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June 2005
Introduction
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he feet and toes are surely among the most abused and
least appreciated regions of the human anatomy. There
are few structures in the body, indeed, even fewer man-made
devices or appliances, that are subjected to such intense repetitive, relentless punishment in such an unforgiving environment, yet expected to perform without flaws. Though not
the only animal species capable of mobility on two feet, the
human is, nonetheless, the only species that is exclusively
bipedal and cannot fly. With human girth and mass showing
unprecedented increases of heretofore unimagined demographic proportions, it appears that the human foot will be
tested in the future more than it has ever been tested in the
past.
Only those with bad feet can truly appreciate the bliss of
having good feet. Yet bad feet and good feet alike are seldom
afforded the attention and respect that should be their due.
The good foot is expected to support a mass 200 to 300 times
its own, on a surface area no more than 1% of the body as a
whole, with such assumed performance and durability that
its owner will likely give it no conscious regard. The bad foot
is expected to heal quickly and completely, and preferably
while still in use. The inconvenience of a bad foot is one
which most persons tolerate poorly and with great impatience. But rather than inspiring awe and reverence for the
miracles that the foot routinely performs, such temporary
disabilities more often provoke vexation and resentment at
the unwelcome interruption of mobility. So the host forces
his foot to function while dysfunctional, to heal while unhealthy, and to again withstand the trauma and neglect that
caused the original problem. It is the fate of the feet and toes
to be taken for granted until catastrophe ensues, and even
beyond.
Advances in modern podiatry, plastic surgery, orthopedics, and vascular surgery offer hope and relief for the myriad
problems that beset the modern foot. Most such problems
can either be prevented, or alleviated with orthotic appliances, or corrected with relatively minor surgery. Indeed,
many body parts, including the hips and knees, are ultimately more likely than the foot to fail and require major
surgery. Unlike those structures, however, the foot cannot be
62
Local Factors
Numerous inherent characteristics of the foot itself are responsible for its vulnerability to injury and infection. The
very purposes of the foot are to bear the weight of the body
and provide mobility, and the design of the foot is specific for
those purposes. The bony architecture provides surfaces that
tolerate high pressures by spreading them over as much area
as possible, while allowing the flexibility needed for all varieties of locomotion. Some loss of that architecture can be
tolerated, but more so on the dorsal surface than the plantar.
Deformities that cause pressure points on the plantar surface
are the cause of much dysfunction, disability, and limb loss.
On the dorsal surface, weight bearing is less of an issue, but
an equally serious problem is the thinness of the skin and soft
tissue and relative lack of protection of the underlying tendons, muscles, and joints. Full-thickness skin loss on the
dorsal surface can result in exposure and dessication of the
underlying fascia and tendons, often with few reconstructive
63
Systemic Factors
General Principles
of Amputation
R.G. Atnip
64
not feasible. Amputation is usually an elective procedure, but
may become urgent in cases of aggressive local sepsis, especially if accompanied by systemic toxicity. In such cases, the
patient may require open or guillotine amputation to limit
the spread of infection or to avert life-threatening sepsis. The
level and extent of amputation in these circumstances will be
dictated by both local and systemic factors, but must be chosen to ensure swift and effective reversal of the septic process.
Thorough drainage of deep space infections and debridement of wet gangrene are essential to halt propagation of the
infection. Aggressive initial surgery in these patients will usually preserve ultimate limb length and function rather than
compromise them.
In the more typical elective amputation, the surgeons goal
is to select the level of amputation that will optimize both
healing and function, with the recognition that in most cases,
these dual requirements are at cross purposes. In the presence of normal perfusion to the foot, the patient will, as a
rule, obtain optimal function from an amputation that spares
as much length and tissue as is technically possible. Contrariwise, in the face of trauma, ischemia, or any other circumstance that compromises tissue perfusion, the surgeon must
face a fundamental dilemma: the chance of healing and the
chance of function vary inversely with one another. Perfusion
and healing improve with higher amputations, while function will steadily decline. In each such patient, therefore, the
surgeon will need to carefully analyze the arterial flow to the
limb, optimize it however possible, and then essentially prioritize between function and healing. Factors to be considered in this process include a detailed knowledge of the patients psychosocial history, past and current functional
status, general medical condition, rehabilitation potential,
and an objective assessment of the healing potential of the
selected amputation level(s).
Much has been written about choice of amputation level,
but as yet, no specific tool or technology has proven any more
accurate than the combination of physical examination and
bedside Doppler. Basic surgical principles dictate that amputations are not likely to heal if performed through or near
zones of active cellulitis, suppuration, severe ischemia, or
frank necrosis. The severity of all these conditions can typically be determined by careful physical examination. In the
case of ischemia, however, additional useful information can
be obtained with a portable continuous-wave Doppler, supplemented if necessary by simple noninvasive testing, such as
photoplethysmography (PPG) and transcutaneous oximetry
(TCpO2). Other more sophisticated studies such as laser
Doppler velocimetry and Xenon perfusion are much less
widely used, and do not appear to offer any greater accuracy
of prediction.3
Bedside doppler examination includes quantitative (ankle
systolic pressure, ASP) and qualitative (signal quality) information, which both complement and objectify the basic palpation of femoral, popliteal, and pedal pulses. A manual
pulse examination is essential, and can be surprisingly accurate in predicting healing. At any chosen level, the presence
of a palpable pulse at the nearest proximal joint is associated
with healing rates of 90% or higher, whereas those rates drop
significantly if pulses are palpable only at two or more joints
removed from the selected site. Studies have differed as to the
exact relationship between ankle pressure (or ankle-brachial
Soft Tissue
The single most important technical aspect of amputation (at
any level) is careful handling of tissue. Even the ablative
Bone
The steps of dividing and shaping the bones must be handled
differently in each amputation, but some general concepts
apply. Bones should be transected through the shaft, and
amputations through joints should generally be avoided. Articular cartilage receives its oxygen and nutrient supply from
the synovial fluid, and is at high risk for necrosis if the articular surface is left intact within an amputation wound. Although this particular problem can be averted by removing
the exposed cartilage, an equally significant problem is that
bony articular prominences generally do not make good amputation stumps.
Bones should be methodically stripped of their periosteum, and then transected cleanly with minimal splintering
and fragmentation. Any bone fragements and splinters must
be removed from the wound. Bone edges should be meticulously smoothed, especially in those areas that will lie closest
to the skin. In some cases, beveling of the bone stump is
advisable to avoid sharp edges and pressure points, such as
on the plantar surface of the foot. At every step, the surgeon
must be aware that orthopedic instruments (saws, drills, osteotomes, rongeurs, etc.) have great capacity to damage adjacent soft tissues if used carelessly.
Wound Closure
The meticulous technique employed in the performance of
an amputation must be carried through to placement of the
very last suture. Whether due to trauma, ischemia, local infection and inflammation, age, or other factors, the skin of an
amputation stump is seldom normal and healthy. Yet, the
success of the entire procedure often depends on that skins
ability to heal. Careless and indiscriminate handling of the
65
skin and soft tissues during closure can easily cause an otherwise successful amputation to fail.
The skin is, in fact, often the only tissue layer that can be
readily closed. When a digit or some part of the foot has been
amputated, the surgeon is typically confronted with one or
more bone stumps surrounded by transected joint capsule,
tendons, fascia, muscle, and subcutaneous fat. Depending on
the length of bone stump available, it may be possible to
recess the stump deep enough to allow separate closure of the
fascia or muscle over the bone. The advantages of deep closure coverage of bone and elimination of dead spaceare
substantial. Not infrequently, however, the level of resection
is such that the surgeon must be satisfied with a single layer
skin closure, trusting that the deeper tissues will be coapted
by default.
Specific techniques for closure of the skin vary widely and
are largely the province of personal preference. The author
finds much to recommend in an interrupted nylon, either
simple or vertical mattress, placed without use of forceps and
reinforced by fine Steri-strips. Subcuticular closure or skin
staples are popular in some quarters, although these methods
require more handling of the skin. Whatever method is used,
the goal should be precise alignment and apposition of skin
edges to create the best opportunity for primary healing.
Failure of the skin and subcutaneous tissues to heal primarily
is an ominous development, usually resulting in wound dehiscence and portending greater tissue loss.
The need may occasionally arise to place a wound drain in
an amputation stump, but only if clearly indicated. Standard
measures should be employed to obtain hemostasis, including direct pressure, judicious use of the electrocautery, topical use of local anesthetics containing dilute epinephrine, and
of course ligation of vessels. Even oozing wounds will usually
stop bleeding on re-approximation and closure of the tissues,
particularly if a bulky dressing is applied for added tamponade. If a drain is necessary, it should be inserted through a
separate stab wound, not through the suture line of the
stump; it should be positioned to drain dependently, and
should be removed within 48 hours. Suction drains are preferred to passive drains. A temporary vacuum dressing with
delayed primary closure may be considered in some circumstances.
Dressings
The dressing of amputation stumps is often a matter of religion more than science. Practitioners adopt their favorite
dressings through training and experience, and then adhere
to them fervently. Dressings can be soft or rigid, small or
large, occlusive or open. A good dressing will pad and protect
the stump, inhibit seromas and hematomas, absorb drainage,
immobilize joints, serve as a barrier to contamination, and in
all these ways, generally promote healing. Any given type of
dressing can succeed or fail to accomplish these goals depending on how it is applied. The most common and costly
error in dressing technique is to wrap the dressing too tightly,
resulting in pressure necrosis of the stump or adjacent areas,
which at best will delay healing, and at worst may require
re-amputation. Areas at risk for this complication include the
dorsum of the foot, the malleoli, the heel, and the patella.
Preventive measures include proper technique in applying
R.G. Atnip
66
the dressing, and early frequent dressing changes with skin
inspection, especially if the patient complains of more pain
than expected.
Open amputation stumps are generally handled differently
from closed stumps, with great variation in individual practice. The method chosen may depend on whether the surgeons intention is for early revision, delayed primary closure,
or secondary closure. The use of vacuum-assisted closure
techniques has become increasingly popular.
Postoperative Activity
Postoperative care routines are, again, very surgeon- and amputation-specific. Patient positioning, allowed activity, commencement of physical therapy and weight bearing, use of
antibiotics, and prophylaxis of deep vein thrombosis are all
matters of surgical judgment. A solemn reminder for all caregivers is that patients undergoing limb amputation are
known to be at high risk for eventual loss of the contralateral
limb due to the same factors that caused ipsilateral disease. Of
these factors, one is nosocomial, insidious, and completely
preventable: the calcaneal decubitus ulcer. It is thus imperative that patients who are at bedrest following amputation,
References
1. Esquenazi A: Amputation rehabilitation and prosthetic restoration.
From surgery to community reintegration. Disabil Rehabil 26:831-836,
2004
2. Persson B: Lower limb amputation. Part 1: Amputation methodsa 10
year literature review. Prosthet Orthot Int 25:7-13, 2001
3. Smith DG: Amputation. Preoperative assessment and lower extremity
surgical techniques. Foot and Ankle Clinics 6:271-296, 2001
4. Sachs M, Bojunga J, Encke A: Historical evolution of limb amputation.
World J Surg 23:1088-1093, 1999
to preserving the normal architecture. Multiple ligaments including the large plantar fascia are essential to create and
maintain joint stability.
Sensory innervation is supplied by five nerves: the superficial peroneal for the dorsal surface; the deep peroneal for a
very small area of the first web space; the sural for the posterior and lateral areas; the saphenous for the medial aspect;
and the posterior tibial for the plantar surface. Of these
nerves, only the posterior tibial is crucial for normal function,
as it provides protective sensation on the weight-bearing surface.
Arterial supply derives from the posterior tibial artery, the
dorsalis pedis (a continuation of the anterior tibial), and the
peroneal artery. The latter vessel ends in smaller branches at
the ankle, but the two tibial vessels extend into the foot to
form the plantar arches and directly nourish the forefoot and
toes. Each toe has medial and lateral digital arteries and
nerves.
Phalangeal Amputation
The hallux has two phalanges, and the other four digits have
three, with the distal phalanx being the smallest. Beyond this
simple anatomic difference, the hallux overshadows the
other digits in functional importance by virtue of its roles in
balance of the forefoot and in push-off during ambulation.
Although the second toe can adapt to some extent in the
absence of the great toe, patients who have lost the hallux
invariably notice a substantial difference in the mechanics of
walking, especially after transmetatarsal amputation. Amputations of the great toe should be performed for only the
strictest and most carefully considered indications.
Although amputation of only the distal part of a toe is
technically possible, there is little functional advantage to
having half or two-thirds of a toe, even the great toe. Certainly
in any situation where perfusion is abnormal, digital amputations are best performed through the base of the proximal
phalanx, leaving a relatively short stump with a better likelihood of healing.
Digital amputations are typically performed with a fishmouth technique, which is preferred to a circular incision in
all cases intended for primary closure. Since the vessels
course along the medial and lateral aspects of the toe, it is
sensible to orient the fishmouth in the anterior-posterior
(dorsal-plantar) direction, so that the bases of the flaps are
medial and lateral, including the digital vessels. Nonetheless,
many surgeons obtain equally good results from the use of a
67
R.G. Atnip
68
Transmetatarsal
Amputation (TMA)
This procedure consists of amputation of one or more toes
along with a portion of the corresponding metatarsal bone(s).
The success of the procedure depends heavily on the health
and integrity of the plantar skin and soft tissues that will
provide coverage of the bone stump and ultimately form the
weight bearing surface. Transmetatarsal amputation is a very
useful and effective method for treating ischemic necrosis of
the forefoot, and often represents the patients last hope for
salvage of a functional foot. In cases where the plantar tissues
Figure 1 The skeleton of the foot, showing the level of bony transection for each of the four standard toe or partial foot amputations.
Creation of the soft-tissue flaps for each of these procedures is described in more detail in the text.
69
R.G. Atnip
70
head from the joint capsule (while not entering the adjacent
joints), stripping and resecting the desired length of shaft,
and excising the remnants of joint capsule before closing. The
essentially fixed position of the adjacent metatarsal rays can
make it rather difficult to close an inner-toe TMA without
skin tension. The foot can be wrapped to compress the metatarsals and reduce tension on the suture line, but only if
precautions are taken to avoid pressure ulceration from the
bandage itself.
Multiple TMA
Although in theory any combination of toes could be amputated at the TMA level, such a decision should take into
account the relative importance of the various toes in the
stability of the foot and the mechanics of walking. Significant
stability and function are lost with amputation of the great
toe, especially at the TMA level, and the loss is even greater if
the second toe is also taken. To perform TMA of the first three
toes would likely be a disservice to the patient, leaving him/
71
her with a narrow, tapered, and dysfunctional forefoot. Similarly, the more toes removed from the lateral aspect of the
foot, the greater the asymmetry and imbalance of forces on
the remaining rays.
The technique for multiple TMA is a simple modification
of that for first or fifth ray amputation. An ellipitical incision
is created to encompass the base of the affected toes, modified
as needed to incorporate any areas of dorsal or plantar necrosis. The racket handle then extends along the outer aspect of
the metatarsal shaft. Flaps are created in identical fashion to
standard TMA. The MTP joints are disarticulated, the metatarsal shafts amputated, recessed, and beveled appropriately.
The flaps are then sculpted and closed without tension.
Although preservation of the medial toes is more advantageous than saving the lateral toes, it is questionable whether
TMA of more than two adjacent rays should ever be performed. In patients with diabetic or other polyneuropathies,
amputations that create gross asymmetry of the forefoot are
associated with a notoriously high incidence of subsequent
breakdown and re-amputation. As a general rule, balance,
function, and stump integrity will be better with a complete
(full-foot) transmetatarsal amputation.
Full-Foot TMA
Amputation of the entire forefoot at the transmetatarsal level
is one of the most useful procedures in the surgical armamentarium. When properly performed, full-foot TMA results in a
symmetric stump with favorable weight distribution. Although there is no question that patients with TMA must
learn to adapt their balance, gait, and stride after loss of the
forefoot, most patients will be able to walk, either independently or with simple supportive devices. Foot orthoses or
custom shoes can be useful to facilitate walking, but prostheses are not necessary.
If the plantar tissues are intact, the plantar incision for
TMA crosses the foot as close to the base of the toes as possible. The dorsal incision is made across the mid- to distal
level of the metatarsal shafts, as dictated by the pattern of
forefoot necrosis (Fig. 6). The dorsal and plantar incisions are
then connected by axial incisions made along the shafts of the
first and fifth metatarsals. The result will be a plantar flap of
variable length. In developing the plantar flap, the incision
should be carried down to the MTP joints, which should all
then be disarticulated. This allows the surgeon to find the
proper plane along the plantar surface of the metatarsal head
and shaft. From the plantar approach, the metatarsal shafts
angle toward the dorsum of the foot as they traverse proximally, and it is imperative that the surgeon adhere closely to
the shafts to preserve the muscles and vessels of the plantar
flap.
The dorsal incision is carried directly down through the
soft tissues, extensor tendons, and dorsal vessels to the anterior surface of the metatarsal shafts. At the desired level, these
shafts are stripped of periosteum and divided with bone cutter or rongeur. Working simultaneously from the plantar
surface, the interosseus muscles are divided along with any
remaining ligaments and tendons, and the specimen removed. The metatarsal stumps should be recessed and beveled, shorter on the plantar aspect.
Remaining on the plantar flap at this point will be the
72
R.G. Atnip
Figure 7 Closure of the transmetatarsal amputation with simple interrupted sutures. The metatarsal shafts
have been cut with a posterior bevel,
essentially flush with the dorsal incision. The plantar flap has been
sculpted to approximate the dorsal
tissue without tension or redundancy.
Midfoot Amputations
(Lisfranc and Chopart)
These two surgical procedures were introduced by French
surgeons in the 19th century, and they were supposedly first
Conclusions
Locomotion is a fundamental human activity made possible
by the structure and function of the foot. Most humans consider the potential loss of part or all of the foot as catastrophic,
and view amputation as a disfiguring and destructive procedure. Yet due to either trauma or disease, as many as 150,000
patients per year are confronted with the necessity for amputation surgery, virtually always with no realistic alternative.
For these patients, properly performed amputation surgery is
a reconstructive procedure that rehabilitates and restores quality of life, albeit, a different life than the patient might desire.
Although many patients have such advanced disease that loss
of the entire foot is inevitable, for some the goal of partial foot
salvage is achievable. This chapter has described a variety of
procedures that preserve structure and function of the foot
sufficient to enable ambulation without a limb prosthesis. To
achieve the best results for each patient, the surgeon perform-
73
ing amputations must approach each procedure with the
finest exacting technique and attention to detail worthy of the
craft.
Suggested Reading
Attinger C, Cooper P, Blume P, Bulan E: The safest surgical incisions and
amputations applying the angiosome priciples and using the Doppler to
assess the arterial-arterial connections of the foot and ankle. Foot and
Ankle Clinics 6:745-799, 2001
Crinnion J, Hicks D: Transmetatarsal amputation: an 8-year experience. Ann
R Coll Surg Engl 84:291-295, 2002
Funk C, Young G: Subtotal pedal amputations. Biomechanical and intraoperative considerations. J Am Podiatr Med Assoc 91:6-12, 2001
Pinzur MS, Pinto MA, Schon LC, Smith DG: Controversies in amputation
surgery. Instr Course Lect 52:445-451, 2003
Rumenapf G: Borderline amputations in diabetics open questions and
critical evaluation. Zentralblatt fr Chirurgie 128:726-733, 2003
Sanders LJ: Transmetatarsal and midfoot amputations. Clin Podiatr Med
Surg 14:741-762, 1997
Smith DG: Principles of partial foot amputations in the diabetic. Instr Course
Lect 48:321-329, 1999
Indications
One of the most important requirements for a positive outcome when performing Syme amputation is patient selection.
The principal indications are congenital deformity of the foot
and traumatic foot injuries in which a viable heel pad remains. It can also be performed in patients with peripheral
vascular disease and diabetic infections of the forefoot. A
74
two-stage procedure is recommended in these patients. During the first stage, the ankle joint is disarticulated, followed
six to eight weeks later by osteotomies of the malleoli. A
palpable posterior tibial artery pulse is considered essential
for healing following Syme amputation. In the presence of
vascular insufficiency, patient selection can be further refined
by Doppler studies and transcutaneous PO2 measurements.
An ankle-brachial index of 0.35 to 0.4 or an absolute Doppler
value of 40 to 70 mm of Hg is often quoted as critical to
wound healing.5 An absolute reliance cannot be placed on
these tests, as factors determining the ideal level of amputation in vascular patients are many and complex. Syme amputation should not be performed in the presence of ulceration
involving the heel pad, or when the viability of heel pad is
questionable. Although an insensate stump is generally considered a contraindication, Srinivasan reported good results
in twenty Syme amputations in patients with anesthetic
stumps.6 Gaine and McCreath also reported no problems in
three patients with neuropathic stumps in a review of fortysix cases of Syme amputation.7
Technical Principles
There are several important principles that must be observed
during the procedure to achieve successful outcome. These
were emphasized in the initial report by Syme and later by
Harris.1,2 The posterior tibial artery must be preserved as it
provides the blood supply to the heel flap. It is at risk during
the division of medial ligaments and malleolar transaction.
The heel pad must be dissected subperiosteally from the calcaneum. This ensures that the septae that run from the plantar aponeurosis to the periosteum of the calcaneum remain
intact. These tight compartments contain adipose tissue that
provides resilience and hydraulic resistance to the deforming
forces of weight bearing. If the loculi are opened, the fat is
extruded by pressure because they are no longer closed
spaces. Subperiostal dissection also protects the calcaneal
branches of the posterior tibial artery from injury. The heel
flap lined with periosteum adheres to the cut surface of tibia
more firmly and may allow new bone formation to ensure
firm fixation of the heel flap. The heel flap will contain the
origins of short muscles of the foot. Excessive debridement of
the heel flap should be avoided, as this can lead to damage to
the plantar aponeurosis. Overzealous trimming of the corners of the flap (dog ears) must be avoided, as it may compromise the viability of heel flap. The heel flap must be firmly
secured to the tibia.
75
Operative Technique
Single-Stage Syme Amputation
After appropriate preparation and isolation of any forefoot
infective process, the incision is placed as follows. It begins at
the distal tip of the lateral malleolus and passes along the
anterior aspect of the ankle joint at a point one-finger breadth
inferior to the tip of the medial malleolus. The incision is then
extended across the sole of the foot to the lateral aspect,
ending at the lateral starting point (Fig. 1). All the soft tissues
are transected down to the bone.
The foot is then plantar flexed. The tendons crossing the
ankle joint are sharply divided. Anterior tibial artery is ligated
and anterior capsule of the ankle joint is divided (Fig. 2). The
knife is then inserted into the joint space between the medial
malleolus and talus and the deltoid ligament is divided taking
care to avoid injury to posterior tibial artery. The clacaneofibular ligament on the lateral aspect of the joint is sectioned
in a similar maneuver. A bone hook is placed on the posterior
surface of the talus and foot is further plantar flexed. The
posterior capsule of the ankle joint is then divided. This
brings the superior surface of calcaneus into view. Now begins the painstaking subperiostal dissection of calcaneus. The
dissection is continued posteriorly along the superior surface
of the calcaneus (Fig. 3). Tendo-Achilles is identified at this
stage and divided. The skin in this area is densely adherent to
calcaneum and care must be taken to avoid buttonholing.
Using a periosteal elevator or several sharp knives, the soft
tissues are separated from the medial and lateral surfaces of
the calcaneum. The foot is plantar flexed even more and the
dissection is continued along the inferior surface of the calcaneus to the end of the plantar flap. The entire foot with the
exception of heel pad is then removed from the field. The
S. Sajja
76
Figure 2 The soft tissues are transected down to the bone. Foot is then plantar flexed and the tendons crossing the ankle
joint are sharply divided.
Figure 3 Subperiosteal dissection of the calcaneus is the most pain staking part of the procedure. This is best performed
with a sharp knife.
77
S. Sajja
78
Figure 4 The periosteum is divided one-half centimeter proximal to the joint line so that the line of bone division is
through the superior most part of the articular surface of tibia. This osteotomy should be performed so that the cut
surface will be parallel to the ground when the patient is standing.
Figure 5 To prevent heel pad migration over the cut surface of the tibia, holes are drilled in the anterior edge of tibia and
fibula and plantar fascia is sutured to the bone. A suction drain is recommended and is brought out through a separate
stab incision in the distal third of the leg. The skin of the heel pad is then sutured to the skin of the anterior flap using
nonabsorbable sutures.
79
80
S. Sajja
81
ing ambulation is to be instituted, an ambulatory cast should
be constructed by an expert prosthetist.
Conclusion
This chapter has discussed the historical aspects of and indications for Syme amputation. Particular emphasis is placed on the
technical aspects of the one-stage and two-stage Syme amputation. The surgical principles essential for a successful outcome
are outlined. While the role of Syme amputation is well established in congenital foot deformities and traumatic injuries of
the foot, with appropriate patient selection utilizing segmental
limb perfusion pressures and transcutaneous PO2 measurements, satisfactory results can also be obtained in patients with
vascular insufficiency and diabetic foot infections.
References
1. Syme J: Amputation at the ankle joint. Lond Edinb Month J Med Sci
3:93-96, 1873
2. Harris RI: Symes amputation; technical details essential for success.
J Bone Joint Surg [Br] 38:614-632, 1956
3. Wagner FW Jr: Amputations of the foot and ankle: current status. Clin
Orthop 122:62-69, 1977
4. Saramiento A: A modified surgical-prosthetic approach to the Symes
amputation: a follow-up report. Clin Orthop 85:11-15, 1972
5. Burgess EM: Amputations. Surg Clin North Am 63:749-770, 1983
6. Srinivasan H: Symes amputation in insensitive feet: a review of twenty
cases. J Bone Jont Surg [Am] 55-A:558-562, 1973
7. Gaine WJ, McCreath SW: Symes amputation revisited: a review of 46
cases. J Bone Joint Surg [Br] 78-B:461-467, 1996
elow knee amputation (BKA) is the most commonly performed major limb amputation. With proper patient selection, primary healing can be expected in more than 90% of
patients following BKA.1 Similarly, nearly 90% of patients
with BKA have a realistic chance to ambulate with a prosthesis, compared with only 25% of patients with above knee
amputation.2 The advantages of BKA accrue primarily from
the many benefits of preserving the patients own knee joint.
Indications and
Contraindications
BKA is indicated in patients who have infection, gangrene,
nonhealing ulcers, or severe trauma of an extent that precludes salvage of a functional foot by any of the methods
discussed in prior chapters. It is also indicated in patients
with severe peripheral vascular disease who have failed arterial reconstruction or have presented with unreconstructible
disease and intractable rest pain. BKA is also sometimes performed for cure or palliation of neoplastic disease, or for limb
deformities that impair overall functional status.
BKA is the procedure of choice for patients meeting the
above indications and having a good prognosis for healing
and prosthetic ambulation. BKA (rather than AKA) can be
considered in nonambulatory patients if there is a reasonable
expectation that preservation of the knee joint would improve functional status (for example, by providing better balance and ability to transfer). In chronically ill, debilitated,
and/or institutionalized patients, BKA often leads to flexion
contractures of the knee, which in turn impair sitting and
transfer, and predispose to pressure ulceration. Similarly,
BKA should not be performed in patients with preexisting
flexion contracture of the knee exceeding 15. It is also contraindicated in the presence of anything more than minor
ulceration or skin necrosis proximal to the ankle joint. Spastic and rigid lower extremity following a stroke is also a
contraindication for BKA, as muscle spasticity will produce a
fixed flexion deformity.
82
Technical Principles of
Below Knee Amputation
When BKA is performed for nonischemic causes, the ideal
bone length is 12.5 to 17.5 cm, depending on the patient
height. A general guideline is that 2.5 cm of bone length is
needed for each 30 cm of patient height.2 For ischemic limbs,
transection 10 to 12 cm below the joint line is recommended.
At a recommended minimum, three finger-breadths of tibia
distal to the tibial tuberosity should be preserved to enable
prosthetic fit and function. Amputation through the distal
third of the leg is not advisable, as fitting of the prosthesis
becomes more difficult, soft tissue coverage is inadequate,
and the blood supply is tenuous.
A variety of techniques have been described in the construction of BKA skin flaps, including equal anterior and
posterior flaps, long posterior flaps and medial and lateral or
skew flaps.3,4 Whichever the technique employed, care
should be taken not to dissect skin and deep fascia from the
underlying muscle, at risk of compromising flap viability.
While factors such as location of previous incisions influence the choice of flap design, the long posterior flap (posterior myoplasty) and skew flap techniques are the most
widely applicable. The method of equal anterior and posterior flaps can be used in patients with trauma or neoplasm, but is inadvisable in the setting of ischemia or
diabetic foot disease.
The advantages of posterior myoplasty are the superb soft
tissue coverage and the generally good perfusion afforded by
the calf musculature. Disadvantages include the bulbous
shape of the stump in obese or muscular limbs, and the
tendency to have redundant corners (dog ears) that may
lead to delay in rehabilitation. The skew flap technique is an
alternative that provides improved stump contour leading to
earlier prosthetic fitting. In a multicenter randomized control
trial, Ruckley and coworkers found that both techniques are
comparable in terms of healing, prosthetic limb fitting, and
mobility.5 Similar findings were confirmed in a recent Cochrane database systematic review.6 The choice of incision is
usually based on familiarity with a particular technique and
personal preference. The therapeutic goal of all the techniques is to produce a well-healed, pain free, and functional
stump that can be fitted with prosthesis. With the availability
of modern prosthetic techniques, a successful prosthesis can
be fitted to any well-healed BKA stump with a good functional outcome.
83
cised to provide a reference for the level of tibial division. The
level of transection of the tibia is further marked with a bone
saw.
The muscles of the anterior compartment are divided
slightly longer than the anticipated tibial stump length. The
superficial peroneal nerve is identified coursing just beneath
the fascia of the lateral compartment and is sharply divided
after gentle traction. The anterior tibial vessels are doubly
ligated and deep peroneal nerve is sharply divided after gentle traction.
The tibia is then divided with a reciprocating saw, and the
fibula is divided 1 to 2 cm shorter, using either a saw, or a
rongeur and bone cutter. Using a bone hook, the distal tibia
is pulled anteriorly and deep posterior compartment muscles
are divided 1 cm distal to the tibial section. The posterior
tibial and peroneal vessels are then identified, doubly ligated
and divided. Posterior tibial nerve is gently retracted and
sharply divided. The gastrocnemeus and soleus muscles are
divided in a tangential fashion to form a myofascial flap long
enough to reach the anterior fascia across the tibia (Fig. 2).
The anterior crest of tibia is beveled 45 to 60. Using a rasp or
pneumatic burr, all the sharp edges of the tibia and fibula are
smoothed. The tourniquet is released and hemostasis is secured. The wound is irrigated with antibiotic solution. A
closed suction drain is placed deep to the muscle flap, and
using absorbable sutures, the deep fascia of the posterior flap
is sutured to the deep fascia and periosteum of the anterior
flap. The skin is closed with interrupted nonabsorbable sutures.
Operative Technique
Method of Equal
Anterior and Posterior Flaps
After appropriate anesthesia, the patient is positioned supine
on the operating room table. A pneumatic tourniquet can be
used to minimize blood loss. The desired length of tibia is
measured below the joint line and marked. The anteroposterior diameter of the leg at this level is measured and equal
anterior and posterior flaps are marked, each half the leg
diameter (Fig. 1). The skin and deep fascia are incised along
the marked incisions. As the anterior incision is being carried
over the anteromedial surface of tibia, the periosteum is in-
S. Sajja
84
Figure 2 After the division of tibia and fibula, the muscles of the deep posterior compartment are divided 1 cm distal to
the tibial division. The gastrocnemeus and soleus muscles are divided in a tangential fashion to form a myofascial flap
long enough to reach the anterior fascia across the tibia.
tibial division and skin flaps are one fourth this in length. The
anterior starting point of the incision is 2 cm lateral to the
anterior border of the tibia, over the middle of the anterior
compartment. The posterior point is half way around the
circumference. The incision is extended for about 2 cm anteriorly to facilitate beveling of the tibia (Fig. 5). The skin and
deep fascia are divided along the marked incisions. No attempt is made to separate the deep fascia from the underlying
muscle.
Division of the anterior and lateral compartment muscles and neurovascular structures is performed as described previously. Tibia is sectioned at the chosen level
and fibula divided 2 cm proximally. It is beveled as described previously. A bone hook in the medullary cavity
will help retract tibia anteriorly, and the soft tissues are
separated from the tibia and fibula. The length of the gastrocnemeus and soleus muscle flap should be at least equal
to the diameter of the leg. The muscle bulk is thinned and
some of the muscle from the medial and lateral aspects is
removed while leaving the deep fascia intact (Fig 6). After
hemostasis and irrigation, the muscle flap along with the
attached deep fascia is brought anteriorly and sutured to
the deep fascia and periosteum. The skin flaps enclose the
posterior muscle flap and are closed with interrupted nonabsorbable sutures (Fig. 7).
Postoperative Management
Many experienced amputation surgeons employ rigid
dressings, applied in the operating room to help control
postoperative edema, protect the stump and prevent flexion contracture of the knee. Care should be taken to avoid
proximal constriction of the thigh. As the swelling decreases, a new rigid dressing may need to be applied. A
trained therapist should closely supervise prosthetic ambulation. After two to three weeks, elastic stump socks can
be used to further shape the stump before final prosthetic
fitting.
Figure 3 The incision is marked 8.5 to 12.5 cm below the joint line, or 6 to 10 cm distal to the tuberosity. It should
encompass the anterior hemi-circumference of the leg. The length of the posterior flap should be 2.5 cm longer than the
antero-posterior diameter of the leg at anterior incision line.
85
S. Sajja
86
Figure 4 To create the posterior flap, the author recommends the use of a long very sharp amputation knife. With the
tibia distracted anteriorly with a bone hook, and the entire specimen on gentle caudal traction, the knife is inserted just
along the posterior edge of the fibula. With swift slicing motions, the path of the knife should follow a gentle downward
curve away from the fibula and toward the posterior incision. The result will be a beveled posterior myofascial flap, with
more muscle thickness proximally and less thickness distally.
Figure 5 The incision for skin flaps method is semicircular and is based on a line around the limb at right angles to the
long axis. The circumference of the leg is measured at the chosen level of tibial division and skin flaps are one fourth
this in length. The anterior starting point of the incision is 2 cm lateral to the anterior border of the tibia, over the middle
of the anterior compartment. The posterior point is half way around the circumference. The incision is extended for
about 2 cm anteriorly to facilitate beveling of the tibia.
87
S. Sajja
88
Figure 6 The length of the gastrocnemeus and soleus muscle flap should be at least equal to the diameter of the leg. The
muscle bulk is thinned and some of the muscle from the medial and lateral aspects may need to be removed.
89
Conclusions
References
he previous two chapters have described a series of surgical procedures that illustrate priorities in the management of limb-threatening injury and disease. Failing prevention or successful nonoperative management, the surgeon
selects a level of amputation that minimizes tissue loss, enables healing, and preserves as much function as possible.
Walking will almost always still be possible if only the forefoot is lost. The functionality of mid- and hind-foot amputations is highly variable, but may suffice for younger healthier
patients. If no part of the foot can be salvaged, the surgeon
will then typically be faced with a decision that has major
consequences for the patient: whether to attempt salvage of
the knee joint.
As previously emphasized, loss of the knee joint markedly
reduces the chance of community ambulation in all but the
heartiest and most motivated patients. Yet all amputation
surgeons are familiar with the circumstances that render the
leg and knee unsalvageable: severe ischemia, infection, joint
contractures, crush injuries, or other extensive trauma. The
current chapter will address techniques that again give priority to healing and function, even when the knee joint cannot be preserved.
90
joint, and courses more laterally behind the knee. The popliteal space consists of the vessels and connective tissue surrounding them, both above and below the knee.
Thigh
Extending from the inguinal crease to the knee, the thigh is
comprised of the femur, vessels and nerves, connective tissue, and three groups of muscles. The anterior group includes the quadriceps femoris and sartorius; the medial
group contains the adductor longus and magnus and the
gracilis; the posterior group is the biceps femoris, semitendinosus, and semimembranosus.
Differences in anatomy at different levels are important for
the surgeon to understand, particularly as regards the vascular anatomy. The common femoral artery and vein are essentially subcutaneous, but both the profunda femoris and (superficial) femoral arteries quickly pass deep to fascia and
muscle as they course distally from the femoral triangle. The
profunda passes medial to but toward the femur, while the
femoral artery parallels the femur until the vessel emerges
from the adductor canal as the popliteal artery and passes
posteriorly into the proximal popliteal space.
The femoral nerve passes deep to the inguinal ligament
and immediately divides into a series of both muscular and
cutaneous sensory branches. The saphenous nerve accompanies the femoral artery through the adductor canal, and then
surfaces to accompany the greater saphenous vein, from behind the sartorius tendon. The sciatic nerve, the largest and
longest peripheral nerve in the body, enters the thigh
through the sciatic notch and courses deep to the biceps
femoris muscle until the nerve divides into the tibial and
common peroneal branches proximal to the knee joint.
Knee Disarticulation
General Considerations
Like the Syme amputation, the knee disarticulation has never
been widely accepted by most amputation surgeons, but retains a loyal following among a minority of surgeons and
prosthetists. Its advantages are numerous. It preserves not
only the length of the limb, but also the function of the thigh
muscles, providing a long and strong lever arm for ambulation. No muscles are cut in performing a knee disarticulation, and the tendons and ligaments around the knee can be
readily reattached to the femur. Because the function of all
thigh muscles is preserved, there is much less likelihood of
91
Figure 1 Representative incisions for a knee-disarticulation and for above-knee amputation. Knee-disarticulation
(dashed line below knee): A fish mouth configuration is used, but the anterior flap is typically longer to include the
patella and patellar ligament. The corners are placed at the level of the knee joint, and the anterior flap should extend
about 4 inches distal to the level. The posterior flap is then incised about two or two-and-one-half inches distal to the
knee joint, as depicted. The underlying soft tissues are divided with a gentle bevel corresponding to the flaps themselves. The patellar ligament is divided from its insertion onto the tibial tuberosity. Above-knee amputation (dashed
line above knee): The fish-mouth technique uses equal anterior and posterior flaps, but the length and symmetry of the
flaps can be modified according to the presence of prior incisions, ulcers, or areas of necrosis. The medial and lateral
corners should be at the desired level of bony amputation, and the length of the flaps should be about 3 inches.
Technique
Knee disarticulation is performed with the patient supine,
and with the thigh elevated on a soft roll. A pneumatic tourniquet is preferred by some surgeons, but not mandatory.
Incisions are made and flaps developed by one of several
methods. The classic approach is based on a longer anterior
flap, but the procedure can also be performed with a long
posterior flap, or with equal fishmouth flaps, the latter oriented in either the sagittal or coronal planes. If fishmouth
flaps are used, each should have a length about 2/3 that of the
leg circumference at the site of incision.
Classic Approach
A symmetric anterior curvilinear incision is made from the
level of the joint line, extending to the distal aspect of the
tibial tuberosity (Fig. 1). The incision is taken perpindicular
through the soft tissues down to bone, incising the fascia at
the same length as the skin, which will ensure adequate coverage of the femoral condyles and add durability to the
stump. Periosteum is taken with the flap, which is developed
superiorly, detaching the pes anserinus and patellar ligament
from the tuberosity. The capsule of the knee joint is then
incised anteriorly, medially, and laterally along the margins
of the tibia, exposing the joint itself. Flexion of the knee to
90 aids in exposure of the cruciate ligaments which are then
divided at their tibial insertion site. The posterior capsule is
then located and divided at the tibial attachments (Fig. 2).
At the completion of this sequence of steps, the surgeon
will now be able to visualize the neurovascular bundle within
the popliteal fossa. The veins and artery should be individually exposed, clamped, divided, and doubly ligated (nonabsorbable suture). The tibial nerve should be placed on moderate tension, ligated proximally, then sharply divided and
allowed to retract into the depths of the stump. The neurovascular structures are in some few cases densely adherent to
the posterior capsule and cannot be readily mobilized until
they have been transected. A pneumatic tourniquet is partic-
92
K.M. Anderson
ligament is placed on tension and sutured to the stump of the
cruciate ligaments at the intracondylar notch, thus stabilizing
the quadriceps mechanism and ensuring good muscle function postoperatively (Fig. 3). The remaining biceps tendon
and hamstring tendons are also secured to the cruciate stump
in a similar fashion. Any excess tendon and ligament may be
debrided.
The flaps can now be assessed for length, and carefully
trimmed of redundant or devitalized soft tissues. Once the
flaps are deemed satisfactory, the anterior and posterior fascia
are then closed with interrupted absorbable suture, over a
drain if necessary (see introductory chapter), which is best
brought out through a separate stab wound (Fig. 4). The skin
edges must come together without tension. The surgeons
choice of dressing is then applied.
If appropriate preoperative evaluation has been performed, the flaps will be adequately perfused, with no areas
of infection or necrosis. Should there be major concern during the procedure about the viability or length of the flaps, a
decision will be required to either modify the amputation as
described in the next section, or convert to above-knee amputation. A compression dressing is applied.
Figure 4 A schematic of the completed and closed knee disarticulation, illustrating the relationship of underlying bony and musculotendinous structures. In this illustration, sutures are visible where
the patella has been (optionally) removed from within its tendon.
stump, and modifications of the flaps that are less problematic for the dysvascular limb. The primary disadvantage of the
modified procedures is a moderate increase in technical difficulty. Similar to the classic approach, each of the modified
techniques can be performed with sagittal or coronal flaps of
variable length.
The four common eponymous modifications are as follows:
1. Gritti-Stokes: removes condyles of femur leaving a beveled anterior femoral edge to which the patella is then
anchored.
2. Burgess: removes patella and portion of condyles.1
3. Youkey: removes patella and completely removes the
condyles.2
4. Nellis/Van De Water: removes the femoral condyles
without bevel, and anchors the patella over the distal
end of the femoral stump.3
Technique
The initial stages of these modified procedures are identical
to the classic technique described above. Most authors
strongly recommend use of the pneumatic tourniquet. All
fascia and tendinous attachments to the tibia and fibula are
divided as distally as possible. Disarticulation of the joint
proceeds through the various ligaments. The neurovascular
structures are divided individually and ligated securely.
The popliteal artery should be ligated distal to the origin of
the superior geniculate branches. Because the posterior tissues have a tendency to retract, the posterior flap should be
cut generously long to include portions of both heads of the
gastrocnemius muscle.
If the patella is to be removed, the resection is done subperiosteally; the resulting defect in the patellar tendon must
be carefully closed with interrupted suture. The different
modifications call for variable lengths of the femoral condyles
to be resected perpendicular to the long axis of the femur,
either with or without beveling. The edges of femur and
93
condyles are smoothed with an instrument of choice. Any
remaining cartilage and the synovium may be left in place.
The patellar ligament (with the patella excised) is placed
on tension, brought down around the femoral stump, and
secured to the stump of the cruciates at the level of the intracondylar notch (nonabsorbable suture). The remaining tendinous ends (biceps and hamstrings) are also brought out
around the bony stump and secured to the sides of the patellar ligament/ tendon or the cruciates. Any excess tissue is
debrided. The remainder of the closure includes interrupted
fascial sutures and skin closure. Temporary (48 hrs) suction drainage is optional, but should be actively considered
with modified knee disarticulation to eliminate dead space
and enhance tissue coaptation.
Although the procedures described in the preceding paragraphs are known as modifications of knee disarticulation,
they could just as accurately be considered as modifications
of trans-femoral (above-knee) amputation with a very long
femoral stump. Except for the specific indications noted
above, mainstream opinion holds that standard AKA is
equivalent or superior to through-the-knee amputation for
patients whose knee joints cannot be preserved.
Above-Knee Amputation
General Considerations
The trans-femoral or above-knee amputation (AKA) is indicated for patients with severe disease, injury, or ischemia of
the leg and foot. Patients selected for AKA are generally those
with some combination of necrosis, infection, injury, neoplasm, or ischemia involving the calf or distal thigh, such that
the musculoskeletal structures of the leg are not usable for
below-knee amputation. A second category of patients includes those who have the potential to heal at the BKA level,
but are nonambulatory and debilitated, with a high risk for
developing flexion contracture of the knee after BKA. In this
latter group of patients the major advantage of preserving
limb length relates to balance and stability in the sitting position, as well as ability to transfer from bed to chair. A well
healed BKA with normal range of motion at the knee joint is
highly advantageous for both balance and transfers, but a
contracted knee joint is a major liability. The possible role
and value of knee disarticulation for such patients has already
been reviewed in the previous section.
It is most commonly the patient with the ischemic limb
that presents the difficult decision whether to spare or sacrifice the knee joint. The surgeon must consider a variety of
factors involving the condition of both the limb and the patient (see the Introduction at the beginning of the Journal).
The many factors must be weighed against each other, and
most are relative rather than absolute. Nonetheless, two specific considerations argue very strongly against an attempt to
save the knee: first, a nonambulatory patient, and second, the
presence of significant nonreconstructible arterial occlusive
disease proximal to the femoral artery (as evidenced by absent ipsilateral femoral pulse). In equivocal or borderline
situations, the patient should be counseled that attempted
salvage of the knee may mean longer hospitalization, slower
healing, a more protracted course, and a significant risk of
re-amputation at the AK level.
K.M. Anderson
94
Figure 5 The open stump prior to fascial closure. The anterior and posterior musculature has been transected in slightly
beveled fashion to match the flaps themselves. Vessels and nerves have been ligated at or proximal to the level of the
femoral stump. The anterior edge of the femur should be smoothed with a rasp or burr to avoid erosion of the overlying
skin. It is imperative to amputate the femur short enough to avoid any tension on the flaps. Standard and accepted
closure is by re-approximation of anterior and posterior fascia using interrupted sutures. The surgeon has the choice to
also perform a myodesis by re-approximating the rectus femoris and biceps over the stump of the femur, prior to closing
the superficial fascia.
Technique
The skin incision for AKA is virtually always a fishmouth
configuration with equal anterior and posterior flaps (Fig. 1).
Circular incisions can be used, but are more difficult to close.
Medial and lateral flaps could theoretically be utilized, but
are essentially nonanatomic. The length of the flaps should be
sufficient to provide secure tension-free closure over the femoral stump, without redundant soft tissue or excessive dead
space in the depths of the wound. If myodesis/myoplasty is
planned (fixation of muscle to the femoral stump), the muscle flaps should be fashioned longer.
The incision is made as marked on the skin and carried
sharply through the fascia at the same level. The muscle is
divided at the same level as the skin incision and allowed to
retract. Use of electrocautery for transection of the anterior
musculature will aid with hemostasis, and the electrocautery
is especially useful in distal AKA for division of the patellar
tendon.
The level of amputation will dictate the location of nerves
and vessels. At the more distal levels, the popliteal artery is
located posteromedial to the femur and should be directly
visualized. The artery and accompanying popliteal vein(s)
should be individually isolated and suture ligated, before di-
95
self-adhesive drape (such as the Ioban) covering the entire
stump.
References
1. Burgess EM, Malone JM: Major amputations, in Nora PF (ed): Operative
surgery: principles and techniques (3rd ed). Philadelphia, PA, WB Saunders, 1990, Chapter 52, pp 1242-1265
2. Cull D, Youkey JR: A reappraisal of a modified through-knee amputation
in patients with peripheral vascular disease. Am J Surg 182:44-48, 2001
3. Nellis N, Van De Water JM: Through-the-knee amputation: an improved
technique. The American Surgeon 68:466-469, 2002
Suggested Reading
Burgess EM: Disarticulation of the knee. Arch Surg 112:1250-1255, 1977
Malone JM: Lower extremity amputation, in Moore WS (ed): Vascular surgery: A comprehensive review (5th ed). Philadelphia, PA, WB Saunders,
1998, pp 844-884
Persson B: Lower limb amputation: amputation methods. Prosthet Orthot
Int 25:7-13, 2001
Smith DG: Amputation: preoperative assessment and lower extremity surgical techniques. Foot Ankle Clinics 6:271-296, 2001
Hip Disarticulation:
Surgical Technique
Position
As with all surgical procedures, the operating surgeon must
take primary and personal responsibility for correct identifi-
cation of the patient and operative site/side. Before positioning, a regional anesthetic should be introduced and induction of the general anesthetic completed. Epidural anesthetics
with an indwelling catheter provide an excellent means of
postoperative pain control. In addition, a regional anesthetic
can be highly beneficial by reducing the incidence of phantom pain postoperatively.
A Foley catheter is placed while the patient is in the
supine position. The patient is then moved into a lateral
decubitus position and stabilized with the aid of a bean
bag or other similar apparatus (Fig. 1). The operative
(ipsilateral) side will be facing up. An axillary roll is then
placed beneath the chest wall in the contralateral axilla to
avoid pressure on the brachial plexus and neurovascular
structures. The contralateral arm must be carefully and
naturally positioned on an arm board without unusual
angulation of any joint or pressure against the radial and
ulnar nerves. The ipsilateral arm is often best positioned in
an overhead cradle with generous padding. Foam pads or
blankets should also be used to protect the peroneal nerve
of the contralateral leg and ankle.
It is important to perform the skin preparation and draping as widely as possible so that the surgical field is not
compromised. Failure to prep and drape a wide field may
cause great difficulty in placing correct incisions, and increases the risk of contamination of the surgical field. Patient
positioning, skin preparation, and placement of drapes
should be done under the direct supervision of the operating
surgeon or a very trusted associate.
After antiseptic skin preparation, a U-shaped drape is
placed under the operative leg as close to the midline gluteal
cleft as possible (while excluding the anus). The anterior arm
of the drape is brought along the base of the scrotum, extending to the umbilicus and ending at the level of the sternum.
The posterior arm of the U-drape extends along the midline
of the spine to the lower margin of the twelth rib. A second
rectangular drape is then used to complete the surgical field
connecting the two ends of the U-drape along the lower
margin of the rib cage.
Incision
Department of Orthopedics and Rehabilitation, Penn State Hershey Medical
Center, College of Medicine of the Pennsylvania State University, 500
University Drive, Hershey, PA.
Address reprint requests to Dr. William Parrish, Department of Orthopedics
and Rehabilitation, Penn State Hershey Medical Center, College of Medicine of the Pennsylvania State University, 500 University Drive, Hershey, PA 17033. E-mail: wparrish@psu.edu
96
Dissection
The anterior limb of the incision is developed by exposing
the femoral triangle. The femoral triangle is found in the
97
Figure 1 Posterior view of patient positioning and placement of incisions for hip disarticulation and hemi-pelvectomy.
The incision for hip disarticulation (dotted line) begins approximately one fingerbreadth inferior and medial to the
anterior superior iliac spine (ASIS) and proceeds caudally toward the greater trochanter. From there, the incision
courses posteriorly within the gluteal crease and then curves anteriorly within the medial thigh crease to reach the pubic
tubercle. Shown in Fig 2 is the anterior component of the incision, extending from the pubic tubercle to the ASIS. For
hemi-pelvectomy (solid line), the incision passes posteriorly from the ASIS along the iliac crest toward the posterior
superior iliac spine (PSIS). At this point, the incision is directed postero-laterally to the tip of the greater trochanter, and
then posteriorly along the gluteal crease to the ischium. The incision then courses within the thigh crease anteriorly
toward the inferior pubic ramus, continuing on to the pubic symphysis. Figure 2 shows the anterior incision extending
from the pubic symphysis, along the inguinal ligament, to the ASIS.
W. Parrish
98
Figure 2 Anterior view of the incisions and deep dissection for hip disarticulation and hemi-pelvectomy. Depicted on
the patients right side are the incisions for the two procedures. Both begin at the anterior superior iliac spine (ASIS) and
course along the inguinal ligament. For hip disarticulation, the incision turns posteriorly at the pubic tubercle; for
hemi-pelvectomy, it extends to the pubic symphysis before curving posterior along the lateral border of the perineum
and into the medial thigh crease. Posteriorly, both incisions pass within the gluteal crease toward the greater trochanter.
The hip disarticulation incision then turns superiorly to course directly back to the ASIS. The hemi-pelvectomy incision
travels from the greater trochanter superiorly, posteriorly, and medially toward the posterior superior iliac spine (PSIS).
The posterior component follows the iliac crest back to the ASIS. These relationships are also shown in Fig 1. The left
side of the patient shows the deep dissection for both hip disarticulation and hemi-pelvectomy, as explained in detail
in the chapter text.
leasing the rectus femoris muscle from its origin on the anterior inferior iliac spine. The hip capsule is the incised around
the lip of the acetabulum, and the hip joint dislocated. The
ligamentum teres is divided by electrocautery, completing
the amputation, and allowing removal of the limb from the
surgical field.
Closure
The surgical field is then thoroughly irrigated and inspected for hemostasis. The short external rotator muscles
99
Figure 3 Hip disarticulation before closure with the gluteal flap. The transected and ligated vessels are seen deep in the
wound. Acetabular coverage is obtained by approximating the short external rotator muscles and gluteus medius muscles
with the obturator externus and iliopsoas muscles. One or two large drains can be placed in the surgical bed if desired. The
gluteus maximus flap is then mobilized anteriorly with suturing of the gluteus fascia to the inguinal ligament.
Postoperative Care
The drains should be left in place until output is minimal.
Removal of the drains too quickly will result in the development of a seroma in the large space deep to the gluteal
fascia. The epidural catheter should be left in place for 48
to 72 hours for pain control. Sustained release oral narcotic pain medications should be started while the epi-
W. Parrish
100
Hemi-Pelvectomy:
Surgical Technique
Position
Positioning the patient for a hemi-pelvectomy is in many
ways similar to positioning for a hip disarticulation (Fig. 1).
Preoperative preparation for this procedure should include a
mechanical bowel prep on the night before surgery. A betadine-soaked vaginal sponge may be packed into the rectum
to prevent contamination of the surgical field due to manipulation of the retroperitoneum during the surgical procedure. A stent should be placed in the ipsilateral ureter and a
Foley catheter in the urinary bladder while the patient is in
the supine position. This makes it easier to identify the ureter
during surgery and decreases the risk of injury to it.
The patient is moved into a relaxed lateral decubitus position
with placement of an axillary roll and appropriate padding of
pressure points. For a hemi-pelvectomy, the patient is positioned on the OR table so the flexion break in the table is
centered between the lower ribs and the iliac crest. The bed
is then flexed which opens the space between the ribs and
iliac crest, making the exposure of the retroperitoneum easier. The patient is placed into a relaxed lateral position so that
the trunk and pelvis can be moved forward or backward to
facilitate surgical exposure. The arms are positioned and padded as described for hip disarticulation. Skin preparation and
draping is performed in similar fashion. Although these steps
should not be delegated to subordinates, the principles of
positioning and preparation should be familiar to the entire
OR team.
Incision
Posterior flap hemi-pelvectomy is the most common variant
of this procedure. This method utilizes the gluteus maximus
for closure much as was described for a hip disarticulation.
Occasionally, a tumor may involve the posterior aspect of the
pelvis or gluteus maximus, necessitating the use of an anterior flap hemi-pelvectomy. The anterior flap hemi-pelvectomy utilizes an anterior based myocutaneous flap that is
based on the femoral vessels. The incision used will depend
on the type of flap required. This chapter will describe the
posterior flap hemi-pelvectomy. The incisions are outlined
and described in Figs. 1 and 2.
Dissection
The dissection begins at the posterior superior iliac spine and
extends anteriorly along the iliac crest and the inguinal ligament to the pubic symphysis. The retroperitoneal space is
exposed by releasing the insertion of the abdominal muscles
on the iliac crest and inguinal ligament. The peritoneal sac
and contents are retracted medially with the ureter. The common iliac artery and vein are identified as well as the internal
and external iliac vessels. The level of ligation of these vessels
may be determined by the position of the tumor. For a posterior flap hemi-pelvectomy, preservation of the internal iliac
vessel or at least the first branch (the superior gluteal artery)
will result in better flap viability because the superior gluteal
artery supplies the gluteus maximus. Once the level of ligation is determined, the appropriate vessels are suture ligated
with monofilament nonabsorbable suture no smaller than
Closure
The surgical field should then be irrigated with several liters
of fluid and closed over large drains. Closure is accomplished
by bringing the gluteus maximus flap forward and suturing
the gluteus fascia to the external oblique and rectus abdomi-
101
sumption of an acceptable quality of life. Aggressive rehabilitation enables most of these patients to ambulate with forearm crutches, which many patients choose in preference to a
large unwieldly prosthesis. Amputation support groups can
be instrumental in helping patients make both emotional and
physical adjustments to their disability.
Conclusion
Suggested Reading
Clark MA, Thomas JM: Major amputation for soft-tissue sarcoma. Br J Surg
90:102-107, 2003
Paz IB: Major palliative amputations. Surg Clin N Am 13:543-547, 2004