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together by a stout cord, which, passing over a pulley, serves for the attachment of a suitable weight, (3 to 10 pounds). To bandage the wound, the cord is loosened and the edges of the stockinette turned backward so as to expose the granulating area. In many cases where the skin has not already become adherent, this method suffices to coapt the skin edges; when much retraction has already taken place and the skin has become adherent to the deeper structures, it merely prevents further retraction.
Postural Treatment.—Care must be taken to prevent the development of contractures. The most frequent mistake is in the case of patients with amputations of the thigh or of the calf. The nurse, in her effort to make the patient comfortable, places a pillow beneath the stump, thus flexing the thigh at the hip or flexing the knee. This error, usually unnoticed at the time, results in flexion contractures whose significance is not appreciated until the first fitting of the artificial limb. Then the brace-maker tells the surgeon that something is wrong, and that he cannot make the artificial limb fit correctly. As a consequence months of treatment are required to lengthen the contracted tissues until the free range of motion has again been acquired.
The same principle emphasized in the treatment of injuries to the muscles should be applied to the amputated; the position of the limb should be such as to prevent the overaction of the strong muscles at the expense of the weaker. Thus, at the hip and at the knee, every effort must be made to prevent the strong flexors from overcoming the action of their weaker antagonists. At the shoulder, the strong adductors must not be allowed to contract at the expense of the abductors. The application of the principle is simple. In the case of a patient with thigh amputation, a small pillow is placed under the buttocks so as to allow the thigh by its own weight to fall into the position of slight hyper-extension. For the amputation of the calf, a pillow is placed not in the popliteal space, as is so frequently done, but near the end of the stump, so as to promote the full degree of extension. For amputations of the arm, a small pillow is placed between the chest and the limb, so as to promote abduction. For amputations
of the lower arm, the limb is simply allowed to lie in the fully extended position.
The one exception to this rule is in the case of amputation just below the knee, where the stump is so short that there is no possibility of affixing the artificial limb to the calf. In this event, it is particularly difficult to keep the short segment of the calf extended and as the artificial limb is constructed so as to permit the patient to walk about with the stump flexed, there is no advantage gained in attempting to maintain the extended position.
Re-amputation.—The surgeon should not be too hasty in deciding that re-amputation is necessary. I well recall two instances in which despite the discouraging appearance of the stump, which led me to prepare the patient for operative revision, I was able within several weeks' time to secure excellent results by non-operative procedures. The extension method for exerting traction on the skin has already been described; in addition to this, every effort is made to encourage epithelialization. The presence of scar tissue over the end of the stump does not necessarily mean a poor stump, although it is, of course, preferable to have a normal skin covering
The indications for re-amputation are: (1) projection of the bone beyond the granulation tissue; (2) persistent ulceration of the stump owing to the thinness of the epithelial covering; (3) a fixed contraction of a short stump in such a position as to render application of the artificial limb impossible; (4) in rare instances for painful neuromata which yield to no other form of treatment. A conical stump is in itself no indication for re-amputation since it may, if properly exercised, develop excellent functional capacity.
A discharging sinus, due to the presence of a sequestrum or foreign body, necessitates operative removal (easily accomplished through a small incision) but this operation is in no way analogous to a re-amputation.
Whenever possible, re-amputation should be avoided, since it invariably necessitates shortening the stump. This means loss of power, since the longer the stump, the more accurate its coaptation to the artificial limb and the more effective its action. Of course, if the stump be a long one, with the site of the amputation just above the ankle or the knee, a few inches can be sacrificed without appreciable diminution of power.
The principle of maintaining the maximum length of the stump disagrees with the practice of many eminent surgeons, and therefore deserves further consideration. Thus, it is maintained by Riedel, who himself suffered amputation below the knee-joint, that the stump of the calf, although amply sufficient for the attachment of the artificial limb, was a useless encumbrance. After one year's trial, he insisted upon a reamputation at the knee, using the Gritti method, and professed himself far happier with the short stump than with the longer. My experience has led me to the opposite conclusion. Except in those rare instances already referred to, where the stump of the calf is so short as to make it impossible to grip it in the socket of the artificial limb, every patient whom I treated found it of great advantage to be able to control the prosthesis by the action of the intact quadriceps extensor muscle. Whether the stump was suitable for weight-bearing or not, made far less difference than the additional security given by the voluntary control of the knee-joint. The longer the stump of the calf, the longer the leverage arm controlled by the patient, and the easier for the brace-maker to secure an accurate fit. This is made clear if one thinks of the stump as the piston of an air-pump. Just as the security of the piston is most marked when it is pressed downward its full length into the air-pump, so too, the stability of the stump within the artificial limb is greatest when there is the largest area of contact between it and the prosthesis.
The same holds good for amputations of the thigh, where in the case of the short stump, it is exceedingly difficult for the patient to manipulate the apparatus; whereas, with the long stump, almost the normal stride can be attained. With the upper and lower arm, the effectiveness of the stump for practical purposes is in proportion to its length; and in the case of wounds shortly below the elbow, everything should be done to preserve a stump of the forearm, however short that may be.
In applying the rule relative to the maximum length of the stump, the surgeon must beware of ultraconservatism. Thus, for instance, when an amputation at the ankle is indicated, it would be unwise to leave the astragalus attached to the stump, since in the first place, this bone would render the stump too long for the proper application of the prosthesis; in the second place it would not be as well suited to weightbearing as an osteoplastic stump. George Marks recites an instance of amputation through the mid-calf in the case of a patient whose knee-joint had already been ankylosed. Naturally this ultraconservatism made the normal application of the prosthesis impossible, and the patient had to go about with one thigh apparently 6 inches longer than the other.
The principle of maintaining the maximum length of the limb does not belittle the importance of securing, whenever possible, a weight-bearing stump. If the stump can be rendered capable of supporting the body, the problem of fixing the artificial limb is rendered much simpler. To this end, certain osteoplastic operations are of great value and should be performed wherever feasible. In a class by themselves stand the Pirogoff and Gritti amputations. Both these procedures are excellent examples of the physiological method, and when properly executed invariably give good results.
Of course, an important condition for the success of all the osteoplastic operations is an absolutely aseptic field. When this cannot be had, the operations are contraindicated.
In the calf, when the stump is a long one, so that several inches may be sacrificed with comparatively little loss of power, the Bier osteoplastic method usually results in a weight-bearing stump. When this operation is not feasible, it matters little whether the so-called "aperiosteal” technic is followed, or whether the periosteum is left adherent to the stump. Irrespective of the treatment of the periosteum, it
. will be found that in some cases bony spurs develop, and in others they do not. In all cases of amputation of the calf, the fibula should be divided at least 12 inch above the level of the tibia.
I have found the following technic to give good results in cases where the Bier osteoplastic method is contraindicated. The skin flaps are so planned that the anterior is large enough
to cover the inferior surface of the stump. The muscle flap, on the contrary, is taken from the posterior aspect of the calf, since the fleshy gastrocnemius and soleus furnish the best covering for the inferior surface of the tibia. The muscles are attached to the periosteum by strong sutures anterior to the weight-bearing surface; as the skin suture lies posterior, there is no suture line subjected to pressure when the artificial limb is applied.
In amputasions of the thigh, where the Gritti is not applicable, the Bier method can be followed provided the stump is sufficiently long.
If the stump be short, as little tissue should be sacrificed as possible. An elliptical incision is made, and a cone of granulation tissue and muscle—with its apex at the bone-is excised, the bone sawed off at this level, and the parts drawn together by strong, coapting sutures.
In patients with a femoral stump, not more than 2 or 3 inches long, the presence of an abduction or flexion contracture renders the application of the artificial limb impossible. The problem in these cases is solved most simply by disarticulation of the femur at the hip. Nothing is lost, since the stump is too short to control the artificial limb, and much is gained in the ease of application.
For amputations of the upper limb, the question of weightbearing plays no rôle whatever. The stump should invariably be left as long as possible, and re-amputation performed only when there is urgent indication.
Kinetic Stumps.—Vanghetti and later Ceci attempted the utilization of the latent muscular force of the stump by freeing the tendons or muscle bellies in such a way as to enclose them with skin flaps. These flaps could then be moved by the voluntary muscular contraction of the patient's stump. During the last 3 years the method has been modified by Sauerbruch (until recently professor of surgery at the University of Zurich) and the technic so developed that it can be regarded as a perfected surgical procedure. Figs. 127 et seq. illustrate the steps of the operation. Instead of the original Vanghetti technic a much simpler method has been adopted. After freeing a skin flap of appropriate size (Fig. 127) a