Indication For Amputation
Amputation is among the oldest recorded surgical procedures. It has been documented in the Rig-Veda (c. 1200 BC) and the Temple of Ramses II (13th century BC).1 The major indications for therapeutic amputation have remained constant throughout history and include ischemia, trauma, infection, and malignancy. Of the 623,000 Americans living with the loss of a lower extremity in 2005, 80% had dysvascular disease.
Indication For Amputation
Trauma
The Lower Extremity Assessment Project, a prospective, multicenter,observational study for high-energy trauma to the lower extremity, found that injury severity scoring systems, including the Mangled Extremity Severity Score, the Limb Salvage Index, and the Predictive Salvage Index, were insensitive in identifying persons ultimately needing amputation.
The Mangled Extremity Severity Score, however,was highly specific in ruling out those who did not require amputation. Open tibial fractures, especially Gustilo type IIIB, have a wide spectrum in actual severity, and initial management decisions should be individualized
The difficult decision to amputate should be made expediently because amputations performed after initial discharge have the highest complication rate.
Absolute contraindications for limb salvage have been proposed and include poor preinjury patient health, complete lower limb severance in adults, irreparable vascular injury,segmental tibial loss >8 cm, and ischemia time >6 hours. Transection of the posterior tibial nerve5 or plantarinsensitivity7 as indications for amputation have been challenged by extremity amputations and limb reconstructions despite substantial disability for any above-the-ankle lower extremity amputation following trauma.
Health care costs were similar after 2 years, but projected lifetime costs were greater for amputation than for reconstruction.
Dysvascular
Dysvascular amputations represent several interrelated clinical pathways, including ischemia, infection, and, in 71% of cases, diabetes.2,14 Six percent of all patients aged >60 years experience symptomatic peripheral arterial disease. Unremitting claudication refractory to revascularization can require amputation, and critical limb ischemia may lead to dry gangrene and autoamputation. Nonhealing decubitus ulcers and diabetic foot ulcers may lead to wet gangrene, osteomyelitis,and sepsis
Tumor
In 2005, approximately 13,000 Americans were living with lower extremity amputations necessitated by malignancy.
With the advent of neoadjuvant chemotherapy, amputation can be avoided in nearly 95% of all patients with nonmetastatic osteosarcoma and Ewing sarcoma. In the industrialized world, only cases with significant tumor involvement of neurovascular structures, poor distal extremity function, persistent local recurrence, or multiple failed attempts at limb salvage require amputation.
Five-year survival rates for nonmetastatic high-grade osteosarcoma have improved from about 20% before the mid 1970s to >65% in 2005
Congenital
Congenital limb deficiencies account for most pediatric amputations in the Western world. In less developed countries, traumatic amputations from ongoing hazards, such as land mines, are more frequent, ranging from 40% to 74% of cases. Management of conditions during infancy,such as fibular hemimelia, amniotic band syndrome, and purpura fulminans, may necessitate amputation.
Pediatric amputations are fundamentally different from those in adults in several aspects and demand separate consideration. Major principles include the preservation of important growth plates, the preference for disarticulation over transosseous amputation, and the recognition and use of better soft-tissue healing.
Stump overgrowth is a unique complication in pediatrics and can lead to skin erosion, bursa formation, and residual limb pain.