Amputation

By: John Paul Q. Galleros

 Amputation

 Surgical cutting of a limb or outgrowth of the body

 Removal of a limb or extremity through the continuity of a bone
 Absence of all or part of a limb as a result of surgery, trauma or disease
Classifications of Amputation

 Acquired Amputation
 Loss of a limb as the direct result of trauma or surgery.

 Congenital amputation
 The absence of part or all of an extremity at birth is more appropriately referred
to as congenital skeletal deficiency rather than a congenital amputation
Upper extremity amputation

 Levels of Amputation: Upper extremity stumps are classified by level of

amputation using terminology form that used for congenital skeletal
deficiency. First, the length of the stump must be measured.
 Above – elbow stumps are measured form the tip of the acromion to the
bone end; This measurement is compared to the sound side distance form
arcomion to the lateral epicondyle and is expressed as a percentage of
normal side length.
 Below – elbow measurement is whichever is longer in the stump, and to the
ulnar styloid tip on the sound side

 Objective: preserve maximum length and function since prosthesis offer a

poor substitute and cosmesis is equally important
% of N° Classification
Above elbow
0 Shoulder disarticulation
0 – 30 Humeral neck
30 – 50 Short above elbow
50 – 90 Long Above elbow
90 – 100 Elbow disarticulation
Below Knee
0 – 35 Very Short below elbow
35 – 55 Short below elbow
55 – 90 Long below elbow
90 – 100 Wrist disarticulation
Krukenberg Amputation
 the forearm stump after a below elbow amputation is converted into a
crude pinching mechanism by separating the lower ends of radius and
ulna and cover them with soft tissues
 no prosthesis is used and not popular because of its unsightliness
 Disarticulation through elbow gives a poor stump for prosthesis so it is
discouraged
Short Arm Stump

 amputation may be carried out within 2.5” above the anterior axillary
fold. In amputation at the shoulder, the head and neck of the humerus
should be preserved as possible to minimize disfigurement
Amputation of individual fingers

 Thumb (most commonly amputated digit, and loss of this digit will impair
the patient’s ability to grasp objects)
 Having the patient loss other digits, ability to grasp is affected but they will
still retain some grasping ability.
Multiple finger amputation

 Having loss more than one digit, surgeons may be able to construct
muscles to aid grasping ability
Metacarpal amputation

 Loss of the entire hand but wrist is still intact; the patient however doesn’t
have the ability to grasp
 Wrist disarticulation
 Loss of the hand, but upto the level of the wrist joint.
 Technology now exists to have plastic sockets made to serve as wrists
 although carpus disarticulation has occasionally been possible, this is not
often practical. Disarticulation at the radiocarpal joint is the much more
common site for total head amputation. The carpus is disarticulated at the
radiocarpal wrist, this has the advantage that the prosthesis is need not
include the elbow joint and the pronation and supination are retained
Forearm (transradial) amputation /
Below Elbow Amputation
 Classified by the length of the remaining stump. As stump length
decreases, so does the patient’s ability to pronate.
 the most proximal useful stump measures 1.5” below the insertion of the
biceps tendon. The prosthesis for this stump must be short to allow elbow
flexion yet long enough to hold the stump securely. This may be
accompanied with a special prosthesis
 Elbow disarticulation

 Removal of the entire forearm at the elbow

 patient still has the ability to hold weight
Above-elbow
(transhumeral) amputation
 above elbow amputation are most satisfactory at this level, because
above this functional efficiency
becomes less as shoulder ids approached and at least 2” of bone
stump should remain below anterior axillary fold. Although amputation may
be done through the condyles
of the humerus, the most frequent site is about 2 or 2.5” above the
joint line
 Shoulder disarticulation

 The shoulder blade remains.

 The collarbone may or may not be removed
Forequarter amputation
 Removal of the shoulder blade and collarbone.
 Surgeons would ideally leave some length of bone for prosthetic use
 severe deforming procedure with removal of scapula and most of clavicle
required for treatment of malignant disease
Amputation of the Lower Extremities

 the surgical level may be classified on an anatomical or functional basis

 objective: create a stump optimum for weight bearing
Foot and Ankle
 Lisfranc’s Amputation

 amputation through tarsometatarsal joint that allows function of the foot

distorts muscle balance of foot creating intractable equinos deformity
Chopart Amputation

 through the talonavicular and calcaneocuboid joints

 equinos deformity of stump develops
 similar to a foot of the gorse ans is difficult to have a satisfactory prosthesis
 Symes Amputation

 involves disarticulation at the ankle joints and may include removal of the
medial and lateral malleoli and distal/fibular flares
 not done in vascular conditions as higher level is necessary due to
insufficient blood supply - allows good end
 bearing, the heel pad being sutured into position over the distal end of
the tibia and fibula
 prosthesis is difficult in this type
Pirgoff Amputation

 amputation done which include tibiocalcaneal fusion

 rarely don
Partial Toe Amputation

 through the metatarsophalangeal joint

Partial Foot / Ray Resection

 resection of 3rd, 4th and 5th metatarsal and digit

Transmetatarsal

 through the midsection of all metatarsals

Below Knee Amputation (BKA)

 transtibial amputation
 best done at the junction of the middle and upper thirds of the tibia, between
8 and 18 cm. Below the tibial plateau
Below Knee Amputation (BKA)

 Short Below Knee

 less than 20% of tibial length
 Long Below Knee
 more than 50% of tibial length
 Non – ischemic Limb
 the ideal level for amputation below the knee is at the musculotendinous
junction of the gastrocnemius muscle. The distal third of the leg is not satisfactory
because there the tissues are relatively avascular and soft tissue padding is
scanty.
 Ischemic limb
 amputations performed in ischemic limbs are customarily at a higher level, for
example 10 – 12.5 cm. distal to the joint line, than are amputations in non –
ischemic limbs
 Gritti – Strokes
 a supracondylar amputation
 the patella, after the removal of its articular cartilage, is fastened with its
attached quadriceps ligament surfaces to the cut surface of the lower end
of the femur
 this gives a very durable stump with full end bearing
 the best kind of amputation
 Kirk’s Amputation
 a supracondylar tendoplastic amputation
 method is carried out through the calcaneus bone of supracondylar region
of the femur below the shaft
 - the quadriceps tendon which are included on the long anterior flap is cut
close to its patellar attachment grown over the end sutured with full end
bearing in all cases
 - symmetrical in contours from spurs and of maximum functional length
 Callander Amputation
 a supracondylar amputation with minimum tissue dissection
 - no muscle tissue is excised
 patella is removed from its bed in the quadriceps tendon leaving patellar
ligaments intact and incorporated in the long anterior skin flap
 - the cut of the supracondylar is lower here than in Kirk’s which is
higher
 Roger’s Amputation

 Knee joint disarticulation with arthrodesis (surgical fusion of the patella in

anatomical position of the patella to the front of femur) –
 no cutting of any spracondylar
 - no fibula if the length of the stump is 2 inches higher
 Knee Disarticulation

 through the knee joint

 Long Above Knee
 amputation of more than 60% femoral length
 Above Knee Amputation - because patients knee joint is lost, it is extremely important that
stumps be long as possible to provide a strong lever arm for control of prosthesis. The
conventional, constant friction knee joint used in the most AK prosthesis extends for 9 – 10 cm.
distal to end of prosthetic socket and the bone must be amputated this for proximal to the knee
to allow room for the joint –
 transfemoral amputation most commonly seen in the elderly
 - ideal length is 10 -12 inches below the greater trochanter
 - minimum stump length in which we can have control is 4 inches below the tip of greater
trochanter to fit and above knee amputation
 - greater difficulty in learning to control his prosthesis and achieving good gait since
proprioception from the knee joint is lost and he bears weight at the ischial tuberosity
 - hip flexion contractures easily occurs unless prevented x shorter stump
 – tend to become flexed and abducted due to the strong full of tensor fascia lata x long above
knee stump
 – tend to become flexed and abducted due to the intact abductor group which have a
mechanical advantage over the pull of the short tensor fascia lata
Hip
Hip Disarticulation

 amputation through the hip joint, pelvis intact

 - should be avoided because there is no substitute for anatomical joint
Hemipelvectomy (Hind Quarter
Ablation)
 resection of lower half of the pelvis and bears weight on soft tissues and
chest cage
Hemicorporectomy (Humpty –
Dumpty)
 amputation of both lower limbs and pelvis below L4/L5
 Amputation in Children

 children amputees make up an interesting segment with great

rehabilitation potential - every effort must be made to save the epiphyseal
growth centers
 Surgical ablation should be defend as possible since the amputated limb
tends to at a slower rate than the congenitally deformed limb
Amputation in Children

 Causes: - congenital - traumatic - neoplastic/tumor

 Objectives of Amputation and Prosthesis - facilitate early function - enhance appearance
- produce optimal stump for maturity
 Compilation: bone overgrowth - this overgrowth leads to skin performance and 2nd
degree low infection - often type in humerus, fibula or tibia and unknown cause - usual
treatment is revision of stump, traction at night in the prosthesis is an initial approach
 Prosthesis - standard type that is comfortable and simple - consider the growth factor
(intellectual capacity and neuromuscular maturation) in prosthesis needs frequent
readjustment in the first 2 years and the 2nd major growth spurt is between 11 – 13 in girls
and 13 – 15 in boys
 Upper Limb Amputees - provide a mitten prosthesis as early as 6 months or at the age of
sitting
 Lower Limb Amputees - provide an artificial limb at 9 months (standing age) for the child
to develop an engram or circuitry
 Complications
 There are a number of factors that influence the risk of complications from
amputation:
 age
 type of amputation
 general state of health

 Heart complications
 such as heart attack or heart failure (when the heart has difficulty pumping
blood around the body), blood clots (venous thrombosis), infection at the site of
the surgery, pneumonia (infection of the lungs) further surgery being required
 Complications

 Planned amputations
 involve the leg and are carried out in older people with a restricted blood supply,
who are in a poor state of health and who usually have a chronic (long-term)
health condition, such as diabetes
 Emergency amputations
 involve the arm and are usually carried out in younger people who are often in a
good state of health
Phantom Limb Sensations

 is the sensation of the limb that is no longer there

 described as a tingling, burning, itching, or pressure sensation, sometimes a
numbness
 distal part of extremity most frequently felt
 the sensation is responsive to external stimuli
Phantom Limb Pain

 often follows amputation

 characterized as either a cramping or squeezing sensation, or a shooting
or a burning pain
 pain may be localized or diffuse; it may be continuous or intermittent and
triggered by some external stimuli
 Contractures
Level of Amputation Typical Contracture Method of Prevention
Above Knee Extend When supine in bed, the
patient should be
positioned with sand
bags to prevent external
rotation exercises are
also indicated.

Abduction Range of motion

exercises and resistive
exercises to the hip
abductors are useful

Flexion The patient spent large

portions of each day in
the position
Below Knee Hip Flexion Methods of prevention
are identical to those
listed under above knee
Amputation. Methods of
prevention are identical
PROGNOSIS

 There are number of factors that may affect healing. Postoperative

infection, whether from external or internal sources is a major concern.
Individual with contaminated wounds, from injury, infected foot ulcers, or
other causes are at greater risk. Research indicates that smoking is major
deterrent to wound healing, with one study reporting that cigarette
smokers had a 2:5 higher rate of infection and reamputation than non –
smokers. There is some indication that failed attempts at limb
revascularization may negatively influence healing at below – knee levels.
Other factors influencing wound healing are the severity of the vascular
problems, diabetes, renal disease, and other physiologic problems such as
cardiac disease.
PROGNOSIS

 Upper Limb Amputees

 provide a mitten prosthesis as early as 6 months or at the age of sitting
 Lower Limb Amputees
 provide an artificial limb at 9 months (standing age) for the child to develop an
engram or circuitry