Main indications for amputation
Indications are divided into peacetime and wartime, as well as emergency and secondary. In peacetime, amputations are most commonly performed due to arterial disease in atherosclerosis, thromboangiitis obliterans, or severe road traffic injuries.
Secondary amputations are indicated when all conservative methods for treating infection have been exhausted. These include:
- Extensive soft tissue trauma with fractures complicated by anaerobic infection.
- Severe purulent processes in tubular bones and joints accompanied by sepsis and intoxication.
- Recurrent hemorrhage from eroded large vessels in purulent wounds refractory to therapy.
- Extremity necrosis following ligation or obliteration of main arteries.
- Grade IV frostbite (after necrectomy).
Classification and methods of soft tissue transection
Depending on the type of tissue transection, amputations are divided into circular and flap methods.
The flap method allows for the formation of a functional stump suitable for prosthetics. In this case, the skin scar is shifted from the weight-bearing area to the non-weight-bearing area (optimally to the posterior surface for the thigh and lower leg).
Flaps can be long or short:
- Long flap: length is $2/3$ of the limb diameter, width equals the full diameter.
- Short flap: length is $1/3$ of the limb diameter.
If fascia is included in the flap, the operation is called fascioplastic.
Stages of the surgery
Any amputation consists of four main stages:
- Transection of skin, subcutaneous tissue, and muscles.
- Bone sawing.
- Vessel ligation and nerve transection.
- Suture of the surgical wound.
A classic example is Pirogov's three-step cone-circular thigh amputation, aimed at creating a conical stump. Soft tissues are transected in three steps while retracting the skin with a retractor.
Management of bone, vessels, and nerves
To cover the bone stump, fascia (fascioplastic), muscles (myoplastic), or a bone graft (osteoplastic amputations) are used.
Bone management in adults is performed using the aperiosteal method: the periosteum is circularly incised and pushed downward (distally) by 0.5 cm with a Farabeuf periosteal elevator so that the saw does not damage it. The subperiosteal method (pushing the periosteum upward) is used exclusively in children.
Vessel management is performed before removing the tourniquet. Two ligatures are applied to large arteries, with the lower one being a transfixing ligature to prevent slippage.
Nerve management is performed after bone sawing. The nerve is transected with a sharp scalpel or blade 5–6 cm proximal to the stump level. This prevents neuroma ingrowth into the scar and the development of phantom pain. Transecting too high risks muscle atrophy.
Briefly: answers to topical questions
What are the types of circular amputations based on the number of tissue transection steps?
Circular amputations on the lower extremities are used in areas where the bone is uniformly surrounded by soft tissues. Based on the number of soft tissue transection steps, guillotine, single-step, two-step, and three-step circular amputations are distinguished. A classic example of the three-step cone-circular method is N.I. Pirogov's operation, which is performed in three stages to form a conical stump. The first step involves skin transection, the second involves fascia and the superficial muscle layer, and the third involves the deep muscle layer.
Remember the 4 steps of amputation: Tissues, Bone, Vessels-Nerves, Sutures (TBVNS).
Class and exam questions
Why use a transfixing ligature when ligating arteries?
Transfixing both walls of the artery securely anchors the knot and prevents it from slipping after the tourniquet is removed.
Which instrument must categorically not be used to transect a nerve?
The nerve must not be stretched or cut with scissors. Only a sharp razor blade or scalpel is used.
What else to study on this topic
- Pirogov's three-step cone-circular thigh amputation: detailed technique
- Features of fascioplastic, myoplastic, and osteoplastic amputations
- Instruments for soft tissue retraction (retractors)
- Formation of skin, cylindrical, and osteomuscular stumps
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