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
