Editing Amputation (section)

== Surgery ==

===Method===
[[File:Curvy amputation knife DSC09451.jpg|thumb|200px|Curved knives such as this one were used, in the past, for some kinds of amputations.]]
Surgeons performing an amputation have to first [[ligature (medicine)|ligate]] the supplying [[artery]] and [[vein]], so as to prevent [[hemorrhage]] (bleeding). The muscles are transected, and finally, the [[bone]] is sawed through with an [[oscillating saw]]. Sharp and rough edges of bones are filed, skin and muscle flaps are then transposed over the stump, occasionally with the insertion of elements to attach a [[prosthesis]].

[[File:Últimos_momentos_do_heroico_1º_tenente_-_Mariz_e_Barros_-_commandante_do_encouraçado_-_Tamandaré._-.jpg|thumb|left|Amputation of the leg of First Lieutenant [[Antônio Carlos de Mariz e Barros]], commander of the Brazilian [[Brazilian ironclad Tamandaré|Battleship ''Tamandaré'']] (Henrique Fleiuss, ''Semana Illustrada'', [[1866]])]]

Distal stabilisation of muscles is often performed. This allows effective muscle contraction which reduces atrophy, allows functional use of the stump and maintains soft tissue coverage of the remnant bone. The preferred stabilisation technique is myodesis where the muscle is attached to the bone or its periosteum. In joint disarticulation amputations tenodesis may be used where the muscle tendon is attached to the bone. Muscles are attached under similar tension to normal physiological conditions.<ref>{{cite book| vauthors = Smith DG |title=Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic and Rehabilitation Principles|date=2004|publisher=American Academy of Orthopaedic Surgeons|isbn=978-0892033133|pages=21–30|chapter=Chapter 2. General principles of amputation surgery.}}</ref>

An experimental technique known as the "Ewing amputation" aims to improve post-amputation [[proprioception]].<ref>{{Cite news |last=Springer |first=Shira |date=2018-04-13 |title=How The Marathon Bombing Helped Bring Innovation To Amputation |work=[[WBUR]] |url=https://www.wbur.org/news/2018/04/13/stepping-strong-brigham-amputation |access-date=2021-06-28}}</ref><ref>{{Cite web |date=2016-11-21 |title=Jim Ewing, Dynamic-Model Amputation Patient |url=https://www.brighamandwomensfaulkner.org/about-bwfh/news/ewing |access-date=2021-06-28 |website=Brigham and Women's Faulkner Hospital}}</ref> Another technique with similar goals, which has been tested in a clinical trial,<ref>[https://news.mit.edu/2021/surgery-control-prosthetic-limbs-0215 New surgery may enable better control of prosthetic limbs]</ref> is Agonist-antagonist Myoneural Interface (AMI).<ref>[https://www.media.mit.edu/projects/agonist-antagonist-myoneural-interface-ami/overview/ Agonist-antagonist Myoneural Interface (AMI)]</ref>

In 1920,&nbsp; Dr. Janos Ertl Sr. of [[Hungary]], developed the Ertl procedure in order to return a high number of amputees to the workforce.<ref>{{cite web|url=http://www.ertlreconstruction.com/|archive-url=https://web.archive.org/web/20040201185051/http://www.ertlreconstruction.com/|url-status=usurped|archive-date=February 1, 2004|title=Ertl Reconstruction - amputation|website=www.ertlreconstruction.com|access-date=2018-11-24}}</ref>  The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques.<ref>{{Cite journal |vauthors=Fischgrund JS |date=June 2016 |title=JAAOS Research |journal=The Journal of the American Academy of Orthopaedic Surgeons |volume=24 |issue=6 |page=392 |doi=10.5435/jaaos-d-16-00309 |pmid=27213622 }}</ref>

=== Post-operative management ===
A 2019 [[Cochrane (organisation)|Cochrane]] [[systematic review]] aimed to determine whether rigid dressings were more effective than soft dressings in helping wounds heal following transtibial (below the knee) amputations. Due to the limited and very low certainty of evidence available, the authors concluded that it was uncertain what the benefits and harms were for each dressing type. They recommended that clinicians consider the pros and cons of each dressing type on a case-by-case basis: rigid dressings may potentially benefit patients who have a high risk of falls; soft dressings may potentially benefit patients who have poor skin integrity.<ref>{{cite journal | vauthors = Kwah LK, Webb MT, Goh L, Harvey LA | title = Rigid dressings versus soft dressings for transtibial amputations | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD012427 | date = June 2019 | issue = 6 | pmid = 31204792 | pmc = 6573094 | doi = 10.1002/14651858.cd012427.pub2 }}</ref>

A 2017 review found that the use of rigid removable dressings (RRD's) in trans-tibial amputations, rather than soft bandaging, improved healing time, reduced edema, prevented knee flexion contractures and reduced complications, including further amputation, from external trauma such as falls onto the stump.<ref>{{cite journal | vauthors = Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD | title = Removable Rigid Dressings for Postoperative Management of Transtibial Amputations: A Review of Published Evidence | journal = PM&R | volume = 10 | issue = 5 | pages = 516–523 | date = May 2018 | pmid = 29054690 | doi = 10.1016/j.pmrj.2017.10.002 | s2cid = 21732925 }}</ref>

Post-operative management, in addition to wound healing, considers maintenance of limb strength, joint range, edema management, preservation of the intact limb (if applicable) and stump desensitization.