AMPUTATIONS

-RISHI RAJGUDE
(Intern)
Definition
• Amputation is the removal of limb, part or total from the body.
• Disarticulation is the removal of limb through a joint.
• Generally the amputation of lower Limb are more common than those of upper
limb
Incidence:
• Age - 50-70yrs
• Gender - Male= 75%, Female= 25%
• Limbs - Lower limb = 85%, Upper limb= 15%
Indications
• Trauma - RTA or Gun shot
• Malignant tumors
• Nerve injuries & infections
• Extreme heat and cold- burn, gangrene
• Peripheral vascular insufficiency
• Congenital absence of limbs or malformation
• Severe infection
Causes of Amputation
• Natural causes
• Accidental causes
• Ritual, Punitive and legal amputations
• Cold steel & gunshot causes
Natural causes
• Congenital absence
• Arterial diseases
• Frostbite
• Ergot and other toxins
• Wound infections
• Diabetes Mellitus
• Dietary deficiency
• Tumors
Accidental causes
• Falls when running or from heights
• Crushing by trees
• Savaging by wild creatures
• Natural hazards
Gangrene of right great toe in diabetic patient. Phalanges were infected, but some
lateral toe skin was salvageable. Forefoot systolic pressure was adequate.
Closure after disarticulation of great toe by using lateral toe flap. Features of Kritter
irrigation system include widely spaced sutures to allow egress of irrigation fluid
and fixation of irrigation catheter to skin.
Types of Amputations
• Closed amputation
• Open amputation
Closed amputation
• It is done as an elective procedure.
• After amputations, the soft tissues are closed primarily over the bony stump.
E.g., above knee, below knee etc.
Open amputation (Guillotine Operation)
• It is done as an emergency procedure. E.g., life threatening infections.
• After amputations, the wound is left open and not closed.
• 2 types depending upon the skin flaps
1) Open amputation with inverted skin flap.
2) Circular open amputation.
Principles of Close amputation
• Tourniquets: desirable except in ischemic limbs.
• Level of amputation: it is very important to fit the prosthesis.
• Skin flaps: good skin coverage is important. Skin should be mobile & sensitive.
• Muscle: is divided at least 5cm distal to the level of intended bone section and
sutured.
Tourniquet
 Contd.
• Methods of muscle suture
• Myodesis- muscle suture to bone
• Myoplasty- muscle is sutured to opposite muscle group under appropriate tension.
• Nerves: cut proximally & allowed yo retract. Large nerves are ligated before division.
• Blood vessels: doubly ligated & cut. Then the tourniquet is released & hemostasis is
completed.
• Bone: section above level of muscle section.
• Drains: removed after 48-72 hours.
Myodesis in transfemoral amputation. Adductor
magnus tendon (arrow) is pulled into cut end of distal
femur and secured through drill hole in lateral cortex.
Contd.
• Compression dressing: either elastic or a rigid plaster dressing fitting
immediately.
• Absolute bed rest with limb elevation: this is acceptable for the conventional
prosthesis with adequate vascularity.
• Limb fitted: conventional prosthesis is fitted a minimum of 8-12 weeks after
surgery. Rigid dressing with temporary pylon prosthesis may be selected as an
alternative.
Principles of open amputation:
• Indication:
1. Severe infections
2. Severe crush injuries
• Types:
1. Open amputation with inverted skin flaps: it is a common choice.
2. Circular open amputation: wound is kept open & closed twice by suture, skin
graft or re-amputated.
Lower limb after
guillotine amputation
Partial closure of infected transtibial amputation
Principle of open amputation
• Rx following amputation:
1. Rigid dressing concept (pylon) : POP cast is applied to the stump over the
dressing after surgery.
2. Soft dressing concept: the stump is dressed with the sterile dressing and
elastocrepe bandage.
Complications
• Hematoma
• Infections
• Necrosis
• Contractures
• Neuroma
Causalgia
• Stump pain
• Phantom sensation
• Hyperesthesia of stump
• Stump edema
• Bone overgrowth
• Causalgia
Diagrams of end-on and side views of amputation stumps.
Local resection produces uneven tension; this is reduced and
evenly distributed after wedge resection.
Questions ?