Peripheral vascular disease with or without
diabetes, which most frequently occurs in
individuals age 50 to 75, is the most common
indication for amputation.
If vascular disease has progressed to the
point of requiring amputation, it is not
limited to the involved extremity.
Most patients also have concomitant disease
processes in the cerebral
vasculature, coronary arteries, and kidneys.
Approximately half of amputations for
peripheral vascular disease are performed on
patients with diabetes.
The most significant predictor of amputation
in diabetics is peripheral neuropathy.
Other documented risk factors include
Prior major amputation
Decreased transcutaneous oxygen levels
Decreased ankle-brachial blood pressure
Before performing an amputation for
peripheral vascular disease, a vascular
surgery consultation is almost always
indicated as improved techniques currently
allow for revascularization of limbs that
previously would have been unsalvageable.
If amputation becomes necessary,
Infection should be controlled
Nutrition and Immune status should be
evaluated. ( Risk for wound complications is
greatly increased in patients whose serum
albumin is less than 3.5 g/dL or whose total
lymphocyte count is less than 1500 cells/mL).
Trauma is the leading indication for
amputations in younger patients
More common in men because of vocational
and avocational hazards.
The only absolute indication for primary
amputation is an irreparable vascular injury in
an ischemic limb.
To predict which limbs will be
salvageable, available scoring systems
predictive salvage index
limb injury score
limb salvage index
mangled extremity syndrome index
mangled extremity severity score.
Of these, Mangled Extremity Severity Score is
most useful as it is easy to apply, grades the
injury on the basis of the energy that caused
the injury, limb ischemia, shock, and the
The system was subjected to retrospective
and prospective studies, with a score of 6 or
less consistent with a salvageable limb.
With a score of 7 or greater, amputation was
the eventual result.
Points × 2 if ischemic time exceeds 6 hours.
Amputation of an injured extremity is
necessary to preserve life as attempts to
salvage a severely injured limb may lead to
metabolic overload and secondary organ
failure which is more common in patients
with multiple injuries and in the elderly.
Thermal or electrical injury to an extremity
may necessitate amputation.
The full extent of tissue damage may not be
apparent at initial presentation, especially
with electrical injury.
Treatment involves early débridement of
devitalized tissue, fasciotomies when
indicated, and aggressive wound
care, including repeat débridements in the
Compared with early amputation, delayed
amputation of an unsalvageable limb has
been associated with increased risk of local
infection, systemic infection, myoglobininduced renal failure, and death.
Frostbite denotes the actual freezing of tissue
in the extremities, with or without central
This is a common problem for high-altitude
climbers, skiers, and hunters.
Also at risk are homeless, alcoholic, and
When heat loss exceeds the body's ability to
maintain homeostasis, blood flow to the
extremities is decreased to maintain central
Actual tissue injury occurs through two
1. Direct tissue injury through the formation of
ice crystals in the extracellular fluid
2. Ischemic injury resulting from damage to
vascular endothelium, clot formation, and
increased sympathetic tone
The first step in treatment is restoration of
core body temperature.
Treatment of the affected extremity begins
with rapid rewarming in a water bath at 40°C
to 44°C which requires parenteral pain
management and sedation.
After initial rewarming, if digital blood flow is
still not apparent, treatment with tissue
plasminogen activator or regional
sympathetic blockade may be indicated.
Tetanus prophylaxis is mandatory
Blebs should be left intact. Closed blebs
should be treated with aloe vera. Silver
sulfadiazine (Silvadene) should be applied
regularly to open blebs.
Low doses of aspirin or ibuprofen also should
be instituted as oral anti-inflammatory
medication and topical aloe vera help to stop
progressive dermal ischemia mediated by
vasoconstricting metabolites of arachidonic
acid in frostbite wounds.
Physical therapy should be started early to
maintain range of motion.
Amputation for frostbite routinely should be
delayed 2 to 6 months.
Clear demarcation of viable tissue may take
Even after demarcation appears to be
complete on the surface, deep tissues still
may be recovering.
Despite the presence of mummified
tissue, infection is rare if local wound
management is maintained.
Triple-Phase Technetium Bone Scan has
helped to delineate deep tissue viability.
Performing surgery prematurely often results
in greater tissue loss and increased risk of
Amputation may be necessary for acute or
chronic infection that is unresponsive to
antibiotics and surgical débridement.
Open amputation is indicated - two methods.
1. A guillotine amputation may be performed
with later revision to a more proximal level
after the infection is under control.
2. Amputation may be performed at the
definitive level by initially inverting the flaps
and packing the wound open with
secondary closure at 10 to 14 days.
Kritter’s method for partial foot amputation
with primary closure in patients with active
By this method, the wound is closed loosely
over a catheter through which an antibiotic
irrigant is infused.
The constant infusion is continued for 5 days.
The wound must be closed loosely enough to
allow the fluid to escape into the dressings.
The dressings must be changed frequently
until the catheter is removed on
postoperative day 5.
This method may allow for primary wound
healing, while avoiding a protracted course of
wound healing by secondary intention.
In the acute setting, the most worrisome
infections are those produced by gas-forming
Typically associated with
Motor vehicle accidents
Civilian gunshot wounds.
Clostridial Myonecrosis- Gram-Positive Rods.
Immediate radical débridement of involved
tissue, high doses of intravenous penicillin
and hyperbaric oxygen.
Emergency open amputation one joint above
the affected compartments often is needed as
a lifesaving measure, but may be avoided if
treatment is initiated early.
Streptococcal Myonecrosis –
Treatment - Debridement of involved muscle
compartments, open wound management,
and penicillin treatment usually allow
preservation of the limb.
Anaerobic Cellulitis - Causative organisms
include clostridia, anaerobic streptococci,
Bacteroides, and gram-negative rods.
Treatment includes débridement and broadspectrum antibiotics. Amputation rarely is
Four issues that must be considered when
contemplating limb salvage instead of
amputation, as follows:
1. Would survival be affected by the treatment
2. How do short-term and long-term morbidity
3. How would the function of a salvaged limb
compare with that of a prosthesis?
4. Are there any psychosocial consequences?
27. 1. Would survival be affected by the treatment
• With the use of multimodal
treatment, including surgery and
chemotherapy, long-term survival for
osteosarcoma patients has improved from
approximately 20% to approximately 70%.
For osteosarcoma of the distal femur, the rate
of local recurrence after wide resection and
limb salvage is approximately 5% to
10%, which is equivalent to the local
recurrence rate after a transfemoral
amputation for osteosarcoma.
28. 2. How do short-term and long-term morbidity
Amputation for malignancy may be
technically demanding, often requiring
nonstandard flaps, bone graft, or prosthetic
augmentation to obtain a more functional
Limb salvage is associated with greater
perioperative morbidity compared with
Limb salvage involves a more extensive surgical
procedure and is associated with greater risk of
infection, wound dehiscence, flap necrosis, blood
loss, and deep venous thrombosis.
Long-term complications vary depending on the
type of reconstruction which include
periprosthetic fractures, prosthetic loosening or
dislocation, nonunion of the graft-host junction,
allograft fracture, leg-length discrepancy, and
A patient with a salvaged limb is more likely
to need multiple subsequent operations for
treatment of complications.
After initial successful limb salvage
surgery, one third of long-term survivors
ultimately may require an amputation.
31. 3. How would the function of a salvaged limb
compare with that of a prosthesis?
With regard to function, the location of the
tumor is the most important factor.
Resection of an upper extremity lesion with
limb salvage, even with sacrifice of a major
nerve, generally provides better function than
amputation and subsequent prosthetic fitting.
Resection of a proximal femoral or pelvic
lesion with local reconstruction generally
provides better function than hip
disarticulation or hemipelvectomy.
Sarcomas around the ankle and foot
frequently are treated with amputation
followed by prosthetic fitting.
Treatment for sarcomas around the knee
must be individualized.
Osteosarcoma around the knee are treated
with one of three surgical procedures—
Wide Resection with Prosthetic Knee
Wide Resection with Allograft Arthrodesis
Patients who had undergone Resection and
Prosthetic Knee Replacement showed higher
self-selected walking velocities and a more
efficient gait with regard to oxygen
consumption than patients with Transfemoral
Individuals with a Transfemoral Amputation
functioned at more than 50% of their
maximum aerobic capacity at free walking
speeds, requiring anaerobic mechanisms to
sustain muscle metabolism, which results in
Patients with an amputation had difficulty
walking on steep, rough, or slippery
surfaces, but were very active and were the
least worried about damaging the affected
Patients with an arthrodesis performed the
most demanding physical work and
recreational activities, but they had difficulty
with sitting, especially in the back seat of
cars, theaters, or sports arenas.
Determining the appropriate level of
amputation requires an understanding of the
tradeoffs between increased function with a
more distal level of amputation and a
decreased complication rate with a more
proximal level of amputation.
The energy required for walking is inversely
proportionate to the length of the remaining
Patients with amputations at the
transfemoral, transtibial, and Syme levels
secondary to trauma or chronic limb ischemia
Compared with controls without amputations,
the self-selected walking velocity for vascular
amputees was 66% at the Syme level, 59% at
the transtibial level, and 44% at the
For traumatic amputees, generally younger
patients, the rates were 87% at the transtibial
level and 63% at the transfemoral level.
At self-selected walking velocities, the slower
rates for amputees seem to be a compensatory
mechanism to conserve energy per unit time.
Patients tended to decrease their velocities to
keep their relative energy costs per minute within
When energy expenditure per minute is not
compensated, anaerobic mechanisms are
summoned to sustain muscle function, and
endurance is greatly compromised.
Thus it becomes apparent that amputation
should be performed at the most distal level
possible if ambulation is the chief concern.
If a patient has no ambulatory
potential, wound healing with decreased
perioperative morbidity should be the chief
Determining the most distal level for
amputation with a reasonable chance of
healing can be challenging.
Clinically - skin colour, hair growth, and skin
InvestigationsThermography or laser Doppler flowmetry as
methods to test skin flap perfusion.
Tissue uptake of intravenously injected
fluorescein or the tissue clearance of
intradermally injected xenon-133.
Transcutaneous oxygen measurements
and Muscle Flaps
Flaps should be kept thick.
Unnecessary dissection should be avoided to
prevent further devascularization of already
The scar should not be adherent to the
underlying bone as an adherent scar makes
prosthetic fitting extremely difficult, and this
type of scar often breaks down after
prolonged prosthetic use.
Redundant soft tissues or large ―dog ears‖
create problems in prosthetic fitting and may
prevent maximal function of an otherwise
Muscles usually are divided at least 5 cm
distal to the intended bone resection.
They may be stabilized by Myodesis (suturing
muscle or tendon to bone) or by Myoplasty
(suturing muscle to periosteum or to fascia of
opposing musculature). (transected muscles
atrophy 40% to 60% in 2 years if they are not
If possible, myodesis should be performed to
provide a stronger insertion, help maximize
strength, and minimize atrophy
Myodesed muscles continue to
counterbalance their antagonists, preventing
contractures and maximizing residual limb
Myodesis may be contraindicated, however, in
severe ischemia because of the increased risk
of wound breakdown.
Except in severely ischemic limbs, the use of
a tourniquet is highly desirable and makes
the amputation easier.
Major blood vessels should be isolated and
Larger vessels should be doubly ligated.
The tourniquet should be deflated before
closure, and meticulous hemostasis should
A drain should be used in most cases for 48
to 72 hours.
A neuroma always forms after a nerve has
A neuroma becomes painful if it forms in a
position where it would be subjected to
Nerves should be isolated, gently pulled
distally into the wound, and divided cleanly
with a sharp knife so that the cut end retracts
well proximal to the level of bone resection.
Strong tension on the nerve should be
avoided during this maneuver; otherwise, the
amputation stump may be painful even after
the wound has healed.
Large nerves, such as the sciatic nerve, often
contain relatively large arteries and should be
Excessive periosteal stripping is
contraindicated and may result in the
formation of ring sequestra or bony
Bony prominences that would not be well
padded by soft tissue always should be
resected, and the remaining bone should be
rasped to form a smooth contour.
An open amputation is one in which the skin
is not closed over the end of the stump.
Indicated in infections and in severe
traumatic wounds with extensive destruction
of tissue and gross contamination by foreign
The operation is the first of at least two
operations required to construct a
It always must be followed by secondary
closure, reamputation, revision, or plastic
The purpose of this type of amputation is to
prevent or eliminate infection so that final
closure of the stump may be done without
breakdown of the wound.
A wound vacuum-assisted closure ( VAC ) is
applied to the open stump immediately after
the initial débridement.
Subsequent débridements are scheduled at
The VAC is reapplied after each débridement
until the wound is ready for closure.
It requires a multidisciplinary team approach
All of the same precautions are followed as
for any major orthopaedic surgery, including
perioperative antibiotics, deep venous
thrombosis prophylaxis, and pulmonary
Pain management includes the brief use of
intravenous narcotics followed by oral pain
medicine that is tapered as soon as tolerated.
If weight bearing ambulation is not planned
in the immediate postoperative period, the
rigid dressing ( POP ) may be applied.
If weight bearing ambulation in the
immediate postoperative period is
anticipated, a true prosthetic cast should be
applied. A metal pylon with a prosthetic foot
is attached to the cast and properly aligned
Advantages of rigid dressing
Prevent edema at the surgical site
Protect the wound from bed trauma
Enhance wound healing and early maturation
of the stump
Decrease postoperative pain
Allow earlier mobilization from bed to chair
and ambulation with support.
For transtibial amputations- prevent the
formation of knee flexion contractures.
Drains usually are removed at 48 hours.
The stump is elevated by raising the foot of
the bed, which helps manage edema and
The patient is cautioned against leaving the
stump in a dependent position.
With transfemoral amputations, the patient is
cautioned against placing a pillow between
the thighs or beneath the stump or otherwise
keeping the stump flexed or abducted. These
precautions are necessary to help prevent
flexion or abduction contractures. Exercises
(muscle-setting exercises followed by
exercises to mobilize the joints ) for the
stump are started under the supervision of a
physical therapist the day after surgery.
Patients should be mobilized from bed to
chair on the first postoperative day.
Early unprotected weight bearing can result in
sloughing of the skin or delayed wound
If the wound is progressing well, weight
bearing can progress in 25-lb increments
Supervision is especially important in patients
with peripheral neuropathy who may have
difficulty judging how much weight they are
placing on their stumps.
Regardless of when prosthetic ambulation is
begun, the rigid dressing should be removed
and the wound inspected in 7 to 10 days.
Cast loosening, fever, excessive drainage, or
systemic symptoms of wound infection are
indications for earlier cast removal.
If the wound is healing well, a new rigid
dressing is applied, and ambulation with or
without prosthetic foot is continued.
The cast should be changed weekly until the
wound has healed.
After the wound is well healed, the rigid
dressing may be removed for bathing and
Use of the rigid dressing is continued until
the volume appears unchanged from the
At that time, the prosthetist may apply the
One or more socket changes frequently are
required over the first 18 months
Meticulous hemostasis before closure, the
use of a drain, and a rigid dressing should
minimize the frequency of hematoma
A hematoma can delay wound healing and
serve as a culture medium for bacterial
If a hematoma does form, it should be treated
with a compressive dressing.
If the hematoma is associated with delayed
wound healing with or without infection, it
should be evacuated
More common in amputations for peripheral
vascular disease, especially in diabetic
Any deep wound infection should be treated
with immediate débridement and irrigation
and open wound management.
Delayed closure may be difficult because of
edema and retraction of the flaps.
Smith and Burgess described a method
whereby the central one third of the wound is
closed, and the remainder of the wound is
This method allows for continued open
wound management, while maintaining
adequate flaps for distal bone coverage.
Necrosis of the skin edges less than 1 cm can
be treated conservatively with open wound
Severe necrosis with poor coverage of the
bone end, wedge resection may be indicated.
The basic principle of wedge resection is to
regard the end of the amputation stump as a
Resection of a wedge incorporating the full
diameter of the stump would allow for
reformation of the hemisphere, while
minimizing local pressures
Mild or moderate contractures of the joints of
an amputation stump should be prevented by
proper positioning of the stump, gentle
passive stretching, and having the patient
engage in exercises to strengthen the
muscles controlling the joint.
Severe fixed contractures may require
treatment by wedging casts or by surgical
release of the contracted structures.
68. 1. Mechanical low back pain has been shown to
be more prevalent in amputees than in the
general population. In addition to other
accepted treatments for back pain, patients
must be instructed on proper prosthetic
ambulation to minimize abnormal stresses on
the lumbar spine.
69. 2. Residual limb pain is caused by
a. Poor fitting prosthesis
b. Painful neuroma
a. Poor fitting prosthesis- The stump should be
evaluated for areas of abnormal
pressure, especially over bony prominences.
- Distal stump edema, often called ―choking,‖
may result if the end is not completely
seated in the prosthesis, and ulceration or
gangrene could result.
- These problems can be avoided with socket
70. b. Painful neuroma -occurs when the nerve end
is subjected to pressure or repeated irritation.
- A painful neuroma usually can be prevented
by gentle traction on the nerve followed by
sharp proximal division, allowing the nerve
end to retract deep into the soft tissue.
- A painful neuroma usually is easily palpable
and often has a positive Tinel sign.
- Treatment initially consists of socket
- If this fails to relieve symptoms, simple
neuroma excision or a more proximal
neurectomy may be required.
Patients should be instructed to wash their
stumps with a mild soap at least once a day.
The stump should be thoroughly rinsed and
dried before donning the prosthesis.
The prosthesis should be kept clean and
should be thoroughly dried before donning.
Contact dermatitis is common and causes
skin inflammation which is associated with
intense itching and burning when wearing the
Cause:-failure to rinse detergents from stump socks
-nickel, chromates used in leathers
-skin creams, antioxidants in rubber
Treatment consists of removal of the irritant,
soaks, steroid cream, and compression.
Bacterial folliculitis may occur in areas of
hairy, oily skin.
The problem may be exacerbated by shaving
and by poor hygiene.
Treatment initially consists of improved
hygiene and possibly socket modifications to
relieve areas of abnormal pressure.
Occasionally, cellulitis develops that requires
antibiotic treatment, or an abscess forms that
requires incision and drainage.
Epidermoid cysts develop at the socket brim.
These frequently occur late and are best
treated with socket modification. Excision
may be required.
Verrucous hyperplasia refers to a wartlike
overgrowth of the skin at the end of the
It is caused by proximal constriction that
prevents the stump from fully seating in the
This ―choking,‖ as previously mentioned,
causes distal stump edema followed by
thickening of the skin, fissuring, ulceration,
and possibly subsequent infection.
Treatment initially is directed toward treating
The skin should be treated with soaks and
salicylic acid to soften the keratin.
Socket modification is mandatory because
pressure on the distal skin is essential to
treat the problem and to prevent recurrences.
Amputations in children is divided into two
general categories—congenital (60%) and
Causes of Acquired amputations:Secondary to trauma
Motor vehicle accidents, gunshot
wounds, and power tool injuries are the most
common causes of limb loss from injury in
older children; in young children, accidents
with power tools, such as lawnmowers, and
other household accidents are the most
Dysvascular amputations in children are
rare, but when they do occur, they usually are
secondary to thrombotic or embolic events
caused by another underlying problem.
Causes of congenital amputations
Amniotic band syndrome
Exposure to teratogens ( thalidomide )
Congenital pseudoarthrosis of the tibia and
fibula, radius and ulna
Constrictions of the leg
Congenital deficiencies of the long bones
Preserve important growth plates
Perform disarticulation rather than
transosseous amputation whenever possible
Preserve the knee joint whenever possible
Stabilize and normalize the proximal
portion of the limb
Be prepared to deal with issues in addition
to limb deficiency in children with other
clinically important conditions.
It is crucial as 75% of the growth of the femur
occurs at the distal growth plate.
Consequently, any transfemoral amputation
performed in a young child would result in a
very short stump as an adult.
Conversely, even a very short transtibial
stump in a young child may result in a
functional stump as an adult if the growth
plate is preserved.
Disarticulation can provide a child with a
well-balanced, sturdy stump capable of end
Length and physes are preserved without the
risks of terminal overgrowth.
Prosthetic suspension is improved with a
disarticulation secondary to preservation of
the metaphyseal flares. This is important
because of the high mechanical demands that
children often place on their prostheses.
It is a significant problem in a child amputee
with a transosseous amputation.
It does not occur after disarticulation.
The overgrowth is caused by appositional
new bone formation and is unrelated to the
growth of the physis.
The resulting bone is elongated and often
It may cause swelling, edema, pain, and bursa
formation and in severe cases may penetrate
Overgrowth is more common after traumatic
amputations than after amputations
performed for other indications.
It also is more common in younger children
than in older children and occurs most often
in the humerus and fibula and less often in
the tibia, femur, radius, and ulna, in that
Prevention of overgrowth can be done by
capping the bone with an epiphyseal graft
harvested from the amputated limb at the
index procedure or by capping with tricortical
iliac crest graft at a revision operation.
It can be treated effectively with surgical
resection of the excess bone.
Transtibial amputation in
Distal fibula from
amputated leg is
fashioned to fit into cut
end of tibia.
Fibula is press-fit into
87. 1. Because of growth issues and increased
body metabolism, children often can tolerate
procedures on amputation stumps that are
not tolerated by adults, which includes
More forceful skin traction
Application of extensive skin grafts
Closure of skin flaps under moderate tension.
88. 2. Complications after surgery tend to be less
severe in children, which includes
Painful phantom sensations do not develop
Neuromas rarely are troublesome enough to
Extensive scars usually are tolerated well.
One or more spurs usually develop on the
end of the bone, but, in contrast to terminal
overgrowth, almost never require resection.
Psychological problems after amputation are
rare in children
90. 3. Children use prostheses extremely well, and
their proficiency increases as they age and
In general, a progressive prosthetic program
should be designed that parallels normal
At a young age, children function well with
As they grow, modifications may be
made, such as the addition of a knee joint, a
mobile elbow joint, or a mechanical hand.
By the time children reach adolescence, they
may begin to take advantage of the most
Because of their activity level and growth,
children with amputations must be observed
closely for prosthetic repair, for frequent
changes in the socket, and for fitting with
Transtibial amputations are the most
common amputations performed for
peripheral vascular disease.
All technical procedures may be divided into
those used for
93. Non ischemic limb
Muscle flaps- both
Myoplasty and Myodesis
can be done
Myodesis is contraindicated as it may further
compromise an already
marginal blood supply
Skin flaps- both anterior
and posterior skin flaps
can be equal
Long posterior flap and
short/absent anterior flap
is recommended as
anteriorly the blood
supply is less abundant
than elsewhere in the leg
The optimal level of amputation has been
chosen to provide :A stump length that allows a controlling lever
arm for the prosthesis
Sufficient ―circulation‖ for healing
Sufficient ―soft tissue‖ for protective end
The amputation level also is governed by the
cause (e.g., clean end margins for
tumor, level of trauma, and congenital
A longer residual limb would have a more
normal gait appearance, but it is not true for
stumps extending to the distal third of the
leg, as:There is less soft tissue available for weight
The distal third of the leg is relatively
avascular and slower to heal than more
In adults, the ideal bone length for a below-knee
amputation stump is to allow 2.5 cm of bone
length for each 30 cm of body height.
Stumps lacking quadriceps function are not
In a short stump whether fibula should be
removed or preserved is controversial as fitting
of the prosthesis depends on it.
Transecting the hamstring tendons to allow a
short stump to fall deeper into the socket also
may be considered
97. A. Fashioning of
equal anterior and
flaps, each one half
diameter of leg at
level of bone
98. B. Division and
ligation of anterior
tibial vessels and
division of deep
99. C. Fashioning of
100. D. Suture of
myofascial flap to
101. E. Closure of skin
An immediate postoperative rigid dressing
helps control edema, limits knee flexion
contracture, and protects the limb from
Weight bearing is limited initially, with
bilateral upper extremity support from
parallel bars, a walker, or crutches.
The cast can be changed every 5 to 7 days for
Within 3 to 4 weeks, the rigid dressing can be
changed to a removable temporary prosthesis
which is later changed to a permanent
103. A. Fashioning of
short anterior and
long posterior skin
104. B. Separation and
removal of distal
105. C. Tailoring of
mass to form flaps
106. D. Suture of flap to
deep fascia and
107. E. Closure of skin
The stump, in the initial stages, is usually
unsuitable for prosthetic fitting due to stump
oedema, and subsequent bandaging to
reshape the stump causes a considerable
delay in prosthetic fitting.
Suture line passes over the distal end of the
tibia which remains vulnerable to trauma due
to the high pressure generated on this area
while using the prosthesis.
The principle of the skew flap technique is based
on the observations that thermographic mapping
of the leg shows a higher temperature profile on
the anteromedial as well as the posterolateral
It indicates a better blood flow of the
anteromedial ( saphenous nerve artery) as well
as the posterolateral (sural nerve artery) areas
below the knee joint.
This was also determined by the transcutaneous
measurement of partial pressure of oxygen. The
skew flap technique is based on these
observations. The skin flaps correspond closely
to the characteristic warm pattern of skin and
A circumferential marking was made 15 cm
below the knee joint line.
This was bisected equally, keeping one end at
a point 2.5 cm lateral to the tibial crest, with
the opposite point coming on the
Semicircular flaps were then marked from
these points, keeping the length of the flaps
at least one-quarter of the circumference
If immediate prosthetic ambulation is not to
be pursued, the stump can be dressed in a
simple, well-padded cast that extends
proximally to midthigh and is applied in such
a manner as to avoid proximal constriction of
The cast should be removed in 5 to 7
days, and if wound healing is satisfactory, a
new rigid dressing or prosthetic cast is
If immediate prosthetic ambulation is
pursued, a properly constructed prosthetic
cast is best applied by a qualified prosthetist.
113. Advantages of skew flap amputation over
Hazards of constricting bandages are avoided
as there is less of stump edema.
Early application and ambulation in a
Early healing of the skin incision
Lessened risk of wound breakdown
Complications of skew flap amputation
Delayed wound healing
Re-amputation may be needed
Retrimming procedure may be needed
Amputation of the great toe does not
functionally affect standing or walking at a
If the patient walks rapidly or
runs, however, a limp appears because of the
loss of push-off normally provided by the
Amputation of the second toe frequently is
followed by severe hallux valgus because the
great toe tends to drift toward the third toe to
fill the gap left by amputation.
Amputation of all toes causes little
disturbance in ordinary slow walking, but is
disabling during a more rapid gait and when
spring and resilience of the foot are required.
It interferes with squatting and tiptoeing.
Usually, amputation of all toes requires no
prosthesis, other than a shoe filler
An insole is used for
metatarsal to relieve
weight from the
A cavus support for the
A cork or foam toe
block is attached
distally as a filler.
A rocker sole may be
necessary to replace the
action of rocking forward
on the foot.
The sole can be stiffened
with a long steel spring
Maintaining the base of the proximal phalanx
often is preferable to metatarsophalangeal
This allows for retention of some weight
bearing properties, especially in the
hallux, where 1 cm of proximal phalanx
allows for some contribution by the flexor
hallucis brevis and the plantar fascia.
It also may slow the deviation of adjacent
toes when one of the lesser digits is
The skin incision varies with the toe involved.
A long posteromedial flap is desired for great
Begin the incision at the base of the toe in the
midline anteriorly, and curve it distally over the
medial and posteromedial aspects for a distance
slightly greater than the anteroposterior diameter
of the digit; extend it proximally across the
plantar surface of the toe to the web.
In the second, third, and fourth toes,
amputation is performed through a short
dorsal racquet-shaped incision.
Begin the incision 1 cm proximal to the
metatarsophalangeal joint, and pass it distally
to the base of the proximal phalanx, dividing
it to pass around the toe and across the
plantar surface at the level of the flexor
In the fifth toe, fashion a lateral flap long
enough to cover the defect left by the
Raise the flaps to the level of the MTP joint.
Identify the capsule of the MTP joint and, with
the toe in acute flexion, incise its dorsal side
first; straighten the toe, and expose and
incise the remainder of the capsule after
dividing the flexor tendons and neurovascular
Removing the sesamoids in the insensate foot
Draw the tendons distally, divide them, and
allow them to retract.
Identify the digital nerves, and divide them
proximal to the end of the bone, and divide
and ligate the digital vessels.
Close the skin edges with interrupted
Protected weight bearing with crutches or a
walker for 5 to 10 days is indicated for
When the sutures have been removed, the
patient may need a shoe with an open toe
box because of edema.
When the edema has subsided, ambulation in
a supportive, soft-soled, accommodating
shoe is allowed.
Amputation through the metatarsals causes
loss of push-off in the absence of a positive
fulcrum in the ball of the foot which is chiefly
responsible for impairment of gait.
No prosthesis is required other than a shoe
Lisfranc’s Amputation- amputation at the
level of tarsometatarsal joint.
Chopart’s Amputation- amputation at the
level of calcaneocuboid and talonavicular
Pirogoff’s Amputation- calcaneus is rotated
forward to be fused to the tibia after vertical
section through its middle
Lisfranc or Chopart amputations often results
in an equinus deformity because of loss of
the foot dorsiflexor attacments.
Dorsiflexors of the foot and their insertion-
Tibialis anterior- medial cuneiform and base
of 1st metatarsal bone
EDL- extensor expansion of lateral four toes
Peroneus tertius- base of 5th metatarsal bone
EHL- base of the distal phalanx of great toe
By performing tenotomy of
tendoachilles, Roach and McFarlane were able
to prevent early equinus deformities from
becoming fixed. (Although push-off is
compromised, the stump before lengthening
of the Achilles tendon is not capable of much
push-off in the presence of a fixed equinus
Tendon transfers can be done
The patient can be kept in a slight DF rigid
dressing for 6 wks to prevent equinus
deformity and allow for incorporation of the
transferred ankle dorsiflexors
129. Tendon transfers:
Transfer the anterior tibial tendon to the neck
of the talus, using a drill hole or by creating a
trough in the talus and using suture or a
staple to secure fixation.
Transferring the anterior tibial tendon to
the neck of the talus and transferring the
peroneus brevis to the anterior process of
Anterior tibial and the EHL tendons can be
transferred to the neck of the talus, and the
EDL can be transferred to the anterior
aspect of the calcaneus.
Syme’s Amputation- amputation at the distal
tibia and fibula 0.6 cm proximal to the
periphery of the ankle joint and passing
through the dome of the ankle centrally.
Modified Syme’s Amputation ( Sarmiento)transection of the tibia and fibula
approximately 1.3 cm proximal to the ankle
joint and excision of the medial and lateral
Boyd Amputation- talectomy, forward shift of
the calcaneus, and calcaneotibial arthrodesis.
Amputation at the distal tibia and fibula 0.6
cm proximal to the periphery of the ankle
joint and passing through the dome of the
The tough, durable skin of the heel flap
provides normal weight bearing skin.
Posterior migration of heel pad
Skin slough resulting from overly vigorous
trimming of ―Dog ears‖.
Cosmesis- the stump is large and bulky
(bulbous) because of the flair of the distal
tibial metaphysis which is covered with
heavy plantar skin. ( not recommended for
Begin the incision at the
distal tip of the lateral
malleolus, and pass it across
the anterior aspect of the
ankle joint at the level of the
distal end of the tibia to a
point one fingerbreadth
inferior to the tip of the
medial malleolus; extend it
directly plantarward and
across the sole of the foot to
the lateral aspect, and end it
at the starting point
Place the foot in marked
equinus, and divide the
anterior capsule of the ankle
joint + insert knife b/w
medial malleolus and the
talus and lateral malleolus
and the talus to section the
deltoid and calcaneofibular
Bone hook pulling
surface of tibia and
Dissection of soft
Division of tibia and
fibula just through dome
of ankle joint centrally
0.6 cm proximal to the
The plane of the
transection should be
such that the cut surfaces
of the tibia and fibula are
parallel to the ground
when the patient is
Holes drilled in
anterior edge of
tibia and fibula to
anchor heel pad
Edge of deep fascia
lining heel pad is
anchored to tibia
Skin closure over drain, and
application of above-knee
―Dog ears,‖ are found at
each end of the suture line;
these should never be
removed because they carry
a large share of the blood
supply to the heel flap and
disappear later under
If ambulation is to be delayed until wound
healing is assured, a simple well-padded cast
If early ambulation is preferred, or when
subsequent prosthetic ambulation is to be
instituted in the postoperative period, a true
prosthetic cast should be applied.
Apply a light sterile dressing to the wound,
and apply a sterile stump sock.
Sterile felt pads are appropriately fashioned
and skived by the prosthetist to relieve
pressure over the tibial crest and the edges of
the transected bones; the prosthetist glues
these pads to the stump sock with medical
adhesive and applies the plaster cast.
Use elastic plaster of Paris in the initial wrap
to provide good control of tension; reinforce
this with conventional plaster.
Gentle compression should be maximal over
the end of the stump and gradually decrease
The end of the rigid dressing is flattened for
weight bearing by pressing a board against
the wet plaster.
The proximal part of the dressing is molded
to create a patellar bar and a popliteal
bulge, as in a patellar tendon–bearing
prosthesis, to allow partial weight bearing by
the patellar tendon and tibial condyles.
A filler block is added if needed to correct
leg-length discrepancy, and a Syme
prosthetic foot or a rubber walking heel is
attached to the cast.
A waist belt and suspension straps are used
for additional suspension
Wagner et al. popularised the technique and
was used in diabetic patients with gross
infection or gangrene of the forefoot who did
not respond to conservative treatment.
Had 95% success rate.
Many authors believe that both stages can be
safely combined when infection is not
adjacent to the heel pad.
1st stage- ankle disarticulation, preserving
the tibial articular cartilage and the
malleoli, and performing a Syme-type closure
over a suction-irrigation system that allows
installation of an antibiotic solution into the
wound. Irrigation is continued until local and
systemic signs of infection have resolved.
2nd stage-After 6 weeks, if the stump is
healed, a second procedure is performed to
remove the malleoli and narrow the stump for
good prosthetic fitting.
The prosthesis used for a classic Syme
amputation consists of a molded plastic
socket, with a removable medial window to
allow passage of the bulbous end of the
stump through its narrow shank, and a solidankle, cushioned-heel (SACH) foot prosthesis
The socket, a sock or gel liner, a suspension
system, a knee joint (articulating joint), the shank
(a pylon), and a foot (terminal device)
150. Lower extremity prosthesis components
The foot-ankle assembly is designed to provide a
base of support during standing and walking, in
addition to providing shock absorption and pushoff during walking on even and uneven terrain.
Four general categories of foot-ankle assemblies
Prosthetic feet are classified into five types:
The SACH foot
Single axis foot
The multi-axis foot
The solid ankle flexible keel foot
The energy storing foot
Designed in 1958 by Eberhart and Radcliffe
One of the most widely prescribed foot is
the solid-ankle-cushion-heel (SACH) foot,
due to its simplicity, low cost, and durability
and light weight.
It has a cushioned heel that compresses
during heel strike,simulating plantar
flexion, and a rigid anterior keel to roll over
during the stance phase.
It is prescribed for juvenile and geriatric
amputees but may be inappropriate for
active community ambulators and sports
Madras foot is mainly used in the southern
part of India
It is composed of :Wooden keel
the Advantage of bare foot walking,
durability and cultural modifications like toe
155. SACH foot
SACH Foot doesn't look like a
SACH Foot requires a closed shoe
to protect as well as hide it.
It looks like a Normal Foot.
No such need or requirement with
Jaipur Foot. But in case someone
wants to wear a shoe, he can do it
comfartably with a flat heel shoe.
Wooden Keel is long enough to
Metallic keel (carriage bolt) is
restrict/limit movements in all
confined to ankle only. So no
direction and what so ever
restriction of movement and all the
movements take place they occur at movements take place at natural
Squatting is not possible with SACH Squatting is easily achieved; as a
foot as it requires dorsiflexion at
sufficient range of dorsiflexion is
ankle joint, which due to its rigid
keel is not possible.
156. No cross- leg sitting is possible
because it requires adduction at
forefoot & transverse rotation of
foot in relation to shank.
Cross- legged sitting is possible
because sufficient forefoot
adduction & transverse rotation of
foot in relation to shank is
As there is almost no movement at
sub-tarsal joint inversion or
eversion is not possible; so SACH
Foot is suitable only for walking on
level ground. Walking on uneven
grounds & rough terrain is very
As there is adequate inversion &
eversion at subtarsal level, so
walking on uneven ground and
rough terrain is very comfortable.
Bare-Foot walking is not possible.
Single axis foot- has a single mechanical axis
for PF and DF motion limited by anterior and
posterior bumpers,allowing quicker foot
flat,which results in a more stable knee.
Multi axis foot- allows DF/PF,
inversion/eversion and are good for walking
on uneven ground or for an excessively
scarred and sensitive residual limb,because of
better shock absorption
Solid ankle flexible keel foot- has a flexible
anterior keel. Provides limited inv/eversion.
Energy storing feet- stores and release
energy as the limb is weighted and
unweighted, giving a springy feeling, which
results in a higher self selected walking speed
The shank corresponds to the anatomical lower
leg, and is used to connect the socket to the anklefoot assembly.
In an endoskeletal shank, a central pylon, which is
a narrow vertical support, rests inside a foam
Endoskeletal systems allow for adjustment and
realignment of prosthetic components.
In an exoskeletal shank, the strength of the shank
is provided by a hard outer shell that is either
hollow or filled with lightweight material.
Exoskeletal systems are more durable than
endoskeletal systems; however, they may be
heavier and have a fixed alignment, making
Suspension devices should keep the prosthesis firmly in place
during use and allow comfortable sitting.
Several types of suspension exist, both for the transtibial and
Common transtibial suspensions include sleeve,
supracondylar, cuff, belt and strap, thigh-lacer, and suction
Sleeves are made of neoprene, urethane, or latex and are
used over the shank, socket and thigh.
Supracondylar and cuff suspensions are used to capture the
femoral condyles and hold the prosthesis on the residual
The belt and strap method uses a waist belt with an anterior
elastic strap to suspend the prosthesis, while the thigh-lacer
method uses a snug-fitting corset around the thigh.
The suction method consists of a silicone sleeve with a short
pin at the end. The sleeve fits over the residual limb and the
pin locks into the socket.
Types – PTB socket, soft and hard sockets,flexible
The socket enables the prosthesis to connect and
fit to the stump (residual limb).
This is the most important prosthetic component
as a good fit is critical.
A socket that is uncomfortable is a common reason
why a prosthesis is rejected.
Contoured sockets fit closer to the remaining
bones, muscles, and soft tissues providing better
support, and provide relief where it's needed for