. Youkey: removes patella and completely removes thecondyles.2

4. Nellis/Van De Water: removes the femoral condyleswithout bevel, and anchors the patella over the distalend of the femoral stump.3

echniquehe initial stages of these modified procedures are identical

o the classic technique described above. Most authorstrongly recommend use of the pneumatic tourniquet. Allascia and tendinous attachments to the tibia and fibula areivided as distally as possible. Disarticulation of the jointroceeds through the various ligaments. The neurovasculartructures are divided individually and ligated securely.

The popliteal artery should be ligated distal to the origin ofhe superior geniculate branches. Because the posterior tis-ues have a tendency to retract, the posterior flap should beut generously long to include portions of both heads of theastrocnemius muscle.

If the patella is to be removed, the resection is done sub-eriosteally; the resulting defect in the patellar tendon muste carefully closed with interrupted suture. The differentodifications call for variable lengths of the femoral condyles

o be resected perpendicular to the long axis of the femur,

igure 4 A schematic of the completed and closed knee disarticula-ion, illustrating the relationship of underlying bony and musculo-endinous structures. In this illustration, sutures are visible wherehe patella has been (optionally) removed from within its tendon.

ither with or without beveling. The edges of femur and r

ondyles are smoothed with an instrument of choice. Anyemaining cartilage and the synovium may be left in place.

The patellar ligament (with the patella excised) is placedn tension, brought down around the femoral stump, andecured to the stump of the cruciates at the level of the intra-ondylar notch (nonabsorbable suture). The remaining ten-inous ends (biceps and hamstrings) are also brought outround the bony stump and secured to the sides of the patel-ar ligament/ tendon or the cruciates. Any excess tissue isebrided. The remainder of the closure includes interruptedascial sutures and skin closure. Temporary (�48 hrs) suc-ion drainage is optional, but should be actively consideredith modified knee disarticulation to eliminate dead space

nd enhance tissue coaptation.Although the procedures described in the preceding para-

raphs are known as modifications of knee disarticulation,hey could just as accurately be considered as modificationsf trans-femoral (above-knee) amputation with a very longemoral stump. Except for the specific indications notedbove, mainstream opinion holds that standard AKA isquivalent or superior to through-the-knee amputation foratients whose knee joints cannot be preserved.

bove-Knee Amputationeneral Considerations

he trans-femoral or above-knee amputation (AKA) is indi-ated for patients with severe disease, injury, or ischemia ofhe leg and foot. Patients selected for AKA are generally thoseith some combination of necrosis, infection, injury, neo-lasm, or ischemia involving the calf or distal thigh, such thathe musculoskeletal structures of the leg are not usable forelow-knee amputation. A second category of patients in-ludes those who have the potential to heal at the BKA level,ut are nonambulatory and debilitated, with a high risk foreveloping flexion contracture of the knee after BKA. In this

atter group of patients the major advantage of preservingimb length relates to balance and stability in the sitting po-ition, as well as ability to transfer from bed to chair. A wellealed BKA with normal range of motion at the knee joint isighly advantageous for both balance and transfers, but aontracted knee joint is a major liability. The possible rolend value of knee disarticulation for such patients has alreadyeen reviewed in the previous section.It is most commonly the patient with the ischemic limb

hat presents the difficult decision whether to spare or sacri-ce the knee joint. The surgeon must consider a variety ofactors involving the condition of both the limb and the pa-ient (see the Introduction at the beginning of the Journal).he many factors must be weighed against each other, andost are relative rather than absolute. Nonetheless, two spe-

ific considerations argue very strongly against an attempt toave the knee: first, a nonambulatory patient, and second, theresence of significant nonreconstructible arterial occlusiveisease proximal to the femoral artery (as evidenced by ab-ent ipsilateral femoral pulse). In equivocal or borderlineituations, the patient should be counseled that attemptedalvage of the knee may mean longer hospitalization, slowerealing, a more protracted course, and a significant risk of
e-amputation at the AK level.

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Once the decision has been made to perform AKA, theurgeon then faces a second and sometimes equally difficulthoice: the level of the AKA. Preservation of femoral lengthlearly yields better function, but only if the amputationeals. Differences in functionality of long versus short AKAre not so dramatic as the difference between BKA and AKA,ut neither can the differences be dismissed. A generallyseful guideline is that the greater the prospect for ambula-ion, the greater the length of femur that should ideally beetained.

echniquehe skin incision for AKA is virtually always a fishmouthonfiguration with equal anterior and posterior flaps (Fig. 1).ircular incisions can be used, but are more difficult to close.edial and lateral flaps could theoretically be utilized, but

re essentially nonanatomic. The length of the flaps should beufficient to provide secure tension-free closure over the fem-ral stump, without redundant soft tissue or excessive deadpace in the depths of the wound. If myodesis/myoplasty islanned (fixation of muscle to the femoral stump), the mus-le flaps should be fashioned longer.

The incision is made as marked on the skin and carriedharply through the fascia at the same level. The muscle isivided at the same level as the skin incision and allowed toetract. Use of electrocautery for transection of the anteriorusculature will aid with hemostasis, and the electrocautery

s especially useful in distal AKA for division of the patellarendon.

The level of amputation will dictate the location of nervesnd vessels. At the more distal levels, the popliteal artery isocated posteromedial to the femur and should be directlyisualized. The artery and accompanying popliteal vein(s)

Figure 5 The open stump prior to fascial closure. The antbeveled fashion to match the flaps themselves. Vessels afemoral stump. The anterior edge of the femur should beskin. It is imperative to amputate the femur short enouclosure is by re-approximation of anterior and posterioralso perform a myodesis by re-approximating the rectus fthe superficial fascia.

hould be individually isolated and suture ligated, before di- a

iding the femur or the posterior flap. In the mid- to proximalhigh, the (superficial) femoral artery lies deep to the sarto-ius within the adductor canal, more medial and less poste-ior than the popliteal artery. Branches of the profunda fem-ris will also be encountered in proximity to the femur.After division of the anterior muscles, the periosteum of

he femur is scored circumferentially, and elevated as high asesired. In the mid- to distal thigh, clearing the femur willequire division of the adductor insertions along the lineaspera on the posteromedial surface of the bone. The femurhould be divided at least 3 to 5 cm proximal to the line ofkin incision, more if possible, so that the flaps will coaptasily and cover the femoral stump generously. The correctool for cutting the femur is a matter of individual preference,ut power saws are clearly more efficient and probably lessraumatic.

A bone hook placed in the distal femur will now allowxposure of the posterior muscle groups and facilitate theirivision with an amputation knife. The sciatic nerve is iden-ified between the adductor magnus and hamstrings as a largend often rather vascular structure. It should be placed onoderate tension, firmly and securely ligated proximally,

harply divided, and allowed to retract into the proximaluscle bed. Hemostasis is then obtained by electrocautery

nd ligation, taking care to preserve the fascial-cutaneousaps both medially and laterally. If myodesis alone is plannedhe posterior muscle flaps are left 2 inches longer than theevel of bony transection. If both myodesis and myoplasty arelanned all muscle groups are left long (Fig. 5).In performing myodesis, a series of small (ex. –7/64 inch)

rill holes are placed in the cortex of the femur about 3/8 inchrom the cut end. Loop mattress sutures of strong braidedolyester suture are placed through the major muscle groups

d posterior musculature has been transected in slightlyves have been ligated at or proximal to the level of thehed with a rasp or burr to avoid erosion of the overlyingavoid any tension on the flaps. Standard and acceptedsing interrupted sutures. The surgeon has the choice toand biceps over the stump of the femur, prior to closing

erior annd nersmootgh tofascia uemoris

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edullary cavity of the femur. Only gentle tension is placedn the suture to avoid necrosis as well as to allow continuedull extension of the hip. If feasible, a long quadriceps flapith its fascia can be sutured to the posterior fascia and majoruscle groups. This myoplasty technique helps further cen-

ralize the femur, a goal that can also be accomplished byyodesis of the adductor muscle group to the femur. Note

hat myodesis and myoplasty are typically not employed inmputations performed for ischemia.

After hemostasis and irrigation, the length and conditionf the flaps is now evaluated. It is not uncommon to find thatore of the femur needs to be removed to allow for optimal

losure. Once these issues have been addressed, the superfi-ial fascia is closed with interrupted suture (over a drain ifesired), and the skin re-approximated without tension.Dressings can be most difficult at this level, particularly for

igh AKA. An elastic bandage placed in the hip spica config-ration is ideal, but usually impractical to apply. A useful
lternative is a bulky gauze dressing held in place with a large
elf-adhesive drape (such as the Ioban®) covering the entiretump.

eferences. Burgess EM, Malone JM: Major amputations, in Nora PF (ed): Operative

surgery: principles and techniques (3rd ed). Philadelphia, PA, WB Saun-ders, 1990, Chapter 52, pp 1242-1265

. Cull D, Youkey JR: A reappraisal of a modified through-knee amputationin patients with peripheral vascular disease. Am J Surg 182:44-48, 2001

. Nellis N, Van De Water JM: Through-the-knee amputation: an improvedtechnique. The American Surgeon 68:466-469, 2002

uggested Readingurgess EM: Disarticulation of the knee. Arch Surg 112:1250-1255, 1977alone JM: Lower extremity amputation, in Moore WS (ed): Vascular sur-

gery: A comprehensive review (5th ed). Philadelphia, PA, WB Saunders,1998, pp 844-884

ersson B: Lower limb amputation: amputation methods. Prosthet OrthotInt 25:7-13, 2001

mith DG: Amputation: preoperative assessment and lower extremity surgi-
cal techniques. Foot Ankle Clinics 6:271-296, 2001

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9

ip Disarticulation and Hemi-Pelvectomyilliam Parrish, MD

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mputations through the hip joint or pelvis are most oftenindicated for radical treatment of neoplasia when a pri-

ary malignant soft tissue or osseous tumor of the extremitynvolves several compartments, the sciatic nerve, or the fem-ral neurovascular structures. The goal of these procedureshen performed for neoplastic indications is to provide localisease control. If a primary malignant bone tumor involveshe hip joint or a large portion of the ilium, a hemi-pelvec-omy may be indicated. If the tumor involves only a limitedortion of the pelvis but no neurovascular structures, an

nternal hemi-pelvectomy may be possible to preserve thextremity. Amputations through the hip joint or pelvis resultn very similar functional results.

Less often, such amputations may be required in theetting of vascular catastrophe, such as prosthetic graftnfection or nonhealing of above-knee amputation. Otherndications may include severe trauma with extensiveone or soft tissue loss and neurovascular injury, or ag-ressive infectious diseases such as necrotizing fasciitis oras gangrene.Surgical planning for hip disarticulation or hemi-pelvec-

omy should be based on imaging studies which clearly de-ne the vascular status of the extremity, the anatomic mar-ins of a tumor, or the extent of tissue loss or necrosis fromrauma or an infection. CT scan will provide the best imageso define osseous structures. MRI is most useful for definingoft tissue extension of a tumor, relationship of a tumor toeurovascular structures, and extent of marrow involvement.RI is also helpful in defining the limits of cellulitis or muscle

ecrosis that may occur with aggressive infections. Appropri-te vascular studies such a doppler ultrasound, digital sub-raction angiography, or venography may be useful whenvaluating the patient with vascular disease.

ip Disarticulation:urgical Techniqueositions with all surgical procedures, the operating surgeon must

ake primary and personal responsibility for correct identifi-

epartment of Orthopedics and Rehabilitation, Penn State Hershey MedicalCenter, College of Medicine of the Pennsylvania State University, 500University Drive, Hershey, PA.

ddress reprint requests to Dr. William Parrish, Department of Orthopedicsand Rehabilitation, Penn State Hershey Medical Center, College of Med-icine of the Pennsylvania State University, 500 University Drive, Her-

tshey, PA 17033. E-mail: [email protected]


ation of the patient and operative site/side. Before position-ng, a regional anesthetic should be introduced and induc-ion of the general anesthetic completed. Epidural anestheticsith an indwelling catheter provide an excellent means ofostoperative pain control. In addition, a regional anesthetican be highly beneficial by reducing the incidence of phan-om pain postoperatively.

A Foley catheter is placed while the patient is in theupine position. The patient is then moved into a lateralecubitus position and stabilized with the aid of a “beanag” or other similar apparatus (Fig. 1). The operativeipsilateral) side will be facing up. An axillary roll is thenlaced beneath the chest wall in the contralateral axilla tovoid pressure on the brachial plexus and neurovasculartructures. The contralateral arm must be carefully andaturally positioned on an arm board without unusualngulation of any joint or pressure against the radial andlnar nerves. The ipsilateral arm is often best positioned inn overhead cradle with generous padding. Foam pads orlankets should also be used to protect the peroneal nervef the contralateral leg and ankle.It is important to perform the skin preparation and drap-

ng as widely as possible so that the surgical field is notompromised. Failure to “prep and drape” a wide field mayause great difficulty in placing correct incisions, and in-reases the risk of contamination of the surgical field. Patientositioning, skin preparation, and placement of drapeshould be done under the direct supervision of the operatingurgeon or a very trusted associate.

After antiseptic skin preparation, a U-shaped drape islaced under the operative leg as close to the midline glutealleft as possible (while excluding the anus). The anterior armf the drape is brought along the base of the scrotum, extend-ng to the umbilicus and ending at the level of the sternum.he posterior arm of the U-drape extends along the midlinef the spine to the lower margin of the twelth rib. A secondectangular drape is then used to complete the surgical fieldonnecting the two ends of the U-drape along the lowerargin of the rib cage.

ncisionee Figs. 1 and 2.

issectionhe anterior limb of the incision is developed by exposing

he femoral triangle. The femoral triangle is found in the

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Hip disarticulation and hemi-pelvectomy 97

ubfascial space of the proximal thigh. The femoral artery,ein, and nerve pass through this anatomic area as theyxit the pelvis beneath the inguinal ligament and descendnto the leg. The position of the neurovascular structuresn the femoral canal are nerve, artery, vein, and lymphaticsn a lateral to medial progression (NAVL). The femoralriangle is bounded by the adductor longus muscle medi-lly, the sartorius muscle laterally, and the inguinal liga-ent superiorly. The iliopsoas and pectineus muscles

orm the floor of the femoral triangle (Fig. 2).The most reliable landmark for identification of the femo-

al vessels is the inguinal ligament, specifically the inferiorshelving” edge, sometimes referred to as Poupart’s ligament.articularly in patients with previous arterial surgery in theroin, the inguinal ligament can be the only constant struc-ure. Division of the sartorius muscle at its origin will furtherid in exposing the femoral neurovascular structures in theemoral triangle. Once exposed, the femoral artery and vein

ust be encircled, controlled, and individually suture ligatedith nonabsorbable monofilament suture of 3-0 or larger

ize. The femoral nerve is then gently placed under tension,igated as it exits beneath the inguinal ligament, divided, andllowed to retract into the pelvis.

The greater saphenous vein enters the femoral vein veryroximally and may need to be separately ligated. In addi-ion, the obturator, pudendal, and superficial epigastric ves-els may require separate ligation. The lateral femoral cuta-eous nerve should be identified as it exits the pelvis justeneath the anterior superior iliac spine. This should belaced under gentle traction, ligated, and allowed to retract

Figure 1 Posterior view of patient positioning and placemThe incision for hip disarticulation (dotted line) beginsanterior superior iliac spine (ASIS) and proceeds caudcourses posteriorly within the gluteal crease and then curtubercle. Shown in Fig 2 is the anterior component of thhemi-pelvectomy (solid line), the incision passes postersuperior iliac spine (PSIS). At this point, the incision is dithen posteriorly along the gluteal crease to the ischiumtoward the inferior pubic ramus, continuing on to the pufrom the pubic symphysis, along the inguinal ligament,

nto the pelvis. The round ligament in a woman or spermatic A

ord in a male may be encountered during dissection of theidline part of the incision. These should be exposed but not

esected with the specimen.Once these neurovascular structures have been identi-

ed and divided, the dissection continues through the softissues toward the hip joint. Proceeding anterior to poste-iorly, the iliopsoas muscle is released from its insertionnto the lesser trochanter of the femur. Circumflexranches of the femoral vessels may be encountered dur-

ng the dissection. The pectineus and adductor musclesre transected at their origins on the bony pelvis. Careust be taken to ligate the obturator vessels during thisart of the dissection.As the dissection is carried posteriorly, all the muscles

riginating on the ischium are released at their origin. Thisill include the gracilis and the hamstring muscles. This partf the dissection is most easily completed with the leg in aexed, abducted, and externally rotated position. The poste-ior limb of the incision is then developed by dividing theluteus maximus muscle and releasing the gluteus mediusnd minimus muscles from their insertions on the greaterrochanter. This will provide exposure of the deep posteriorhigh including the sciatic nerve and the short external rota-ors of the hip. The sciatic nerve should be placed underentle traction, securely ligated, divided, and allowed to re-ract proximally beneath the piriformis muscle. The remain-ng external rotator muscles are then released from their fem-ral insertion.Attention is then redirected to the anterior limb of the

ncision. The dissection from the greater trochanter to the

incisions for hip disarticulation and hemi-pelvectomy.ximately one fingerbreadth inferior and medial to theward the greater trochanter. From there, the incisioneriorly within the medial thigh crease to reach the pubicion, extending from the pubic tubercle to the ASIS. Forrom the ASIS along the iliac crest toward the posteriorpostero-laterally to the tip of the greater trochanter, andncision then courses within the thigh crease anteriorly

physis. Figure 2 shows the anterior incision extendingASIS.

ent ofappro

ally toves ante incisiorly frected. The ibic sym

SIS is completed by dividing the tensor fascia lata and re-

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98 W. Parrish

easing the rectus femoris muscle from its origin on the ante-ior inferior iliac spine. The hip capsule is the incised aroundhe lip of the acetabulum, and the hip joint dislocated. Theigamentum teres is divided by electrocautery, completinghe amputation, and allowing removal of the limb from theurgical field.

losurehe surgical field is then thoroughly irrigated and in-

Figure 2 Anterior view of the incisions and deep dissectithe patient’s right side are the incisions for the two procedcourse along the inguinal ligament. For hip disarticulahemi-pelvectomy, it extends to the pubic symphysis befand into the medial thigh crease. Posteriorly, both incisioThe hip disarticulation incision then turns superiorly to ctravels from the greater trochanter superiorly, posteriorlyThe posterior component follows the iliac crest back toside of the patient shows the deep dissection for both hin the chapter text.

pected for hemostasis. The short external rotator muscles a

nd gluteus medius muscles are then approximated withhe obturator externus and iliopsoas muscles to cover thecetabulum. One or two large drains are then placed in theurgical bed and the gluteus maximus flap is mobilizednteriorly with suturing of the gluteus fascia to the ingui-al ligament (Fig. 3). Deep dermal sutures are placed andhe skin is closed with interrupted sutures or staples. Aterile dressing is placed on the wound and may be se-ured with a long six inch elastic wrap that is secured

hip disarticulation and hemi-pelvectomy. Depicted onoth begin at the anterior superior iliac spine (ASIS) ande incision turns posteriorly at the pubic tubercle; forving posterior along the lateral border of the perineum

s within the gluteal crease toward the greater trochanter.directly back to the ASIS. The hemi-pelvectomy incision

edially toward the posterior superior iliac spine (PSIS).IS. These relationships are also shown in Fig 1. The leftticulation and hemi-pelvectomy, as explained in detail

on forures. B

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ostoperative Carehe drains should be left in place until output is minimal.emoval of the drains too quickly will result in the devel-pment of a seroma in the large space deep to the glutealascia. The epidural catheter should be left in place for 48o 72 hours for pain control. Sustained release oral nar-

Figure 3 Hip disarticulation before closure with the glutewound. Acetabular coverage is obtained by approximatingwith the obturator externus and iliopsoas muscles. One orgluteus maximus flap is then mobilized anteriorly with sut

otic pain medications should be started while the epi- t

ural is in place and should be titrated to the patient’s painequirements as the epidural is weaned. Once the incisionine is completely healed, the patient is referred to pros-hetics to initiate fabrication of prosthesis. A preoperativeisit with a prosthetist can be most helpful for the patiento understand the concept and process of prosthetic fit-

The transected and ligated vessels are seen deep in theort external rotator muscles and gluteus medius musclesge drains can be placed in the surgical bed if desired. Thef the gluteus fascia to the inguinal ligament.

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emi-Pelvectomy:urgical Techniqueositionositioning the patient for a hemi-pelvectomy is in manyays similar to positioning for a hip disarticulation (Fig. 1).reoperative preparation for this procedure should include aechanical bowel prep on the night before surgery. A beta-ine-soaked vaginal sponge may be packed into the rectumo prevent contamination of the surgical field due to manip-lation of the retroperitoneum during the surgical proce-ure. A stent should be placed in the ipsilateral ureter and aoley catheter in the urinary bladder while the patient is inhe supine position. This makes it easier to identify the ureteruring surgery and decreases the risk of injury to it.The patient is moved into a relaxed lateral decubitus position

ith placement of an axillary roll and appropriate padding ofressure points. For a hemi-pelvectomy, the patient is posi-ioned on the OR table so the flexion break in the table isentered between the lower ribs and the iliac crest. The beds then flexed which opens the space between the ribs andliac crest, making the exposure of the retroperitoneum eas-er. The patient is placed into a relaxed lateral position so thathe trunk and pelvis can be moved forward or backward toacilitate surgical exposure. The arms are positioned and pad-ed as described for hip disarticulation. Skin preparation andraping is performed in similar fashion. Although these stepshould not be delegated to subordinates, the principles ofositioning and preparation should be familiar to the entireR team.

ncisionosterior flap hemi-pelvectomy is the most common variantf this procedure. This method utilizes the gluteus maximusor closure much as was described for a hip disarticulation.ccasionally, a tumor may involve the posterior aspect of theelvis or gluteus maximus, necessitating the use of an ante-ior flap hemi-pelvectomy. The anterior flap hemi-pelvec-omy utilizes an anterior based myocutaneous flap that isased on the femoral vessels. The incision used will dependn the type of flap required. This chapter will describe theosterior flap hemi-pelvectomy. The incisions are outlinednd described in Figs. 1 and 2.

issectionhe dissection begins at the posterior superior iliac spine andxtends anteriorly along the iliac crest and the inguinal liga-ent to the pubic symphysis. The retroperitoneal space is

xposed by releasing the insertion of the abdominal musclesn the iliac crest and inguinal ligament. The peritoneal sacnd contents are retracted medially with the ureter. The com-on iliac artery and vein are identified as well as the internal

nd external iliac vessels. The level of ligation of these vesselsay be determined by the position of the tumor. For a pos-

erior flap hemi-pelvectomy, preservation of the internal iliacessel or at least the first branch (the superior gluteal artery)ill result in better flap viability because the superior gluteal

rtery supplies the gluteus maximus. Once the level of liga-ion is determined, the appropriate vessels are suture ligated
ith monofilament nonabsorbable suture no smaller than t
-0. Surgeons not familiar with handling of large vesselshould obtain assistance from a vascular surgeon, especially ifhe vessels are heavily calcified or aneurysmal. The iliopsoasuscle is divided near the inguinal ligament. In most cases,

he iliacus will be included in the surgical specimen and theajority of the psoas muscle preserved. The femoral nerve isnally identified, ligated, and divided (Fig. 2).The perineal dissection is then performed. The bladder is

etracted along with the urethra and protected with a broadalleable retractor. The ischiorectal space is the exposed as

he dissection is extended along the inferior pubic ramus andhe ischium by releasing the muscles of the pelvic floor ashey insert on the boney pelvis. The bladder, urethra, andpermatic cord should be protected during this part of theissection. An osteotome is then used to divide the pubicymphysis.

The posterior segment of the dissection is then completedy extending the incision from the PSIS to the greater tro-hanter, then along the inferior border of the gluteus maxi-us, connecting to the perineal incision and region of dis-

ection. If possible, the gluteus maximus muscle is preservedith the posterior flap; however, it may be necessary with

ome tumors to sacrifice the gluteus maximus to achieve ancceptable surgical margin. This myocutaneous or fasciocu-aneous flap is then developed in an anterior to posteriorirection.As the flap is developed posteriorly, the superior gluteal

rtery should be preserved in those cases using a myocuta-eous gluteus flap. The superior gluteal artery will exit theelvis through the greater sciatic notch and is tightly adher-nt to the bone in this location. Once the posterior flap iseveloped, the deep posterior hip musculature and sciaticerve will be visible. The piriformis muscle is divided toeveal the sciatic nerve as it exits the pelvis. The very largeerve must be firmly ligated, divided, and allowed to retract

nto the pelvis. The inferior gluteal artery will exit the pelvisnferior to the piriformis muscle. This artery should be iden-ified and ligated to avoid bleeding. The thick broad sacro-uberous ligament will then be encountered extending fromhe lateral border of the sacrum to the ischial tuberosity, andust be divided.Once division of the soft tissues and neurovascular struc-

ures are completed, attention is then directed to final step:acral osteotomy. The standard hemi-pelvectomy is com-leted by passing a series of osteotomes through the sacro-

liac joint. A blunt ribbon retractor is placed through theciatic notch into the pelvis along the anterior margin of theacro-iliac joint to protect the anterior structures. The sur-eon then directs the osteotomes serially through the joint toomplete the amputation. The amputation specimen isassed from the surgical field and hemostasis obtained. Theresacral area is highly vascular with great potential for ve-ous bleeding, which must be controlled with suture liga-ures or electrocautery.

losurehe surgical field should then be irrigated with several litersf fluid and closed over large drains. Closure is accomplishedy bringing the gluteus maximus flap forward and suturing
he gluteus fascia to the external oblique and rectus abdomi-

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us fasciae of the abdominal wall. Scarpa’s fascia may bee-approximated according to the surgeon’s preference,long with the desired method of skin closure. The rectalacking should be removed and a bulky dressing placed onhe wound, secured with a large elastic bandage around theaist.

onclusionip disarticulation and hemi-pelvectomy procedures result

n major functional disabilities, but do not preclude the re- P

umption of an acceptable quality of life. Aggressive rehabil-tation enables most of these patients to ambulate with fore-rm crutches, which many patients choose in preference to aarge unwieldly prosthesis. Amputation support groups cane instrumental in helping patients make both emotional andhysical adjustments to their disability.

uggested Readinglark MA, Thomas JM: Major amputation for soft-tissue sarcoma. Br J Surg

90:102-107, 2003
az IB: Major palliative amputations. Surg Clin N Am 13:543-547, 2004

2005, vol.7, no.2, lower extremity amputations

Health & Medicine

Transcript of 2005, vol.7, no.2, lower extremity amputations