I need to know about amputation

hazellsephine said:

Hi. I'm new. Great site - learned alot about cracked ribs.
I need to know about amputation, especially low-tech. Character gets her right foot/ankle removed under les than ideal conditions.

I need to know how much would be removed, how the muscles and tendons are/aren't reattached, things like that - technical stuff. Also, how titanium is grafted into bone.

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You have to cut the skin further down the limb than you plan to cut the muscles and those are cut further down than the bone, because you need something to cover the bone or it will simply poke through and set up osteomyelitis (bone infection), which is very difficult to treat. So you cut the skin, peel it back, cut the muscles, peel them back, then cut the bone, making sure to remove shards, and oversewing or cauterizing the bleeders as you go. Some of the vessels may be too big to cauterize depending upon what you are amputating. A gigly saw works much better than a hacksaw for not leaving shards. Bone marrow is where the blood is made, so you use bone wax (sterilized beeswax would work) to plug the end of the bone to stop the bleeding. The loose muscles are trimmed back to fresh margins (where it is still bleeding, since devascularized tissue will set up infection). The muscle flaps are sewn over the bone stump, then you do the same with the skin. Preferrably a permanent monofilament rather than a braided suture would be used to lessen the risk of infection. If you are out in the wilderness, a thin fishing line would probably work better than most commercial threads.

Titanium is not grafted, it is screwed or hammered in, and then you wait for the bone to remodel around it before it is stable. Unless you have some magic or high tech something that currently does not exist, any titanium has to be completely covered by soft tissue and skin, or it will be a portal of entry for bacteria to infect the bone

It takes a few months for the stump to heal to the point that any consideration for a prosthesis can be undertaken. It also depends upon why the amputation was needed. A healthy trauma patient will heal faster than someone with extensive vascular disease. For the latter, being walking on a prosthesis within a year is a reasonable target.

For titanium rods etc, which would not likely be used in an amputation setting, but rather a limb sparing procedure, physical therapy might start in a week or two and bearing full weight in 6-8 weeks is a reasonable goal, but again that's for a healthy person. Generally the person needing such procedures have comorbidities that make it take longer.

On rereading I might have mislead a little. I haven't done an amputation in like 13 years. The skin flaps are mobilized as little as possible, because the more you mobilize it, the more likely it will get devascularized, but you do need some thing to sew to, to close the wound. So when I say the skin is peeled back, that means for only a few centimeters. The muscle flap is the big "flap" since that's where the arteries are. Think about a ham or some other bone in roast where the bone is pointing up. Take a filet knife and cut sideways into the meat and then down along the bone, with the vertical portion of the cut long enough down, such that the flap created will be able to cover the defect after the bone is transected and the muscle on the opposite side of the bone is amputated. then the flap is laid over the wound, excess is trimmed back to bleeding tissue and sewn in place.

hazellsephine said:

Would it be normal for the patient to have phantom pains? Would the leg feel oddly light? Would the movement feel different because of the alterations to the muscles?

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yes to all