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Amputations
Symposium on Orthopedic Surgery
Amputations
Ernest M. Burgess, M.D.*
Most amputations today result from ischemia of a limb. This circumstance has changed traditional management in that an understanding of the nature and course of peripheral vascular disease is essential for effective amputation surgery and rehabilitation. The decision to amputate may be obvious, in the presence of end-stage limb viability. More often, the surgeon will be faced with a less clear-cut decision requiring considerable experience, judgment, and evaluation when several treatment options are available. Retention by vascular reconstruction of a severely impaired limb whose function is painful and disabling can be less effective than a lowlevel amputation fitted with a modern prosthetic substitute. Neurologic deficit in many diabetics with impaired circulation and the presence of infection will force the surgeon to consider surgical staging in the light of excellent, currently available supportive therapy. Ischemia of a limb is primarily a disease of elderly persons. Associated health problems may compromise mobility as much as the amputation itself. Institutional and bed confinement compound disability among these older persons whose remaining days may be few. The cost of prolonged, high technology care must also be considered. Whether tax supported or from other sources, the financial cost ultimately rests with society. Amputations resulting from trauma are second in frequency and much fewer in number. Much of our knowledge and practice of amputations for trauma has been war related. Notable is the experience with amputation in the Napoleonic wars, the American Civil War, and, more recently, the two World Wars. Surgical principles and techniques in general have been profoundly influenced by centuries of experience with amputation. The accounts of amputation recorded in the pages of medical history provide fascinating and often times inspiring reading. The recent development of microsurgical techniques, composite tissue grafting, and ingenious surgical revascularization along with other forms of operative limb reconstruction has introduced a greater level of competence for saving a limb injured by trauma. As with ischemia caused by peripheral *Principal Investigator, Prosthetics Research Study; Clinical Professor, University of Washington School of Medicine, Seattle, Washington
Surgical Clinics of North America-Yo!. 63, No. 3, June 1983
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vascular disease, it is important to evaluate carefully for each patient the place of limb replantation or extensive, complicated limb salvage weighed against physiologic amputation and modern prosthetic rehabilitation. These hard decisions arise almost daily in major trauma centers. Surgeons responsible for the care of these injuries continue to update guidelines based not only on improved, dramatic surgical techniques but also on the great advances in the field of prosthetics. A relatively small group of persons come to amputation for tumors, acute and chronic infections, congenital limb deficiencies, and metabolic disorders. Their proper management is also individualized, challenging the surgeon to understand clearly the surgical alternatives based on fundamental principles of wound healing and selection of prostheses. Amputations, both major and minor, are a unique physiologic and psychologic experience. The loss is complete. It is often said that only an amputee understands what it is like to experience life with a missing limb. Much has been written about the psychologic aspects of losing a limb. Acceptance by peers of physical disability together with a world-wide awareness of rehabilitation has contributed greatly to a positive social profile for most amputees.
THE PRINCIPLES OF AMPUTATION For decades, surgical texts have presented a standard set of principles and guidelines with only relatively minor variations. Until recently, only a few significant articles have appeared in current medical periodicals. The comprehensive Atlas of Amputations authored by Slocum at the end of World War II was never revised, nor has it a recent counterpart. Levels of amputation, surgical management, and early postoperative care have not, until recently, reflected the rapid progress in other areas of surgery. Amputation has too often been relegated to near the end of the operative schedule to be performed by junior house officers often unsupervised. In recent years and particularly since the end of the Vietnam war, amputation has entered the mainstream of surgical progress. This trend continues and is accelerating. The amputee today, whether an elderly patient with diabetes or a young person injured in a motorcycle accident can anticipate a vastly improved quality of life when compared with people similarly disabled a few years ago. Current surgical writing mirrors this change. The first principle of amputation surgery is attitudinal. The surgeon's primary charge is the reconstruction of a physiologic residual limb. As with all surgery, uneventful healing of the wound is the primary goal. This accomplishment in itself does not ensure optimum functional recovery. The residual limb will be called on to function with an inert limb substitute. As nearly as possible, the remaining portion of the limb must retain the strength, sensibility, motor control, and proprioception in the terminal end-organ, such as the hand or foot. To the surgeon with this attitude, the amputation becomes a challenging, reconstructive, often demanding, surgical exercise. Effective postoperative management coupled with early
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prosthetic rehabilitation can offer a remarkable degree of comfortable activity. With younger, physically active, unimembral amputees, this level of activity can include vigorous sports and prolonged endurance (Fig. 1). The level of amputation is established by the disease and by the adaptability of available limb substitutes. With but few exceptions, the older, standard levels of election are no longer valid. Modern surgery is directed toward the creation of a physiologic terminal end-organ. Maximum length is generally desirable. The actual length, however, will be at a level that provides nontender, nonadherent, healthy skin coverage with retention of as much of the soft tissue of the stump as can be properly saved, especially muscle. For stump muscles to be physiologically active, they must have some degree of distal stability. Muscle stabilization when surgically possible is a basic principle. Sensation and blood supply, especially to the skin, are retained as with other plastic reconstructive procedures. ' Positioning of the scar or scars is relatively unimportant. Most modern prostheses totally contact the residual limb. As long as the scar is nontender, nonadherent, durable, and tolerant of the opposing inert prosthetic surface, its position is inconsequential. Placing of incisions, skin flaps, and on occasions, skin grafts, follows this principle. Augmentation of the length of the limb by composite grafting or other measures will occasionally be indicated. Sites for this type of surgery and consideration of the few undesirable upper and lower limb levels will be discussed individually. Length of the limb should not be achieved at the expense of a painful, pressure-intolerant stump, subject to breakdown of the wound. When length retention is critical, surgical ingenuity using plastic and reconstructive techniques becomes especially important. VIABILITY OF THE LIMB Whether from trauma, peripheral vascular disease, or other local vascular insult, the surgeon must know the degree of viability of limb tissues, especially skin. This knowledge directly influences the level of amputation. The wound cannot heal successfully unless the skin and deeper tissues have sufficient healing potential to withstand the trauma of the surgery and the postoperative inflammatory response. The history and physical examination coupled with experience and clinical judgment are the most important prognosticators. Several useful laboratory tests are also available. Vascular surgeons, vascular physiologists, and orthopedists involved in research on limb viability are adding useful information to this area. Relatively few surgeons have wide experience performing amputations for ischemia. The surgeon who occasionally performs amputations as well as the surgeon directing an amputation service can benefit from noninvasive, inexpensive laboratory tests, which assist in determining the level of limb viability. Reamputations can be avoided, yet maximum length of limb can be attained by the use of this additional information. Objective tests supplement a careful physical examination. No single test can be relied on
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Figure 1. A to C, Sports performance by persons with amputations below the knee. Many other vigorous sports are performed with professional competence by amputees.
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with complete accuracy. Surgeons responsible for large numbers of amputations may achieve a high rate of successful low levels of amputation by experience, careful history, and physical examination alone. More and more, however, the laboratory data to be described are supportive. Angiography is an obvious presurgical requirement when vascular reconstruction is carried out. This demonstration of the patency and physical nature of the vessels provides the road map identifYing a possible surgical course to be taken. The same information is of less value to the surgeon planning an amputation. Amputation alters the blood flow by removing distal vascular runoff as well as collateral pathways. Although measuring techniques can provide information about a number of factors involved in the circulation of the extremity, none of these factors specifically quantifies the ability of the amputation site to heal. A number of other conditions will influence the success or failure of the amputation at a given level. These include the details of surgical technique, the specifics of postoperative care, and the health of the patient. For these reasons, techniques for assessing limb viability are generally more useful in predicting failure rather than success of an amputation at a given level. Limb viability can be assessed by a number of laboratory measurements: extremity blood flow, arterial blood flow, muscle perfusion, skin blood flow, oxygen delivery to the skin, segmental blood pressure, skin blood pressure, and skin function. In the interest of completeness, the present sources of such objective information are listed in Table l. Current practical application of this long list of clinical and research tests are those measuring segmental blood pressure, skin blood pressure, and skin temperature. Clearance of xenon-133, transcutaneous P0 2 , and Doppler flowmetry using ultrasound and laser measure these factors. Optical flowmetry, multispectral reflectrometry, and measurement of heat conductivity may prove valuable, but more experience is needed at this time before their value is known. Segmental Blood Pressure One of the most widely used techniques at this time is the measurement of the segmental blood pressure in the limb. The correctly sized blood pressure cuff is placed on the limb at the level for measuring pressure, and it is briefly inflated to above the patient's systolic blood pressure. Cuff pressure is then progressively reduced to a point where the distal blood flow recommences. This pressure is the segmental systolic blood pressure. The onset of distal blood flow is most frequently indicated by the return of the ultrasound Doppler signal from a superficial artery. The comparison of the segmental pressure in the lower limb with that of the brachial artery is frequently used. If the segmental blood pressure in the lower limb is 35 to 40 per cent of the brachial systolic pressure, amputation at that level is considered appropriate. As to an absolute Doppler value, various investigators quote a critical value ranging from 40 to 70 mmHg. There are certain pitfalls in complete reliance on readings of segmental limb blood pressure. In large patient populations, however, it appears that a real correlation does exist between segmental pressure and the success of amputation. The
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Table 1. Assessment of Limb Viability Extremity blood How Venous filling time Plethysmography, wave form analysis, and pulse volume recording Volume plethysmography Circumference plethysmography Photoplethysmography Noninvasive electromagnetic Howmetry Isotope scans Arterial blood How Pulses by palpation Arteriography Doppler effect Invasive electromagnetic Howmetry Muscle perfusion Muscle pH Muscle P02 Muscle blood How Skin blood How Total skin blood How Visual observation Photoplethysmography Multispectral analysis Skin temperature Palpation Thermistor thermography Liquid crystal thermography Infrared thermography Fluorescein angiography Laser Doppler Howmetry Skin Hap bleeding at time of surgery Nutritional skin blood How 133Xenon washout Injected Epicutaneous Hydrogen washout Cutaneous oxygen delivery Intracutaneous Polarographic Mass spectrometric Transcutaneous P0 2 measurement Segmental blood pressure Skin Hush Doppler technique Plethysmography Strain gauge plethysmography Volume plethysmography Photoplethysmography Impedance plethysmography 133Xenon clearance (distal blood pressure) Skin blood pressure Blanching of histamine-injected skin Photoelectric technique 133Xenon clearance 131 Iodine clearance Laser Doppler Howmetry Skin function Observation of ability to maintain skin envelope Observation of ability to produce cutaneous appendages Ability of skin to heal incisions
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method can be used to determine levels of amputation for fingers and toes as well as for the more proximal levels. Skin blood pressure and skin blood flow are measured successfully by using xenon-133 clearance. This technique requires the availability of the isotope and a means for detecting xenon clearance. Malone, in Arizona, reported 100 per cent successful primary wound healing of amputations when the skin blood flow as measured by the xenon-133 technique was in excess of 2. 6 ml per 100 gm of tissue per minute. Below that level, failures occurred. The author does not use skin isotope clearance as a routine clinical tool. Its use is reserved as a comparative research measurement. Backscatter readings from laser beam-Doppler signal is a new, noninvasive, simple measure of skin blood pressure. 7 Its use is gaining clinical acceptance. Transcutaneous oxygen measurement is a noninvasive means of evaluating adequacy of local cutaneous circulation. Studies indicate that this measurement reflects a balance between oxygen delivery to the skin and cutaneous oxygen consumption. Transcutaneous (Tc) P0 2 clinically depends upon the local arterial venous gradient. This dependence becomes progressively more sensitive as the local gradient approaches low values, around 20 mmHg. In a substantial series of cases, all amputations below the knee performed for ischemia when the transcutaneous P02 level below the knee was 40 mmHg or greater went on to primary healing. With TcP02 recorded at 20 mmHg or less below the knee at the site of planned surgery, the primary healing rate dropped sharply. Recent development of equipment measuring TcP0 2 simultaneously at multiple sites on the limb allows scanning as a simple, noninvasive, nonpainful technique requiring less than a half-hour. The factors determining the ideal level for amputation in patients with peripheral vascular insufficiency are many and complex. At this time, it appears unrealistic to expect absolute accuracy of prediction in any single test or group of tests. The development of increasingly precise tests and their integration with overall clinical assessment are nevertheless placing preoperative determination of amputation levels on a far more scientific footing (Fig. 2). AMPUTATIONS OF THE LOWER LIMB Amputations Through the Foot and Ankle (Fig. 3) Loss of one or all of the four lesser toes causes only minor disability. Absence of the great toe is a significant deficit. "Push off' is impaired, and the size of the pedal platform is decreased so that balance and gait are moderately affected. Either sagittal or coronal skin flaps can be used. A loose skin closure is mandatory. Tight skin predisposes the patient to failure of skin healing and wound breakdown. Even when healing occurs, pressure-sensitive areas remain of the type often seen with "hammer toes" and bunions. Thus, skin is disposed to callosities, secondary wound complications, and infection. It-
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Figure 2. Portable testing equipment for limb viability. Included are TcPO,, laser Doppler, and multispectral analysis units. Ultrasound doppler and skin temperature equipment also are routinely used but are not shown.
Figure 3. A and B, Through foot amputations. Variations of older techniques are useful with modern partial foot prostheses.
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is not routinely necessary to remove the cartilage from phalanges or metatarsal heads. Revision of the metatarsal head, especially that of the first metatarsal, should be performed carefully, keeping in mind the necessity for freely movable nontender skin over the rigid, deeper structures, primarily bone and cartilage. The basic principles of forefoot surgery apply. When gangrenous toes are removed to provide drainage, they should be severed by dividing the skin transversely. Longitudinal incisions for drainage of infection, particularly in the foot of a person with diabetes, are not acceptable. Adequate drainage can be better obtained by transverse incisions or open amputation. When two or three of the lesser toes require amputation, it is generally better to remove the adjacent minor toes. Deformity and subsequent complications are avoided without any real loss of function. Independent removal of the great toe may not induce subsequent deformity and deviation of the otherwise functional lesser toes. On the other hand, removal of all of the lesser toes leaving the great toe intact can cause lateral migration of the toe through the metatarsal phalangeal joint. This circumstance does not automatically require amputation or stabilizing surgery of the great toe. It can be left as a single digit when circumstances otherwise permit. It will remain a functional member. If significant deviation and deformity do result, subsequent amputation can be performed. Transmetatarsal amputation and single or multiple ray resection are increasingly valuable levels of surgery. With an improved understanding of limb viability and available, light, clean, partial foot orthoses, these amputations are gaining favor both for trauma and ischemia. Gentle, meticulous surgical technique is mandatory. Plantar scars are avoided. Weight-bearing surfaces are covered with pressure-tolerant skin from the sole of the foot. Tight skin closure is strictly avoided. Postsurgical wound drainage is ordinarily required. Prominent rigid structures, bone and cartilage, are contoured and tailored carefully to eliminate pressure on overlying skin when the patient is standing, walking, and wearing shoes.
Amputations Through the Mid-Foot As the foot is reduced in size by amputation proximal to the tarsalmetatarsal joints, muscle imbalance may increasingly deform the remaining foot segment. When local blood supply is adequate to permit rebalancing tendon surgery, these mid-foot amputations can provide long-term painless function. Comfortably fitted with modern ankle-foot orthoses, it is possible to take advantage of full leg length and the plantar weight-bearing surface. Gravity push-off is obtained by mechanically blocking ankle dorsiflexon with the orthosis so that gait is remarkably normal when walking at medium cadence. Fast walking and running are somewhat more difficult. The combination of carefully planned reconstructive mid-foot amputation surgery and light, dynamic, partial foot orthoses has extended the importance of amputations through the mid-foot, operations that had until recently been largely discarded. This situation exists for both trauma and ischemia.
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Hind-foot amputation with retention of the talus and os talus, popularized by Boyd, is rarely indicated in the adult. Children whose legs are not of equal length may benefit by modifications of this procedure. The Insensitive Foot Protective sensation is necessary if breakdown of the skin is to be avoided. The unhappy triad seen so often in the diabetic person's footjoint deformities, hypesthesia, and infection-challenges the surgeon. Stable healing of the wound at transmetatarsal or mid-foot levels will not ensure successful weight-bearing when the skin is insensitive. A Syme' s amputation or one below the knee will be preferred. The resurgence of interest in major amputations through the foot will continue. Not many years ago, amputations even as high as the level below the knee were shunned in the presence of peripheral vascular disease. Many elderly people with ischemic limbs requiring amputation and who would have sustained a level above the knee a few years ago can walk, with surgery being performed distal to the knee. A selected number of these patients will heal and successfully walk on well-planned amputations through the foot. Contrary to past teachings, these residual limbs will not cause insurmountable prosthetic problems, nor will late ulceration of the skin or breakdown necessarily occur. The Syme' s Amputation Few surgical procedures have withstood the test of time as well as the modified ankle disarticulation described by James Syme in 1842. His original description has been often reprinted essentially without change down through the years. It remains today a useful, physiologic, well-conceived operation exhibiting the specific advantages described originally (Fig. 4). A century and a half of experience has established indications. When these indications are followed, and when the surgical technique and aftercare are proper, the one-stage Syme's amputation fills a definite and important role. A past major criticism has been the awkward, heavy, unsightly Syme' s prosthesis. Current limb designs have effectively minimized this drawback. When compared with the level below the knee, the advantages of the Syme's amputation are well known. Less consumption of energy is required, a much larger degree of end-bearing is obtained, the amputation is particularly durable, and pain is uncommon. Full weight-bearing without a prosthesis is well tolerated. Unequal length of legs does not prevent comfortable walking for short distances without a prosthesis. A simple Syme' s extension boot further simplifies standing and walking in the house without wearing the prosthesis. When the heel skin is good, the one-stage Syme' s technique is particularly valuable for saving the forefoot injured by severe trauma. Congenital limb deficits with deformities of the foot, ankle, and lower leg occasionally will be best managed by the Syme' s technique, care being taken to preserve distal leg epiphyses. The high failure rate associated with one-stage Syme' s amputation for ischemia has discouraged its use. In recent years, the two-stage operation
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Figure 4. A classic Syme's amputation for peripheral vascular disease.
as popularized by Wagner has reestablished this level as a valuable amputation for ischemia, particularly in the patient with diabetes. The first stage is essentially a closed ankle disarticulation with a Syme' s type heel flap and skin closure over a closed irrigation system. The skin flaps are made somewhat longer and more bulky to accommodate the malleoli that are left intact. Several weeks after healing of the initial amputation, the malleoli are removed through two small incisions, one lateral and one medial. Recent excellent descriptions of the two-stage technique are available. Amputations Below the Knee
Amputation through the lower leg is unquestionably the single most important level. Improvement in surgical techniques has developed over the last few years, and, together with the clinical importance of knee retention, has emphasized the importance of a thorough understanding of the below-knee level by surgeons performing amputations (Fig. 5). The quality of amputee care for ischemia can be judged by the ratio of aboveknee to below-knee amputations surgically performed that proceed to stable wound healing. Recent reports from many institutions substantiate this fact. The current preponderance of successful amputations below the knee
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Figure 5. A to C, Amputations below knee for ischemia. Several levels are shown. All are functional with modern, total contact below knee prostheses.
especially in peripheral vascular disease represents the most important recent advance in amputee care. Thousands of elderly persons walk successfully with single or bilateral amputations below the knee. Had these amputations been performed at a higher level, most would be confined to a wheelchair. The difference in lifestyle is self-evident. The amputation below the knee for peripheral vascular disease is relatively short (7 to 10 em below the tibial plateau). The scar is placed anterior with a long posterior myocutaneous flap; a sagittal SC\U' with relatively short, equal myocutaneous flaps is also effective. Routine use of the long anterior skin flap with posterior incisional scar is unacceptable. Initial failure and long-term prosthetic problems have eliminated this earlier classic technique. The tibia is very carefully beveled and rounded to prevent pressure intolerance of the anterior and medial socket. The fibula is sectioned 1 em shorter. The residual limb is cylindrical rather than tapered, and muscle activity is preserved as completely as possible by some degree of distal major stabilization of muscles as provided by the long posterior flap technique. This modern amputation below the knee has been often described in detail. Though it is not technically demanding, it does require particular attention to gentle management of tissues and precise surgery. The film
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libraries of the American College of Surgeons and the American Academy of Orthopaedic Surgeons both contain excellent visual aids demonstrating surgical management below the knee. Successful prosthetic rehabilitation depends on a functioning knee able to actively extend to within 15° of normal. Knees with a greater degree of fixed, uncorrectable flexion deformity compromise a stable prosthetic fit below the knee. Range of motion and muscle control of the knee and hip must be carefully evaluated when determining this level of amputation especially with the geriatric patient. When the remaining portion of the limb to the level below the knee is functional, amputation below the knee should be successfully performed in 65 to 85 per cent of all patients requiring major lower limb ablation for ischemia. These figures have been verified by many surgical services throughout the world. The theme of modern amputation is the successful attainment of lower levels of physiologic amputation. Nowhere is this more important than in the elderly patient with peripheral vascular disease. The importance of saving a functional knee cannot be overestimated. Saving the knee is equally important when amputating for trauma. Preservation of length and retention of stump muscle require well-planned, reconstructive management, often staged. There is no longer a "site of election" at the belowknee level. All length is saved down to the lower one fourth (musculotendinous junction). The area between the ankle and junction of the lower three fourths of the leg is unacceptable even in the presence of a functional knee, permitting extension as previously described. The short (8 to 10 em) level has proven most effective, however, with ischemia. Amputation below the knee is particularly suitable for early postsurgical rehabilitation, which includes rigid dressing with immediate or early postsurgical prosthetic fitting. Specific postoperative treatment will be outlined later in the text. Knee Disarticulation Improvements in knee disarticulation surgery and important prosthetic advances for this level have enhanced its usefulness. An ideal candidate is the younger, physically active person of either sex who will especially benefit by the long lever arm, the improved proprioception, and the endbearing capacity all providing stronger, more precise prosthetic control (Fig. 6). Recent surgical improvements include (1) positive stabilization of the major thigh muscle groups with tendon fixation in the femoral intercondylar notch; (2) substitution of the classic long anterior skin flap by use of equal sagittal skin flaps or shorter, more nearly equal coronal flaps; and (3) remodeling of distal femoral condyles to reduce end bulk. Enough gentle bone contouring is done to provide stability of the stump-socket and yet allow the prosthesis to be worn easily. Prosthetic cosmesis is also improved by contouring the femoral condyle. The very low transcondylar level incorporating muscle stabilization and patellar removal is a recent technical change gaining acceptance. Prosthetic improvements include four-bar linkage knee systems, intrinsic hydraulic knee controls and light, cosmetic materials. When considering
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Figure 6. Knee disarticulation with retention of patella.
knee disarticulation, the surgeon should consult preoperatively with the prosthetist whenever possible. Knee disarticulation was for many years considered a valuable level of amputation for peripheral vascular disease. Today, most patients for whom this surgery would be considered will heal at the short level below the knee, thus retaining the knee joint. With bilateral lower limb amputations, where maximum length and strength are especially valuable, knee disarticulation has a special place. Amputations Above the Knee There are no sites of level election through the thigh. All length is saved down to and including the transcondylar level consistent with surgical principles outlined earlier (Fig. 7). There is a difference of opinion about the intertrochanteric and short subtrochanteric level. Fixed flexion and abduction of the short residual limb may make prosthetic fit difficult. Some surgeons prefer hip disarticulation over the very short level above the knee. Surgical objectives differ depending upon the reason for amputation. When operating for ischemia, the primary objective is a healed residual limb. Stabilization of muscle under these circumstances may well compromise blood supply to tissues already at risk. A simple fascial and skin closure is selected with adequate soft tissues distal to the bone end and with short skin flaps of equal length. When perfusion of muscle and skin is
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Figure 7. Cylindrical, muscular amputation above knee. Stabilization of muscle is necessary for good prosthetic control.
good as in trauma and amputation for tumors, it is essential that the severed muscles be properly stabilized by distal myoplasty or myodesis or a combination of the two. Exact placement of the skin scar is ordinarily not important. Principles of plastic surgery are followed. The physiologic amputation above the knee should be cylindrical and strong, with good muscle control and without significant hip contractures. A great deal of prosthetic research has been directed toward knee mechanisms and socket designs for the amputee with an amputation above the knee. Quadrilateral flexible brim sockets casted with the thigh in adduction are major improvements in socket-interface control. Hydraulic, pneumatic, and, more recently, experimental myoelectrically controlled knee designs allow remarkable replacement function. Synchronized prosthetic knee and ankle mechanisms, intrinsic stabilizing knee designs, and biofeedback potential, all improve stance and gait. Younger, active persons with physiologic amputations above the knee can often perform remarkably. Dancing, ice skating, golf, racquet sports, and many other vocational and recreational activities are skillfully performed. Much of the success and degree of subsequent function will be determined at the operating table by the surgeon who performs a truly physiologic residual limb reconstruction. Hip Disarticulation and Hemipelvectomy (Figs. 8 and 9) Improvements in the area of total loss of the lower limb relate to limb substitution. The surgery, though major, is relatively straight forward. Prostheses for hip disarticulation may be heavy, complicated, and unduly physically demanding for the elderly patient. Younger, vigorous persons handle these newer prostheses remarkably well. The elderly patient with high thigh or hip disarticulation will be best served by the use of external aids, including a wheelchair rather than prosthetic rehabilitation.
AMPUTATIONS OF THE UPPER EXTREMITY Steady progress in limb substitution has produced a variety of externally powered prostheses for the upper extremities. Most of the technologically
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Figure 8. Healed hip disarticulation with classic Boyd anterior closure.
advanced countries are deeply involved in this research. Surface or implant voluntary myoelectric signals, amplification, batteries, and motors are the sources of terminal device control. Retention of good voluntary activity of the stump muscle simplifies the prosthetic/electrical engineer's challenge (Fig. 10). In general, all length is saved when amputating through the upper limb. This is true from the fingers up to complete limb loss. Skin, muscle, nerve, and vascular and bone management follow those guidelines described for the lower limb. Functional length is a major consideration. Upper limb prostheses also abut the stump totally so that scar placement is of secondary importance. Early prosthetic function is vital to the unilateral upper limb amputee. Delay in prosthetic fitting and training will discourage the amputee because so many activities can be successfully performed with the intact, remaining upper limb. Effective manual function can be obtained in most motivated, unilateral upper limb amputees if the patient and the rehabilitation team work together. The bilateral upper limb amputee presents a radically different problem. Here prosthetic function is so critical to quality of life that prosthetic substitutes and the best training techniques are critically sought after by
Figure 9. Healed hemipelvectomy for malignant disease. Prosthetic use is difficult at this level except in the very young patient.
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Figure 10. Myoelectric prosthesis for amputation below elbow.
the amputee and the rehabilitation team. Under these circumstances, remarkable function can be regained either by externally powered prosthetic units or by those devices using body control (Fig. 11). IMMEDIATE AND POSTSURGICAL MANAGEMENT The goal of postsurgical management is uncomplicated wound healing. The surgeon seeks to provide an environment favorable to the uneventful healing process. That environment relates to management of the local wound and to the systemic, functional state of the person. The elderly patient with ischemic limbs has compromised healing from poor viability of the local tissue as well as the systemic sequelae of aging and disease. By contrast, the adolescent patient with malignant disease of the distal limb
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Figure 11. Biceps cineplasty in amputation below elbow showing prosthesis. A seldom-performed but useful amputation.
that is amputated through essentially normal tissue presents minimal difficulty in wound healing. The exact opposite is true for an elderly, insulin-dependent patient, poorly nourished, who has been a cigarette smoker since youth. These latter patients are today the majority who require amputations. Cell reproduction is the essence of life. Our knowledge of the process is monumental, yet so much is unknown. Clinical experience continues in a large measure to direct postoperative wound management. Control of postoperative edema, immobilization of tissue, surgical cleanliness, and prevention of hematoma all reinforce gentle, efficient surgery. The amputation presents an ideal wound for application of these principles. It is terminal. Since no portion of the limb remains distal to the amputation site, it is appropriate to apply immobilization, pressure, and other external physical constraints without compromising uninvolved structures beyond the site of the surgery. The closed, rigid dressing treatment best fulfills the requirements for optimum wound healing in most cases. Details of the rigid dressing technique as applied to amputations are widely available. A recent text Amputations-Immediate and Early Prosthetic Management by Gerhardt, King, and Zettl describes the technique in detail. This manual is recommended as a source of reference for all surgeons using this system. Soft dressings with or without compression are still used. Under certain circumstances, when the wound requires frequent inspection, soft dressings are appropriate and can be improved by accompanying external splints. Even when skillfully applied, soft dressings alone tend to poorly control distal wound pressure and wound pain. Joint contractures can develop early, and wound contamination is at greater risk. The criticism that rigid dressings do not permit sufficient wound inspection is not valid. Repeated, frequent wound dressings, inspection, manipulation, and the application of a variety of external chemical agents are not conducive to uneventful healing in otherwise clean wounds. Their use should be reserved for a few specific indications.
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The rigid dressing technique can be reinforced by early, controlled prosthetic function. Immediate prosthetic fit with limited weight-bearing for the lower extremity amputee has been harmful to wound healing when undue stress is applied to the wound site. Early rehabilitation is promoted, however, by progressive function using a variety of temporary terminal devices that can be incorporated in the rigid dressing system. A variety of air splints and controlled environment treatment equipment has met with some recent success. The Roehampton, England flowthrough air bag system enjoys popularity. Its use in this country has been limited, nonetheless, quite successful. The entire postoperative period from wound closure to definitive limb fit is geared to early rehabilitation. Uneventful wound healing, tissue maturation, and initial and early prosthetic function are all incorporated in rapid rehabilitation. To be effective, this implies the need for the amputeeprosthetic team.
THE AMPUTEE TEAM Successful function of the amputee requires a substitute limb, the prosthesis. The surgeon cannot provide this service. Interdependence between the surgeon and the prosthetist demands team management. Before World War II, this relationship was generally ineffective. It was common practice for the surgeon to perform the amputation, observe the amputee until the healed wound was stable, then refer the patient to the prosthetic facility for limb fit and rehabilitation. This referral would involve a simple prescription or note to the prosthetist requesting a substitute limb. The surgebn' s responsibility ended at this point unless wound complications developed. The prosthetists were primarily artisans, trained by apprenticeships and lacking any formal education in prosthetic rehabilitation. The result of this course of treatment was usually uninformed neglect. The many amputations incurred during combat in World War II led to the concept of the amputee team. The Department of Defense wisely established amputation centers. Comprehensive rehabilitation of the amputee became a reality. Mandatory referral of amputees to these military hospital centers and rehabilitation units promptly upgraded the function of the amputee. Political pressures were so great at the end of World War II that Congress appropriated monies specifically directed to the Veterans Administration for amputee and prosthetic services. The team approach later extended through the Veterans Administration into management of civilian amputees. Team membership was enlarged to include rehabilitation personnel, social service, psychologic counseling, education, job placement, and engineering. Funding for prosthetic research was made available. The amputee team is now recognized as an indispensable, integral, structural necessity. Biomedical and prosthetic engineering concerned with substitute limbs continues at an accelerated pace. The basic amputee team consists of the surgeon, the prosthetist, and the rehabilitation therapist. When properly communicating and working as
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a team, these three disciplines are effective. Larger caseloads and amputation services involve a variety of other research and health care persons noted previously. For these reasons, a team setting is an indispensable requirement for enlightened rehabilitation of amputees. In the years since World War II, engineering technology has advanced dramatically. Open heart surgery, the artificial heart, kidney and lung transplants, inert total joint replacements, and the application. of external energy for the performance of body functions all exemplify the medicalengineering union. This unity has always been a primary need for amputations-prosthetics. The prosthesis is an artificial organ and is as important in its particular capacity as an artificial kidney or heart is.
FUTURE TRENDS AND RESEARCH The next advances will be in the field of prosthetics. Limb substitutes will be fabricated, using a wide array of thermoplastic, synthetic materials, metals, elements, and composites. Physiologic, force-related movement will beL incorporated into the materials. This feature will complement the function of components, particularly artificial joints, and reduce dependence on them. Over the past decade, research has concentrated on improvement of components: prosthetic feet, knees, elbows, wrists, and hands. Technical progress will continue in this area, but the ability to use modern synthetic materials will allow lightweight durability, simplicity, and memory-programmed function to establish designs. Recreation equipment exemplifies this principle. Boron and graphite fishing rods, oars used for sculls and kayaks, composite plastic poles for pole vaulting, and other similar equipment point out the opportunity to transfer this knowledge to limb substitutes. The field of orthotics is already well along in technology transfer. Polypropylene, ortholene, and other substances have radically changed orthotic devices. To properly use these force-responsive materials physiologically, it will be necessary to reevaluate limb function particularly in the lower limbs. This will include not only modernizing present extensive information on normal stance and gait; it will require a critique of a much larger number of physical activities such as running, jumping, and adaptation to irregular surfaces. The combination of design improvements for components (hydraulic and pneumatic joints) and the introduction of newer materials will open a wide range of new prosthetic use. Computer-directed synergistic, single, and multiple electrical joint control provided by intrinsic motor signals with appropriate amplification and electrical motor power can be expected to radically negate neuromuscular deficits. Socket design and construction, the man-machine interface, will continue to improve as we more nearly understand the residual limb (Fig. 12). Through these types of prosthetic development, the amputee will experience improved function. This will directly affect the quality of life. Cost effectiveness is important. Significant research is underway to provide fabrication techniques that reduce the expense of prostheses. Individual fittings will always be required, since no amputee is identical.
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Figure 12. Modern belowknee prosthesis demonstrating excellent cosmesis and simplicity.
An individual hands-on prosthetic responsibility continues to provide the necessary support for quality prosthetic rehabilitation. Improvements in amputation are also continuing. Much of the surgical progress during the past 15 years has not been incorporated into general practice. Educating surgeons about modern operative care is a priority at this time. Earlier in this section, I called attention to limb replantation and to reconstructive techniques for saving the limb by composite grafting using microvascular microsurgery. This surgical arena is challenging and fascinating. At present, it is not appropriate for most limbs at risk. Using recent surgical advances not yet in common practice should be emphasized. The quality of life for amputees will be improved by continued progress in the field of rehabilitation. Superior training techniques can be expected and will incorporate simple, objective, functional assays by using observations obtained, for example, from gait analysis equipment. Biofeedback systems can also be helpful. This article began by noting the major role of limb ischemia as the cause for amputation. One of the most important areas of research is related to the study of limb viability. Vascular physiologists and others are pushing forward the frontiers of knowledge about limb perfusion, peripheral circu-
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lation, and tissue healing in blood supply deprivation. The limb viability laboratory with which I am associated has a wide variety of coordinated research, including a study of standardized microwounds performed on ischemic limbs before amputation. These tissues are harvested at the time of surgery and are studied by using scanning and electron microscopy as well as other biologic tests. Basic knowledge from this type of research can be transferred to the surgery of limb loss. SUGGESTED READINGS Atlas of Limb Prosthetics: Surgical and Prosthetic Principles. St. Louis, C. 'V. Mosby, 1981. Banerjee, S. N., (ed.): Rehabilitation Management of Amputees. Baltimore, Williams and Wilkins, 1982. Burgess, E. M.: Wound healing after amputation: Effect of controlled environment treatment. J. Bone Joint Surg. 60A:245-246, 1978. Burgess, E. M., and Zettl, J. H.: Immediate postsurgical prosthetics. Orthop. Prosthet., 21:105-112, 1967. Burgess, E. M., Matsen, F. A., Wyss, C. R., et al.: Segmental transcutaneous measurements ofP02 in patients requiring below-the-knee amputation for peripheral vascular insufficiency. J. Bone Joint Surg., 64A:378-382, 1982. Friedman, L. W., (ed.): The Surgical Rehabilitation of the Amputee. Springfield, Charles C Thomas, 1978. Holloway, G. A., and Watkins, D. W.: Laser Doppler measurement of cutaneous blood flow. J. Invest. Dermatol. 69:306-309, 1977. Holloway, G. A., and Burgess, E. M.: Cutaneous blood flow and its relation to healing of below knee amputation. Surg. Gynecol. Obstet., 146:750-756, 1978. Kegel, B.: Controlled environment treatment (CET) for patients with below knee amputations. Phys. Ther., 56:1366-1371, 1976. Kostuik, J.P., Wood, D., Hornby R., et al.: The measurement of skin blood flow in peripheral vascular disease by epicutaneous application of xenon 133. J. Bone Joint Surg., 58A:833837, 1976. Kostuik, John P. (ed.): Amputation Surgery and Rehabilitation. The Toronto Experience. New York, Churchill Livingstone, 1981. Slocum, D. B. (ed.): An Atlas of Amputations. St. Louis, C. V. Mosby, 1949. 1102 Columbia Eklind Hall Rm. 409 Seattle, WA 98104
Amputations
Ernest M. Burgess, M.D.*
Most amputations today result from ischemia of a limb. This circumstance has changed traditional management in that an understanding of the nature and course of peripheral vascular disease is essential for effective amputation surgery and rehabilitation. The decision to amputate may be obvious, in the presence of end-stage limb viability. More often, the surgeon will be faced with a less clear-cut decision requiring considerable experience, judgment, and evaluation when several treatment options are available. Retention by vascular reconstruction of a severely impaired limb whose function is painful and disabling can be less effective than a lowlevel amputation fitted with a modern prosthetic substitute. Neurologic deficit in many diabetics with impaired circulation and the presence of infection will force the surgeon to consider surgical staging in the light of excellent, currently available supportive therapy. Ischemia of a limb is primarily a disease of elderly persons. Associated health problems may compromise mobility as much as the amputation itself. Institutional and bed confinement compound disability among these older persons whose remaining days may be few. The cost of prolonged, high technology care must also be considered. Whether tax supported or from other sources, the financial cost ultimately rests with society. Amputations resulting from trauma are second in frequency and much fewer in number. Much of our knowledge and practice of amputations for trauma has been war related. Notable is the experience with amputation in the Napoleonic wars, the American Civil War, and, more recently, the two World Wars. Surgical principles and techniques in general have been profoundly influenced by centuries of experience with amputation. The accounts of amputation recorded in the pages of medical history provide fascinating and often times inspiring reading. The recent development of microsurgical techniques, composite tissue grafting, and ingenious surgical revascularization along with other forms of operative limb reconstruction has introduced a greater level of competence for saving a limb injured by trauma. As with ischemia caused by peripheral *Principal Investigator, Prosthetics Research Study; Clinical Professor, University of Washington School of Medicine, Seattle, Washington
Surgical Clinics of North America-Yo!. 63, No. 3, June 1983
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vascular disease, it is important to evaluate carefully for each patient the place of limb replantation or extensive, complicated limb salvage weighed against physiologic amputation and modern prosthetic rehabilitation. These hard decisions arise almost daily in major trauma centers. Surgeons responsible for the care of these injuries continue to update guidelines based not only on improved, dramatic surgical techniques but also on the great advances in the field of prosthetics. A relatively small group of persons come to amputation for tumors, acute and chronic infections, congenital limb deficiencies, and metabolic disorders. Their proper management is also individualized, challenging the surgeon to understand clearly the surgical alternatives based on fundamental principles of wound healing and selection of prostheses. Amputations, both major and minor, are a unique physiologic and psychologic experience. The loss is complete. It is often said that only an amputee understands what it is like to experience life with a missing limb. Much has been written about the psychologic aspects of losing a limb. Acceptance by peers of physical disability together with a world-wide awareness of rehabilitation has contributed greatly to a positive social profile for most amputees.
THE PRINCIPLES OF AMPUTATION For decades, surgical texts have presented a standard set of principles and guidelines with only relatively minor variations. Until recently, only a few significant articles have appeared in current medical periodicals. The comprehensive Atlas of Amputations authored by Slocum at the end of World War II was never revised, nor has it a recent counterpart. Levels of amputation, surgical management, and early postoperative care have not, until recently, reflected the rapid progress in other areas of surgery. Amputation has too often been relegated to near the end of the operative schedule to be performed by junior house officers often unsupervised. In recent years and particularly since the end of the Vietnam war, amputation has entered the mainstream of surgical progress. This trend continues and is accelerating. The amputee today, whether an elderly patient with diabetes or a young person injured in a motorcycle accident can anticipate a vastly improved quality of life when compared with people similarly disabled a few years ago. Current surgical writing mirrors this change. The first principle of amputation surgery is attitudinal. The surgeon's primary charge is the reconstruction of a physiologic residual limb. As with all surgery, uneventful healing of the wound is the primary goal. This accomplishment in itself does not ensure optimum functional recovery. The residual limb will be called on to function with an inert limb substitute. As nearly as possible, the remaining portion of the limb must retain the strength, sensibility, motor control, and proprioception in the terminal end-organ, such as the hand or foot. To the surgeon with this attitude, the amputation becomes a challenging, reconstructive, often demanding, surgical exercise. Effective postoperative management coupled with early
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prosthetic rehabilitation can offer a remarkable degree of comfortable activity. With younger, physically active, unimembral amputees, this level of activity can include vigorous sports and prolonged endurance (Fig. 1). The level of amputation is established by the disease and by the adaptability of available limb substitutes. With but few exceptions, the older, standard levels of election are no longer valid. Modern surgery is directed toward the creation of a physiologic terminal end-organ. Maximum length is generally desirable. The actual length, however, will be at a level that provides nontender, nonadherent, healthy skin coverage with retention of as much of the soft tissue of the stump as can be properly saved, especially muscle. For stump muscles to be physiologically active, they must have some degree of distal stability. Muscle stabilization when surgically possible is a basic principle. Sensation and blood supply, especially to the skin, are retained as with other plastic reconstructive procedures. ' Positioning of the scar or scars is relatively unimportant. Most modern prostheses totally contact the residual limb. As long as the scar is nontender, nonadherent, durable, and tolerant of the opposing inert prosthetic surface, its position is inconsequential. Placing of incisions, skin flaps, and on occasions, skin grafts, follows this principle. Augmentation of the length of the limb by composite grafting or other measures will occasionally be indicated. Sites for this type of surgery and consideration of the few undesirable upper and lower limb levels will be discussed individually. Length of the limb should not be achieved at the expense of a painful, pressure-intolerant stump, subject to breakdown of the wound. When length retention is critical, surgical ingenuity using plastic and reconstructive techniques becomes especially important. VIABILITY OF THE LIMB Whether from trauma, peripheral vascular disease, or other local vascular insult, the surgeon must know the degree of viability of limb tissues, especially skin. This knowledge directly influences the level of amputation. The wound cannot heal successfully unless the skin and deeper tissues have sufficient healing potential to withstand the trauma of the surgery and the postoperative inflammatory response. The history and physical examination coupled with experience and clinical judgment are the most important prognosticators. Several useful laboratory tests are also available. Vascular surgeons, vascular physiologists, and orthopedists involved in research on limb viability are adding useful information to this area. Relatively few surgeons have wide experience performing amputations for ischemia. The surgeon who occasionally performs amputations as well as the surgeon directing an amputation service can benefit from noninvasive, inexpensive laboratory tests, which assist in determining the level of limb viability. Reamputations can be avoided, yet maximum length of limb can be attained by the use of this additional information. Objective tests supplement a careful physical examination. No single test can be relied on
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Figure 1. A to C, Sports performance by persons with amputations below the knee. Many other vigorous sports are performed with professional competence by amputees.
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with complete accuracy. Surgeons responsible for large numbers of amputations may achieve a high rate of successful low levels of amputation by experience, careful history, and physical examination alone. More and more, however, the laboratory data to be described are supportive. Angiography is an obvious presurgical requirement when vascular reconstruction is carried out. This demonstration of the patency and physical nature of the vessels provides the road map identifYing a possible surgical course to be taken. The same information is of less value to the surgeon planning an amputation. Amputation alters the blood flow by removing distal vascular runoff as well as collateral pathways. Although measuring techniques can provide information about a number of factors involved in the circulation of the extremity, none of these factors specifically quantifies the ability of the amputation site to heal. A number of other conditions will influence the success or failure of the amputation at a given level. These include the details of surgical technique, the specifics of postoperative care, and the health of the patient. For these reasons, techniques for assessing limb viability are generally more useful in predicting failure rather than success of an amputation at a given level. Limb viability can be assessed by a number of laboratory measurements: extremity blood flow, arterial blood flow, muscle perfusion, skin blood flow, oxygen delivery to the skin, segmental blood pressure, skin blood pressure, and skin function. In the interest of completeness, the present sources of such objective information are listed in Table l. Current practical application of this long list of clinical and research tests are those measuring segmental blood pressure, skin blood pressure, and skin temperature. Clearance of xenon-133, transcutaneous P0 2 , and Doppler flowmetry using ultrasound and laser measure these factors. Optical flowmetry, multispectral reflectrometry, and measurement of heat conductivity may prove valuable, but more experience is needed at this time before their value is known. Segmental Blood Pressure One of the most widely used techniques at this time is the measurement of the segmental blood pressure in the limb. The correctly sized blood pressure cuff is placed on the limb at the level for measuring pressure, and it is briefly inflated to above the patient's systolic blood pressure. Cuff pressure is then progressively reduced to a point where the distal blood flow recommences. This pressure is the segmental systolic blood pressure. The onset of distal blood flow is most frequently indicated by the return of the ultrasound Doppler signal from a superficial artery. The comparison of the segmental pressure in the lower limb with that of the brachial artery is frequently used. If the segmental blood pressure in the lower limb is 35 to 40 per cent of the brachial systolic pressure, amputation at that level is considered appropriate. As to an absolute Doppler value, various investigators quote a critical value ranging from 40 to 70 mmHg. There are certain pitfalls in complete reliance on readings of segmental limb blood pressure. In large patient populations, however, it appears that a real correlation does exist between segmental pressure and the success of amputation. The
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Table 1. Assessment of Limb Viability Extremity blood How Venous filling time Plethysmography, wave form analysis, and pulse volume recording Volume plethysmography Circumference plethysmography Photoplethysmography Noninvasive electromagnetic Howmetry Isotope scans Arterial blood How Pulses by palpation Arteriography Doppler effect Invasive electromagnetic Howmetry Muscle perfusion Muscle pH Muscle P02 Muscle blood How Skin blood How Total skin blood How Visual observation Photoplethysmography Multispectral analysis Skin temperature Palpation Thermistor thermography Liquid crystal thermography Infrared thermography Fluorescein angiography Laser Doppler Howmetry Skin Hap bleeding at time of surgery Nutritional skin blood How 133Xenon washout Injected Epicutaneous Hydrogen washout Cutaneous oxygen delivery Intracutaneous Polarographic Mass spectrometric Transcutaneous P0 2 measurement Segmental blood pressure Skin Hush Doppler technique Plethysmography Strain gauge plethysmography Volume plethysmography Photoplethysmography Impedance plethysmography 133Xenon clearance (distal blood pressure) Skin blood pressure Blanching of histamine-injected skin Photoelectric technique 133Xenon clearance 131 Iodine clearance Laser Doppler Howmetry Skin function Observation of ability to maintain skin envelope Observation of ability to produce cutaneous appendages Ability of skin to heal incisions
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method can be used to determine levels of amputation for fingers and toes as well as for the more proximal levels. Skin blood pressure and skin blood flow are measured successfully by using xenon-133 clearance. This technique requires the availability of the isotope and a means for detecting xenon clearance. Malone, in Arizona, reported 100 per cent successful primary wound healing of amputations when the skin blood flow as measured by the xenon-133 technique was in excess of 2. 6 ml per 100 gm of tissue per minute. Below that level, failures occurred. The author does not use skin isotope clearance as a routine clinical tool. Its use is reserved as a comparative research measurement. Backscatter readings from laser beam-Doppler signal is a new, noninvasive, simple measure of skin blood pressure. 7 Its use is gaining clinical acceptance. Transcutaneous oxygen measurement is a noninvasive means of evaluating adequacy of local cutaneous circulation. Studies indicate that this measurement reflects a balance between oxygen delivery to the skin and cutaneous oxygen consumption. Transcutaneous (Tc) P0 2 clinically depends upon the local arterial venous gradient. This dependence becomes progressively more sensitive as the local gradient approaches low values, around 20 mmHg. In a substantial series of cases, all amputations below the knee performed for ischemia when the transcutaneous P02 level below the knee was 40 mmHg or greater went on to primary healing. With TcP02 recorded at 20 mmHg or less below the knee at the site of planned surgery, the primary healing rate dropped sharply. Recent development of equipment measuring TcP0 2 simultaneously at multiple sites on the limb allows scanning as a simple, noninvasive, nonpainful technique requiring less than a half-hour. The factors determining the ideal level for amputation in patients with peripheral vascular insufficiency are many and complex. At this time, it appears unrealistic to expect absolute accuracy of prediction in any single test or group of tests. The development of increasingly precise tests and their integration with overall clinical assessment are nevertheless placing preoperative determination of amputation levels on a far more scientific footing (Fig. 2). AMPUTATIONS OF THE LOWER LIMB Amputations Through the Foot and Ankle (Fig. 3) Loss of one or all of the four lesser toes causes only minor disability. Absence of the great toe is a significant deficit. "Push off' is impaired, and the size of the pedal platform is decreased so that balance and gait are moderately affected. Either sagittal or coronal skin flaps can be used. A loose skin closure is mandatory. Tight skin predisposes the patient to failure of skin healing and wound breakdown. Even when healing occurs, pressure-sensitive areas remain of the type often seen with "hammer toes" and bunions. Thus, skin is disposed to callosities, secondary wound complications, and infection. It-
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Figure 2. Portable testing equipment for limb viability. Included are TcPO,, laser Doppler, and multispectral analysis units. Ultrasound doppler and skin temperature equipment also are routinely used but are not shown.
Figure 3. A and B, Through foot amputations. Variations of older techniques are useful with modern partial foot prostheses.
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is not routinely necessary to remove the cartilage from phalanges or metatarsal heads. Revision of the metatarsal head, especially that of the first metatarsal, should be performed carefully, keeping in mind the necessity for freely movable nontender skin over the rigid, deeper structures, primarily bone and cartilage. The basic principles of forefoot surgery apply. When gangrenous toes are removed to provide drainage, they should be severed by dividing the skin transversely. Longitudinal incisions for drainage of infection, particularly in the foot of a person with diabetes, are not acceptable. Adequate drainage can be better obtained by transverse incisions or open amputation. When two or three of the lesser toes require amputation, it is generally better to remove the adjacent minor toes. Deformity and subsequent complications are avoided without any real loss of function. Independent removal of the great toe may not induce subsequent deformity and deviation of the otherwise functional lesser toes. On the other hand, removal of all of the lesser toes leaving the great toe intact can cause lateral migration of the toe through the metatarsal phalangeal joint. This circumstance does not automatically require amputation or stabilizing surgery of the great toe. It can be left as a single digit when circumstances otherwise permit. It will remain a functional member. If significant deviation and deformity do result, subsequent amputation can be performed. Transmetatarsal amputation and single or multiple ray resection are increasingly valuable levels of surgery. With an improved understanding of limb viability and available, light, clean, partial foot orthoses, these amputations are gaining favor both for trauma and ischemia. Gentle, meticulous surgical technique is mandatory. Plantar scars are avoided. Weight-bearing surfaces are covered with pressure-tolerant skin from the sole of the foot. Tight skin closure is strictly avoided. Postsurgical wound drainage is ordinarily required. Prominent rigid structures, bone and cartilage, are contoured and tailored carefully to eliminate pressure on overlying skin when the patient is standing, walking, and wearing shoes.
Amputations Through the Mid-Foot As the foot is reduced in size by amputation proximal to the tarsalmetatarsal joints, muscle imbalance may increasingly deform the remaining foot segment. When local blood supply is adequate to permit rebalancing tendon surgery, these mid-foot amputations can provide long-term painless function. Comfortably fitted with modern ankle-foot orthoses, it is possible to take advantage of full leg length and the plantar weight-bearing surface. Gravity push-off is obtained by mechanically blocking ankle dorsiflexon with the orthosis so that gait is remarkably normal when walking at medium cadence. Fast walking and running are somewhat more difficult. The combination of carefully planned reconstructive mid-foot amputation surgery and light, dynamic, partial foot orthoses has extended the importance of amputations through the mid-foot, operations that had until recently been largely discarded. This situation exists for both trauma and ischemia.
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Hind-foot amputation with retention of the talus and os talus, popularized by Boyd, is rarely indicated in the adult. Children whose legs are not of equal length may benefit by modifications of this procedure. The Insensitive Foot Protective sensation is necessary if breakdown of the skin is to be avoided. The unhappy triad seen so often in the diabetic person's footjoint deformities, hypesthesia, and infection-challenges the surgeon. Stable healing of the wound at transmetatarsal or mid-foot levels will not ensure successful weight-bearing when the skin is insensitive. A Syme' s amputation or one below the knee will be preferred. The resurgence of interest in major amputations through the foot will continue. Not many years ago, amputations even as high as the level below the knee were shunned in the presence of peripheral vascular disease. Many elderly people with ischemic limbs requiring amputation and who would have sustained a level above the knee a few years ago can walk, with surgery being performed distal to the knee. A selected number of these patients will heal and successfully walk on well-planned amputations through the foot. Contrary to past teachings, these residual limbs will not cause insurmountable prosthetic problems, nor will late ulceration of the skin or breakdown necessarily occur. The Syme' s Amputation Few surgical procedures have withstood the test of time as well as the modified ankle disarticulation described by James Syme in 1842. His original description has been often reprinted essentially without change down through the years. It remains today a useful, physiologic, well-conceived operation exhibiting the specific advantages described originally (Fig. 4). A century and a half of experience has established indications. When these indications are followed, and when the surgical technique and aftercare are proper, the one-stage Syme's amputation fills a definite and important role. A past major criticism has been the awkward, heavy, unsightly Syme' s prosthesis. Current limb designs have effectively minimized this drawback. When compared with the level below the knee, the advantages of the Syme's amputation are well known. Less consumption of energy is required, a much larger degree of end-bearing is obtained, the amputation is particularly durable, and pain is uncommon. Full weight-bearing without a prosthesis is well tolerated. Unequal length of legs does not prevent comfortable walking for short distances without a prosthesis. A simple Syme' s extension boot further simplifies standing and walking in the house without wearing the prosthesis. When the heel skin is good, the one-stage Syme' s technique is particularly valuable for saving the forefoot injured by severe trauma. Congenital limb deficits with deformities of the foot, ankle, and lower leg occasionally will be best managed by the Syme' s technique, care being taken to preserve distal leg epiphyses. The high failure rate associated with one-stage Syme' s amputation for ischemia has discouraged its use. In recent years, the two-stage operation
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Figure 4. A classic Syme's amputation for peripheral vascular disease.
as popularized by Wagner has reestablished this level as a valuable amputation for ischemia, particularly in the patient with diabetes. The first stage is essentially a closed ankle disarticulation with a Syme' s type heel flap and skin closure over a closed irrigation system. The skin flaps are made somewhat longer and more bulky to accommodate the malleoli that are left intact. Several weeks after healing of the initial amputation, the malleoli are removed through two small incisions, one lateral and one medial. Recent excellent descriptions of the two-stage technique are available. Amputations Below the Knee
Amputation through the lower leg is unquestionably the single most important level. Improvement in surgical techniques has developed over the last few years, and, together with the clinical importance of knee retention, has emphasized the importance of a thorough understanding of the below-knee level by surgeons performing amputations (Fig. 5). The quality of amputee care for ischemia can be judged by the ratio of aboveknee to below-knee amputations surgically performed that proceed to stable wound healing. Recent reports from many institutions substantiate this fact. The current preponderance of successful amputations below the knee
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Figure 5. A to C, Amputations below knee for ischemia. Several levels are shown. All are functional with modern, total contact below knee prostheses.
especially in peripheral vascular disease represents the most important recent advance in amputee care. Thousands of elderly persons walk successfully with single or bilateral amputations below the knee. Had these amputations been performed at a higher level, most would be confined to a wheelchair. The difference in lifestyle is self-evident. The amputation below the knee for peripheral vascular disease is relatively short (7 to 10 em below the tibial plateau). The scar is placed anterior with a long posterior myocutaneous flap; a sagittal SC\U' with relatively short, equal myocutaneous flaps is also effective. Routine use of the long anterior skin flap with posterior incisional scar is unacceptable. Initial failure and long-term prosthetic problems have eliminated this earlier classic technique. The tibia is very carefully beveled and rounded to prevent pressure intolerance of the anterior and medial socket. The fibula is sectioned 1 em shorter. The residual limb is cylindrical rather than tapered, and muscle activity is preserved as completely as possible by some degree of distal major stabilization of muscles as provided by the long posterior flap technique. This modern amputation below the knee has been often described in detail. Though it is not technically demanding, it does require particular attention to gentle management of tissues and precise surgery. The film
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libraries of the American College of Surgeons and the American Academy of Orthopaedic Surgeons both contain excellent visual aids demonstrating surgical management below the knee. Successful prosthetic rehabilitation depends on a functioning knee able to actively extend to within 15° of normal. Knees with a greater degree of fixed, uncorrectable flexion deformity compromise a stable prosthetic fit below the knee. Range of motion and muscle control of the knee and hip must be carefully evaluated when determining this level of amputation especially with the geriatric patient. When the remaining portion of the limb to the level below the knee is functional, amputation below the knee should be successfully performed in 65 to 85 per cent of all patients requiring major lower limb ablation for ischemia. These figures have been verified by many surgical services throughout the world. The theme of modern amputation is the successful attainment of lower levels of physiologic amputation. Nowhere is this more important than in the elderly patient with peripheral vascular disease. The importance of saving a functional knee cannot be overestimated. Saving the knee is equally important when amputating for trauma. Preservation of length and retention of stump muscle require well-planned, reconstructive management, often staged. There is no longer a "site of election" at the belowknee level. All length is saved down to the lower one fourth (musculotendinous junction). The area between the ankle and junction of the lower three fourths of the leg is unacceptable even in the presence of a functional knee, permitting extension as previously described. The short (8 to 10 em) level has proven most effective, however, with ischemia. Amputation below the knee is particularly suitable for early postsurgical rehabilitation, which includes rigid dressing with immediate or early postsurgical prosthetic fitting. Specific postoperative treatment will be outlined later in the text. Knee Disarticulation Improvements in knee disarticulation surgery and important prosthetic advances for this level have enhanced its usefulness. An ideal candidate is the younger, physically active person of either sex who will especially benefit by the long lever arm, the improved proprioception, and the endbearing capacity all providing stronger, more precise prosthetic control (Fig. 6). Recent surgical improvements include (1) positive stabilization of the major thigh muscle groups with tendon fixation in the femoral intercondylar notch; (2) substitution of the classic long anterior skin flap by use of equal sagittal skin flaps or shorter, more nearly equal coronal flaps; and (3) remodeling of distal femoral condyles to reduce end bulk. Enough gentle bone contouring is done to provide stability of the stump-socket and yet allow the prosthesis to be worn easily. Prosthetic cosmesis is also improved by contouring the femoral condyle. The very low transcondylar level incorporating muscle stabilization and patellar removal is a recent technical change gaining acceptance. Prosthetic improvements include four-bar linkage knee systems, intrinsic hydraulic knee controls and light, cosmetic materials. When considering
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Figure 6. Knee disarticulation with retention of patella.
knee disarticulation, the surgeon should consult preoperatively with the prosthetist whenever possible. Knee disarticulation was for many years considered a valuable level of amputation for peripheral vascular disease. Today, most patients for whom this surgery would be considered will heal at the short level below the knee, thus retaining the knee joint. With bilateral lower limb amputations, where maximum length and strength are especially valuable, knee disarticulation has a special place. Amputations Above the Knee There are no sites of level election through the thigh. All length is saved down to and including the transcondylar level consistent with surgical principles outlined earlier (Fig. 7). There is a difference of opinion about the intertrochanteric and short subtrochanteric level. Fixed flexion and abduction of the short residual limb may make prosthetic fit difficult. Some surgeons prefer hip disarticulation over the very short level above the knee. Surgical objectives differ depending upon the reason for amputation. When operating for ischemia, the primary objective is a healed residual limb. Stabilization of muscle under these circumstances may well compromise blood supply to tissues already at risk. A simple fascial and skin closure is selected with adequate soft tissues distal to the bone end and with short skin flaps of equal length. When perfusion of muscle and skin is
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Figure 7. Cylindrical, muscular amputation above knee. Stabilization of muscle is necessary for good prosthetic control.
good as in trauma and amputation for tumors, it is essential that the severed muscles be properly stabilized by distal myoplasty or myodesis or a combination of the two. Exact placement of the skin scar is ordinarily not important. Principles of plastic surgery are followed. The physiologic amputation above the knee should be cylindrical and strong, with good muscle control and without significant hip contractures. A great deal of prosthetic research has been directed toward knee mechanisms and socket designs for the amputee with an amputation above the knee. Quadrilateral flexible brim sockets casted with the thigh in adduction are major improvements in socket-interface control. Hydraulic, pneumatic, and, more recently, experimental myoelectrically controlled knee designs allow remarkable replacement function. Synchronized prosthetic knee and ankle mechanisms, intrinsic stabilizing knee designs, and biofeedback potential, all improve stance and gait. Younger, active persons with physiologic amputations above the knee can often perform remarkably. Dancing, ice skating, golf, racquet sports, and many other vocational and recreational activities are skillfully performed. Much of the success and degree of subsequent function will be determined at the operating table by the surgeon who performs a truly physiologic residual limb reconstruction. Hip Disarticulation and Hemipelvectomy (Figs. 8 and 9) Improvements in the area of total loss of the lower limb relate to limb substitution. The surgery, though major, is relatively straight forward. Prostheses for hip disarticulation may be heavy, complicated, and unduly physically demanding for the elderly patient. Younger, vigorous persons handle these newer prostheses remarkably well. The elderly patient with high thigh or hip disarticulation will be best served by the use of external aids, including a wheelchair rather than prosthetic rehabilitation.
AMPUTATIONS OF THE UPPER EXTREMITY Steady progress in limb substitution has produced a variety of externally powered prostheses for the upper extremities. Most of the technologically
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Figure 8. Healed hip disarticulation with classic Boyd anterior closure.
advanced countries are deeply involved in this research. Surface or implant voluntary myoelectric signals, amplification, batteries, and motors are the sources of terminal device control. Retention of good voluntary activity of the stump muscle simplifies the prosthetic/electrical engineer's challenge (Fig. 10). In general, all length is saved when amputating through the upper limb. This is true from the fingers up to complete limb loss. Skin, muscle, nerve, and vascular and bone management follow those guidelines described for the lower limb. Functional length is a major consideration. Upper limb prostheses also abut the stump totally so that scar placement is of secondary importance. Early prosthetic function is vital to the unilateral upper limb amputee. Delay in prosthetic fitting and training will discourage the amputee because so many activities can be successfully performed with the intact, remaining upper limb. Effective manual function can be obtained in most motivated, unilateral upper limb amputees if the patient and the rehabilitation team work together. The bilateral upper limb amputee presents a radically different problem. Here prosthetic function is so critical to quality of life that prosthetic substitutes and the best training techniques are critically sought after by
Figure 9. Healed hemipelvectomy for malignant disease. Prosthetic use is difficult at this level except in the very young patient.
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Figure 10. Myoelectric prosthesis for amputation below elbow.
the amputee and the rehabilitation team. Under these circumstances, remarkable function can be regained either by externally powered prosthetic units or by those devices using body control (Fig. 11). IMMEDIATE AND POSTSURGICAL MANAGEMENT The goal of postsurgical management is uncomplicated wound healing. The surgeon seeks to provide an environment favorable to the uneventful healing process. That environment relates to management of the local wound and to the systemic, functional state of the person. The elderly patient with ischemic limbs has compromised healing from poor viability of the local tissue as well as the systemic sequelae of aging and disease. By contrast, the adolescent patient with malignant disease of the distal limb
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Figure 11. Biceps cineplasty in amputation below elbow showing prosthesis. A seldom-performed but useful amputation.
that is amputated through essentially normal tissue presents minimal difficulty in wound healing. The exact opposite is true for an elderly, insulin-dependent patient, poorly nourished, who has been a cigarette smoker since youth. These latter patients are today the majority who require amputations. Cell reproduction is the essence of life. Our knowledge of the process is monumental, yet so much is unknown. Clinical experience continues in a large measure to direct postoperative wound management. Control of postoperative edema, immobilization of tissue, surgical cleanliness, and prevention of hematoma all reinforce gentle, efficient surgery. The amputation presents an ideal wound for application of these principles. It is terminal. Since no portion of the limb remains distal to the amputation site, it is appropriate to apply immobilization, pressure, and other external physical constraints without compromising uninvolved structures beyond the site of the surgery. The closed, rigid dressing treatment best fulfills the requirements for optimum wound healing in most cases. Details of the rigid dressing technique as applied to amputations are widely available. A recent text Amputations-Immediate and Early Prosthetic Management by Gerhardt, King, and Zettl describes the technique in detail. This manual is recommended as a source of reference for all surgeons using this system. Soft dressings with or without compression are still used. Under certain circumstances, when the wound requires frequent inspection, soft dressings are appropriate and can be improved by accompanying external splints. Even when skillfully applied, soft dressings alone tend to poorly control distal wound pressure and wound pain. Joint contractures can develop early, and wound contamination is at greater risk. The criticism that rigid dressings do not permit sufficient wound inspection is not valid. Repeated, frequent wound dressings, inspection, manipulation, and the application of a variety of external chemical agents are not conducive to uneventful healing in otherwise clean wounds. Their use should be reserved for a few specific indications.
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The rigid dressing technique can be reinforced by early, controlled prosthetic function. Immediate prosthetic fit with limited weight-bearing for the lower extremity amputee has been harmful to wound healing when undue stress is applied to the wound site. Early rehabilitation is promoted, however, by progressive function using a variety of temporary terminal devices that can be incorporated in the rigid dressing system. A variety of air splints and controlled environment treatment equipment has met with some recent success. The Roehampton, England flowthrough air bag system enjoys popularity. Its use in this country has been limited, nonetheless, quite successful. The entire postoperative period from wound closure to definitive limb fit is geared to early rehabilitation. Uneventful wound healing, tissue maturation, and initial and early prosthetic function are all incorporated in rapid rehabilitation. To be effective, this implies the need for the amputeeprosthetic team.
THE AMPUTEE TEAM Successful function of the amputee requires a substitute limb, the prosthesis. The surgeon cannot provide this service. Interdependence between the surgeon and the prosthetist demands team management. Before World War II, this relationship was generally ineffective. It was common practice for the surgeon to perform the amputation, observe the amputee until the healed wound was stable, then refer the patient to the prosthetic facility for limb fit and rehabilitation. This referral would involve a simple prescription or note to the prosthetist requesting a substitute limb. The surgebn' s responsibility ended at this point unless wound complications developed. The prosthetists were primarily artisans, trained by apprenticeships and lacking any formal education in prosthetic rehabilitation. The result of this course of treatment was usually uninformed neglect. The many amputations incurred during combat in World War II led to the concept of the amputee team. The Department of Defense wisely established amputation centers. Comprehensive rehabilitation of the amputee became a reality. Mandatory referral of amputees to these military hospital centers and rehabilitation units promptly upgraded the function of the amputee. Political pressures were so great at the end of World War II that Congress appropriated monies specifically directed to the Veterans Administration for amputee and prosthetic services. The team approach later extended through the Veterans Administration into management of civilian amputees. Team membership was enlarged to include rehabilitation personnel, social service, psychologic counseling, education, job placement, and engineering. Funding for prosthetic research was made available. The amputee team is now recognized as an indispensable, integral, structural necessity. Biomedical and prosthetic engineering concerned with substitute limbs continues at an accelerated pace. The basic amputee team consists of the surgeon, the prosthetist, and the rehabilitation therapist. When properly communicating and working as
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a team, these three disciplines are effective. Larger caseloads and amputation services involve a variety of other research and health care persons noted previously. For these reasons, a team setting is an indispensable requirement for enlightened rehabilitation of amputees. In the years since World War II, engineering technology has advanced dramatically. Open heart surgery, the artificial heart, kidney and lung transplants, inert total joint replacements, and the application. of external energy for the performance of body functions all exemplify the medicalengineering union. This unity has always been a primary need for amputations-prosthetics. The prosthesis is an artificial organ and is as important in its particular capacity as an artificial kidney or heart is.
FUTURE TRENDS AND RESEARCH The next advances will be in the field of prosthetics. Limb substitutes will be fabricated, using a wide array of thermoplastic, synthetic materials, metals, elements, and composites. Physiologic, force-related movement will beL incorporated into the materials. This feature will complement the function of components, particularly artificial joints, and reduce dependence on them. Over the past decade, research has concentrated on improvement of components: prosthetic feet, knees, elbows, wrists, and hands. Technical progress will continue in this area, but the ability to use modern synthetic materials will allow lightweight durability, simplicity, and memory-programmed function to establish designs. Recreation equipment exemplifies this principle. Boron and graphite fishing rods, oars used for sculls and kayaks, composite plastic poles for pole vaulting, and other similar equipment point out the opportunity to transfer this knowledge to limb substitutes. The field of orthotics is already well along in technology transfer. Polypropylene, ortholene, and other substances have radically changed orthotic devices. To properly use these force-responsive materials physiologically, it will be necessary to reevaluate limb function particularly in the lower limbs. This will include not only modernizing present extensive information on normal stance and gait; it will require a critique of a much larger number of physical activities such as running, jumping, and adaptation to irregular surfaces. The combination of design improvements for components (hydraulic and pneumatic joints) and the introduction of newer materials will open a wide range of new prosthetic use. Computer-directed synergistic, single, and multiple electrical joint control provided by intrinsic motor signals with appropriate amplification and electrical motor power can be expected to radically negate neuromuscular deficits. Socket design and construction, the man-machine interface, will continue to improve as we more nearly understand the residual limb (Fig. 12). Through these types of prosthetic development, the amputee will experience improved function. This will directly affect the quality of life. Cost effectiveness is important. Significant research is underway to provide fabrication techniques that reduce the expense of prostheses. Individual fittings will always be required, since no amputee is identical.
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Figure 12. Modern belowknee prosthesis demonstrating excellent cosmesis and simplicity.
An individual hands-on prosthetic responsibility continues to provide the necessary support for quality prosthetic rehabilitation. Improvements in amputation are also continuing. Much of the surgical progress during the past 15 years has not been incorporated into general practice. Educating surgeons about modern operative care is a priority at this time. Earlier in this section, I called attention to limb replantation and to reconstructive techniques for saving the limb by composite grafting using microvascular microsurgery. This surgical arena is challenging and fascinating. At present, it is not appropriate for most limbs at risk. Using recent surgical advances not yet in common practice should be emphasized. The quality of life for amputees will be improved by continued progress in the field of rehabilitation. Superior training techniques can be expected and will incorporate simple, objective, functional assays by using observations obtained, for example, from gait analysis equipment. Biofeedback systems can also be helpful. This article began by noting the major role of limb ischemia as the cause for amputation. One of the most important areas of research is related to the study of limb viability. Vascular physiologists and others are pushing forward the frontiers of knowledge about limb perfusion, peripheral circu-
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lation, and tissue healing in blood supply deprivation. The limb viability laboratory with which I am associated has a wide variety of coordinated research, including a study of standardized microwounds performed on ischemic limbs before amputation. These tissues are harvested at the time of surgery and are studied by using scanning and electron microscopy as well as other biologic tests. Basic knowledge from this type of research can be transferred to the surgery of limb loss. SUGGESTED READINGS Atlas of Limb Prosthetics: Surgical and Prosthetic Principles. St. Louis, C. 'V. Mosby, 1981. Banerjee, S. N., (ed.): Rehabilitation Management of Amputees. Baltimore, Williams and Wilkins, 1982. Burgess, E. M.: Wound healing after amputation: Effect of controlled environment treatment. J. Bone Joint Surg. 60A:245-246, 1978. Burgess, E. M., and Zettl, J. H.: Immediate postsurgical prosthetics. Orthop. Prosthet., 21:105-112, 1967. Burgess, E. M., Matsen, F. A., Wyss, C. R., et al.: Segmental transcutaneous measurements ofP02 in patients requiring below-the-knee amputation for peripheral vascular insufficiency. J. Bone Joint Surg., 64A:378-382, 1982. Friedman, L. W., (ed.): The Surgical Rehabilitation of the Amputee. Springfield, Charles C Thomas, 1978. Holloway, G. A., and Watkins, D. W.: Laser Doppler measurement of cutaneous blood flow. J. Invest. Dermatol. 69:306-309, 1977. Holloway, G. A., and Burgess, E. M.: Cutaneous blood flow and its relation to healing of below knee amputation. Surg. Gynecol. Obstet., 146:750-756, 1978. Kegel, B.: Controlled environment treatment (CET) for patients with below knee amputations. Phys. Ther., 56:1366-1371, 1976. Kostuik, J.P., Wood, D., Hornby R., et al.: The measurement of skin blood flow in peripheral vascular disease by epicutaneous application of xenon 133. J. Bone Joint Surg., 58A:833837, 1976. Kostuik, John P. (ed.): Amputation Surgery and Rehabilitation. The Toronto Experience. New York, Churchill Livingstone, 1981. Slocum, D. B. (ed.): An Atlas of Amputations. St. Louis, C. V. Mosby, 1949. 1102 Columbia Eklind Hall Rm. 409 Seattle, WA 98104