1. APOLLO BGS HOSPITALS

2. “Surgical removal of limb or part of
the limb through a bone or multiple
bones”
Disarticulation
“Surgical removal of whole limb or part of
the limb through a joint”

3. Most ancient of surgical procedure.
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.
Ambroise Pare ( a France military
surgeon) introduced artery forceps. He
also designed prosthesis.
Amputation of a leg without anaesthetic, 1593

4.  Derived from the Latin amputare.
 "to cut away", from ambi- ("about", "around") and putare
("to prune").
 The English word "amputation" was first applied to surgery
in the 17th century.

5. In Europe and the USA -≈ 80 % of amputations are performed
for ischaemia secondary to vascular disease.
The life expectancy of the elderly group of patients is limited,
mainly due to concomitant cardiovascular and cerebrovascular
disease.
 Approximately 50 per cent of vascular amputees will die within
3 years.
The main consideration in performing the amputation is to
obtain stump healing

6. ‘DDD’
Dead
Deadly
Dam Nuisance

7.  L/E-≈20-30% of all amputations
 U/E- 77%
 Trauma is the leading indication for amputation
in younger age group.
 Men > women.
 The only absolute indication for primary
amputation is an irreparable vascular injury in
an ischemic limb.
 The decision to amputate should be made
immediately—a late amputation represents
a failure of management.

8.  L/E 60-70% of amputations
 U/E 6%
Patient with rest pain, sepsis, or gangrene
with the aim of primary wound healing.
+/-Diabetes
Most significant predictor of amputation in
diabetes:- peripheral neuropathy
Decrease ankle-brachial blood pressure
index

9.  Clostridial myonecrosis-
 Within 24 hr.
 Bronze discoloration
 Serosanguineous exudates, musty odor
 Immediate radical debridement
 I/V penicillin or clindamycin
 Streptococcal myonecrosis- 3-4 days
 Anaerobic cellulitis or necrotizing
fasciitis that is unresponsive to antibiotics
and surgical debridement.

10.  L/E ≈5% of all amputations
U/E -8%
 Amputation is performed less frequently
with the advent of advanced limb-salvage
techniques.

11. Burns
 Delayed aputation
 Local infection
 Systemic infection
 Myoglobin induced renal failure
 Death
Frostbite
 Direct tissue injury- ice crystals in ECF
 ischaemic injury- vascular endothelium
 Clot formation
 wait 2-6 month demarcation

12. congenital absence of the fibula, resulting in
shortening of the lower leg
Deformities of digits and/or limbs
Extra digits and/or limbs (e.g. polydactaly)

13. Types of amputation include
Leg
I.Amputation of digits(ray,transmetatarsal)
I.Partial foot amputation (chopart, lisfranc )
II.Ankle disarticulation (syme)
III.Below-knee amputation (transtibial eg. Burgess
,skew)
IV.Knee-bearing amputation (Gritti or gritti-stokes)
V.Above knee amputation (transfemoral)
VI.Hip disarticulation
VII.Hemipelvectomy/hindquarter amputation

14. Arm
I.Amputation of digits
II.Metacarpal amputation
III.Wrist disarticulation
IV.Forearm amputation
(transradial)
V.Elbow disarticulation
VI.Above-elbow amputation
(transhumeral)
VII.Shoulder disarticulation and
forequarter amputation
VIII.Krukenberg procedure

15. GENERAL PRINCIPLES FOR AMPUTATION SURGERY
Involve appropriate management of skin, bone,
nerves, and vessels, as follows: -
 The greatest skin length possible should be
maintained for muscle coverage and a tension-free
closure.
 Muscle is placed over the cut end of bones via a
myodesis (ie, muscle sutured through drill holes in
bone),
 A long posterior flap sutured anteriorly, or a well-
balanced myoplasty (ie, antagonistic muscle and
fascia groups sutured together ).

16. Skin flaps are as broad as possible and the scar
should be pliable, painless, and nonadherent.
For most transfemoral and nondysvascular
transtibial amputations, equal length anterior and
posterior flaps are used, placing the scar at the
distal end
Long posterior flaps are often used in
dysvascular transtibial amputations

17.  Nerves are transected under tension, proximal to the cut end of bones
 Ligation of large nerves can be performed when an associated vessel is present.
 The larger arteries and veins are dissected andseparatelyligated.
 Bonyprominences around disarticulations are removed with a saw and filed smooth.
 Below-knee amputations are best performed 12.5-17.5 cm below the joint line for
nonischemic limbs for ischemic limbs, a higher level of 10-12.5 cm below the joint
line

18. In adult periosteum should not be stripped proximal to the level of
transection .
In children 0.5cm removal of distal periosteum prevents terminal
growth .
Ideal stump
Should be of optimal length
Should be smoothly rounded and firm with good vasularity of flaps
Bony ends should be smooth with no projecting ends
The resulting scar should be fully mobile and should not be
adherent nor infolded

19. Preserve the physis.
 Amputations through the metaphysis (such as above-knee or distal forearm
level) or diaphysis are not recommended in children because of the
progressive relative shortening of the residual limb.
Disarticulate when possible
The pediatric amputation stump becomes conical with growth, so
preservation of bony architecture such as a short segment of proximal fibula
or the distal condyles of the humerus will assist in subsequent rotational
control of the prosthesis.

20. To heal -a palpable pulse over the dorsal pedal or posterior tibial artery
Digital block anesthesia is ideal
 all four digital nerve branches are blocked.
 If multiple toe amputations are required, an ankle block, epidural anesthesia,
spinal anesthesia, or general anesthesia can be used.

21. Tennis-racket - a straight incision along the dorsal surface metatarsal bone with
circumferential incision around the base of the toe.
Goal- to save all available viable skin on the toe
The incision down to the bone to prevent damage to the digital vessels laterally
The metatarsal bone is transected across the shaft

22. In case of trauma if possible
the skin is approximated with
simple interrupted non
absorbable monofilament
sutures

23. Ray amputation of great toe/ more than one smaller toe is required then
it is preferable to perform a trans metatarsal amputation of the forefoot.
Because-adequate skin coverage is difficult to achieve with a great-toe /
multiple-toe ray amputation
Ray amputation of more than one of the middle toes causes central
deviation of the remaining outside toes, leading to ulcerations

24. Highest failure rate among amputation for iscchemic limb
Indication- tissue loss in the forefoot involving, two or more of the other
metatarsal heads, or the dorsal forefoot
Contraindicated-
If extensive skin loss on the plantar surface of the foot or on the dorsum
proximal to the midshaft of the metatarsal bones.
(The peroneus longus and the peroneus brevis insert on the proximal portions
of the fourth and fifth metatarsal bones; if these insertions are sacrificed,
inversion of the foot results, leading to chronic skin breakdown)
A preexisting footdrop

25. OPERATIVE TECHNIQUE
Spinal, epidural, or general anesthesia
Incision
 dorsum - at the level of the middle of the shafts of the metatarsal bones,
extending medially and laterally to the level of the center of the first and fifth
metatarsal bones, respectively
 plantar- incision is extended distally to a point just proximal to the toe crease

26. A plantar flap is created by making an incision adjacent to the
metatarsophalangeal joints
The first metatarsal is transected perpendicular to its shaft at the level of the
dorsal skin incision
This process is repeated for each individual metatarsal bone
All visible digital arteries are clamped and tied with absorbable ligatures

27. amputation of the foot by a
mid tarsal disarticulation.
these amputations are not
recommended in patients with
or without vascular damage.
Rationale-the poor healing and
inevitable equinus deformity
caused by unopposed
contraction of the ankle

28.  amputation of the foot between the metatarsus and tarsus.

29.  Best for patients with extensive non-ischaemic damage
to the forefoot
It involves removal of foot with calcaneum and cutting of
lower end of tibia just above the ankle mortis with
retaining the heel flap
The anterior incision just below the lateral malleolus
and moved across the sole to a point ½ inch below
medial malleolus
amputation provides an end-bearing stump that in many
circumstances allows ambulation without a prosthesis
over short distances.
 It is an excellent amputation for children, in whom it
preserves the physes at the distal end of the tibia and
fibula

30. ◦ The Boyd procedure provides a
broad weight-bearing surface of
the heel by creating an
arthrodesis between the distal
tibia and the tuber of the
calcaneus after talectomy
◦ Compared to a Syme’s
amputation, it provides more
length and better preserves the
weight-bearing function of the
heel pad.

31. Indicated for a patient with extensive wet
gangrene
A circumferential incision is made at the
narrowest part of the ankle (ie., At the proximal
malleoli)
line of incision across the tendons, thereby
preventing bleeding from transected muscle bellies.
 The incision is then carried through the skin and
soft tissues to the bone.
 The distal tibia and fibula are then divided with a
gigli saw.
 Hemostasis is achieved with suture ligation and
electrocauterization.

32. This is the most common amputation performed for vascular disease
variant of the Burgess long posterior flap technique.
complex technique- the skew-flap which produces a more ideal conical stump.
 Healing good-a palpable femoral pulse +warm skin and free of lesions at the
distal calf

33. OPERATIVE TECHNIQUE
Epidural, spinal, or general
anesthesia.
The primary level of amputation - 10
cm from the tibial tuberosity ,
 The stump should be as short as
possible to maximize the chances of
healing but long enough to allow
optimal use of a below-knee prosthesis:
9 cm from the knee joint line is ideal
in thin legs, 11 cm in fat legs, and 7.5 cm
can be regarded as the absolute
minimum.

34. Tibia transected just proximal to skin incision
Fibula transected at least 1 cm cephalad to the tibial
transection
The anterior & posterior tibial, and peroneal arteries
and veins are clamped
The posterior tibial and sural nerves are clamped

35. The bulk of the flap is reduced by
complete removal of the soleus
The flap brought forward, deep fascia
sutured to periosteum and deep fascia,
The skin edges are accurately apposed
& sutured over a vacuum drain
Padded posterior splint or cast is
applied to prevent flexion contracture.

36. In non-ischaemic limbs where the knee joint is non-functional
Advantages: it is quick and easy to perform, the creation of an endbearing stump
and preservation of the distal femoral physes, which is particularly desirable in
children
Lateral flaps are end-bearing, has good leverage, and the bulbous bony shape can
be used to suspend the prosthesis
Knee disarticulation is most useful in young athletic amputees in whom a below-
knee amputation is not feasible.

37. Variety of through-knee amputation
Useful for patients with or without vascular disease.
 The operation is useful for patients with ischaemic limbs who have good
perfusion below the knee but do not have the posterior flap of skin available to allow
below-knee amputation
 The key point is the fixation of the patella remnant to the cut end of the femur.

38. Indication
Lower extremity is unsalvageable and there is no femoral pulse.
Tissue necrosis or uncontrollable infection extending cephalad to the midleg.
The procedure of choice in case of gangrene or ulceration of a completely
nonfunctional lower extremity
The minimum length of stump that can be used to fit an above-knee prosthesis is
7.5 cm below the adductor muscle insertion
For the best functional results, it is desirable to keep the femur as long as
possible
(If the pelvic circulation is severely compromised, a shorter stump )

39. Operative technique
Epidural, spinal, or general anesthesia
Anterior and posterior flaps of equal length
The posterior incision is made first to minimize bloody
field.
Superficial femoral artery and vein are isolated and
clamped & divided
 the femur is scored circumferentially.
The sciatic nerve is placed on gentle traction, clamped,
divided, and ligated
The deep fascia is approximated with interrupted
absorbable sutures

40. The principle is to remove the required extent of the limb leaving a posterior flap
with a layer of viable muscle that can be used to cover and cushion the deep
structures
Mortality is high and serious consideration should be given in the elderly to non-
intervention to allow death with dignity.

41. Upper limb amputations
Finger and partial hand amputation
The usual indication is trauma
Principle is to preserve as much viable tissue as
possible, particularly preserving palmar surface skin
and as much of the thumb as is practicable
 Medial and lateral flaps should be used, which
may be closed unless there has been gross
contamination.

42. 
 Supination and pronation of the forearm, flexion and extension of the wrist
occurs at this level,
 Ideally, a long full-thickness palmar and shorter dorsal flap should be created
in a ratio of 2:1.
 The wrist flexors and extensors should be anchored to the remainingcarpus
in line with their insertions to preserve active wrist motion

43. Provides a long lever arm and preserved
supination and pronation.
Preserving the triangular fibrocartilage
shortening of the radial styloid should be
avoided that improves prosthetic suspension
procedure of choice in children

44. Ideally its 7-8 inch from the tip of olecranon
Shortest stump is 7.7 cm
Equal length extensor and flexor flaps are fashioned
Interosseous membrane and muscles divided and
muscles sutured over the bone

45. Krukenberg described a technique that
converts a forearm stump into a pincer that
is motorized by the pronator teres muscle
 Indications - bilateral upper-extremity
amputations
not recommended as a primary procedure
at the time of an amputation
the ulna and radius must extend distal to
the majority of the pronator teres (the
motor for pinching) and an elbow flexion
contracture of less than 70°.

46.  Wrist Disarticulation vs. Transradial
Disarticulation offers potential of better active pronation and
supination of forearm
Disarticulation poor aesthetically, difficult to fit prosthetic
Transradial often difficult to transmit rotation through prosthesis
Transradial needs to be done 2 cm or more proximal to joint to allow
prosthetic fitting
Transradial usually favored

47.  Transhumeral vs. Elbow Disarticulation
Adults: Elbow disarticulation allows enhanced suspension and
rotation control of prosthesis however retention of full length
precludes use of prosthetic elbow. Long transhumeral favored
Pediatrics: Transhumeral amputation results in high incidence of
bony overgrowth. Elbow disarticulation is level of choice. Humeral
growth slowed after trauma.

48. 1.Failure of wound to heal
2.Infection : open – flaps retract / edematous
3. Phantom limb sensation :- diminishes over time
4. Pain and phantom pain
5. Edema
6. Joint contacture
7. Deep vein thrombosis

49. The phantom limb
 Phantom is the sensation of the limb that is no longer there
 Is often described as a tingling, pressure sensation,
sometimes a numbness

The phantom pain
 A cramping, squeezing sensation, or a shooting or a
burning pain
 May be localized or diffuse; continuous or intermittent and
triggered by some external stimuli
 It may diminish over time or may become a permanent and
often disabling condition

50.  The patients are usually told to view the phantom as a part
of themselves
 Sometimes, wearing a prosthesis will ease the phantom
pain
 Ultrasound, icing, TENS ( trans cutaneous electric nerve
stimulation), or massage have been used with varying
success
 Chordotomies, rhizotomies, and peripheral neurectomies
have been tried with limited success
The Phantom Pain

51. Goals of Postoperative Management
 Prompt, uncomplicated wound healing
 Control of edema
 Control of Postoperative pain
 Prevention of joint contractures
 Rapid rehabilitation

52. Rigid dressing
An attachment incorporated at the distal end of the
dressing allows the later addition of foot and
pylon allowing limited weight-bearing ambulation
within a few days or a week of surgery
(immediate postoperative prosthesis)

53. 1. Limits the development of postoperative edema
2. Allows for early ambulation
3. Allows for early fitting of the permanent prosthesis by
reducing the length of time needed for shrinking the
residual limb
4. Configured to each individual residual limb

54. 1. Requires careful application by an individual
knowledgeable about prosthetic principles
2. Requires close supervision during the healing stage
3. Does not allow for daily wound inspection and
dressing changes

55.  It provides better control of edema than the soft dressing
(Unna’s dressing, air splinting, and controlled
environmental treatment ….)
 The air splint is a plastic double wall bag that is pumped to
the desired level of rigidity
*It allows improved wound inspection
*The constant pressure does not intimately
conform to the shape of residual limb

58.  The postsurgical dressing, degree of postoperative pain,
and healing of the incision will determine when resistive
exercises for the involved extremity can be started
 The hip extensors and abductors, and knee extensors and
flexors are particularly important for prosthetic
ambulation
 Sitting and standing balance activities are a useful part of
the early postsurgical program

60. Advantages in using a temporary prosthesis
1. It shrinks the residual limb more effectively than the elastic
2. It allows early bipedal ambulation
3. Many elderly people can walk safely with a temporary prosthesis
4. Some individual can return to work
5. It provides a means of evaluating the rehabilitation potential of
individuals with a questionable prognosis

62. Desensitization is started with a towel for distal residual extremity
pressure, and distal-end bearing is started on a soft structure (usually a bed).

63. Up to 2/3 of amputees will manifest postoperative
psychiatric symptoms
 Depression
 Anxiety
 Crying spells
 Insomnia
 Loss of appetite
 Suicidal ideation

64. 1. Residual Limb Shrinkage and
Shaping
2. Limb Desensitization
3. Maintain joint range of motion
4. Strengthen residual limb
5. Maximize Self reliance
6. Patient education: Future goals
and prosthetic options

65. It is a replacement of Substitution of a
Missing or a diseased Part

66. Endoprosthesis- implants used in
Orthopaedic surgery eg; austin
moore
Prosthesis
Exoprosthesis-external replacement
for
A lost part of the limb

67. Temporary –
Used
Following amputation
Till pt. Is fitted with
Permanent prosthesis eg; pylon
Permanent prosthesis

68. 1.For disarticulation of hip and Hemipelvectomy
2.For transfemoral amputation
Suction socketed
two way valve mechanism
negative pressure
Snuggly fits
Useul in young pt.
Best for cilindrical stumps
Non suction socketed-pelvicbands in place of
negative pressure to hold

69.  Suction socketed
 Less skin infection
 Feel of close contact with
prosthesis
 Socks are not necesssary
 Not easy to wear
 Less comfortable
 Non suction socketed
 More incidence of skin Infection
 Not so Necessary
 Easy to wear
 More comfortable

70. PTB PROSTHESIS
Socket fits exactly over the patellar tendon and tibial
condyles

71. Conventional type Prosthesis
Consists of
 Thigh corset
 Side steels
 Knee joint
 Shin piece
 Ankle joint
 Foot piece

72. -Have close sockets or open sockets
-Full weight bearing or modified end
bearing

73.  Made of rubber(waterproof)
Aluminium(for leg piece)
 Cheap ,strong, rust free
 Allows sitting , squating,
 does not require a shoe

74. Forequarter amputations-
prosthesis merely serves a cosmetic
purpose
Shoulder amputations:
- Shoulder piece extended cap to hold
prosthesis
- Elbow piece can be flexed b pulling on
the flexion cord with the protractors
of th shoulder
-Handpiece either cosmetic or splint
hook type.

75. Same as prosthesis for Shoulder Disarticulation exept
Elbow flexion is Stronger due to Action of arm
muscles along the protractors
Below elbow amputation
There is a cop socket attached to terminal Device
Terminal device can Be activated through a loop
harness

76. Split socket forearm and a wrist rotation device is
provided
A device can be provided to lock for supination and
pronation