AMPUTATION

DR AHMAD AFFIQ HADRI BIN AHMAD FITRI

DEFINITION
• “Surgical removal of limb or part of the limb
through a bone or multiple bones”
• Derived from the Latin amputare - "to cut away“
• From ambi- (about, around) and putare (to-prune)
HISTORY
• Most ancient of surgical procedure.
• Historically were stimulated by the
aftermath of war.
• It was a crude procedure - limb was
rapidly severed from unanesthetized
patient.
• The open stump was then crushed or
dipped in boiling oil to obtain
hemostasis.
• Hippocrates was the first to use ligature circa 400BC
• Ambroise Pare - a France military
surgeon introduced artery forceps. He
also designed prosthesis in 16th century.
INDICATION
(3D DEAD , DEADLY , DAM NUISANCE)
• DEAD
• DRY GANGRENE
• DEADLY
• INFECTION EG : WET GANGRENE / NECROTIZING FASCITIS
• PERIPHERAL VASCULAR DISEASE / THROMBOEMBOLISM
• MALIGNANCY
• TRAUMA
• DAM NUISANCE
• NERVE INJURY
• CONGENITAL ANOMALIES – DYSMELIA
• RECURRENT SEPSIS
• LOSS OF FUNCTION
• OTHERS – MADURA FOOT / ELEPHANTIASIS
INDICATION
(3D DEAD , DEADLY , DAM NUISANCE)
INCIDENCE
• Male > Female (70:30)
• Younger patient <50 years old – traumatic amputation
• Older patient – peripheral vascular disease , diabetes
• Scoring use
• Mangled extremity severity index , used since 1990 (most useful)
• 7 and below : salvage , 8-12 : amputate
• Predictive salvage index
MESS (mangled extremity severity score)
PLANNING FOR AMPUTATION?
In HSNI setting
• Patient comorbid – high risk consent
• Infection - control using antibiotic and proper dressing
• Decision of level of amputation by
– Limb condition
– CTA finding
• Informed consent should be taken
• Blood picture – Hb , urea
• Amputation form
• Psychological counselling
• Plan for prosthesis & rehabilitation by physiotherapist &
rehabilitation team later
PRINCIPLE OF AMPUTATION
PRINCIPLE OF AMPUTATION IN CHILDREN
• Preserve the physis
• Amputation made over metaphysis – above
knee or distal forearm
• Diaphysis amputation are not recommended in
children because of progressive shortening of
residual limb , most critical in femur
• Disarticulate when possible – eliminate the
terminal overgrowth problem and subsequent
revision surgery
TECHNIQUE : DETERMINATION OF LEVEL
• Zone of injury (trauma)
• Adequate circulation (PVD)
• Adequate margin (tumour)
• Control of infection
• Soft tissue envelope
• Bone and joint condition
• Comorbid and nutritional status
• High voltage or burn injury require careful evaluation – deep tissue
necrosis may be present while superficial muscle remain viable
TECHNIQUE
• Skin
• ensure adequate coverage flap , to achieve tension-free closure. Interupped suture is preferable
• Racquet / posterior flap / fish mouth flap
• Muscle – ensure adequate padding coverage , closure by myodesis/myoplasty
• Periosteum – avoid proximal stripping above the amputation level to prevent
formation of bony spur
• Bone – to achieve smooth beveled anterior part
• Vessel – should secure by double ligation and hemostasis should be achieved prior
closure to prevent hematoma subsequently infection
• Nerve – draw distally, cut and let it retract proximally to prevent neuroma formation.
Ligation of large nerve may be performed if associated with vessel – vasa vasorum
TECHNIQUE
MYODESIS VS MYOPLASTY
• Myodesis : muscle and fascia is sutured to the bone using drill hole
• Myoplasty : muscle and fascia is sutured together to the opposing
muscle of the residual limb
TECHNIQUE : MYODESIS
TECHNIQUE : PREOPERATIVE
PROCEDURE
• Anesthesia – GA / spinal
• Position – supine
• Preincision – prophylactic antibiotic , skin prep and draped ,
application of tourniquet
TECHNIQUE : PROCEDURE BKA
• Outline flap long posterior flap and short anterior flap ,combined length should be
1.5x diameter of the leg at the level of amputation
• Dissection by layer until reach bone. Periosteum raised.
• Section tibia at level of incision and bevel anteriorly. Fibular section 2-3cm proximally
• Vessel identified and double ligated , nerve pulled down, ligated, cut and allow to
retract proximally
• Posterior flap created using blunt knife cutting along transected tibia
• Irrigation done and hemostasis secured
• Myodesis or myoplasty done over a drain after trimming msucle
• Close skin by interrupted non absorbable suture.
• Wound dressing applied.
LOWER LIMB AMPUTATION
LOWER LIMB AMPUTATION
LOWER LIMB AMPUTATION
LOWER LIMB AMPUTATION
LOWER LIMB AMPUTATION
BELOW KNEE AMPUTATION
• 15cm from tibial tuberosity
• Minimum length 8cm from TT
• Long posterior flap with scar anteriorly
• Fibula to be divided at higher level
LOWER LIMB AMPUTATION
ABOVE KNEE AMPUTATION
• Equal anterior and posterior flaps
• Ideal femur stump should be 25 cms long.
• Not done in children as growing epiphysis of
femur is in lower end.
• Minimum stump should be 10cms long.
• It is technically easy, healing chances are
better and faster.
• Cosmetic results poor, prosthesis fitting is not
• proper, pt limps while walking and need
support
UPPER LIMB AMPUTATION
• Transcarpal amputation
• Wrist amputation
• Forearm amputation
• Krukenberg’s amputation
• Done in trauma patient
• Forearm amputation
• Gap between radius and ulna to form claw
UPPER LIMB AMPUTATION
• Forequarter amputation
• Interscapulo thoracic amputation
• Excision of upper limb with scapula, lateral 2/3 of clavicle
• Indication – malignancy involving axial skeleton
COMPLICATION
EARLY COMPLICATION
• Hematoma and infection - application of rigid dressing
• Stump necrosis
• Wound breakdown – gapping more than 1cm required
• Phantom pain and sensation
• 3 source of pain (wound, back and phantom pain)
• Wound/surgical pain respond well to opioids
• Phantom pain vs phantom sensation
• Burning pain , aggravated by anxiety and stress
• Painkiller and desensitization
• If persist >6months postop – prognosis is unfavorable
LATE COMPLICATION
• Contracture
• Application of splint/backslab – eg BKA to prevent posterior popliteal tendon
contracture
• Amputee should lie prone / side lying 15 mins 3x a day to prevent flexion
contracture
• Neuroma
• Thickening of a nerve stump after amputation of a limb and is tender to
pressure and transmit strong pain signals.
• Telescoping
• Sensation that distal part of amputated extremity move proximally up
• Sensation that entire extremity shrunk up – eg hand is now up to the elbow
• Terminal overgrowth (in children)
• Choked stump syndrome/Stump edema
syndrome
• An incorrectly fitted socket may imposing pressure
distribution that can disturb local circulation.
• Edematous skin of the distal part of the stump become
pinched and strangulated may cause ulceration or
gangrene as a result of the impaired blood supply.
• The pigmentary changes is due to hemosiderin or blood
pigment deposited within the distal stump skin
• Terminal overgrowth
• Caused by appositional bone formation and is unrelated to growth of the
physis
• Elongated and pencil-shaped like
• Humerus > tibia/fibula > femur
IDEAL STUMP
1. Sufficient length to bear prosthesis
• Below knee 7.5 - 12.5 cm from tibial tuberosity
• Above & Below Knee 20cm stump
• Above Knee - 25 cm from greater trochanter
2. Rounded and conical for AKA stump , cylindrical for BKA stump
3. Adequate muscle padding – pain free
4. Adequate joint movement, blood supply.
5. Heal by primary intention
6. Scar - thin, placed where it is not exposed to pressure,
freely mobile over underlying tissues - not interfere with
prosthetic function
7. Skin should not be infolded and no redundant soft tissue.
POSTOPERATIVE MANAGEMENT
• Uncomplicated wound healing
• Control of edema
• By rigid dressing – diagonal and spiral bandaging should be used , avoid
circular turn
• Good bandaging mold the stump to conical shape to accept prosthesis
• Control of post operative pain
• Prevention of joint contracture by splinting or muscle excercise
• Rapid rehabilitation – wheelchair ambulation within 48 hours ,
prosthesis within 6 weeks , limb strengthening
POSTOPERATIVE MANAGEMENT
REFERENCES
• Bailey and Love’s Short practice of surgery
• Manipal manual surgery 4th edition