Limb amputations

Absolute and relative indications

Indications for removing a limb segment are divided into two broad groups depending on the degree of threat to the patient's life and the reversibility of the pathological process.

Absolute indications are dictated by a direct threat to life or complete loss of tissue viability. These include:

• Traumatic avulsions, where the connection to the body is maintained only by tendons or a skin flap, and replantation is impossible.
• Severe open injuries with crushing of the muscle mass, multiple fractures, and fatal damage to major vessels and nerves.
• Progressive infections posing a threat to life (sepsis, anaerobic infection).
• Tissue non-viability against the background of gangrene of various etiologies (diabetic, ischemic, thromboembolic), as well as deep burns, frostbite, and electrical injuries.
• Malignant tumors of the extremities.

Relative indications are associated with severe chronic diseases and persistent loss of limb function:

• Chronic infections unresponsive to conservative therapy (e.g., trophic ulcers or chronic osteomyelitis complicated by internal organ amyloidosis).
• Incurable functional inferiority due to extensive bone defects, congenital underdevelopment, or severe acquired deformities.

Classification by timing of execution

Depending on the clinical situation and the time of complication development, three main types of surgical interventions are distinguished:

1. Primary amputations. Performed at the stage of primary surgical debridement of the wound, strictly before the development of purulent-infectious complications.
2. Secondary amputations. Performed in cases where conservative treatment or limb-sparing operations proved ineffective, and a direct threat to the patient's life arose against the background of a developing infectious process.
3. Reamputations (repeat). Indicated for unsatisfactory outcomes of a previous operation (e.g., suppuration or necrosis of the stump, progression of the underlying disease) or for shaping an anatomically correct stump suitable for prosthesis fitting.

Determining the level of truncation

The approach to choosing the level at which the truncation will be performed depends on the urgency of the operation.

In emergency (primary) interventions, the surgeon's main task is to preserve as much viable tissue as possible. Truncation is performed as distally as possible. In such situations, atypical amputations are permitted, representing extended surgical wound debridement with excision of necrotic areas without classical stump formation.

In secondary amputations the level is dictated by the anatomical tasks of future prosthetics. However, the general modern principle states that the operation must be as conservative as possible and performed within healthy tissues. Modern technologies allow for the manufacture of a high-quality prosthesis for almost any level of truncation.

Main stages of surgical intervention

The operation is performed under general or regional anesthesia. To ensure hemostasis, a tourniquet is applied 10–12 cm proximal to the sawing level. The intervention includes several key stages.

Soft tissue incision The choice of technique depends on the severity of the patient's condition:

• Circular amputation (tissues are incised at a right angle to the axis). Used to reduce operation time in severe conditions or massive infectious processes. The extreme variant is «guillotine» amputation, where the bone and tissues are crossed at the same level.
• Flap methods. One or two flaps are fashioned from skin and subcutaneous tissue to cover the stump. The flap may include fascia (fascioplastic amputation) or a bone fragment (osteoplastic).

Bone sawing and management Soft tissues are retracted proximally using a retractor. The optimal technique requires preliminary incision of the periosteum and its displacement with a periosteal elevator. The bone is sawed with slow movements using a special hand saw to avoid thermal burn and bone necrosis.

Functionally advantageous position and ankylosis

If it is impossible to preserve the full range of motion in a joint (ankylosis), the limb is given a position that optimizes its use. For the upper extremity, this is a position ensuring the best application of preserved gripping and movement mechanisms of the hand. For the lower extremity, it is critically important to ensure the possibility of stable weight-bearing load.

Surgical treatment of ankylosis aims to improve function. Corrective osteotomies (to correct the limb axis) and resection of the ankylosed joint zone followed by total arthroplasty are used, which is the modern method of choice for restoring mobility.

Class and exam questions

What else to study on this topic

• Technique of performing the three-stage circular amputation according to N.I. Pirogov.
• Features of forming osteoplastic and fascioplastic flaps.
• Principles of managing blood vessels and nerve trunks during amputation.
• Methods of corrective osteotomy in the surgical treatment of ankylosis.
• Modern approaches to arthroplasty after resection of an ankylosed joint.

Other topics in the section "General Questions of Traumatology and Orthopedics"

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