Stump-plasty: An Operation Born of Necessity in Gaza

AIM AND OBJECTIVE: The most recent wave of lower limb amputees in Gaza arises from ballistic injuries sustained during protests. This study evaluates the requirement for surgical revision of these mature stumps to allow prosthetic fit and mobility. MATERIALS AND METHODS: A multidisciplinary team (MDT) comprising a prosthetist, orthopaedic and plastic surgeons and a physiotherapist screened 104 amputee stumps (103 cases). The 27 cases selected for surgical revision (stump-plasty) are the subject of this study. The MDT prescriptions of care issued at screening were compared to surgical procedures performed at stump-plasty and the findings. Compliance with the MDT prescription was recorded. Stump issues are identified to propose modifications of primary amputation technique to mitigate future revisions. Patients’ healthcare status was assessed by questionnaire (EQ-5D-L5) at screening, then subsequently post-stump-plasty. RESULTS: More below-knee amputees (BKAs) than above-knee amputees (AKAs) required stump-plasty. Revisions varied according to the quality of tissue present at the amputation level. AKA revisions addressed bulk and contour issues whereas BKA revisions related to bone prominence, neuroma formation and lack of soft tissue cover. Despite many variations in tissue-targeted procedures being possible, the MDT prescription was followed accurately at surgery. Suggested modifications at primary amputation to decrease revisions include improved bone tip bevelling at BKA and greater soft tissue reduction at AKA. Severed nerve management needs to be rationalised to reduce primary neuroma formation and neuroma revision at stump-plasty requires consideration to attempt to reduce the recurrent risk. Removal of the fibular remnant in short BKA stumps at primary amputation could mitigate common peroneal nerve hypersensitivity later. Following stump-plasty, amputees recorded a significantly improved score in three of five dimensions of the EQ-5D-L5 questionnaire: activities, anxiety levels and pain. CONCLUSION AND CLINICAL SIGNIFICANCE: Primary ballistic injury dictates the level of amputation and the resultant stump quality. Issues arising in these complex amputee stumps benefited from measured decisions and specialist care delivered by the MDT. Stump-plasty aims to improve the amputees’ prosthetic fit, mobility and health. HOW TO CITE THIS ARTICLE: Godwin Y, Almaqadma A, Abukhoussa H, et al. Stump-plasty: An Operation Born of Necessity in Gaza. Strategies Trauma Limb Reconstr 2021;16(2):102–109.