Extremity Amputations: Principles, Techniques, and Recent Advances

Carol D. Morris, MD, MS Benjamin K. Potter, MD Edward A. Athanasian, MD Valerae O. Lewis, MD

Abstract require considerable preoperative plan- It is estimated that approximately 1.7 million Americans are living with the loss of a ning, knowledge of prosthetic design, limb, and this number is expected to nearly double by 2050. The most common reasons and consideration of postoperative ex- for amputation include vascular compromise, trauma, cancer, and congenital deformities. pectations. This chapter reviews the Orthopaedic surgeons are often called on to manage patients requiring an amputation or principles and techniques for perform- those with amputation-related conditions. It is helpful to review the principles and techniques ing lower and upper limb amputations, for performing lower and upper limb amputations, with a focus on common complications with a focus on common complications and how to avoid them and to be familiar with recent advances in prosthetic design and and how to avoid them, and discusses management of a residual limb. recent advances in prosthetic design Instr Course Lect 2015;64:105–117. and management of the residual limb.

It is estimated that approximately have decreased over time, but compli- Upper Limb Amputations 1.7 million Americans are living with cations from vascular disease leading to Amputation Levels the loss of a limb, and this number is amputation have increased. The num- Fingertip amputations are commonly expected to nearly double by 2050. Vas- ber of amputations performed for con- seen in the emergency department. cular compromise, trauma, cancer, and genital deformities has remained steady. Treatment methods vary and are large- congenital deformities are among the Although amputation is typically ly based on the level of amputation, the most common reasons for amputation. considered a nonchallenging surgical angle of injury, and soft-tissue status. Traumatic and neoplastic etiologies procedure, good functional results Transverse injuries may be allowed to heal by secondary intention in most cases because skin match and sensation Dr. Morris or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons. Dr. Potter or an immediate family member serves as a board member, owner, offi cer, or are often superior to grafting. At times, committee member of the Society of Military Orthopaedic Surgeons and the American Academy of Orthopaedic Surgeons. bone shortening may be required. V-Y Dr. Lewis or an immediate family member has received research or institutional support from Stryker and serves as a board Atasoy and Cutler fl aps may be used on member, owner, offi cer, or committee member of the American Academy of Orthopaedic Surgeons and the Western Ortho- 1 paedic Association. Neither Dr. Athanasian nor any immediate family member has received anything of value from or has occasion. Severe oblique injuries may stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter. require full-thickness skin grafting,

volar advancement fl aps, or coverage from adjacent digits (for example, cross-fi nger fl aps, reverse cross-fi nger fl aps, and dorsal metacarpal artery fl aps). More proximal-level traumatic digit amputations are most commonly closed directly with some shortening or conversion to a ray amputation. In- dications for ray amputation must take into account individual patient considerations. Preoperative consultation should include discussion of cosmetic change, neuroma formation, and grip strength reduction.2 Replantation may be considered for amputations in single digits distal to the fl exor digitorum Figure 1 Clinical photograph of a superfi cialis insertion on the middle Figure 2 Clinical photograph of a double ray (index and middle fi nger) ring and small fi nger amputation for phalanx, multiple digits, and thumbs amputation for sarcoma. sarcoma. and in children. rarely will metacarpophalangeal dis- Elective Digit and articulation be favored by patients. highest rate of painful neuromas.4,5 Ray Amputation Ray amputation without transpo- Phantom sensation is common, but Elective digit amputation may be in- sition is an excellent treatment op- phantom pain is infrequent. Rarely, dicated in patients with vascular defi - tion for severe ring avulsion injuries painful neuromas may require reexci- ciency, infection, or tumors. In the or malignant tumors of the digits.2 sion or cryoablation. elective setting, the level of amputa- Transposition may be considered for Multiple ray amputation may be tion and fl ap design can be carefully the treatment of middle fi nger lesions; required in the presence of tumor or planned. Fish-mouth incisions often however, it is often not needed. During severe trauma. The defect produced have the optimal appearance. Vo- this procedure, the base of the index by multiple ray amputation is much lar fl aps are particularly useful in the metacarpal is osteotomized, and the en- more apparent (Figures 1 and 2). setting of distal interphalangeal joint tire digit is transposed to the position of Grip strength is often dramatically de- disarticulation or interphalangeal dis- the middle ray. The index metacarpal is creased. In the tumor setting, it may be articulation in the thumb. The volar then fi xed to the base of the transected reduced by 75%.5 Function is markedly skin provides excellent sensation and middle fi nger metacarpal. Attention to diminished. durable skin and may maximize tactile digit rotation is critical. This procedure Thumb ray amputation is not fre- sensation. The level of amputation re- can improve the appearance of the hand quently indicated. Whenever possible, quired may infl uence the decision for but at the risk of malrotation, nonunion, thumb salvage procedures should be ray amputation. When amputation at and (in the presence of tumors) contam- considered.6 Tumors distal to the in- the proximal phalanx level is indicated ination of the index ray. terphalangeal joint often can be treated in the digits, ray amputation should be Metacarpal ligament reconstruction safely with interphalangeal disarticu- considered. The cosmetic appearance allows narrowing of the defect and lation. Tumors at the proximal pha- and function are often superior in the improves cosmetic appearance. Grip lanx level often can be widely excised setting of ray amputation. If breadth of strength is often reduced by approx- with reconstruction of the defect using the palm is important for function, ray imately 30%.3 Neuroma formation is bone, tendon, and vascular and nerve amputation may not be elected. Only common, and the index ray has the grafts with microsurgical soft-tissue

reconstruction. Ray amputation of the assistive devices and greater use of the thumb produces a substantial function- contralateral limb. Transhumeral-level al defi cit. Toe-to-thumb transfer or in- amputation may be required for severe dex pollicization may be reconstruction forearm trauma, traumatic amputation, options in this setting. or tumors of the proximal forearm or Wrist disarticulation is rarely re- elbow with involvement of multiple ma- quired in the tumor setting. Large jor nerves. Wide excision of the entire tumors in the region of the wrist usu- elbow with reconstruction may be an al- ally require forearm-level amputation. ternative if major nerves can be spared. Smaller tumors may be amenable to In the presence of a malignant tu- wide excision and reconstruction us- mor, the humerus-level amputation site ing vascularized and nonvascularized is determined in large part by the level Figure 3 Intraoperative pho- bone grafts with wrist arthrodesis. At of injury or the level of amputation re- tograph of a myoplasty for a forearm-level amputation. times, bone transport can be used to quired for achieving a wide excision. bridge defects at the wrist. However, In general, amputations that maximize wrist disarticulation may be considered length are preferred, as are anterior and posteriorly or anteriorly. Vessels are su- in the trauma setting when replanta- posterior fi sh-mouth–type fl aps. The ture ligated, nerves are transected prox- tion is not possible. Equal fl aps dorsally triceps and brachialis are used for myo- imally, and the clavicle is disarticulated and palmarly are ideal, but the extent of plasty closure. Nerves are transected at the sternum or transected medially. soft-tissue injury may determine which proximally to minimize pain from neu- Skin fl aps may be determined by the fl aps are appropriate. romas. Suture ligation of vessels is pre- extent of tumor contamination and Forearm-level amputation may be ferred to control proximal level vessels. previous surgical procedures. Preoper- required for large wrist-level or carpal Shoulder disarticulation may be re- ative plastic surgery consultation may tunnel–based tumors. This level of quired for very proximal-level humeral be helpful in planning closure. At times, amputation is functionally devastat- amputations or when the presence of a fi llet forearm fl ap from the amputated ing. Because patients may have diffi - malignancy dictates the need for am- limb may facilitate closure.8 culty coping with the loss, preoperative putation at the level of the joint. Most psychological counseling should be commonly, a lateral fl ap is used for cov- Lower Limb Amputations routinely considered. Most commonly, erage. If the deltoid can be spared, it is General Principles when major nerves can be spared, incorporated into the fl ap. More prox- Between 30,000 and 40,000 lower wide excision and reconstruction are imal level amputations are commonly limb amputations are performed in preferred. Fish-mouth incisions with associated with phantom sensation and the United States annually, and this volar and dorsal fl aps are ideal. Myo- phantom pain. rate has remained fairly steady during plasty will ensure durable soft-tissue Forequarter amputation is most the past 15 years.9 The main causes of coverage for the amputated bone ends commonly indicated for very large these amputations are vascular disease (Figure 3). Myodesis may improve re- shoulder girdle tumors or multiple (54%, including diabetes and peripheral sidual forearm rotation and may facil- recurrent shoulder-level tumors.7 Am- arterial disease) and trauma (45%); can- itate prosthetic function. Nerve ends putation at this level produces a major cer is responsible for less than 2%.10 In should be resected proximally to allow cosmetic defect and functional defi cit. elderly patients or those with ischemic adequate soft-tissue coverage for the Preoperative counseling should be disease, amputation of one lower limb is neuromas, which routinely form after strongly considered. Prosthetic use is often followed by the amputation of the amputation. Prosthetic fi tting should usually limited to a shoulder pad that contralateral limb; 15% to 28% of such be encouraged, but many patients com- supports clothing. Anterior, posterior, amputations occur within 3 years.11,12 monly use prostheses only for specifi c or combined approaches may be used. Despite the advances in medicine, these activities or tasks. Most patients will Periscapular muscles are transected statistics have not greatly improved for adapt with the use of nonprosthetic posteriorly. Vessels can be approached the dysvascular amputee. Only 50% of

elderly dysvascular amputees survive tissue at the end of the residual limb be- control, protection of the suture site, the fi rst 3 years after an amputation.13 cause the extra tissue makes prosthesis contracture prevention, and possibly However, an amputation should not wear and control quite diffi cult. To help earlier ambulation; however, consen- be considered a failure of treatment. avoid extra tissue, the muscle should be sus on the most effective dressing is Frequently, an amputation is the treat- transected to the level where the skin lacking.14 ment of choice for a devastating injury has naturally retracted after the skin to the lower extremity, especially when incision, which should be distal to the Amputation Levels reconstruction may be a long and costly level of the bone osteotomy. The term classic hemipelvectomy is used process that results in a functionally un- The handling of the nerves during to describe an amputation of the pelvic satisfactory limb. an amputation remains controversial. ring via disarticulation of the pubic sym- Although amputation may be per- There is a consensus that the nerves physis and the sacroiliac joint, division ceived as a technically nonchallenging should be isolated and gently pulled into of the common iliac vessels, and closure procedure, it must be well planned to be the wound before transection. Addi- with a posterior fasciocutaneous fl ap. well performed. Although each ampu- tional treatment of the severed nerve Another current term for this proce- tation and amputation level has specifi c ending with ligation and/or injection dure is hindquarter amputation. Older considerations, there are several funda- with anesthetic is controversial because terms include interpelviabdominal or mental principles common to amputa- there is no defi nitive evidence-based interinnomino-abdominal amputation. tion. Skin and muscle fl aps should be consensus. Major blood vessels should Hemipelvectomy may be indicated for fashioned to achieve the longest resid- be tied with a double ligature. If a tour- patients with massive pelvic trauma, ual limb that will give the patient the niquet is used, it should be released, and uncontrollable sepsis of the lower ex- best functional outcome. This length meticulous hemostasis should be ob- tremity, pervasive metastatic lesions of depends not only on the amount of vi- tained before wound closure. The use the extremity, or primary pelvic bone able tissue but on the anatomic location of drains is encouraged to help prevent and soft-tissue tumors. The three es- and the desired prosthesis that will be the development of hematomas. sential components for a functional leg fashioned (for example, high-function- The treatment of an amputee does are the lumbosacral plexus, the femoral ing knee joint or ankle joint). Skin fl aps not start and end in the operating room. neurovascular bundle, and the hip joint. can be uniform (such as fi sh-mouth or Preoperative and postoperative plan- If two of these three structures are not posterior-anterior–based fl aps) but in ning is important. Preoperative consul- functional, then amputation is usually the dysvascular, traumatic, or oncologic tation with a prosthetist can facilitate indicated. Pelvic resections have been setting, the fl aps are often nonconven- the choice of appropriate limb length classifi ed by Enneking and Dunham15 tional. It is important to carefully eval- and help set a patient’s expectations. to facilitate consistent discussions about uate the blood supply to the area before There are two schools of thought resection and reconstruction technique. initiating the fl ap design. There are sev- regarding the postoperative dressing: The basic pelvic resection types are as eral methods that can predict at which soft versus rigid. When a soft dressing is follows: type I, resection of the iliac level of the lower limb the circulation used, the wound is closed, a small sterile wing; type II, resection of the peria- in the skin is adequate for primary dressing is applied to the incision, and cetabular regions of the pelvic bone; wound healing; these methods include an elastic bandage is snugly wrapped and type III, resection of the obturator. xenon-133 clearance and transcutane- over the dressing and around the resid- Preoperative planning for hind- ous measurement of oxygen tension. ual limb. Throughout the postoperative quarter amputations is essential. To These measures are particularly helpful period, the residual limb is kept snugly decrease the possibility of intraoper- in patients with dysvascular disorders. wrapped in an elastic bandage until the ative contamination and improve in- As mentioned previously, the length prosthesis is fi t. When a rigid dressing traoperative surgical view and bowel of the residual limb can be critically is used, a plaster of Paris or fi berglass handling, some surgeons advocate the important, both in terms of prosthesis cast is applied to the residual limb af- use of preoperative bowel preparation. wear and the type of prosthesis that can ter surgery. The rigid dressing offers In theory, a bowel preparation will de- be worn. It is important to avoid extra the benefi t of pain reduction, edema crease the bacterial count and volume

of bowel contents if there is spillage into the wound. However, recent gynecologic literature suggests that mechanical bowel preparation may not provide a substantial advantage in this regard.16 The placement of stents in the ureters can be benefi cial and will help iden- tify the ureters within the surgical fi eld. Arterial and venous access should be established to facilitate intraoperative monitoring of the hemodynamic status and fl uid resuscitation. Discussion of the surgical procedure is not within the scope of this chapter, Figure 4 Intraoperative photograph of an anterior-based hemipelvectomy but it should be noted that care must be fl a p . taken when performing a hindquarter amputation on the right side because the inferior vena cava lies on this side, inferior to the aorta. The surgeon must take care not to damage nor sacrifi ce the inferior vena cava when attempt- ing to ligate the common iliac artery. The most common fl ap used in hemi- pelvectomies is a posterior-based fl ap. When the inferior gluteal vessels and cuneal vessels are preserved and the gluteus maximus muscle can be incorporated into the fl ap, the closure will be myocutaneous. The anterior-based fl ap, which is used less commonly, is a long anterior myocutaneous fl ap that generally includes the quadriceps muscle (Figure 4). Its blood supply is based on the femoral vessels. If local anterior or posterior fl ap-based coverage is not an option, a free fi llet lower leg fl ap can be used. Fillet fl aps are axial-pattern Figure 5 Clinical photographs of the anterior (A) and lateral (B) views of a fl aps that function as composite tissue hemipelvectomy prosthesis. transfers. They can be used as pedicled or free fl aps and are a good option for independence. Patients who are young, many patients fi nd that ambulating reconstructing large defects. motivated, and in good physical condi- with crutches is much faster than with Patients with hindquarter ampu- tion with a good sense of balance may a prosthesis and requires no additional tations can regain the ability to walk ambulate without external aids. How- expenditure of energy. (Figure 5). Modern advances in tech- ever, many patients may need some type Patients with this level of amputa- nology afford the patient the opportuni- of assistive device, such as a cane or tion who ambulate with a prosthesis ty to regain functional and ambulatory a walker, for ambulation. In addition, have increased energy expenditures

up to 200%.17 The prosthesis uses the disarticulation rather than an above- lower section of the rib cage for weight knee amputation. Although it is impor- bearing and stabilization. Skin grafts tant to preserve as much femoral length and sutures in this area should be avoid- as possible during the amputation, it is ed, and any transected bone should equally important to provide a re sidual be beveled and rounded to lessen the limb that has the proper amount of chance of skin breakdown from a sharp clearance for the prosthetic knee and to bony end contained within the socket. match the prosthetic knee to the center The lower back absorbs forces during of the sound knee. The femur should be ambulation. Stabilization of the hip transected approximately 12 to 14 cm and knee joints at heel strike places ab- above the joint line. normally high forces along the spine. There are two schools of thought Forward propulsion of the prosthesis and possibilities for muscle closure. through the swing phase of gait requires Myoplasty is the closure of the quad- aggressive lateral trunk shifts, increased riceps to the hamstrings. This method lumbar lordosis, and transverse rotation does not stabilize the femur, but it al- of the lumbar spine in conjunction with lows the femur to move freely within Figure 6 Illustration showing contralateral vaulting. the soft-tissue envelope. There is less attachment of the adductor mag- An amputation through the hip limb control with this method, and nus to the lateral part of the femur. (Courtesy of John Bowker, MD, joint is called a hip disarticulation. It is movement may result in pain. Myod- and reproduced from Gottschalk F: commonly used for failed vascular pro- esis consists of attaching the adductor Transfemoral amputation: Surgical cedures after multiple lower-level ampu- magnus muscle to the lateral aspect of management, in Smith DG, Michael JW, Bowker JH, eds: Atlas of Am- tations or for massive trauma with crush the femur, thus stabilizing the femur putations and Limb Defi ciencies, injuries to the lower extremity. In this and re-creating the adductor moment ed 3. Rosemont, IL, American procedure, the acetabulum and poste- arm (Figure 6). This is accomplished Academy of Orthopaedic Surgeons, 2004, pp 533-540.) rior soft tissues are spared. The incision, by placing drill holes in the residual fe- which transverses around the posterior mur and securing the adductor to the thigh, distal to the gluteal crease, gener- bone with heavy suture, such as polyes- the fi rst postoperative day and begin ally provides suffi cient posterior cover- ter suture. Attaching the adductors to hip range-of-motion exercises when age. The posterior myocutaneous fl ap is the lateral aspect of the distal femur not comfort permits. the most common method of coverage. only pulls the femur into an adducted Transfemoral prostheses stabilize An anterior myocutaneous fl ap also has position but also provides good distal the pelvis through ischial containment, been described, although it is not often padding over the cut end of the femur. ischial weight bearing, and hydrostatic used.18 The prosthesis incorporates the The attachment of the quadriceps and pressures within the socket. With the ischium into the prosthesis, which not hamstring muscles to the opposite sides fulcrum (ischial tuberosity) placed at only allows the patient to bear weight of the femur from which they originate the pelvic region, controlling the distal through the ischium but also secures further secures the femur. The overly- femur requires a strong muscle contrac- the prosthetic limb. It acts as a fulcrum ing fascia and skin fl aps are then closed. tion from the adductor group with ev- through which the pelvis is kept level After surgery, to minimize the de- ery step. The resulting outcome is high during ambulation. velopment of hip fl exion contractures, energy consumption and fatigue com- Transfemoral (above-knee) ampu- the iliac crest should be incorporated pared with normal gait. The amount of tations are performed, as the name into the dressing. If it is not, it is rec- energy expenditure increase compared suggests, through the femur, and the ommended that the patient lie prone for with baseline energy expenditure also knee joint is sacrifi ced. Residual limbs 20 to 30 minutes, three times per day, relates to the reason the amputation shorter than 5 cm (measured from the to reduce the risk of contracture devel- occurred. Patients with traumatic lesser trochanter) function like a hip opment. Patients should be mobilized transfemoral amputations have a 68%

increase in energy expenditure, whereas benefi t. With the condyles intact, the control. However, it may be benefi cial those with vascular amputation have prosthetic socket can be suspended by to sacrifi ce some length to allow more a 100% increase. Strengthening and compression immediately proximal to room for modern prosthetic foot com- training are necessary to obtain a con- the femoral condyles. Shaving the fem- ponents. Carbon fi ber foot and strut sistent, unnoticeable gait pattern. The oral condyles will improve the cosmetic systems reduce oxygen consumption at most common gait deviation is that of appearance by reducing coronal bulk at velocities exceeding self-selected walk- lateral trunk lean. the distal end of the prosthetic socket. ing speeds. These feet are relatively tall If the femur is kept in an adducted Without the condyles, the prosthesis and can require up to 7 inches of clear- position, patients expend less energy can be suspended with suction. ance between the residual limb and the during ambulation because lateral trunk The addition of a prosthesis on the fl oor. Therefore, preoperative consulta- lean is reduced. If femoral adduction amputated side results in knee-center tion with a prosthetist is important.21 is not maintained, patients are forced discrepancies, which are especially ob- The surgical issues discussed for to dramatically shift their weight over vious when the patient is seated. For transfemoral amputation hold true for the prosthetic side during single-limb this reason, a patient may opt for a a transtibial operation. Closure of the stance to allow for swing phase clear- transfemoral amputation instead of a muscle layer can be performed through ance of the sound leg and to maintain knee disarticulation. In patients who a myodesis in which the muscles are coronal stability. This procedure results have not reached skeletal maturity, the sutured to the bone under physiologic in additional energy expenditure and an option of arresting the distal growth tension or myoplasty in which the mus- exaggerated Trendelenburg gait. Several plate on the involved limb can pro- cles are attached to their opposing mus- variations in socket design to main- vide a shorter femoral length at bone cle group. Myodesis provides greater tain femoral adduction and improve maturity and thus enhance cosmetic control and motion of the residual limb. gait have met with varying success, outcome by providing symmetric knee Typically, the fascia of the superfi cial especially in the absence of adductor centers. The advantages of a knee dis- posterior compartment is advanced myodesis. articulation over a transfemoral ampu- forward and attached to the anterior A knee disarticulation is an amputa- tation include a weight-bearing stump, periosteum of the tibia and the fascia of tion through the knee joint. By preserv- normal alignment of the residual limb, the anterior compartment. Additional ing the distal insertion of the adductor a more effi cient gait, and less energy anchorage of the muscles may be ac- muscle group, the femur maintains its expenditure.19,20 complished through drill holes medial normal adduction angle, which allows Transtibial amputations are typi- and lateral to the tibial crest, although for a more energy-effi cient gait than cally performed for patients with foot this technique also may limit excursion that typically obtained in a transfemoral or tibial tumors or major trauma. Al- of the muscle advancement. Again, ex- amputation. The fulcrum in the knee though experienced prosthetists can cessive fl aps should be avoided because disarticulation socket is moved distally often accommodate residual limbs as extra distal soft tissue will become a to the femoral condyles, thereby mim- short as 5 cm of tibia, to create a max- large loose mass of tissue at the end of icking normal biomechanical loading imally functional limb, 2.5 cm of tibia the residual limb, making stabilization and alignment, which also allows for a are required for each 30 cm of adult of the limb in the socket diffi cult.22 more normal and energy-effi cient gait height. This formula generally results in Transtibial amputations are ex- pattern. an amputation at the level of the mus- tremely functional. Resumption of a Although the prosthesis does not culotendinous junction of the gastroc- preamputation lifestyle and activity require ischial weight bearing and thus nemius muscle. Residual limbs that are level, including participation in sports does not extend as far proximally, the shorter than 5 cm are not functional, and recreational activities, is possible.23 aesthetics of the prosthesis itself often and it is recommended that if such a Rotationplasty, fi rst described by can be disappointing. The retention residual limb is expected, then a knee Borggreve24 in 1930, was popularized of the condyles will make for a bulky disarticulation should be performed. by Van Nes25 for proximal femoral fo- prosthesis. However, this adverse cos- As with other amputations, a longer re- cal defi ciency. Essentially, the rotation- metic result is offset by the functional sidual limb results in better prosthetic plasty creates a transtibial amputation

and/or a carbon plate to provide stability and push-off during ambulation. Amputations through the midfoot include Chopart and Lisfranc amputations. The Lisfranc amputation is performed at the tarsometatarsal joint, and the Chopart amputation is performed through the midtarsal joints. Prevention

Figure 7 Illustrations of Syme (A) and Pirogoff (B) amputation of the foot. of equinus and equinovarus deformities The shaded area represents the level of amputation. In a Pirogoff amputation, after these procedures is critical to avoid an osteotomy is performed through the calcaneus perpendicular to the long a foot with limited functional benefi t.28 axis (arrow). Overall, complete ray resections produce minimal deformity, which is from a transfemoral resection. It is an a weight-bearing distal end, which af- especially true in the lateral column of excellent alternative to a transfemoral fords the patient the ability to ambulate the foot where partial metacarpal resec- amputation and can be a salvage pro- for short distances without the pros- tion can cause a substantial functional cedure for patients with an infected thesis. However, early weight bearing defi cit, but ray resection will not. In ad- prosthesis, failed endoprosthesis, or without a prosthesis should be avoided. dition, the gap caused by ray resection local tumor recurrence. Rotationplasty The main difference between these can be closed with minimal deformity requires an intact sciatic nerve, a func- procedures is that with the Pirogoff and, unlike in the hand, ray transpo- tional ankle joint, and an intact foot. procedure, an osteotomy is performed sition is rarely needed or performed. Initially thought to be best in children through the calcaneus perpendicular After healing, normal shoe wear is pos- aged 8 to 10 years, rotationplasties are to the long axis, resulting in a posterior sible, and gait is unaffected. However, being performed in older patients. The fl ap that contains the calcaneal rem- amputation of the fi rst ray can cause main issue in older patients is the de- nant and the fat pad. The benefi t of this functional gait disturbances by com- creased fl exibility of the ankle.26 procedure is that the fat pad, which is promising late stance and push-off. A Functionally, rotationplasty offers prone to migration during the healing total contact shoe insert with fi ller and the advantage of a longer lever arm, a process after a Syme amputation, is at- carbon plate may be needed to establish functional knee joint, and an end (foot) tached to the calcaneus and, therefore, the third rocker of stance. that tolerates socket load better than a fat pad migration is rare. However, the transfemoral amputation stump. As a disadvantage is that calcaneal-tibial fu- Residual Limb result, there is lower energy consump- sion is required for the residual limb to Considerations and tion with ambulation, patients are able be successful and functional. Although Prosthetic Advancements to walk for longer periods of time, and these amputations offer the benefi t of a Initial Residual Limb they can participate in vigorous sport- weight-bearing stump, cosmesis can be Considerations ing activities that require knee fl exion. a problem. The bulbous appearance of After initial wound healing has been With advancements in limb salvage, the stump can be unappealing to some. achieved after amputation from any this procedure has become less pop- In addition, not only is the choice of cause—trauma, tumor, infection, or ular. However, psychologically, these prosthetic foot limited, but the pros- ischemia—attention turns toward patients do quite well. They tend to thesis, which fi ts over the end of the prosthetic fi tting and rehabilitation. adjust quickly to the limb appearance stump, often necessitates the use of a A viable and durable terminal residual and often do not view themselves as shoe lift on the side of the healthy limb limb remains an essential prerequisite amputees.27 to level the pelvis. to successful prosthesis fi tting and The Syme and Pirogoff amputations Transmetatarsal, midfoot, and ray use. Therefore, robust, mobile soft- (Figure 7) are both hindfoot amputa- resections may require shoe modifi - tissue coverage is at least as important tions that generate a residual limb with cation, a total contact insert toe fi ller, to ultimate amputee function as the

underlying osseous platform.29 Al- revision surgery is necessary. In the ex- though length preservation is generally perience of this chapter’s authors, many desirable, a shorter residual limb with a split-thickness skin grafts after severe healthy soft-tissue envelope will com- trauma serve as a length-preserving monly pose fewer long-term problems bridge to delayed soft-tissue revision, and fi tting diffi culties than a longer and a high reoperation rate should be limb with marginal coverage. Atypi- anticipated.34 cal, “tweener” amputation levels (for example, very long transtibial or trans- Complications femoral amputations) should generally Complications and/or persistently be avoided because, as a result of a com- symptomatic residual limbs fre quently bination of suboptimal soft-tissue cov- develop after amputation.35-37 Deep in- Figure 8 Clinical photograph erage and novel socket requirements, fection or overt wound failure represent showing poor terminal coverage such residual limbs typically offer the absolute indications for surgical inter- of the remaining femur with a limitations of the proximal and distal vention. Certain other symptoms (for split-thickness skin graft. adjacent amputations levels without example, phantom pain) cannot gener- achieving the full benefi ts of either. ally be effectively managed with surgical (particularly nondominant) upper limb Stable deep muscle anchorage via myo- intervention, but aggressive treatment amputees continue to favor simple, du- desis should be performed to maximize of focal, “fi xable” problems can dra- rable, body-powered terminal devices residual limb control and anchor deep matically improve amputee comfort, or abandon their prostheses altogether, padding,29-32 and the overlying myo- satisfaction, and function.38 Surgically myoelectric devices incorporating mul- plasty should be anchored to the fascia correctable symptom generators include tiple degrees of freedom have become of the underlying myodesis whenever neuromata, failed myodesis, unstable increasingly advanced and common- practicable. Mobile fasciocutaneous myoplasty, redundant soft tissue, ul- place.40-43 Conventional myoelectric tissue over a terminal residual limb is ceration or poor soft-tissue coverage, devices have been widely available for desirable; mobile muscle groups are not, and symptomatic heterotopic ossifi ca- nearly two decades and typically receive and they can produce painful symp- tion.39 Although revision surgery can input signals from underlying muscle toms associated with deep bursa that be avoided by refusal to reoperate on groups with surface electrodes with- form beneath hypermobile, unstable the patient, this approach—beyond a in the prosthetic socket. Myoelectric myoplasties. Split-thickness skin grafts reasonable period of nonsurgical man- hands (Figure 9) commonly outper- represent an occasionally necessary and agement with medical management, form sequential, body-powered devices viable alternative to more proximal re- injections, and/or socket modifi ca- for precise tasks. Problems associated vision33 but should be placed only over tions—may result in a severely disabled with weight, battery life, and limited viable, supple muscle and subcutaneous and dissatisfi ed patient with a marginal functions have been increasingly solved tissues (Figure 8). Grafts that adhere to residual limb who rejects the prosthesis by improved technologies borrowed the periosteum or the immobile tendon unnecessarily.29,35,36 from other industries. or fascia frequently develop ulceration Since the approval and release of or overt wound failure when subjected Prosthetic Advancements the initial C-leg (Ottobock; Figure 10), to prolonged direct pressure and shear Building on the prosthetic ingenuity microprocessor knee joints have dra- forces with regular prosthesis wear. of past researchers (for example, suc- matically improved function for many Dermal substitutes may be helpful in tion socket suspension was patented patients with an amputation at or prox- terms of augmenting the durability of in the United States in 1863) and the imal to the knee joint with onboard eventual split-thickness skin grafts; accelerating pace of available modern sensors that detect limb position and they also may reconstitute an effective technology, modern prosthetic de- accommodate activities through func- neodermis that facilitates improved vices continue to evolve at an impres- tions such as stance fl exion and stumble closure and coverage in the event that sive rate.40 Although many unilateral recovery.44,45 Newer-generation devices,

futile because of the hastening specter of obsolescence.

Future Directions One persistent, problematic theme, particularly for proximal transfemoral and transhumeral amputees, relates to diffi culties with prosthesis suspension because of weight and comfort in conventional sockets. Within the past two decades, European investigators have developed osseointegrated, “endo-exo” devices for the direct skeletal anchorage and attachment of prostheses.47-50 Func- Figure 9 Photograph illustrating a myoelectric hand. When tying tion has been dramatically improved shoelaces, a myoelectric hand Figure 10 Photograph of the for many patients, but complications can be used to stabilize and hold C-leg by Ottobock. related to infection persist because the the laces, while the opposite hand maneuvers the laces. (Reproduced skin-implant interface is an imperfect from Atkin DJ: Prosthetic training, in such as stair climbing.46 Clearly, pow- and unsolved problem. Loosening Smith DG, Michael JW, Bowker JH, ered prosthetics represent the wave of and fracture also have been variably eds: Atlas of Amputations and Limb Defi ciencies, ed 3. Rosemont, IL, the future. reported. Of particular concern, revi- American Academy of Orthopaedic Nevertheless, although improved sion surgery to revise and replace or for- Surgeons, 2004, pp 275-284.) gait patterns and energy expenditure mally remove an osseointegrated stem have been objectively documented in typically requires substantial residual including the Genium/X2 (Ottobock) these new devices,44-46 patient com- limb and/or bone shortening. No os- have shown quick patient adaption, bet- mitment to rehabilitation and recov- seointegrated implants for major limb ter use of stance fl exion for a more nor- ery remains essential. Importantly, the amputations are currently available in mal and symmetric gait, and increased microprocessor knee or other devices the United States, although FDA trials versatility for ambulating in different do not “make” the amputee walk; the are in development. environments or over variable terrain.40 amputee has to learn to walk again. Fur- Targeted muscle reinnervation The fi rst powered prosthetic knee thermore, the acceleration of prosthetic (TMR), as described by Kuiken et al51,52 joint is now commercially available technology within the past decade has and Dumanian et al,53 via reinnerva- (Power Knee; Ossur). Although in the outstripped investigators’ ability to ad- tion of “unemployed” muscles and/or experience of this chapter’s authors equately, objectively, and critically study reassignment of residual nerves may many patients still prefer micropro- and assess the putative end-user benefi ts increase signal intensity and clarity cessor knees because of weight, noise, of each new breakthrough. Each new while increasing the number of poten- and versatility concerns, the advent of device will help some patients and be tial myoelectric target sites for proximal adequate robotic power to assist am- ignored or rejected by others; prosthetic upper limb amputees. For transhumeral bulatory function represents a marked fi tting has never been and may never be amputees, TMR typically involves cre- “step” forward for many patients and a “one size fi ts all” methodology, re- ating four independently controlled prosthetic technology. More recent gardless of future innovations. There- nerve-muscle units by transferring the commercial breakthroughs have led fore, although the objective assessment distal radial/posterior interosseous to microprocessor and powered an- of new general technologies remains nerve to the lateral head of the triceps kles (BiOM Foot; iWalk), which may important, comparing and contrasting and the median nerve motor branch improve function over energy-storing, specifi c, often competing, prosthetic to the medial (short) head of the bi- passive devices for everyday activities components has become increasingly ceps (Figure 11). When present, the

brachioradialis also may be targeted for and obviating problems related to sig- reinnervation with the ulnar nerve. For nal noise, involuntary cocontraction of patients with shoulder disarticulation, antagonist muscles, and diffi cult socket the musculocutaneous nerve is typically fi t or sweating (because they decrease transferred to the clavicular head of the conventional myoelectric prosthesis pectoralis major; the median nerve to function).54,55 Intracranial signal recep- the sterna head of the pectoralis major; tors placed over the homunculus offer the radial nerve to the thoracodorsal similar potential for proximal upper nerve; and the ulnar nerve to the pec- limb amputees and patients with high toralis minor, the long thoracic nerve, spinal cord or brachial plexus injuries. or a redundant motor branch of the In addition, numerous haptic feedback split pectoralis major. Other transfer technologies are in development to Figure 11 Intraoperative or target sites are possible depend- offer proxy sensory input from myo- photograph of a posterior targeted ing on the residual limb anatomy and electric prostheses to the amputee and muscle reinnervation procedure on a transhumeral amputee. available musculature. In addition to facilitate improved fi ne motor tasks and The terminal radial-posterior increasing the number and signal clarity touch feedback. interosseous nerve has been of nerve-muscle myoelectric target sites, An additional treatment strategy on attached to the deliberately denervated and reinnervated lateral a critical advantage of TMR is that the the horizon for upper limb amputees, head of the triceps (arrow). resultant end prosthesis actions may be particularly of the dominant limb or bi- intuitively programmed (for example, lateral limbs, is that of composite tissue upper limb or hand transplants have the median nerve closes the hand). allotransplantation (for example, hand been performed worldwide to date) are A related, but different, techno- transplantation). Substantial headway promising, offering midterm function logic advancement to TMR is that of has been made in the past decade with that is comparable with or, in some advanced pattern recognition. In am- regard to microsurgical techniques and cases, better than reimplantation and putees who have undergone previous improved immunosuppression, immu- generally better function than is achiev- TMR procedures or in those who have nomodulation, and immunotolerance able with currently available prosthe- not but experience diffi culty with myo- protocols.56-58 Modern protocols include ses. With such advancements currently electric control, computer-assisted in- steroid sparing/avoiding techniques, being evaluated, hand transplantation terpretation of surface electrode signals cell-based immunomodulation strate- may become more widely accepted and is used to decode electrical signals in a gies, immunosuppression reduction as feasible in the near future. more consistent and intuitive fashion. tolerance increases, and topical thera- These signals are then appropriately pies that limit overall systemic immuno- Summary reassigned in a customized fashion to suppression. Critics remain concerned Advancement in prosthetic design is the patient’s prosthesis so that volitional about the lack of convincing long-term paralleling the increasing number of intent more closely mirrors prosthesis functional data; an unclear and evolv- amputations. It is important for or- response, and prosthesis responsiveness ing risk-benefi t ratio; and potential thopaedic surgeons to know how to and signal reliability are improved. life-shortening or fatal complications perform “good” amputations to allow In the near future, implanted myo- related to immunosuppression, includ- patients to achieve the maximum ben- electric signal amplifi ers in the resid- ing hyperglycemia, hyperlipidemia, efi ts from modern prostheses. Metic- ual limb may further improve signal impaired renal function, arterial hypo- ulous attention to surgical technical quality and interpretation of upper tension, and/or lymphoproliferative dis- details and familiarity with residual limb amputees, thus improving pros- orders. However, early results in a small limb options are crucial to achieving thesis responsiveness and function number of patients (approximately 100 the desired outcome.

References Principles and Practice. Philadelphia, PA, 23. Hagberg E, Berlin OK, Renström P: Lippincott-Raven, 1998, pp 1517-1544. Function after through-knee com- 1. Atasoy E, Ioakimidis E, Kasdan ML, pared with below-knee and above- Kutz JE, Kleinert HE: Reconstruc- 13. Bohne WHO, Ertl JP: Amputations of knee amputation. Prosthet Orthot Int tion of the amputated fi nger tip with a the lower extremity, in Chapman MW, 1992;16(3):168-173. triangular volar fl ap: A new surgi- ed: Chapman’s Orthopaedic Surgery, ed 3. cal procedure. J Bone Joint Surg Am Philadelphia, PA, Lippincott Williams 24. Borggreve J: Kniegelenksersatz durch 1970;52(5):921-926. & Wilkins, 2001, pp 3149-3173. das in der Beinlängsachse um 180 gedrehte Fussgelenk. Arch Orthop 2. Steichen JB, Idler RS: Results of 14. Smith DG, McFarland LV, Sangeor- Unfallchir 1930;28:175-178. central ray resection without bony zan BJ, Reiber GE, Czerniecki JM: transposition. J Hand Surg Am Postoperative dressing and manage- 25. Van Nes CP: Rotation-plasty for 1986;11(4):466-474. ment strategies for transtibial ampu- congenital defects of the femur: tations: A critical review. J Rehabil Res Making use of the ankle of the short- 3. Peimer CA, Wheeler DR, Barrett A, Dev 2003;40(3):213-224. ened limb to control the knee joint Goldschmidt PG: Hand function fol- of the prosthesis. J Bone Joint Surg Br lowing single ray amputation. J Hand 15. Enneking WF, Dunham WK: 1950;32(1):12-16. Surg Am 1999;24(6):1245-1248. Resection and reconstruction for primary neoplasms involving the 26. Hillmann A, Rosenbaum D, 4. Puhaindran ME, Athanasian EA: innominate bone. J Bone Joint Surg Am Gosheger G, Hoffmann C, Rödl R, Double ray amputation for tumors 1978;60(6):731-746. Winkelmann W: Rotationplasty type B of the hand. Clin Orthop Relat Res IIIa according to Winkelmann: Elec- 2010;468(11):2976-2979. 16. Won H, Maley P, Salim S, Rao A, tromyography and gait analysis. Clin Campbell NT, Abbott JA: Surgical Orthop Relat Res 2001;384:224-231. 5. Puhaindran ME, Healey JH, Atha- and patient outcomes using me- nasian EA: Single ray amputation for chanical bowel preparation before 27. Clerici CA, Ferrari A, Luksch R, tumors of the hand. Clin Orthop Relat laparoscopic gynecologic surgery: A et al: Clinical experience with psycho- Res 2010;468(5):1390-1395. randomized controlled trial. Obstet logical aspects in pediatric patients 6. Puhaindran ME, Rothrock CP, Atha- Gynecol 2013;121(3):538-546. amputated for malignancies. Tumori 2004;90(4):399-404. nasian EA: Surgical management for 17. Nowroozi F, Salvanelli ML, Ger- malignant tumors of the thumb. Hand ber LH: Energy expenditure in hip 28. Wallace GF, Stapleton JJ: Transmeta- (N Y) 2011;6(4):373-377. disarticulation and hemipelvectomy tarsal amputations. Clin Podiatr Med 7. Puhaindran ME, Chou J, Forsberg amputees. Arch Phys Med Rehabil Surg 2005;22(3):365-384. 1983;64(7):300-303. JA, Athanasian EA: Major upper-limb 29. Tintle SM, Keeling JJ, Shawen SB, amputations for malignant tumors. J 18. Vancabeke M, Harper L, Penders Forsberg JA, Potter BK: Traumatic Hand Surg Am 2012;37(6):1235-1241. W, Putz P: Anterior fl ap for cov- and trauma-related amputations: Part 8. Sakamura R, Nohira K, Shibata erage following hip disarticulation I. General principles and lower- M, Sugihara T: Coverage of a large for osteomyelitis. Acta Orthop Belg extremity amputations. J Bone Joint Surg soft-tissue defect of the chest with 1999;65(2):223-225. Am 2010;92(17):2852-2868. a free fi llet forearm and hand fl ap. J 19. Batch JW, Spittler AW, McFaddin JG: 30. Gottschalk F: Transfemoral amputa- Reconstr Microsurg 2001;17(4):229-231. Advantages of the knee disarticulation tion: Biomechanics and surgery. Clin 9. Bodily KC, Burgess EM: Contra- over amputations through the thigh. J Orthop Relat Res 1999;361:15-22. Bone Joint Surg Am 1954;36(5):921-930. lateral limb and patient survival 31. Pinzur MS, Gottschalk F, Pinto MA, after leg amputation. Am J Surg 20. Waters RL, Perry J, Antonelli D, Smith DG: Controversies in lower 1983;146(2):280-282. Hislop H: Energy cost of walking extremity amputation. Instr Course Lect 10. Ziegler-Graham K, MacKenzie EJ, of amputees: The infl uence of level 2008;57:663-672. Ephraim PL, Travison TG, Brook- of amputation. J Bone Joint Surg Am 1976;58(1):42-46. 32. Smith DG, Fergason JR: Transtibial meyer R: Estimating the prevalence amputations. Clin Orthop Relat Res of limb loss in the United States: 21. Torburn L, Schweiger GP, Perry J, 1999;361:108-115. 2005 to 2050. Arch Phys Med Rehabil Powers CM: Below-knee amputee gait 2008;89(3):422-429. in stair ambulation: A comparison of 33. Anderson WD, Stewart KJ, Wilson stride characteristics using fi ve differ- Y, Quaba AA: Skin grafts for the 11. Mazet R Jr: The geriatric amputee. salvage of degloved below-knee Artif Limbs 1967;11(2):33-41. ent prosthetic feet. Clin Orthop Relat Res 1994;303:185-192. amputation stumps. Br J Plast Surg 12. Pandian G, Hamid F, Hammond 2002;55(4):320-323. 22. Chiodo CP, Stroud CC: Optimal MC: Rehabilitation of the patient 34. Polfer EM, Tintle SM, Forsberg with peripheral vascular disease and surgical preparation of the residual limb for prosthetic fi tting in JA, Potter BK: Split-thickness skin diabetic foot problems, in DeLisa JA, grafts for residual limb coverage and Gans BM, eds: Rehabilitation Medicine: below-knee amputations. Foot Ankle Clin 2001;6(2):253-264. preservation of amputation length. American Academy of Orthopaedic

Surgeons 2014 Poster Presentation of myoelectric and body pow- Kingdom experience. Prosthet Orthot Abstract. Available at: http://www. ered prostheses while performing Int 2003;27(2):114-120. abstractsonline.com/plan/ViewAb- common activities. Prosthet Orthot Int stract.aspx? Accessed May 20, 2014. 2009;33(2):179-186. 51. Kuiken TA, Dumanian GA, Lip- schutz RD, Miller LA, Stubblefi eld 35. Harris AM, Althausen PL, Kel- 43. Kyberd PJ, Chappell PH: The South- KA: The use of targeted muscle lam J, Bosse MJ, Castillo R; Lower ampton Hand: An intelligent myo- reinnervation for improved myo- Extremity Assessment Project electric prosthesis. J Rehabil Res Dev electric prosthesis control in a bilateral (LEAP) Study Group: Complications 1994;31(4):326-334. shoulder disarticulation amputee. following limb-threatening lower Prosthet Orthot Int 2004;28(3):245-253. extremity trauma. J Orthop Trauma 44. Dale B, Olson MD, Larntz K: 52. Kuiken TA, Li G, Lock BA, et al: 2009;23(1):1-6. Perceived stability, function, and satisfaction among transfemoral Targeted muscle reinnervation for 36. Pierce RO Jr, Kernek CB, Ambrose amputees using microprocessor and real-time myoelectric control of TA II: The plight of the traumatic am- nonmicroprocessor prosthetic knees: multifunction artifi cial arms. JAMA putee. Orthopedics 1993;16(7):793-797. A multicenter survey. J Prosthet Orthot 2009;301(6):619-628. 2009;21(1):32-42. 37. Tintle SM, Keeling JJ, Forsberg JA, 53. Dumanian GA, Ko JH, O’Shaugh- Shawen SB, Andersen RC, Potter BK: 45. Wong CK, Benoy S, Blackwell W, nessy KD, Kim PS, Wilson CJ, Kui- Operative complications of combat- Jones S, Rahal R: A comparison of ken TA: Targeted reinnervation for related transtibial amputations: A energy expenditure in people with transhumeral amputees: Current sur- comparison of the modifi ed burgess transfemoral amputation using mi- gical technique and update on results. and modifi ed Ertl tibiofi bular synos- croprocessor and non-microprocessor Plast Reconstr Surg 2009;124(3):863-869. tosis techniques. J Bone Joint Surg Am prostheses: A systematic review. J 54. Parker P, Englehart K, Hudgins 2011;93(11):1016-1021. Prosth Orthot 2012;24(4):202-208. B: Myoelectric signal process- 38. Tintle SM, Baechler MF, Nanos GP, 46. Aldridge JM, Sturdy JT, Wilken JM: ing for control of powered limb Forsberg JA, Potter BK: Reoperations Stair ascent kinematics and kinetics prostheses. J Electromyogr Kinesiol following combat-related upper- with a powered lower leg system 2006;16(6):541-548. extremity amputations. J Bone Joint Surg following transtibial amputation. Gait 55. Tintle SM, Baechler MF, Nanos GP Am 2012;94(16):e1191-e1196. Posture 2012;36(2):291-295. III, Forsberg JA, Potter BK: Trau- 39. Potter BK, Burns TC, Lacap AP, 47. Aschoff HH, Kennon RE, Keggi JM, matic and trauma-related amputa- Granville RR, Gajewski DA: Hetero- Rubin LE: Transcutaneous, distal tions: Part II. Upper extremity and topic ossifi cation following traumatic femoral, intramedullary attachment future directions. J Bone Joint Surg Am and combat-related amputations: for above-the-knee prostheses: An 2010;92(18):2934-2945. Prevalence, risk factors, and prelim- endo-exo device. J Bone Joint Surg Am 56. Brandacher G, Ninkovic M, inary results of excision. J Bone Joint 2010;92(suppl 2):180-186. Piza-Katzer H, et al: The Innsbruck Surg Am 2007;89(3):476-486. 48. Hagberg K, Brånemark R: One hand transplant program: Update at 8 40. Harvey ZT, Potter BK, Vandersea J, hundred patients treated with osse- years after the fi rst transplant. Trans- Wolf E: Prosthetic advances. J Surg ointegrated transfemoral amputation plant Proc 2009;41(2):491-494. Orthop Adv 2012;21(1):58-64. prostheses: Rehabilitation perspective. 57. Lanzetta M, Petruzzo P, Dubernard J Rehabil Res Dev 2009;46(3):331-344. 41. Brenner CD: Wrist disarticulation and JM, et al: Second report (1998-2006) transradial amputation: Prosthetic 49. Hagberg K, Häggström E, Uden of the International Registry of Hand management, in Smith DG, Michael M, Brånemark R: Socket versus and Composite Tissue Transplanta- JW, Bowker JH, eds: Atlas of Ampu- bone- anchored trans-femoral pros- tion. Transpl Immunol 2007;18(1):1-6. tations and Limb Defi ciencies: Surgical, theses: Hip range of motion and 58. Petruzzo P, Lanzetta M, Duber- Prosthetic, and Rehabilitation Principles, sitting comfort. Prosthet Orthot Int nard JM, et al: The international ed 3. Rosemont, IL, American Acad- 2005;29(2):153-163. registry on hand and composite emy of Orthopaedic Surgeons, 2004, tissue transplantation. Transplantation pp 223-230. 50. Sullivan J, Uden M, Robinson KP, Sooriakumaran S: Rehabilitation of 2008;86(4):487-492. 42. Carey SL, Dubey RV, Bauer GS, the trans-femoral amputee with an os- Highsmith MJ: Kinematic comparison seointegrated prosthesis: The United