Late Stump Complications and Revision

The Scar Solution Natural Scar Removal

Scar Solution By Sean Lowry

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Following surgery, amputation stumps may prove suitable for provision of satisfactory prostheses, or may not, because of a variety of established conditions. Earlier authors were especially concerned about continued suppuration, failure to heal, "sugar-loaf" formation with bone protrusion, painful scars and overlong below-knee stumps which prevented efficient use of a kneeling peg-leg. Poor or failed healing necessitated permanent bandaging to protect fragile tissues from further damage and also to absorb chronic discharge, a common picture demonstrated in Bosch's drawings of below-knee amputees (see Fig. 2.4). Bone protrusion was diminished by sawing off the excess, leaving a bony ulcer which might exfoliate spontaneously leaving, at best, an indurated and sensitive scar. Before anaesthesia, a few resolute patients insisted on or accepted reamputation, an operation particularly undertaken for the over-long stump; the risks were great, mainly from infection, and not all survived (see Chapter 6).

It must be remembered that even a soundly healed stump changes in contour and size during the first few months after surgery and also that stump complications have changed in the last two centuries in response to an aging population, to new surgical techniques and to artificial limb innovations. Complications observed by a variety of authors selectively follow, recognising these are noted in publications principally from the late 18th century onwards. Alanson's list for 1782 is recorded in the quotation heading this chapter, emphasising the significance of absent bacteriological knowledge at that time.

Velpeau listed postoperative complications as follows:

i. Cone formation (sugar-loaf) of the stump, which was rare thanks to improved circular incisions and primary wound healing, but still provoked by suppuration.

ii. Exfoliation of bone ends, which often took 3 or 4 months to necrose and discharge naturally or with surgical assistance; this was long regarded as inevitable, perhaps induced by heated cauterisation or caustic remedies formerly in vogue.

iii. Hospital gangrene, a frequent and perilous infection which might necessitate amputation at a higher level.

iv. Swelling of the stump, sometimes associated with erysipelas infection, likely when primary healing was attempted, for it was rare with delayed healing methods. Treatment necessitated opening the stump wound, applying leeches or, most efficaciously, making multiple and deep incisions. On survival, further treatment included reamputation; Gourand reported 10 such operations between 1814 and 1815 with 9 cures.

v. Phlebitis with suppuration carried a high mortality and was associated with infection of the bony medullary cavities propagating infection to the heart.

vi. Cystitis mainly in lower limb amputees who often needed catheterisation.21

In 1839, Sédillot listed a similar series of complications, adding tetanus as a particular problem among military amputees. He also studied the anatomy of stumps during their early years of formation, distinguishing those which healed primarily, with a linear, lightly puckered scar and those healing secondarily, with a more irregular scar attached to bone. Stump dissection demonstrated that muscle tissues were largely absorbed, the principal vessels were converted to fibrous tissue, nerve ends were enlarged and bone ends presented no evidence of a medullary canal, which closed over with dense fibrous tissue. Sedillot suggested extensive examination of postmortem stumps would prove informative. He noted many amputees gained weight and advised dieting and regular venesection.22 Liston did not list stump complications in 1837 but discussed reamputation for inconvenient length, tenderness, prominent bone ends, infection, ulceration and nerve adhesions. In most cases he advised a simple filleting out of 2 or 3 inches of bone and, if necessary, shortening of nerve trunks.23 Chelius found similar stump complications in 1847, noting severe problems induced by infection and also torpid patients who showed insufficiency of inflammation with a flabby wound not inclined to heal, for which local aromatic remedies and poultices were recommended.24

In 1872, Bryant considered most through-femoral and -humeral stumps became conical with time as a result of muscle wasting whereas this was rare when double bones of the forearm and shin were divided or after elbow and knee joint disarticulation. He said conical formation in childhood was inevitable, especially below the knee where normal bone growth, due to the upper tibial epiphysis, might require shortening on more than one occasion; this also involved the humerus

Fig. 12.4. Disarticulated humerus excised for natural bony overgrowth of an above-elbow stump, for a compound fracture sustained by a boy of 6 years run over by a heavy wagon; the protrusion of the humerus is marked with formation of a bone ulcer. The second operation took place when he was 15 years old; specimen was deposited in 1897. (With permission of the Royal College of Surgeons of England.)

Fig. 12.4. Disarticulated humerus excised for natural bony overgrowth of an above-elbow stump, for a compound fracture sustained by a boy of 6 years run over by a heavy wagon; the protrusion of the humerus is marked with formation of a bone ulcer. The second operation took place when he was 15 years old; specimen was deposited in 1897. (With permission of the Royal College of Surgeons of England.)

(Fig. 12.4). Painful stumps caused by neuroma formation were cured by nerve excision (see Fig. 12.4), although extreme pain caused by hyperesthesia was resistant to operation but might benefit from local belladonna, opium or stramonium.25 Watson's chapter on stump classification proves disappointing, merely calling stumps good, bad or indifferent, and noting conical and infected stumps, exostosis formation and rare bowing or twisting of juvenile bones.26 Huggins, on the basis of extensive experience of military amputees from World War I, was very critical of guillotine amputations which often needed reamputation but warned it was prudent to delay further surgery until 6 months after septic stumps settled, when he advised an oblique rather than a transverse guillotine reamputation.27

Little's practical handbook, as he modestly subtitled his book of 1922, was based on extensive experience of World War I amputees. He instituted accurate measurement of stump lengths and also a study to estimate normal bone lengths of 100 men with their heights for comparative purposes. Little cited the following complications as sources of common delay in fitting:

i. Sinus formation due to bony sequestrum formation, the persistence of missile fragments or unabsorbed ligatures such as silk, all of which demanded exploration.

ii. Painful nerves or tenderness caused by to inflammation, especially bulbous formation of divided nerves trapped in scar tissue, more troublesome in the upper limb. Persistence of pain after 3 months required high division of bulbous nerves (Fig. 12.5), then crushing followed by the injection of absolute alcohol, although he admitted some patients did not respond to these measures. He mentioned causalgia, but does not enlarge on its management, and also jactitating stumps which on the slightest pressure induced clonic spasms of the stump, often difficult to treat.

iii. Unsound scars, usually associated with suppuration and failed primary union, especially after gas gangrene when no flaps were made, leading to heavy scarring adherent to bone. Although unfit to bear weight, many such stumps could be fitted with a prosthesis, but the remainder needed scar excision or, as a last resort, reamputation. If skin and bone were short, up to 10 pounds weight extension via adhesive strapping

Fig. 12.5. Excised above-elbow stump for persistent pain caused by adherence of bone and nerves to scar; the humerus has been shortened with the ulnar, median and radial nerves which are seen to terminate in large neuromata in the scar tissue. Deposited in 1949. (With permission of the Royal College of Surgeons of England.)

Boy Amputees Stumps

Fig. 12.5. Excised above-elbow stump for persistent pain caused by adherence of bone and nerves to scar; the humerus has been shortened with the ulnar, median and radial nerves which are seen to terminate in large neuromata in the scar tissue. Deposited in 1949. (With permission of the Royal College of Surgeons of England.)

was applied for some weeks (see Fig. 12.3); with upper limb extension the patient could be ambulatory. For below-knee stumps, complete excision of the fibular shaft sometimes provided adequate skin cover.

iv. Contractures in the neighbourhood of joints above amputations were a serious drawback. Stiff shoulders hampered the action of prostheses for above-elbow sections markedly but a stiff elbow was less troublesome for below-elbow sections. Most serious was the stiff hip with flexion and/or abduction contractures, commonly seen with short thigh stumps which, nevertheless, might be fitted with a prosthesis without treatment. For long thigh stumps, strenuous physiotherapy was recommended or, if necessary, surgical excision of contractures or, as a last resort, excision arthro-plasty of the hip joint. He stated only 30° of knee flexion is necessary for a walking prosthesis although at least 90° is required to sit comfortably.28

In an addendum, Little illustrated radiographic features of stumps from a collection of 116 prints which he donated to the Royal College of Surgeons of England, some showing spur formation that caused no symptoms and were associated with good stump function whereas good radiographs might hide painful stumps.29

Largely based on World War II experience, Thomas and Haddan attributed most stump difficulties to the following:

"1. Faults in the stump itself, due to improper operative technic, infection, or improper preparation of the stump for the prosthesis. 2. Poor stump hygiene, with resulting skin irritation or infection. 3. Faulty fitting of the prosthesis. (This, though most often blamed, is probably the least frequent of all causes.)"30

Detailed complications were as follows:

i. Persistent tenderness after fitting a prosthesis caused by low-grade infection, vascular disturbances, adherent scar and irritable neuroma; painful neuromata were not so common as generally thought, but if pain was suspected and abolished by local anaesthetic infiltration, nerve resection was indicated.

ii. Phantom pain and causalgia, noting that all amputees experienced sensations relating to ablated anatomy, usually not disturbing and per sisting briefly. Commoner in the upper than lower limb, the severity was related to amount of sepsis experienced in the stump. Sensations of warmth, itching, burning, throbbing, piercing, cramping, sticking and of the limb being crushed or torn were described although, fortunately, intractable pain in the phantom was rare. They added psychic factors played a role in susceptible individuals and noted Leriche and Livingstone's investigation of the part played by the autonomic nervous system and the help given to some cases by injection of sympathetic ganglia. Their review of the literature confirmed cure was difficult. If local anaesthesia of paravertebral ganglia was effective, repeat injections or ganglionectomy was justified, and for the extremely introspective patient, frontal lobotomy was a possibility. Initial pain due to sepsis, tight bandaging, insufficient sedation and painful dressing changes indicated probable factors that should be avoided.

iii. Ulceration, associated with an overlong stump, especially below the knee; venous stagnation and swelling was more marked in those with peripheral vascular disease. Sinus formation was usually the result of osteomyelitis, and X-rays might confirm bony sequestra for removal.

iv. Bursal formation often developed over bony points subject to friction by a socket and required adjustment of the prosthesis.

v. Skin irritation, furunculosis, infected sebaceous cysts and eczematous dermatitis were associated with lack of stump hygiene or a poorly fitting socket.31

Gillis developed extensive expertise in managing painful stumps, devoting a chapter to this in 1954, and suggested the following factors, including a growing trend by several authors to implicate prostheses in the 20th century.

i. Local stump pathology of skin, fat and fascia, muscle, nerve, vessels or bone.

ii. Pain associated with artificial limbs caused by poor fit, faulty alignment, poor supporting appendages and controls.

iii. In the lower limb, remote causes due to lumbar disc prolapse,spinal arthritis or hip or knee arthritis, possibly on the good side.

iv. Central causes, producing phantom and perhaps causalgia.

v. Psychogenic of economic, emotional, hysterical or, rarely, self-inflicted origin.32

Gillis discussed these in more detail and illustrated problems with X-rays and excised stump pathology, many of which excisions are now exhibited in the Anatomico-Pathological Museum of the Royal College of Surgeons in London (see Fig. 12.5). In 1957, Gillis provided an analysis of 2000 consecutive surgical procedures performed at Roehampton, the national centre for amputation management. Of these, 738 (36.9%) were primary amputations, 926 (46.15%) were reamputations and 339 (16.95%) were lesser operations on the stump, including scar, nerve, ulcer, bursa and tumour excisions, sequestrectomy and bone excisions, draining of abscesses, sympathectomies for pain, and secondary suturing. Of the 2000 procedures, 1262 were performed for pathological conditions of the stump, that is, 63.1% of all operations.33 In the 1963 edition of Campbell's Operative Orthopaedics, Slocum provided an exhaustive and practical analysis of stump complications, including a list of causes and specific treatments. There were 12 main complications and 34 causes, mostly related to primary surgical imperfections, for none were attributed to an ill-fitting prosthe-sis34; recent editions of Campbell's Operative Orthopaedics no longer include this classification.

In 1986, Vitali et al. did not discuss what they termed short-term stump pathology, as this either resolved or progressed to reamputaton, being more concerned with long-term pathology, which was listed under three headings:

i. Preamputation pathology, firstly with respect to the skin especially when vascular deficient, scarred after compound fractures, anaesthetic due to neurological factors or ulcerated and affected by chilblains, and the effect of adjacent flail, unstable, restricted or ankylosed joints.

ii. Postamputation pathology, with reference to the skin and scar, muscles and nerves, along the lines noted by previous authors.

iii. Stump pathology initiated by unsatisfactory prosthetic fitting, including dermoid cysts, eczema, problems caused by the amputee gaining weight to alter forces between stump and prosthesis, and prosthetic misalignment.

Each amputation site was reviewed for specific surgical and prosthetic pathology.35

In contrast to the problems of bone protrusion and "sugar-loaf" formation, stumps can be too short for adequate fitting of prostheses and may require reamputation at a higher level or, possibly, lengthening the shortened bone as described in 1990. Eldridge, Armstrong and Krajbich were able to lengthen a tibial stump from 7 to 11.5 cm using the Ilizarov circular distraction frame on an 18-year-old man who had sustained a traumatic amputation close to the knee as a 5-year-old. As bone lengthening proceeded to a tibial length of 15 cm, they encountered bone penetration of the overlying skin with infection and eventually had to sacrifice 3.5 cm of gain, followed by skin grafting. For future stump lengthening, they concluded prior skin reconstruction was essential.36

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  • sandra pisani
    Do dr's inject abk stumps?
    8 months ago

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