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O&P Library > Atlas of Limb Prosthetics > Chapter 3

Reproduced with permission from Bowker HK, Michael JW (eds): Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons, edition 2, 1992, reprinted 2002.

Much of the material in this text has been updated and published in Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles (retitled third edition of Atlas of Limb Deficiencies), ©American Academy or Orthopedic Surgeons. Click for more information about this text.


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Chapter 3 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Planning for Optimal Function in Amputation Surgery

Thomas J. Moore, M.D.

Although most surgeons consider amputation to be the ultimate surgical failure, a well-planned and executed amputation can remove a painful, dysfunctional limb and allow rehabilitation with a prosthetic limb to a functional, painless state. In this regard, amputation surgery may be considered reconstructive surgery, with results similar to amputation of an arthritic femoral head and prosthetic replacement (total-hip replacement).

Amputation surgeons must recognize the global problems associated with amputation surgery. In the United States, the most common reason for lower-limb amputation is peripheral vascular disease. Oftentimes, these patients have the same process in the contralateral limb, as well as coronary artery and cerebral vascular disease. Several series of dysvascular amputees in the 1960s and 1970s reported contralateral limb amputation rates of 15% to 28% within 3 years of the initial amputation and a 50% mortality rate during the same time period. Despite significant improvements in the care of the dysvascular amputee (diabetic management, nutrition, antibiotic management, vascular reconstructive procedures, etc.) the contralateral limb amputation rate and long-term survival rates have not significantly changed.

The role of the amputation surgeon involves much more than the actual surgical procedure. The initial, most basic decision is whether to proceed with amputation or to attempt limb salvage. In peripheral vascular disease, advances in vascular reconstructive procedures have allowed limb salvage in both nondiabetic and diabetic patients. Advances in trauma management such as arterial and venous repairs, bony stabilization, and free-tissue transfers have resulted in limb salvage in severely traumatized limbs that previously would have been amputated. Improvements in adjunctive chemotherapy and surgical technique have allowed en bloc resection of certain bony tumors and limb salvage with either custom prosthetic implants or allograft replacement.

Once an amputation is decided upon, preoperatively the most distal level of amputation compatible with wound healing and subsequent satisfactory prosthetic fitting should be determined by clinical evaluation and laboratory evaluation. The environment for wound healing should be maximized by evaluating the patient's nutritional status, control of diabetics' blood glucose, and the use of antibiotics in infected patients. Appropriate surgical technique should be utilized to produce an acceptable stump for subsequent prosthetic fitting. Postoperatively, appropriate judgment should determine prosthetic candidacy in elderly dysvascular amputees.

Modern amputee management involves a multidisci-plinary approach to address the global problems (medical, surgical, social, rehabilitative, and economic) involved in amputees. Planning for optimal function in amputation surgery should consist of preoperative, operative, and postoperative considerations.

PREOPERATIVE CONSIDERATIONS

Amputation vs. Limb Salvage

Trauma

Modern advances in trauma management such as fracture stabilization and free-tissue transfers have allowed salvage in limbs that previously would have been amputated. Despite these advances, the amputation rate in grade IIIC tibial fractures is still greater than 50% in recent series. In addition, several series have shown that there is significant morbidity, increased economic cost, and psychological effects involved in limb salvage in severely traumatized limbs. Lange et al. have developed narrow absolute criteria (prolonged warm ischemia time greater than 6 hours and/or anatomic disruption of the posterior tibial nerve in adults) for primary amputation in grade IIIC tibial fractures. Other groups have developed more comprehensive rating systems to evaluate severe limb injuries to allow objective criteria for limb salvage vs. amputation decisions. (See Chapter 2B for a detailed discussion.)

Peripheral Vascular Disease

The largest number of amputations done in the United States are for peripheral vascular disease. As the population of the United States ages, more patients will be evaluated for dysvascular disease in lower limbs. Oftentimes, early amputation at the most distal level possible and rehabilitation with a prosthesis offer the best solution for a painful, dysvascular limb. However, before undergoing amputation, many of these patients should be evaluated for consideration for vascular reconstructive procedures that may allow either limb salvage or a more distal amputation level.

Vascular reconstruction in limbs at risk for amputation may have some drawbacks. Arterial reconstructive surgery is expensive and may delay eventual definitive treatment, and the outcome is uncertain. However, several series have demonstrated no adverse effect of failed vascular reconstructive procedures on the ultimate level of amputation or clinical outcome.

The vast majority of lower-limb amputations for peripheral vascular disease occur in diabetics. Often diabetics with dysvascular disease are thought to have "small-vessel disease" not treatable with vascular reconstructive procedures. This concept probably originated in an article by Goldenberg et al. in 1959 that described arteriosclerosis in the arterioles of diabetics that was thought to be unique. However, subsequent series have not confirmed small-vessel disease as unique to diabetes mellitus. In addition, multiple series have demonstrated that when modern techniques of vascular reconstructive surgery are applied to diabetics, long-term limb salvage rates are comparable to nondia-betics treated in a similar manner. Therefore, diabetics should not be automatically excluded for consideration for vascular reconstructive procedures in limb-threatening conditions. (See Chapter 2C for a detailed discussion.)

Tumors

The field of musculoskeletal oncology is rapidly evolving. In the 1960s and early 1970s, 5-year survival rates for patients with osteogenic sarcoma were in general less than 20%. The advent of more sophisticated radiographic preoperative staging and the use of preoperative and postoperative adjunctive chemotherapy have improved 3-year survival rates in osteogenic sarcoma to 60% to 85% in some studies. En bloc resection of osteosarcomas and limb salvage with either customized orthopedic implants or allograft implantation has been developed in the last decade. Several institutions report similar overall survival rates of patients who underwent primary amputation and of those who underwent segmental limb resection. Survival rates may actually be improved in those patients who undergo an en bloc resection because the patients selected for this treatment are likely to have more limited disease. At the present time, en bloc resection with limb salvage in osteosarcoma should probably be restricted to centers with a large oncology section and is probably con-traindicated in patients with large tumors who exhibit minimal response to preoperative chemotherapy. (See Chapter 2E for a detailed discussion.)

Site of Amputation

Before World War II, the majority of lower-limb amputations were transfemoral because such procedures yielded healing rates approaching 100% in ischemic limbs. In the 1960s and early 1970s, several factors combined to reverse the ratio of transfemoral to trans-tibial amputations. The use of a long posterior myofasciocutaneous flap in dysvascular patients, with its increased blood supply, improved the success rate in transtibial amputations. In addition, the development of preoperative objective criteria for amputation site viability allowed more distal amputations to be done.

Lower-limb amputations in the dysvascular patient should be performed at the most distal site compatible with wound healing to achieve the optimal potential for ambulation. Several well-documented studies have shown that energy expenditure with prosthetic ambulation is markedly increased in more proximal amputations. Waters and coworkers found that energy expenditure during ambulation, as measured by oxygen consumption per kilogram of body weight per meter traveled, was significantly increased in transfemoral amputees vs. transtibial amputees. Fisher et al., in a review of previous energy studies in amputees, found that lower-limb amputees expend more energy (kilocal-ories per meter) in ambulation than do nonamputees and have a compensatory decrease in gait velocity. Huang and associates showed that oxygen consumption during ambulation was increased 9% in transtibial amputees, 49% in transfemoral amputees, and 280% in bilateral transfemoral amputees when compared with nonamputees.

Preservation of the knee joint has even more significance when the rate of contralateral limb amputation is considered. Mazet and coworkers, in their series of dysvascular amputees, had a 33% contralateral limb amputation rate within 5 years. Other authors reported contralateral amputation rates of 15% to 28%.Ambulation ability in bilateral amputees is, of course, less than in unilateral amputees. For geriatric patients with bilateral transfemoral amputations, ambulation is probably not feasible in most cases, and wheelchair locomotion is indicated. In contrast to some older reports, recent studies have demonstrated the enhanced ambulation potential of patients with at least one knee joint preserved as compared with patients having bilateral trans-femoral amputations. However, in elderly debilitated patients with limited or no ambulatory potential, knee disarticulation or transfemoral amputation is preferable to transtibial amputation to prevent knee flexion contractures and subsequent breakdown of the stump.

Various methods have been developed to objectively determine the most distal level at which amputation is likely to be successful. Clinical parameters such as the lowest palpable pulse, skin temperature, and bleeding at surgery have been used with varying success to predict healing of amputation sites. The use of Doppler ultrasonography to measure arterial blood pressure at the proposed amputation site has been advocated as a predictor of amputation success. Barnes and coworkers found that transtibial amputations healed in all patients with popliteal systolic pressures of more than 70 mm Hg. Wagner has suggested comparing the pressure at the proposed amputation site to that of the brachial artery; a ratio of >0.35 is adequate for healing in the nondiabetic, while a ratio of 0.45 is adequate for the diabetic.

However, there are inconsistencies with Doppler determinations of the amputation site. A calcified, non-compressible artery will give falsely elevated values. In addition, the pressure in a deep artery may not correlate with skin healing. Other authors also suggest that the segmental arterial pressure in diabetics is not always helpful in preoperative determination of amputation levels.

Two methods use clearance of 133Xe to measure dermal vascularity. In one method, cutaneous diastolic pressure is estimated by determining the applied pressure necessary to stop clearance of intradermally injected 133Xe. Holstein et al., in a study of 60 transtibial amputees, found that when the skin perfusion pressure was <20 mm Hg, only 25% of these amputations healed; when the skin perfusion pressure was >30 mm Hg, 90% healed. From 20 mm Hg to 30 mm Hg of pressure, 67% of amputations healed.

In a second method, cutaneous blood flow is measured by determining the rate of clearance of 133Xe injected intradermally or epicutaneously. The skin blood flow per unit volume is inversely related to the time required for the detected activity of the 133Xe to decrease by half. With intradermally injected 133Xe, Moore found that amputation sites with a value of &#2265 2.7 mL/ min/100 g healed successfully 97% of the time. Kostuik et al. injected 133Xe epicutaneously and determined that wound healing was predictable with skin blood flow above 0.90 mL/min/100 g of tissue. Other authors have not found the skin flow measurements with 133Xe to be so reliable. The method is exacting to carry out, and the trauma of injecting 133Xe may in and of itself elevate the skin blood flow.

Measurement of transcutaneous Po2 is another method of determining the amputation level. It is not invasive and does not require radioactive isotopes. This method involves warming the skin to 44C with a heated electrode, which then measures the oxygen emanating from the skin. This method is based on the fact that the oxygen tension measured over locally warmed skin reflects the metabolic and perfusion capabilities of the skin and hence its healing potential. In a study of 37 dysvascular patients, Burgess and Matsen found that with transcutaneous Po2 values >40 mm Hg, transtibial amputations in 15 patients healed with no delay. Three patients with transcutaneous Po2 levels of zero had transtibial amputations that failed. In 17 of 19 patients with transcutaneous Po2 values of >0 mm Hg to 40 mm Hg, transtibial amputations healed. Other authors found that an increase of 10 mm Hg of transcutaneous Po2 over a baseline value while inhaling 100% oxygen is predictive of wound healing.

Other preoperative methods of determining amputation level such as fluorescein angiography, skin temperature measurements, and pulse volume recordingshave been used. Recently, laser Doppler velocimetry has been used to assess the viability of amputation levels.

Burgess and Matsen have pointed out that preoperative measurements to determine amputation level are more beneficial in predicting failure than in predicting success. Factors such as alteration in collateral circulation, decreased distal vascular runoff as a result of surgery, surgical technique, the nutritional status of the patient, infection, concomitant medical illnesses, and postoperative care cannot be assessed in the preoperative period. However, preoperative laboratory assessment of the amputation level does give an indication whether adequate circulation exists for a favorable outcome.

Nutrition

The significant incidence of malnutrition in hospitalized patients has been well documented. Jensen and associates reported a 42% incidence of laboratory-proven malnutrition in orthopedic patients undergoing surgical procedures, including elective total-hip replacements. Patients undergoing lower-limb amputations are often elderly and debilitated. In addition, diabetics with dysvascular limbs often have open wounds and systemic sepsis causing increased metabolic demands.

Protein malnutrition has an adverse affect on morbidity and mortality in hospitalized patients. The cell-mediated and humoral immune systems are impairedwith resultant decreased host resistance. Dickhaut and coworkers, using serum albumin levels and total lymphocyte counts, found that successful healing of Syme's amputations (ankle disarticulations) occurred in only 2 of 11 malnourished patients despite adequate preoperative Doppler criteria for healing.

Trauma or infection increases energy requirements 30% to 55% from basal values. Patients undergoing a semielective lower-limb amputation should undergo at least a baseline nutritional assessment, including a serum albumin determination and total lymphocyte count. If the initial values are abnormal (serum albumin <3.4 g/dL or a total lymphocyte count of < 1,500 cells per cubic millimeter), then a more formal assessment should be done. There have been no prospective series to demonstrate decreased mortality or morbidity in malnourished patients treated with nutritional supplementation before amputation. However, if time permits, enteral or intravenous hyperalimentation should be considered in a malnourished patient being evaluated for amputation.

Antibiotics

The use of antibiotics as prophylaxis in orthopedic surgery, especially surgery involving implants, is well established. The use of antibiotics as prophylaxis in patients undergoing lower-limb amputation is less well defined. In cases of open, draining wounds or gas-forming infection, the use of antibiotics in the perioperative period is mandatory.

Most lower-limb amputations for dysvascular disease in the United States are in diabetic patients. In neurotrophic ulcers in diabetes mellitus, the infection is usually polymicrobial, including both anaerobic and aerobic species. Therefore, broad-spectrum antibiotics should be used initially until specific organisms are recovered in culture.

In dysvascular patients undergoing elective amputation, the effectiveness of prophylactic antibiotics in the perioperative period has not been established. However, Sonne-Holm and coworkers have shown a statistically significant decrease in wound infections in dysvascular amputees treated with a broad-spectrum (cephalosporin) antibiotic in the perioperative period. At Rancho Los Amigos Medical Center, patients with infected dysvascular limbs who are being considered for amputation are initially debrided surgically, and specimens for aerobic and anaerobic culture and sensitivity are obtained at this procedure. Broad-spectrum antibiotics are begun parenterally until specific organisms and antibiotic sensitivities are available. Parenteral antibiotic treatment is continued until clinical evidence of infection (e.g., leukocytosis, erythema) is diminished. Then a definitive amputation can be carried out. In most cases, the wound can be loosely closed over drains. In cases of systemic sepsis or severely infected limbs, a preliminary guillotine amputation is done. Parenteral antibiotic therapy is continued until the sepsis is quiescent, at which time the definitive amputation is done. In cases of noninfected dysvascular amputations, prophylactic antibiotic therapy (usually a first-generation cephalosporin) is begun at the time of surgery and continued for 48 hours following the amputation.

Diabetes

Five out of six major lower-limb amputations are done in diabetics. Although previously it was believed that diabetics were doomed to an amputation in a dysvascular limb, several series have shown equivalent results with vascular reconstructive procedures in diabetics and nondiabetics. However, there are problems unique to diabetics that require consideration.

Neuropathy develops in the majority of diabetic patients, and therefore, minor traumatic events in the insensate limb can result in limb-threatening ulcers. The altered metabolic state in uncontrolled diabetes mellitus can decrease granulocyte function and collagen synthesis and result in an increased susceptibility to infection and delayed wound healing. Vigorous control of blood glucose in diabetics undergoing lower-limb amputation, especially in the perioperative period, can enhance collagen synthesis and the inflammatory response to infection. In some series, healing of amputations of lower limbs in patients with diabetes mellitus has been similar to healing in nondiabetics.In addition, amputations in diabetics with dysvascular and neurotrophic ulcers can be avoided with conservative nonoperative care and education.

OPERATIVE CONSIDERATIONS

In order to enhance the potential for prosthetic ambulation following lower-limb amputation, the amputation surgeon must apply appropriate surgical technique to allow wound healing at the most distal amputation site possible. This involves, especially in dysvascular patients, handling soft tissue in a nontraumatic manner. Therefore, tissue forceps should be avoided in handling the skin in these patients.

As already described, it is important to salvage the most distal amputation site feasible (transtibial vs. transfemoral amputations) in potential prosthetic ambulators. In addition, Gonzales et al. have shown that there is decreased energy expenditure in transtibial amputees with a long stump. They defined the stump as being long if it is 50% of the length of the remaining contralateral leg, medium if 20% to 50% the length the contralateral leg, and short if less than or equal to 25% of the length of the contralateral limb. They found oxygen consumption during ambulation to be 10% higher in amputees with long stumps and 40% higher in amputees with short stumps when compared with nonampu-tees. Modern management of soft-tissue injuries such as free-muscle transfers and tissue expanders has allowed salvage of longer amputation stumps in trauma. Large skin defects can be covered by utilization of viable skin from amputated parts. Inadequate short transtibial amputation stumps have even been lengthened by the Ilizarov technique.

Grossly contaminated traumatic wounds and some infected dysvascular limbs with gangrene should not be closed primarily following amputation. In general, skin traction should not be used, especially in dysvascular amputees. Delayed primary closure, split-thickness skin grafting, or free-muscle transfer can be done when local sepsis is diminished. When clinical judgment is not clear on timing of closure of contaminated wounds, then a centimeter of tissue can be obtained for quantitative bacterial counts. If the quantitative bacterial count is less than 10, then closure can be done. If the quantitative bacterial count is greater than 10, then further debridement is necessary before attempting closure.

In addition to the goal of obtaining the most distal amputation site possible, the stump should have sufficient soft-tissue coverage to resist the shear forces involved in prosthetic ambulation. Weight bearing occurs at the distal part of the stump in transfemoral amputations and knee disarticulations. Painful neuromas should be avoided at the site of weight bearing by sharply dividing nerves and allowing their retraction into sufficient soft-tissue cover.

POSTOPERATIVE CONSIDERATIONS

In the immediate postoperative period, amputation stumps should be splinted with well-padded rigid dressings to prevent joint contractures. The use of an immediate postoperative prosthesis (IPOP) has been advocated to allow early prosthetic ambulation, decrease stump edema, and diminish postamputation depression. However, others have found significant wound problems with IPOP. In general, IPOP should probably be reserved for young, traumatic amputees.

The most basic decision following wound healing in amputees is determination of appropriate candidacy for prosthetic ambulation. Moore et al. evaluated the variables associated with successful prosthetic ambulation in lower-limb amputees. The presence of coronary artery disease in transfemoral amputees precluded prosthetic ambulation, presumably because of insufficient cardiac reserve for the increased energy demands of prosthetic ambulation. In this study, 32% of lower-limb amputees fit with a prosthesis did not utilize it.

An overall assessment of the lower-limb amputee should be done prior to prosthetic fitting. The patient's social situation should be evaluated. Such factors as impaired vision from diabetic retinopathy, poor balance from concomitant cerebral vascular accidents, significant psychological problems, or additional musculoskeletal problems such as rheumatoid arthritis should be considered prior to prosthetic fitting. In an elderly, dysvascular lower-limb amputee with significant coronary artery disease, optimum planning in amputation surgery may involve wheelchair locomotion, which has been shown to be equivalent in energy expenditure to normal bipedal gait.

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Chapter 3 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

O&P Library > Atlas of Limb Prosthetics > Chapter 3

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