Search

Objective: Partial foot amputations are feasible regardless of the causal condition, including peripheral vascular disease with a few exceptions. Compared to higher amputation levels, a good foot stump permits full end bearing and enables the patient, even with a hindfoot stump, to walk without the need for a prosthesis. The more peripheral the amputation level selected, the greater the need for gentle tissue handling and meticulous postoperative care, but also the greater the risk of a breakdown requiring stump revision surgery. In the forefoot, partial amputation of the metatarsals preserves the length of the stump and, thus, minimizes the loss of weight-bearing surface. The resection of metatarsal and midfoot bones without removing the toes, called a "hidden" amputation, is more acceptable to the patient who does not feel as if he/she has become an amputee. In addition, no neuroma or phantom pain is experienced. Biomechanically, this amputation hardly differs from a classical amputation., Indications: Amputation cannot be avoided by any conservative or operative means., Contraindications: Absolute: rapidly progressing peripheral arterial diseases, i.e., Buerger-Winiwarter's disease. Relative: renal failures requiring dialysis or kidney transplantation., Surgical Technique: Patient in prone position, keep foot and calf free, protect heel from pressure. Mark the skin incisions. A long plantar flap covers the bones and is sutured to the short dorsal flap at the dorsum of the foot. Begin with the dorsal incision down to the bones. After separating the bones, turn the distal part down and separate the plantar soft tissue flap. The bones are well aligned and shaped. Longitudinal amputations preserve a larger load-bearing surface and, therefore, are preferred, if possible. Another alternative is the "hidden" amputation. Except for amputations in peripheral vascular diseases, the digits and their neurovascular supplies are preserved. Only the bones are resected, from transmetatarsal to Chopart. The toes will retract within a few weeks. The patients do not feel as if she/he has become an amputee, although the biomechanics of the foot are about the same as after a total amputation. In case of infection, wound debridement, open wound treatment, and delayed primary closure are recommended., Postoperative Management: Full plantar weight bearing in plaster cast or walker is possible 4-6 weeks after surgery. In the case of diabetic foot, healing can require weeks. Total contact prosthesis without limiting the range of motion (ROM) of the ankle and the subtalar joint after 6 weeks. Best results are obtained with prostheses using the silicone technique. Alternative: orthopedic footwear., Results: It is desirable to maintain the greatest length possible; wound healing disorders are observed in over half of all cases. Operative stump corrections are justified in 20-30%; a transtibial amputation is seldom necessary.

Objective: A knee disarticulation or a through-knee stump is superior compared to a transfemoral stump. The thigh muscles are all preserved, and the muscle balance remains undisturbed. The range of motion of the hip joint is not limited. The bulbous shape of the stump allows full weight bearing at the stump end and can easily be fitted with a prosthesis. An amputee with a bilateral knee disarticulation is able to walk "barefoot"., Indications: A more distal amputation level, e.g., an ultra-short transtibial amputation, is not possible. Important alternative to transfemoral amputations. Possible for any etiology except for Buerger-Winiwarter's disease. New indications are infected and loosened total knee replacements., Contraindications: Preservation of the knee joint is possible., Surgical Technique: Knee disarticulation is a very atraumatic procedure, compared to transfemoral amputations. Neither bones nor muscles have to be severed, just skin, ligaments, vessels, and nerves. Even the meniscal cartilages may be left in place to act as axial shock absorbers. The cartilage of the femur is not resected, but only bevelled in case of osteoarthritis. There are no tendon attachments or myoplastic procedures necessary. The patella remains in place and is held in position only by the retinacula. Skin closure must be performed without the slightest tension, and if possible not in the weight-bearing area. Transcondylar amputations across the femoral condyles only are indicated when there are not sufficient soft tissues for wound closure of a knee disarticulation. Alternatives as the techniques of Gritti, Klaes, and Eigler, the shortening of the femur and the Sauerbruch's rotation plasty [14] are presented and discussed., Postoperative Management: The risk of decubital ulcers is rather high. Correct bandaging of the stump is, therefore, particularly important. Prosthetic fitting is possible 3-6 weeks after surgery. The type of prosthesis depends on the amputee's activity level., Results: The superior performance of amputees with knee disarticulations in sports prove the superiority of that amputation level compared to transfemoral amputees. However, because less than 5% of amputations are knee disarticulations, statements about statistical significance cannot be made. On the other hand, one should do everything to preserve an ultra-short transtibial stump.

Objective: To make a transtibial stump as long as possible, free from local and phantom pain with a maximum of terminal load bearing. In order to preserve the knee joint, an ultra-short tibial stump of 5-6 cm may be indicated., Indications: A hindfoot amputation level is not possible to achieve., Contraindications: In amputations for peripheral vascular diseases, amputations through the distal third of the tibia are not recommended. If they still heal, the level selection might have been too proximal., Surgical Technique: According to Verduyn and Burgess, a long posterior muscular flap covering the stump is attached ventrally to a short anterior flap. Modifications: fibular bone bridge (Guedes), resection of the soleus muscle (Baumgartner), Myodesis (Bowker), and Brückner's procedure. Alternative: rotation plasty according to Borggreve-van Nes-Winkelmann., Postoperative Management: Special diagonal elastic bandaging over the knee that must be changed daily. Early prosthetic fitting (in general after 4-6 weeks) after wound has healed. Physical therapy: gait training with 2 crutches or parallel bars with or without an inflatable "prosthesis". Isometric training of the quadriceps. A stump requires several months until it has achieved its final form. During this time, the prosthesis must be adjusted accordingly. Modifications in the home, workplace, and automobile must be made. Sport for the disabled!, Results: In order to preserve a maximum of stump length, wound healing problems are to be taken into consideration, requiring surgery and sometimes even reamputation through or above the knee joint. If it is possible to preserve the knee joint, the rehabilitation results, even with an ultra-short transtibial stump, are far superior to any more proximal amputation level.

Objective. Amputation through the diaphysis of the femur at the most peripheral level possible. The stump, covered with soft tissue flaps, is free from pain. It can be fitted with a total contact prosthetic socket. The hip joint is preserved with its full range of motion.Indications. When no possibility to amputate at a more distal level through the tibia or the knee joint exists.Contraindications. When it is possible to amputate at a more distal level.Surgical technique. Symmetrical flaps in the frontal plane are recommended. Asymmetrical flaps and flaps in the sagittal plane can also be made. Their muscles are fixed to each other (myodesis) or the bone end by means of transosseous sutures (myopexy). The ischial nerve has to be shortened about 2 inches proximal to the end of the femur.In peripheral vascular diseases, this procedure is not suitable. An alternative technique is suggested.In chronic osteomyelitis (e.g., after intramedullary nailing), the ventral half of the femur can be removed and the medullary cavity cleansed and filled with a muscular flap in order to maintain length. Lengthening procedures of the femur are discussed.Postoperative management. Avoid active or passive movement of the stump for the first 2 weeks in order not to disturb healing of the muscle sutures. Physical therapy, prosthetic fitting after 4–6 weeks, according to the expected functional level 0–4. Aids: crutches, wheel chair, adjustable bed, modified hand-controlled automobile.The walking ability of a patient with a double amputation above the knee is severely limited and in patients with peripheral artery disease remains the exception.

Objectives: To evaluate the influence of secondary infection on major amputation in chronic critical leg ischemia (CLI)., Design: Prospective, controlled observational study., Materials and Methods: Sixty-seven patients with CLI and ischemic lesions participated in the study. Presence of infection was defined by clinical, laboratory and radiological criteria. Patients were categorized as having no local infection, soft tissue infection or osteomyelitis treated without antibiotics, amoxicillin/clavulanacid for 1 month or ciprofloxacin and clindamycin for 3 months, respectively. Clinical outcome was assessed at 2, 6 and 12 months. Study endpoints were major amputation and mortality. Analyses were performed using the Kaplan-Meier method., Results: Forty-seven of 67 patients had a local infection. Major amputation was lower in patients with successful revascularization as compared to patients unsuitable for or with failed (without) revascularization (0% vs 26%, p<0.01). In patients with successful revascularization the probability of complete healing was lower with secondary infection (23% vs 71%, p=0.03). In patients without revascularization complete healing was rare (<10%), but secondary infection did not influenced major amputation, mortality or serious adverse events., Conclusion: Secondary infection reduces the likelihood of successful healing following revascularisation of CLI.

The rare case of a child with gangrene of all extremities following intravascular coagulation in pneumococcus septicaemia is described. The two years old spanish girl showed a gangrene of all four extremities and accompanying celloid scars. The operative treatment, the orthopaedic technical fitting as well as the problems are discussed.

The object of the Krukenberg procedure invented in 1916 is to convert the forearm stump into an active pincer with two opposable branches covered with skin and with normal sensibility. The procedure was devised during World War I and particularly used and developed on further war amputees. Whereas functional results are mostly excellent, the cosmetic appearance of a Krukenberg hand nowadays is considered to be obsolete by most surgeons. The authors have reexamined 20 patients, 13-45 years after surgery and have studied the relevant literature. All but one patient are satisfied with their Krukenberg hand as its performance is superior compared to the even most modern prosthetic devices. Therefore, the principles of the operative techniques are recalled and, based on the analysis of results, today's indications for the Krukenberg procedures are specified.

The incidence of amputation rises dramatically in old age. Trauma and tumors are uncommon reasons in this age group, however; 90% of amputations in such patients are performed for occlusive disease. These patients are distinguished from all other amputees by their multiple morbidity, which must be borne in mind at all stages, from the decision to operate to rehabilitation. This paper briefly indicates the points that are important for an optimal result of rehabilitation, starting with selection of the amputation level and extending through to provision of the prosthesis and mobilization. The paper ends with a presentation and discussion of the results of rehabilitation in 90 patients aged over 70.

Congenital limb deficiencies pose quite a number of questions, problems and tasks that go far beyond the surgical and prosthetic-orthotic aspects present. The question of amputation in view of improved function and appearance as well as easier prosthetic provision can be answered only in the context of the orthopaedic-surgical and prosthetic possibilities available. Social, cultural and religious factors are in addition enumerated that have to be taken into account.

A knee disarticulation or a trough-knee amputation stump is superior to an above-knee stump. Knee disarticulation does not require that bone be sectioned or muscle cut. The stump allows total end-load capacity. The muscle balance remains undisturbed. Due to the bulbous shape of the stump prosthetic fitting of modern appliances no longer presents problems. An operative technique especially developed for vascular patients is described in detail, including the postoperative treatment and the principles of prosthetic fitting.

At La Neuveville (Switzerland) close to the Blanche Eglise a separately buried amputated leg from the 19th century was discovered. The pathological lesions of the knee joints are most likely due to a nonspecific infection (Osteomyelitis). However, postmortal defects made an exact diagnosis difficult. Two foot-amputated male burials were discovered on St. Petersinsel (Switzerland) in the monastery cemetery of the 11th to 15th century. The possible causes of these amputations are being discussed within the historical context.

If below-knee amputation is impossible, knee disarticulation should be considered before above-knee amputation, regardless of age and etiology. Knee disarticulation which leaves the femur and patella untoched offers many advantages. The surgical technique is simple and non-traumatic since no bone or muscle tissue is to be dissected. The thigh muscles are completely preserved and thus there is no muscular imbalance. The stump permits total end bearing and its bulbous shape permits easy and firm attachment of the prosthesis. A specially designed double-wall socket and various types of knee joints are presented. Modern prostheses are superior to above-knee prostheses with regard to function, comfort and cosmesis. Results of 72 patients of all age groups are presented and discussed.

Rehabilitation after amputations is a complex interdisciplinary task which depends on numerous factors: the reason for and the level of the amputation, the quality of the stump and the limb fitting, the patient's general mental and physical state, and particularly his and his family's motivation. Strictly speaking, the normal functions can never be fully restored, even with the help of the most up-to-date techniques and rehabilitation facilities. For optimal results, full coordinated use should be made of the available methods of diagnosis and treatment. The course of rehabilitation is determined from the outset by the level of the amputation and the surgical technique. Emphasis is put on stump treatment, limb fitting, and training of the amputee, with or without a prosthetic replacement. Technical aids also are extensively used in the rehabilitation of amputees and includes various items for performing daily activities, from the workplace to the wheel chair. Even when fully equipped, a small number of amputees still remain permanently dependent on others.

Long-term results over a period of more than 10 years give evidence of the superiority of the through-knee compared to the above-knee stump. However, failures in through-knee stumps before, during and after operation and pitfalls in prosthetic fitting are still too frequent. They are mostly due to errors because the peculiarities of the stump and the prosthetic management are not recognised. This paper emphasizes frequent causes of failure in the selection of the level of amputation, the operative technique, post-operative treatment and prosthetic rehabilitation in order to reduce the complication rate.