|Amputation for War Wounds (ICRC, 30 p.)|
Revision of a stump months or years after skin closure is commonly requested to facilitate the fitting of or weight bearing on a prosthesis. The common indications are: neuroma; a painful scar tethered to bone; chronic sinus from a non absorbable suture or a sequestrum; in the case of below knee amputations, a long fibular section (figure 10), a tibial section without anterior bevelling or a bone spike from the residual periosteum.
In children, the bone ends continue to grow and so may eventually protrude through the scar; this is particularly common in forarm amputations.
The aim of the revision is to remove the cause of the problem and to leave a stump as long as possible which is well covered by soft tissue. The myoplastic amputations described above are rarely appropriate for stump revision unless reamputation at a much higher level is being considered.
Revision for neuroma need only involve excision of the neuroma and distraction of the nerve before its higher division.
The operation should be performed with a tourniquet on the limb with a single intravenous dose of benzyl penicillin. Both muscle and bone are wasted in any stump and so both are more easily cut. The stump can be closed primarily as long as the revision was not undertaken for an infected sinus. Vacuum drainage of the closed stump is recommended if the revision has involved division of bone or muscle.