When revising an amputation the surgeon manages each tissue type with the same goals as when proceeding with the primary amputation. In revision amputation cases, the muscles may be scarred and atrophic. Unfortunately muscle stabilization, while technically possible, is less effective with each successive operation. None the less, muscle stabilization should always be considered an essential goal of secondary reconstruction. Some muscle stabilization, limited though it may be, is better than none at all.

Postoperative Management
Most other surgical procedures are considered complete when the wound is healed. This is not the case in amputation surgeries. Unless the healed residual limb is fitted with an appropriate limb substitute or prosthesis, no functional restoration is possible and the process remains unfinished. The empty sleeve or empty trouser leg is an arresting testimony of incomplete postoperative management. Since postoperative care requires the residual limb to interface and direct the prosthetic device, surgical responsibility ends only when maximum functional restoration has been achieved. The surgeon must always remember the ultimate goal: to replace the limb and restore life.

The primary goals of post-surgical amputation management include prompt, uncomplicated wound healing, control of edema, control of postoperative pain, prevention of joint contractures and rapid rehabilitation to optimum levels of activity. Before attempting prosthetic fitting, the residual limb changes shape and volume, muscles re-adapt and the limb "matures". Time and maturation are necessary in order to avoid a painful mismatching between the shape of the residual limb and prosthetic socket. Without proper patience and preparation, a prosthesis can be fabricated too early, only to become quickly result in a socket that is incompatible with the changing shape of the stump. In these lamentable cases, the patient is left with a fancy, expensive and high technology limb that is useless to him, because it does not fit. To be refitted, the patient often has to wait for approval of a new socket by a funding agency. Once he has approval, he has to go through the time-consuming process of another socket fabrication, reassembly and realignment. It is far wiser to instead to use progessive protocols that allow frequent modification, adjustment and replacement of check sockets or other temporary devices. These protocols can allow ongoing rehabilitation combined with appropriate management of the healing process and inevitable volume changes before definite fitting and thereby avoid this all too frequent and very frustrating scenario.

Soft Dressing
Compressive wound dressings have long been recognized as essential for controlling swelling, minimizing post-operative pain and promoting stable limb volume. Though nurses, therapists and other providers are carefully trained in techniques of residual limb wrapping and bandaging, these techniques are not always easy or problem free. Soft dressings are sterile, compressible and cover the wound beneath a layer of elastic bandages. The bandages support the amputation site under compressive pressure, but care must be taken that they not be so tight as to lead to proximal constriction or a tourniquet effect. While an unquestionable benefit to the healing process, elastic bandages need frequent changing and require close monitoring to maintain the correct amount of pressure. Proper soft dressing protocol requires careful judgement, technical skill and vigilance. The advantages of soft dressing management include the apparent ease of application, and because they provide easier access to the wound, the surgeon can inspect the wound site frequently as it heals. However, complications can arise from poor wrapping of the residual limb, and it is not uncommon to develop joint contractures. When used exclusively, soft dressings frequently make muscle conditioning and pain control more difficult. Even though many surgeons consider simple soft dressings outdated, in comparison to the semi-rigid and rigid postoperative prosthetic techniques available, they are still the method preferred by many amputation surgeons.

Rigid Dressings
For many years, both open and closed amputations have been treated by the early application of rigid dressings. This technique was first described immediately following World War I, and we are fortunate that these first experiences were documented in comprehensive writings charting both clean and infected lower limb amputation procedures. Wilson first published his experiences with early weight bearing and the treatment of amputations of the lower limbs in 1922. He advanced further into post-operative prosthetic care when he applied the first simple functional prosthetic units to the rigid dressings, and allowing his patients to ambulate with some degree of weight bearing on the healing amputated limb. Wilson’s methods received little attention until surgeons in France and Poland resurrected his work following World War II. At the end of World War II, thousands of soldiers were left with unhealed or poorly healed amputations. Given this increase in patient population, Drs. Berlemont in France, Weiss in Poland and later Burgess in the United States revived medical interest in the use of rigid dressings and the refining of early postoperative prosthetic techniques.

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