Strategies in Trauma and Limb Reconstruction

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VOLUME 16 , ISSUE 2 ( May-August, 2021 ) > List of Articles

Original Article

Stump-plasty: An Operation Born of Necessity in Gaza

Yvette Godwin, Ahmed Almaqadma, Hafez Abukhoussa, Mohammed Obaid

Keywords : Ballistic injury, Cohort study, Lower limb amputee, Stump-plasty, Stump revision

Citation Information : Godwin Y, Almaqadma A, Abukhoussa H, Obaid M. Stump-plasty: An Operation Born of Necessity in Gaza. 2021; 16 (2):102-109.

DOI: 10.5005/jp-journals-10080-1526

License: CC BY-NC-SA 4.0

Published Online: 27-10-2021

Copyright Statement:  Copyright © 2021; The Author(s).


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.

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  1. Godwin Y. An epidemic of lower limb gunshot injuries. PMFA J 2020. Available at:
  2. Godwin Y. We need to talk about amputation – a difficult conversation in the developing world. PMFA J 2020. Available at:
  3. EuroQol Research Foundation. EQ-5D-5L User Guide.2019. Available at:
  4. Burgess EM, Zettl JH. Amputations below the knee. Artif Limbs 1969;13(1):1–12. PMID: 5363259.
  5. Burke FD, McGrouther DA, Smith PJ. Principles of hand surgery. 1st ed. Churchill Livingstone; 1990. p. 89.
  6. Hansen ST. The type-IIIC tibial fracture: salvage or amputation. J Bone Joint Surg Am 1987;69(6):799–800. PMID: 3597490.
  7. McCarthy ML, Mackenzie E, Edwin D, et al. Psychological distress associated with severe lower-limb injury. J Bone Joint Surg Am 2003;85(9):1689–1697. DOI: 10.2106/00004623-200309000-00006.
  8. Pierce RO, Kernek CB, Ambrose TA. The plight of the traumatic amputee. Orthopedics 1993;16(7):793–797. PMID: 8361918.
  9. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project (LEAP) – the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am 2010;41(2):233–239. DOI: 10.1016/j.ocl.2009.12.006.
  10. Law MD Jr, Stein RE. Late infection in healed fractures after open reduction and internal fixation. Orthop Rev 1993;22(5):545–552. PMID: 8316418.
  11. Ahmad SS, Kohl S, Evangelopoulos DS, et al. Silent chronic osteomyelitis lasting 30 years before outburst of symptoms BMJ Case Rep 2013. DOI: 10.1136/bcr-2013-009428.
  12. Ives GC, Kung TA, Nghiem BT, et al. Current state of the surgical treatment of terminal neuromas. Neurosurgery 2018;83(3):354–364. DOI: 10.1093/neuros/nyx500.
  13. Vernadakis AJ, Koch H, Mackinnon SE. Management of neuromas. Clin Plast Surg 2003;30(2):247–268. DOI: 10.1016/s0094-1298(02)00104-9.
  14. Peters BR, Russo SA, West JM, et al. Targeted muscle reinnervation for the management of pain in the setting of major limb amputation. Sage Open Med 2020;8(15):1–7. DOI: 10.1177/2050312120959180.
  15. Frantz TL, Everhart JS, West JM, et al. Targeted muscle reinnervation at the time of major limb amputation in traumatic amputees: early experience of an effective treatment strategy to improve pain. JB JS Open Access 2020;5(2):e0067. DOI: 10.2106/JBJS.OA.19.00067.
  16. Fracol ME, Dumanian GA, Janes LE, et al. Management of sural nerve neuromas with targeted muscle reinnervation. Plast Reconstr Surg Glob Open 2020;8(1):e2545. DOI: 10.1097/GOX.0000000000002545. Available at:
  17. Woo SL, Kung TA, Brown DL, et al. Regenerative peripheral nerve interfaces for the treatment of postamputation neuroma pain: a pilot study. Plast Reconstr Surg Global Open 2016;4(12):e1038. DOI: 10.1097/GOX.0000000000001038. Available at:
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