WELCOME

THE DAILY TOPICS PRESENTATION

TO

Dr Md Jobayer Al Mahmud
MS Phase B Resident
Amputation
Outline
• History

• Indication

• Levels of amputation

• Preoperative evaluation

• Operative techniques

• Technical aspects

• Postoperative care

• Complications

• References
 History
• The word amputation is derived from
from the Latin amputare, ‘to cut away’.

• The English word “amputation’’ was

first applied to surgery in 17 century
th

by Peter Lowe in 1612.

• Historically was given as punishment

• However stimulated by the

aftermath of war.
 History (cont…)

• It was a crude procedure by which limb was

rapidly severed from unanaesthesized patient.

• Hippocrates was the first to use ligature.

• Ambroise Pare ( a France military surgeon)

introduced artery forceps. He also designed
prosthesis.
Indication

Alan Apley encapsulated the

indications for amputation in
the ‘three Ds’:
1. Dead or dying limb

2. Dangerous limb

3. Damn nuisance
Indications (cont…)
Dead or dying limb
• Peripheral vascular disease
• Severe traumatised limb
• Burn
• Frost bite
Indications (cont…)
Dangerous limb
• Malignant tumour
• Lethal sepsis
• Crush injury
 Indications (cont…)
Damn nuisance

Remaining the limb is more worse than having no

limb at all because of:
• Pain
• Gross malformation
• Recurrent sepsis
• Severe loss of function
 Level selection
Subjective measures
Clinical examination:

• Skin quality, extent of ischaemia/infection

• Presence of pulse immediately above the level of amputation

Local function:

• Joint and residual limb length salvage is directly correlated to

functional outcome.
 Level selection (cont…)
Prosthetic design:

• Short stump – Slips out from the prosthesis

• Long stump - Pain, ulceration, incorporate of the joint in the prosthesis

Objective test

Non invasive procedures :

• Doppler USG

• Skin perfusion pressure

•Transcutaneous oximetry

Invasive procedures:

• Angiography
Level of amputation
Determination of level

• Zone of injury (trauma)

• Adequate margin (tumour)

• Adequate circulation (vascular disease)

• Soft tissue envelope

• Bone and joint condition

• Control of infection

• Nutritional status
 Pre operative evaluation
History

• Aetiology

• Co-morbidities
Physical examination

• CVS, renal and nervous system

Investigations

• Doppler indices

• Transcutaneuos O2 tension
 Pre operative evaluation (cont…)
Optimisation

• Anaemia, nutrition, hypotension, infection

Consultation

• Nephrologist, cardiologist, neurologist

Counselling and consent

• Procedure, anaesthesia, complications, prosthesis & limitations.

MESS score 7 or more
Ganga Hospital Open Injury Score
 Principles of amputation
• Adequate blood supply

• Skin incision should be marked properly

• Torniquet shouldn’t be used in case of vascular disease

• Proximal part of the flap contains muscle component and distal flap should
contain only skin & deep fascia

• Adequate flap length

• Nerve to be buried deep

• Proper dressing after surgery

• Postoperative active exercise should be given for proximal joint

 Criteria of ideal stump
• Length of the stump should be adequate.
• Muscle power should good in the stump and proximal joint.
• Full ROM in proximal joint.
• Healthy and non adherent scar.
• Adequate muscle covering over distal end and around the stump.
• Normal skin sensation.
• No neuroma.
Criteria of bad stump
• Small and inadequate size.

• Flabby musculature around the stump.

• Bony stump.

• Restricted ROM at proximal joint.

• Painful stump scar.

• Presence of neuroma.
 Technical aspects
Incision:

• Circular

• Elliptical

• Racquet

Skin flaps:

• Flap should be kept thick

• Tense sutures should be avoided

• Apex of fish mouth at the level of bony resection

• Total length of flap anterior + posterior = 1.5 times diameter

• Flap should be semicircular for conical stump

 Technical aspects (cont..)
Muscles:

• Divided at least 5 cm distal to intended bone

resection

• Stabilised by myodesis or myoplasty

Nerves:

• Neuroma formation is inevitable after transaction

• Draw nerve distally, section it, allow to retract

 Technical aspects (cont..)

Blood vessels:

• Large vessels should be double ligated

• Haemostasis achieved prior to closure

Bone:

• Avoid excessive periosteal stripping

• Bevel and smooth the bone end

Closure:

• Don’t close under tension

• Drains are necessary

 Amputation levels
• Forequarter amputation:

Entire upper limb + scapula + clavicle (lateral 2/3rd)

• Shoulder disarticulation:

Done at the level of shoulder with shoulder blade remaining

• Transhumeral:

Done at any level between supracondylar region to axillary fold

• Elbow disarticulation

• Transradial amputation:

Either proximal or distal

 Amputation levels (cont..)
• Wrist disarticulation

• Krukenberg’s amputation:

Gap between radius & ulna like a claw.

• Wrist amputation

• Hand and partial hand amputation

• Hindquarter amputation:

Standard, anterior flap & conservative hemipelvectomy

5 cm above the ASIS to pubic tubercle

• Hip disarticulation:

5 cm distal to adductor muscle & ischial tuberosity, 8 cm distal to greater

trochanter
 Amputation levels (cont..)
• Transfemoral amputation:

Short, medial & long transfemoral, supracondylar

Ideal length 25 from tip of greater trochanter and

minimum stump should be 10 cm
• Knee disarticulation
• Transtibial amputation:

Ideal length of the stump should be 12.5 cm to 17.5 cm

Amputation levels (cont..)
• Syme’s amputation:

Section of tibia-fibula 0.6 cm proximal to ankle retaining heel flap

• Chopart’s amputation:

Disarticulation of talonavicular & calcaneocuboid

• Lisfranc’s amputation:

Disarticulation of tarsometatarsal joint

• Gillies amputation (trans metatarsal)

• Ray amputation:

Amputation of toe + metatarsal head

 Dressing
Rigid dressing:

• Decreases oedema & postoperative pain

• Protect limb from trauma

• Early mobilisation

• Temporary prosthetic fitting

Soft dressing:

• Sterile dressing & crepe bandages applied.

Complications

Early complications:

• Bleeding and haematoma

• Flap necrosis

• Surgical wound infection

• Gas gangrene

Late complications:

• Phantom pain

• Phantom limb

• Dermatological complications

• Joint deformity
 Post surgical rehabilitation
• Primary goal – Reduce pain & oedema, increase strength, prevent
contractures.

• Instructed not to lie on a overly soft mattress.

• Early mobilisation should be encouraged.

• Limb desensitisation.

• Maintain joint range of motion.

• Prosthesis may be fitted a minimum of 8-12 weeks after surgery.

 Psychological stress
Up to 2/3rd amputee will manifest postoperative

psychiatric symptoms

• Depression

• Anxiety

• Crying spells

• Insomnia

• Loss of appetite

• Suicidal ideation
 References
• Selvadurai Nayagam, David Warwick. Orthopaedic
operations; Apley's system of orhtopaedics & fractures,
10 th
Ed; 12:325-328.
• Canale & Beaty: General principles of amputations:Campbell's Operative
Orthopaedics, 14 edition.
th

• John Ebenezer: Amputations; Textbook of

Orthopaedics, 4th Edition; 60:787-791.

• Internet