Amputation- Dr. Kiran Kumar G.


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Amputation- Dr. Kiran Kumar G.

  2. 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. 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. 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. 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. 6. ‘DDD’ Dead Deadly Dam Nuisance
  7. 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. 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. 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. 10.  L/E ≈5% of all amputations U/E -8%  Amputation is performed less frequently with the advent of advanced limb-salvage techniques.
  11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 22. In case of trauma if possible the skin is approximated with simple interrupted non absorbable monofilament sutures
  23. 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. 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. 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. 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. 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. 28.  amputation of the foot between the metatarsus and tarsus.
  29. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 51. Goals of Postoperative Management  Prompt, uncomplicated wound healing  Control of edema  Control of Postoperative pain  Prevention of joint contractures  Rapid rehabilitation
  52. 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. 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. 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. 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
  56. 56.  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
  57. 57. 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
  58. 58. Desensitization is started with a towel for distal residual extremity pressure, and distal-end bearing is started on a soft structure (usually a bed).
  59. 59. Up to 2/3 of amputees will manifest postoperative psychiatric symptoms  Depression  Anxiety  Crying spells  Insomnia  Loss of appetite  Suicidal ideation
  60. 60. 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
  61. 61. It is a replacement of Substitution of a Missing or a diseased Part
  62. 62. Endoprosthesis- implants used in Orthopaedic surgery eg; austin moore Prosthesis Exoprosthesis-external replacement for A lost part of the limb
  63. 63. Temporary – Used Following amputation Till pt. Is fitted with Permanent prosthesis eg; pylon Permanent prosthesis
  64. 64. 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
  65. 65.  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
  66. 66. PTB PROSTHESIS Socket fits exactly over the patellar tendon and tibial condyles
  67. 67. Conventional type Prosthesis Consists of  Thigh corset  Side steels  Knee joint  Shin piece  Ankle joint  Foot piece
  68. 68. -Have close sockets or open sockets -Full weight bearing or modified end bearing
  69. 69.  Made of rubber(waterproof) Aluminium(for leg piece)  Cheap ,strong, rust free  Allows sitting , squating,  does not require a shoe
  70. 70. 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.
  71. 71. 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
  72. 72. Split socket forearm and a wrist rotation device is provided A device can be provided to lock for supination and pronation