Amputation

Dr. C. O. Udemezue
MBBS; FWACS-Ortho
Consultant Orthopaedic Surgeon
 Outline
• Introduction
• Epidemiology
• Indications and contra-indications
• Classification
• Levels of amputation
• Pre-operative details
• Intra-operative considerations
• Post-operative management
• Conclusion
 Introduction
• Amputation is removal of whole or part of the limb
• Disarticulation: removal through the joints
• It is the most ancient of surgical procedures.
• Early surgical amputation was a crude procedure.
Limb was rapidly severed from an un-
anaesthesised patient and the open stump was
then crushed or dipped in boiling oil to obtain
haemostasis. The procedure was associated with a
high mortality rate.
 Epidemiology
• 1.7million indiviuals in USA are amputees
• M>F
• Lower limb > Upper limb
• Diabetes mellitus is the leaving cause of
amputation in our environment
 Indications
Colloquially 3 D’s
• Dead (or Dying) • Dangerous limb
• Dry Gangrene – Malignant tumours
• Osteosarcoma
• Peripheral Vascular disease • Marjolins ulcer
Atherosclerosis • Melanoma
Embolism – Potentially lethal sepsis
DM – Crush Injury
Thromboangitis obliterans – Wet Gangrane
Ergot
• Severe Trauma • Damn Nuisance
• Burns – Pain
• Frost bite – Gross malformation
• Bone setters gangrene – Recurrent Sepsis
– Severe loss of function
– Madura foot
– Elephantiasis
 Contra-indications
• Poor Health impairing patients ability to
tolerate anaesthesia and surgery.

• Lack of informed consent.

 CLASSIFICATIONS/ TYPES
• I: Emergency
• Elective
• II: Provisional – Guillotine
• Definitive (Classical)
• Revision
• III: Cone bearing
• End bearing
• IV: Weight bearing
• Non-weight bearing
 LEVEL
• Upper Extremity • Lower Extremities
– Ray amputation
– Finger amputation
– Ray amputation
– Wrist disarticulation – Partial foot
– Below elbow amputation amputation
– Elbow disarticulation
• Choparts-midtarsal jts.
– Above elbow amputation
– Shoulder disarticulation • Lisfrancis-tarso-
– Fore-quarter amputation metatarsal
– Krukenberg’s operation • Trans metatarsal
• Thro’
metatarsophalalgeal
(toe)
 LEVEL CONT’D
• Syme amputation
• Pirogoff’s amputation
• Below knee amputation (Trans tibial)
• Knee disarticulation
• Gritti-Stokes amputation
• Trans-femoral amputation : Above knee
• Hip disarticulation
• Hindquarter amputation

• Hemicorporectomy (At the waist)

 PRE-OPERATIVE PREPARATION
• Multidisciplinary
• Patient should be given time to come to terms with the
inevitability of amputation
• This approach prevents the feeling that the loss of limb is
being imposed on the individual
• Consent and counselling
• General condition of the patients need to be maintained
and/or improved upon (Resuscitation)
• Physiotherapy before the operation enable patient to become
used to the exercise
• Antibiotics
• Tetanus prophylaxis
 QUALITIES OF AN IDEAL STUMP
• Should heal adequately
• Should have rounded, gently contour with adequate
muscle padding
• Should have sufficient length to bear prosthesis
• Should have thin scar which does not interfere with
prosthetic function
• Should have adequate adjacent joint movement
• Should have adequate blood supply
Parameters for determining site of adequate
blood flow
• Clinical:
-Lowest palpable pulse
-Skin temperature
-Bleeding at surgery
Others:
Doppler ultrasonography to measure arterial pressure at
proposed site
SBP >70mmHg
Comparison to brachial->35%
Xenon 133 clearance
Transcutaneous oxygen tension
• Flourescein angiography
• Infrared thermography
• Pulse volume recording
 INVESTIGATIONS
• FBC
• CRP
• Lymphocyte count
• Serum albumin
• FBS
• E/U/Cr
• Imaging
• Radiograph-plain
• CT Scan
• MRI
• Technitium-99m pyrophosphate
• Doppler USS
• Trans cutaneous oxygen pressure measurement
>40mmHg
 Selection of Level of Amputation
• Determined by the following
• Disease process
• Vascular supply of flaps
• Requirement of limb fitting procedures and
techniques available at the time
 Site of Election
• Golden Rule: Too low a level can be remedied but
too high removal of a limb is beyond repair

• Guidelines
– Forearm: Optimum – 20cm from olecranon
– Upper arm : Optimum 20cm from olecranon
– Lower leg: Syme: Tibia & Fibula divided at or immediately
above level of ankle
– Tibia 14cm
– 8 cm minimum
– Thigh Optimum : 25-30 cm from tip of the trochanter
 OPERATIVE PRINCIPLES
• Meticulous surgery plays an important part in wound
healing especially with respect to tissue viability
• Tourniquet : Unless in attendant insufficiency
• Skin flaps: Cut so that their combined length equals
one & half times the width of the limb at the site of
amputation
• Muscles: Divided distal to proposed site
– Opposing muscle groups sutured
• Nerves: Divided proximal to the bone cut
• Vessels : Doubly ligated
• Tourniquet removed & bleeding point ligated
• Skin: Sutured without tension
• Drainage
• Stump: Firmly bandaged
 Post-operative care
• Aim is integrated rehabilitation of amputee to optimal
functional level
• General Care
– Control of pain
– Prevention of oedema
– Prevention of Infection
– Prevention of DVT
– Care of concurrent medical problems
– Biochemical monitoring
• Physiotherapy
– Muscles are exercised
– Joints kept mobile
– Patients taught to use Crutch and prosthesis
• Regular stump dressing
• Bandaging
 Complications
Early Late
• Haemorrhage • Stump ulceration
• Haematoma • Flap necrosis
• • Painful scar
Infection
• Phantom limb
• Pain • Phantom pain
• Joint stiffness
• Osteomyelitis
• Osteoporosis &
tendency to fracture
 Amputation in Children
• Standard Surgical Principles
• Preservation of physis
• Advantage of disarticulation
• Preservation of stump shape
• Soft tissue coverage
 Outcome & Prognosis
• Success is multifactorial in terms of functional
& emotional satisfaction
• Goal is to achieve useful residual limb in an
individual who is active with a positive
attitude who accepts the amputation and who
continue to be a productive member of
society
 REHABILITATION
• Aim: To bring patient to an optimum of
physical, mental, emotional, social, vocational
& economic efficiency
• Team approach
 PROSTHESIS
• Is
Upper
the substitution
limb prosthesis
of a part of the body to achieve optimum
function
– Depends on level of amputation
• Advantages
– Electrically powered limb available
– Cosmetics
– Function of the part
• Lower limb prosthesis
– Ambulation
– Depends on level of amputation

• Disdavantages
– Infection
– Pressure ulcer
– Joint disability
 Energy expenditure while walking in
amputees
• Syme - 5%
• Traumatic BKA - 25%
• Vascular BKA - 40%
• Traumatic AKA - 68%
• Vascular AKA - 100%
• BKA + BKA - 40%
• AKA + BKA - 118%
• AKA + AKA - >200%
Is amputation the end of life?
 Conclusion
• Amputation is a life-saving procedure and
involves multi-disciplinary approach
(Orthopaedic surgeon, psychologist,
physiotherapist, prosthetist, occupational
therapist, nurses etc).
• Adequate counseling is required for optimal
outcome after amputation