AMPUTATION

Moderator Prepared by
Dr. Chetan Singh Dr. Rohit Patel
 INTRODUCTION
Amputation : Loss of a limb or part of a limb

 The word amputation is derived from the Latin word amputare, "to
cut away"
 Should not be viewed as a failure of treatment but as the first step
in Rehabilitation
INDICATION
ABSOLUTE
 Only absolute indication : irreversible ischemia in
diseased or traumatized limb

RELATIVE
 Peripheral vascular disease
 Trauma

 Burns

 Frostbite

 Infections

 Tumors
 TRAUMA

 Most common in young patients

 Male >Female

 Lange’s absolute indications for amputation in type III C tibial

injuries :
o Crush injury with warm ischemia time of > 6 hrs
 Relative indications :
o Serious associated injuries
o Severe ipsilateral foot injuries

 Decision as to a limb which can be saved , should be saved or not

 Early amputation and prosthetic fitting :
◦ Decreased morbidity
◦ Fewer operations
◦ Shorter hospital stay
◦ Decreased hospital costs
◦ Shorter Rehabilitation
◦ Earlier return to work
• Acute trauma : functional stump length of stump must bemaintained
whenever possible
Score 6 or less salvageable limb, score 7 or more amputation
 Ideal length of amputation stump

 Above knee amputation : 23-27 cm from greater trochanter or 12 cm from

knee

 Below knee amputation : 12 -17 cm stump length

 Above elbow amputation : 20 cm from shoulder

 Below elbow amputation : 18 cm from olecranon

 Factors affecting level of stump

Section of bone above a joint may prevent use of best type of artificial joint

Retention of limb remnants below joint which cannot move distal part is not
justified

When B/K amputation not possible , disarticulation favored

In ischaemic limbs , level just below distal most pulsation

 Ideal stump
Conical shape ( ideal shape )
Ideal length
Good muscle power
Absence of neuroma
Bone well covered by muscles
Muscular and not flabby
free from infection
 What a stump
should look like
What a stump should
not look like
 Efforts should be aimed at

 Stump drainage and removal of drain in time

 Stump splinting

 Proper stump bandaging

 Early starting of stump exercises

 Stump hygiene and intermittent exposure to air

 AMPUTATION

OPEN(Guillotine Operation) CLOSE

-Done as an emergency procedure. -Done as elective

(like life threatening infection ) procedure.

-Wound is left open not closed

 OPEN AMPUTATIONS

 Skin not closed over level of amputations

 at least 2 surgeries used to create functional stump

 Required in :
Extensive contaminated injuries
Infection

 Guillotine amputations : all tissue from skin to bone cut at same level ;
wound left open for further management ; done as an emergency
procedure

 Open amputations with flaps where wound open , flaps covered later
 SURGICAL TECHNIQUE
Tourniquet : Advantageous, contraindicated in ischaemic limbs.

Skin Flap
Flaps should be kept thick
◦ Posterior skin flap should be => anterior skin flap
◦ With modern total contact prosthesis , location of scar not important
◦ Flap should not be adherent to the underlying bone
◦ Preferable to have atypical skin flap than higher level amputation
◦ Combined length of flaps should be 1/3 of circumference of limb at level of
amputation
 Muscles
◦ Muscles sectioned 5 cm distal to level of intended bone resection

◦ May be stabilized by myoplasty or myodesis

◦ Myoplasty : Suturing muscle to periosteum or fascia of opposing musculature

◦ Myodesis : Suturing muscle or tendon to bone

◦ Myodesis should be performed to have stronger insertion , help maximize

strength , minimize atrophy

◦ Myodesed muscle counterbalance antagonists and prevent contractures and

maximize residual limb function

◦ Myodesis contraindicated in severe ischemia due to increased risk of wound

breakdown
MYODESIS IN TRANSFEMORAL AMPUTATION
 Advantages of Myoplasty/Myodesis

Shape of stump is good

Muscles insulate cut nerve endings and bone from prosthesis

Muscles originating proximally to joint produce better stump mobility and increase
leverage

Muscles not acting on joint contract isometrically and assist in venous return

Prevent retraction and painful muscle contractions

 Blood vessels

Larger vessels doubly ligated

Tourniquet should be deflated before closure
Drain preferable for 48-72 hrs
 Nerves

After nerve is divided it almost always forms neuroma

Neuroma is painful if traumatized repeatedly

Techniques to prevent neuroma formation : end loop anastomosis ,

perineural closure , Silastic capping , sealing epineurial tube with butyl-
cyanoacrylate , ligation , cauterization or burying nerve ends in muscle
/bone

Strong tension should be avoided while stretching

Larger nerves may need ligation for blood vessels

 Bone

Excessive periosteal stripping contraindicated

May result in formation of ring sequestrum or bony overgrowth

Bone should be rasped to form a smooth contour- over anterior aspect for below
knee , lateral aspect of femur and over radial styloid

Fibula cut slightly proximally to produce conical stump

AMPUTATION OF LOWER LIMB
THE FOOT
 SYME AMPUTATION
• consist of bone section at
distal tibia and fibula 0.6 cm
proximal to the periphery of
the ankle joint and passing
through the dome of the
ankle centrally
• m/c caz of unsatisfactory
syme stump are post.
Migration of heal pad and
skin
• can be minimised by good
preop planning and surgical
technique.
 CHOPART AMPUTATION
• In chopart one or
more dorsiflexor of
ankle must be
transferred
• Lessening the
planter flexion
strength of the
Achilles tendon is
also necessary.
Transmetatarsal amputation
 Transtibial amputation
• m/c lower extremity amputation.
• rehabilitation after transtibial amputation in
nonischaemic limbs quite successful.
• Frequent
comorbidities in
patient with
ischaemic limbs
• blood supply
better on post.
and medial aspect
of leg
• long post. Flap
technique was
popularized by
BURGESS .
 Knee
disarticulation
• Results in --1)excellent
end bearing stump.
• 2)Creation of long lever
arm controlled by
strong muscles.
• 3)Stability of the
prosthesis.
 Transfemoral amputaion
• 2nd m/c amputation
• Imp for stump to be as long as possible to provide
strong lever arm to control prosthesis.
 Amputation of hip and pelvis
• Disarticulation of hip –1) indicated -- massive trauma,arterial
insufficiency,severe infection, massive decubitous ulcers.

• Boyd disarticulation of hip –;femoral vessels and nerve ligated----

sartorius,rectus femoris,pectineus,and iliopsoasmuscles detached---
gluteal muscles separated from insertions,sciatic nerve and short ext.
rotators devided----hamstring muscles detached from ischeal
tuberosity----finally closure of stump. Done.
 Hemipelvectomy
(hindquarter amputation)
• Frequently performed for tumors not adequetely resected by limb
sparing technique or hip disarticulation also done in life threatening
condition and arterial insufficiency.
• . Standerd hemipelvectomy ---- incision(ASIS-GT-PS) ---transection of
iliac arteries and division of int. iliac vessels ----- release of iliac crest
and gluteus maximus---division of symphysis pubis -------division of
muscle from pelvis.
Amputation of upper extrmities
 AMPUTATIONS OF SINGLE FINGERS
• INDEX RAY AMPUTATION Dorsal skin
incisions planned with marking pen.

Flexor digitorum superficialis and

flexor digitorum profundus tendons
severed proximal to lumbrical origin
after isolation and division of
appropriate neurovascular structures

First dorsal interosseous retained for

insertion into radial base of middle
finger proximal phalanx
MIDDLE OR RING FINGER RAY AMPUTATIONS
• Clinical appearance of unsalvageable
contracted and stiff middle finger after
gunshot wound to hand

• Planned palmar and dorsal incisions for ray

resection

• Cosmetic appearance after partial middle

finger metacarpal amputation.
 LITTLE FINGER AMPUTATIONS
• As much of the little finger as possible should be saved, provided that all
the requirements for a painless stump are satisfied.
• The insertion of the abductor digiti minimi is transferred to the proximal
phalanx of the ring finger
• THUMB AMPUTATIONS
Disarticulation of wrist
• Skin incision---reflection of
palmer flap and section of
wrist joint capsule ----
resection of tips of radial and
ulnar styloids with
preservation triangular
ligament and underlying joint
space---- completed
amputation
 Forearm(transradial) amputation
• Skin incision

• Flaps are reflected and bones and

soft tissue structures are devided

• Completed amputation
 Elbow disarticulation
• The elbow joint is an excellent level for amputation because the broad
flare of the humeral condyles can be grasped firmly by the prosthetic
socket and humeral rotation can be transmitted to the prosthesis.
• In more proximal amputations,humeral rotation cannot be thus
transmitted, so a prosthetic elbow turntable is necessary.
• The difficulties previously experienced in prosthetic fitting at this level
have been overcome by modern prosthetic techniques, and most surgeons
now believe that disarticulation of the elbow is usually preferable to a
more proximal amputation.
 Transhumoral (arm) amputation
• from the supracondylar region
of the humerus distally to the
level of the axillary fold
proximally.
Forequarter amputations
• removes the entire upper extremity in
the interval between the scapula and
the chest wall.
• The operation is performed more
rapidly and easily using the Littlewood
technique.(posterior approach).
• Incision—skin flap undermined from
clavicle—scapula drawn away from
chest wall with hook or retractor
levator scapulae rhomboids major ,
minor divided—exposure of
neurovascular structures –detailed
view of neurovascular structures
 POST OPERATIVE CARE
Treatment of stump crucial from time amputation is completed till definitive
prosthesis is fitted

Gradual shift from conventional soft dressings to rigid dressing

Rigid dressing :

POP cast applied to stump at conclusion of surgery

◦ Appropriate padding of all bony prominences
◦ Avoiding proximal constriction of ring
◦ Use of dependable cast suspension methods

If immediate weight bearing intended , true prosthetic cast should be

applied by certified prosthetist
 POST OPERATIVE CARE
 Prevent flexion or abduction contractures of hip

 2nd post op day : muscle setting and joint mobilization exercisesbegun

 Time for prosthesis application depends upon :

Age
Strength
Patient’s ability to protect stump from excessive weight bearing
 Early unprotected weight bearing may lead to sloughing of skin or
delayed wound healing
 Cast should be removed after 7-10 days
 COMPLICATIONS
 Hematoma
 Infection

 Wound Necrosis

 Contractures

 Pain

 Phantom limb sensation

 Dermatological problems
 Pain :
Phantom limb , Phantom pain, residual pain , pain from distant site
Back ache more common in amputees
Residual pain more often due to improper fitting
Painful neuroma usually is easily palpable
Phantom limb :
 Very common

 Usually not very bothersome

 Law of projection.

 Phantom limb pain bothersome , present mostly in proximal level amputations

 Conservative measures tried

Infection Wound necrosis
 AMPUTATIONS INCHILDREN

 Most often due to trauma followed by neoplasms , infection

 General body growth and stump growth important

 Considerations :
Preserve length as much as possible
Preserve important growth plates
Prefer disarticulation rather than amputation
Preserve knee joint whenever possible
Stabilize and normalize proximal portion of limb
 To prevent stump overgrowth , myodesis must be preferred at the time of
surgery
 Terminal overgrowth : appositional spike like new bone formation

 Regular prosthetic checking