Blood Vessels
Adequate hemostasis and the management of blood vessels and bleeding sites is of utmost importance in amputation surgery. Major arteries and veins should be isolated and ligated securely. Double ligation of large arteries should be standard, especially when the amputation is carried out in the presence of normal blood supply. Cauterization should be reserved for smaller bleeding points only. The central artery of a large nerve such as the sciatic nerve can be a troublesome source of bleeding. Excessive bleeding in this instance can be avoided by ligation with absorbable suture. Bleeding from the sectioned bone end is best controlled by pressure. Occasionally critical intra-osseous vessels will require cauterization or a small amount of bone wax. However, bone wax is in actuality only very rarely required. Bone wax should be used as infrequently as possible because it remains as a foreign body within the surgical site and can lead to potential complications.

Adequate blood supply to the distal tissues and to the wound margins facilitates proper healing. For appropriate blood supply, the surgeon should avoid dissection of the subcutaneous tissue and keep the muscular investing fascia with the skin whenever possible. Dissection should not damage the proximal blood vessels. Skin or preferably fasciocutaneous flaps, even when broad based, should be developed with careful attention to blood supply. This is especially important for patients suffering from vascular disease and diabetes. Careful attention to hemostasis and managing the vascular supply to the flaps can make the difference between healing and failure, particularly when blood supply is marginal.

Amputation sites are usually drained surgically with suction drainage, as sectioned muscle and bone can often result in a surgical site that is not, and cannot be perfectly dry. A post-operative hematoma can be a major complication that predisposes the patient to infection. In worst case scenarios, hematomas result in delayed wound healing or complete failure. If a large post-operative hematoma is identified the patient should be returned to the operating room for evacuation, irrigation and debridement. Complete hemostasis should be attained before leaving the operating room the second time. Revision surgery and higher-level amputation have been necessitated due to hematoma formation. The surgeon should do his utmost to avoid this, but if a hematoma does form, it must be identified early and treated quickly.

Bone Tissue
The forces traveling between prosthesis, residual limb and the remaining body are in large part transmitted through the retained bone in the amputated limb. Diaphyseal bone should be sectioned at the length consistent with reconstructive soft tissue closure. Managing the edges of severed bone is essential to pain-free healing, and the sharp cortical bone edges and irregularities should be carefully contoured and rounded. In each amputation case, bone transection and shaping should take into account the available prosthetic devices for that particular level of amputation. Preoperatively, the surgeon must be sufficiently familiar with the most frequent bone related problems at each level in order to minimize future woes. For example, in transtibial amputations, anterior beveling to remove the distal corner of the tibia is one method of proactive management. Removing the distal plantar corner of the calcaneous in a hindfoot amputation is another example of a preemptive strike against future complications.

Proper foresight and attention to bone preparation eliminates potential areas of high pressure at the bone socket interface. Under normal circumstances there are no sharp, angular surfaces in the palm of the hand or the sole of the foot, and retained distal bone in these areas should come as close to this natural state as possible. Occasionally in disarticulations, it is a good idea to narrow the distal metaphyseal flare of the bone to prevent an overly bulbous and enlarged distal stump. For example, in the Syme ankle disarticulation surgical contouring of the distal tibia and fibula are mandatory, as a bulbous, and non-contoured distal stump will cause increased difficulties in prosthetic fitting. However, in general bone resection is kept to the minimum in most disarticulations.

Protocol for the successful management of the periosteum is less concretely defined. In instances of diaphyseal amputation, children tend to form new bone with periosteal and endosteal bone overgrowth at the end of the amputation. Capping the end of a diaphyseal amputation with osteochondral bone surface (often obtained from part of the amputation specimen itself), has been shown to minimize bony overgrowth. These specific techniques are addressed in the pediatric chapters.

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