The Dysvascular Amputee

Abstract

Summary By far the most common cause of lower extremity amputation in civilian practice is peripheral vascular disease. Many such patients are in their productive years and are not truly elderly, yet they have other stigmata of systemic vascular disease; hence, the term “dysvascular” has been applied to this class of patient. When the dysvascular patient, in particular, becomes an amputee he can function at a satisfactory level only if his energy costs remain relatively low in ambulation. In this regard amputation at as Iowa level as possible is highly desirable. Under certain specific circumstances amputation can be successfully performed about the foot and ankle. In the majority of cases below knee amputation is a feasible level and successful healing ensues. The dysvascular patient who requires amputation above the knee requires a greatly increased energy output for ambulation, and this precludes successful prosthetic rehabilitation in at least half such patients. The precise level of amputation in patients with vascular disease is determined by the lowest level of skin viability. This is best evaluated in the operating room by observation of skin bleeding at the time of incision, although a preliminary estimate of level can be made by noting the warmth and evaluating the sensation of the skin on physical examination. The surgical technique in amputation through tissues of borderline viability should be characterized by gentle handling of the tissues and absolute avoidance of dissection between tissue planes so that the myocutaneous flaps formed are short. With rare exceptions, primary closure is recommended utilizing widely spaced sutures. Prosthetic rehabilitation should begin as soon as possible postoperatively so that interruption of function is minimized. If immediate postsurgical fitting has not been used, early fitting with a temporary plaster leg is highly desirable, ideally within the first two to three weeks postoperatively, Seventy-five per cent of the below knee amputees can be successfully rehabilitated prosthetically, and there is practically no contraindication to fitting these patients. Above knee amputees in the dysvascular group should be carefully selected for fitting on the basis of the overall medical status in view of the high energy costs required in walking. The temporary prosthesis is helpful in selecting patients for definitive fitting. Total contact sockets are preferred for the dysvascular amputee, whether below or above the knee. Prosthetic suspension should be secure but as simple and comfortable as possible. Knee components should be light in weight and afford stability during the stance phase rather than being heavy and designed for swing phase control.