Classification by indications
The surgical strategy depends directly on the clinical situation. There are three main groups of amputations:
- Primary (by primary indications). Performed during primary surgical debridement (PSD) of the wound. The main goal is the rapid removal of the non-viable part of the limb. The surgery is performed early, before the development of clinical signs of infection. The principles are simplicity and speed, and the resection level is chosen within healthy tissues to guarantee saving the patient's life.
- Secondary (by secondary indications). Performed at any period of treatment if conservative methods and previous surgical interventions have proved ineffective, and life-threatening complications have developed.
- Repeat (re-amputations). Indicated for unsatisfactory results of previous resections. Reasons for re-amputation include: formation of a defective stump (hindering prosthetics), spread of necrosis, progression of anaerobic infection, or development of gangrene against the background of obliterating vascular diseases.
Indications for primary amputation
The decision on limb loss is made only in cases of irreversible damage. Absolute indications include:
- Complete or near-complete traumatic separation of the limb.
- Severe injuries accompanied by damage to major vessels, nerve trunks, extensive destruction of soft tissues, and bone comminution.
- Extensive open injuries of bones and joints if their reduction is impossible and secondary circulatory disorders have already developed.
- Massive soft tissue injuries involving more than 2/3 of the limb circumference.
- Severe frostbite and extensive deep burns bordering on tissue charring.
Circular amputation techniques
Circular amputations are used in areas of the limb where the bone is evenly surrounded by soft tissues. They are classified by the number of stages ("moments") of soft tissue incision. Important: sawing the bone is not considered a separate moment.
Guillotine amputation All soft tissues and the bone are transected in a single plane, without preliminary skin traction. Performed strictly within healthy tissues.
- Indication: progressive anaerobic infection.
- Feature: an open wound management method is used. It remains wide open to ensure tissue aeration (in combination with the administration of antibiotics and sera).
- Prognosis: the method saves life, but inevitably leads to the formation of a pathological (defective) stump, as retracted tissues expose the bone. A re-amputation is almost always required in the future.
Single-moment method The skin and subcutaneous tissue are pulled proximally as much as possible. Then, all soft tissues are incised with a single movement of the amputation knife. The muscles are further retracted with a retractor, after which the bone is sawed. Unlike the guillotine method, the bone is transected above the level of the skin incision.
- Disadvantage: creates too small a tissue reserve, insufficient for adequate stump closure.
- Indication: extremely grave condition of the patient, precluding prolonged surgery.
Two-moment method
- 1st moment: circular incision of the skin, subcutaneous tissue, and fascia.
- 2nd moment: along the edge of the retracted skin, all muscles are incised down to the bone. Then the muscles are pulled proximally and the bone is sawed.
Osteoplastic amputations and bone management
Osteoplastic amputations aim to create a functional weight-bearing stump. The pioneer of this approach is N.I. Pirogov, who developed a method for forming a weight-bearing lower leg stump using a calcaneal bone flap (calcaneus). Subsequently, the principle was adapted for other segments (e.g., Bier's lower leg amputation or Gritti's thigh amputation).
These operations are technically complex and require flawless blood supply to all stump tissues, so they are relatively rarely used in modern emergency surgery.
Methods of bone stump management In any amputation, it is important to properly manage the bone cross-section. There are two main methods:
- Periosteal (subperiosteal): the periosteum (periosteum) is incised distal to the intended sawing level and gently pushed proximally to cover the bone cross-section after sawing.
- Aperiosteal method.
Briefly: answers to topical questions
How is Pirogov's three-moment conico-circular thigh amputation performed?
Pirogov's three-moment conico-circular thigh amputation is performed in three stages to form a conical stump, taking into account layered anatomy and tissue contractility.
Stages of the operation:
- Step I — skin incision.
- Step II — incision of the fascia and superficial muscle layer along the edge of the retracted skin.
- Step III — incision of the deep muscle layer along the edge of the retracted soft tissues.
A retractor is used to pull back the soft tissues. The following anatomical layers are visible on the cross-section: bone, periosteum, muscles, skin, fascia.
What is the technique of the aperiosteal method of bone management?
The technique of the aperiosteal method of bone management includes the following steps:
- Circular incision of the periosteum with a scalpel.
- Displacement of the periosteum distally by 0.5 cm using a Farabeuf periosteal elevator.
- Bone sawing: the saw is placed 2–3 mm distal to the smooth edge of the transected periosteum.
Advantages of the method: the periosteum is not traumatized by the saw, and a good blood supply to the bone stump is preserved.
What flap-based methods of lower limb amputation exist?
Flap methods of amputation involve fashioning one or two flaps of skin and subcutaneous adipose tissue to subsequently cover the formed stump.
The following types are distinguished:
- Single-flap.
- Double-flap.
- Fascioplastic amputation — if the fascia is included in the flap.
Calculation of flap dimensions:
- Long flap: length is equal to 2/3 of the limb diameter at the amputation level, width is equal to the full limb diameter.
- Short flap: length is equal to 1/3 of the limb diameter, i.e., half the length of the long flap.
The flap method allows shifting the skin scar from the end, i.e., from the weight-bearing part, to the non-weight-bearing part of the stump, facilitating subsequent prosthetics. The optimal scar location for lower leg and thigh stumps is on the posterior surface.
What is the technique of Pirogov's osteoplastic lower leg amputation?
The technique of osteoplastic below-knee amputation according to Pirogov consists in forming a load-bearing stump using a flap of the calcaneus (calcaneus).
Main stages of the surgery:
- Soft tissue incision — a stirrup-shaped incision is made from malleolus to malleolus across the sole.
- Bone resection — the talus (talus), distal epiphyses of the tibia and fibula, and the anterior part of the calcaneus are removed.
- Sawing of the calcaneus — a vertical cut is performed.
- Stump formation — a segment of the calcaneal tuberosity (tuber calcanei) with the preserved skin flap is fixed to the bone resection line of the lower leg.
To easily remember the indications for reamputation, use the "Four Ps" rule: Poor stump, Progression of anaerobic infection, Persistent tissue necrosis, Poor circulation (gangrene in vascular diseases).
Class and exam questions
Is sawing the bone considered a separate "stage" of amputation?
No, it is not. The classification of circular methods (single-, double-, or triple-stage) is based solely on the number of stages of soft tissue dissection.
Why is a revision surgery always necessary after a guillotine amputation?
In guillotine amputation, tissues are transected in a single plane without a skin reserve, and the wound is left open for aeration. Over time, the soft tissues retract, the bone protrudes, and a faulty stump forms, requiring reamputation.
What is the essence of the periosteal method of bone management?
In this method, the periosteum is incised distal to (below) the level of the planned osteotomy and shifted upward. After the bone is sawed through, this periosteal flap is used to cover the bone stump.
What else to study on this topic
- Technique of the three-stage conical circular amputation
- Features of below-knee stump formation according to Bier's method
- Technique of osteoplastic above-knee amputation according to Gritti
- Aperiosteal method of bone stump management: indications and technique
- Complex therapy of anaerobic infection in open wound management
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