A presentation on the Principles of Amputation

1. PRINCIPLES OF AMPUTATION
Dr Umar M Aminu
Department of Surgery
ATBUTH Bauchi

2. Outline
• Introduction
– Definition
– History
– Epidemiology
• Indications
• Principles
– Preoperative
– Intraoperative
– Postoperative
• Amputation in Children
• Complications
• Prosthesis
• Conclusion

3. Introduction
Definition
• Removal of part of or an entire limb through
one or more bones
• When it is through a joint= disarticulation

4. Introduction
• Not a failure of surgery but a reconstructive
procedure
• Goal is surgical reconstruction that maintains
most functional limb possible

5. Introduction
History
• Earliest reference in Babylonian code of
Hammurabi-1700BC
• Hippocrates in De Articularis-385BC
• William Cloves did first successful AKA-1588
• Botallus and Fabricus Holdani describe use of
torniquet-16th century
• Norman Kick used Guillotine amputation during
World War-1943

6. Introduction
History

7. Introduction
Epidemiology
• 350,000-1 mil amputees
• 20,000-30,000 new amputees a yr
• >> age 50-75yrs
• >> Lower limbs
• >> Males

8. Introduction
Epidemiology
• The estimated prevalence of extremity
amputation in Nigeria is 1.6 per 100,000
• The most frequent indications for
amputation were trauma (34%); complication of traditional
bonesetting (TBS)(23%); malignant tumours (14.5%);
diabetic gangrene (12.3%); infections(5.1%); peripheral
artery disease (2.1%); and burns (2.1%).
• The average age of the Nigerian amputee is 33 years.
• Hospital mortality after amputation is 10.9%.
Extremity amputation in Nigeria a review of indications and
mortality. Thanni LO , Tade AO. Surgeon. 2007 Aug;5(4):213-7.

9. Introduction
Epidemiology
• 320 limb amputations were performed
on adults at the Ahmadu Bello University Hospital, Nigeria over a period of
10yrs.
• Major indication for upper limb amputation was trauma and post-fracture
splintage
gangrene (57%).
• In the lower limb the most common indication for
amputation was advanced squamous cell carcinoma of the skin involving
the
bone.
• No case of peripheral vascular disease in these patients
other than diabetic ulcers
Major Limb Amputation in Adults,Zaria,Nigeria.
Yakubu A , Muhammad I, Mabogunje OA. J R Coll Surg Edinb. 1996 Apr;41(2):102-
4.

10. Introduction
Locally (Amputation in ABUTH)-
• 37 cases
• Commonest age group-10-19
• Commonest indication-Gangrene
• Commonest procedure- Below Knee
Amputation

11. Introduction
Gangrene
40%
Malignancy
19%
Trauma
19%
DMFS
19%
Burns
3%
Indications for amputation in ATBUTH Jan-Sept 2015
Gangrene
Malignancy
Trauma
DMFS
Burns

12. Introduction
BKA
33%
Disarticulation
22%
AKA
17%
BEA
11%
AEA
11%
N A
6%
Types of Amputations done in ATBUTH Jan-Sept 2015
BKA
Disarticulation
AKA
BEA
AEA
N A

13. Classification
• Emergency/Traumatic/Elective
• Provisional/Definitive
• Open/Closed
• End bearing/Cone bearing
• Named/Eponymous amputation
– Gritti-Stoke
– Syme
– Progoff
– Chopart (@ midtarsal joint)
– Lisfranc (@ Tarsometatarsal joint)
– Ray

14. Amputation levels ( upper limbs )
• Hand & Partial-Hand Amputations
Finger, thumb or portion of the hand
below the wrist
• Wrist Disarticulation
Limb is amputated at the level of the
wrist
• Transradial (below elbow
amputations)Amputation occurring in the
forearm, from the elbow to the wrist
• Transhumeral (above elbow
amputations)
Amputation occurring in the upper arm
from the elbow to the shoulder
• Shoulder Disarticulation
Ambutation at the level of the shoulder,
with the shoulder blade remaining.
• Forequarter Amputation
Amputation at the level of the shoulder in
which both the shoulder blade and collar
bone are removed

15. Amputation levels ( lower limbs )
• Foot Amputations
• Amputation of greater toes and other toes
• Amputation through the metatarsal bones
• Lisfranc`s operation : at the level of the
tarsometatarsal joints
• Chopart`s operation : through the midtarsal
joints
• Transtibial Amputations (below the knee)
Amputation occurs at any level from the knee
to the ankle
• Knee Disarticulation
Amputation occurs at the level of the knee
joint
• Transfemoral Amputations (above knee )
Amputation occurs at any level from the hip
to knee joint
• Hip Disarticulation
Amputation is at the hip joint with the entire
thigh and lower portion of the leg being
removed.

16. Indications
• Congenital/ Acquired
• 3 Ds

17. Indications
Congenital
• Hemimalia
• Polydactly
• Congenital
pseudoarthrosis
• PFFD
• Gross congenital
malfiormations
Acquired
– Trauma- Mangled limb,
Crush injury
– Vascular- D M
angiopathy, PVD
– Infectivce-COM,
Clostridia
• Neoplasm-
Osteosarcoma,
• Frost bite
• Burns

18. Indications
3 Ds
• Dead/ limb-Gangrene
• Dying/Deadly/Dangerous limb- Crush injury,
Osteosarcoma, Melanoma
• Damn nuisance-Gross congenital anomalies,

19. Goals of amputation
• To get rid of all necrotic, infected & painful
tissue.
• To have a wound that heals successfully.
• To have an appropriate remnant stump that
is able to accommodate a prosthetic.

20. Pre-Operative Assessment
To:
• Ascertain indication
• Site of amputation
• General medical condition
• Rehabilitation potential
• Counselling
• Consent
• Optimisation

21. Pre Operative Assessment
• Assessment of –
– The affected limb
– The unaffected limb &
– The patient as a whole is conducted thoroughly.
• Assessment of physical, social & psychological status
of the patient should be made.

22. Pre-operative Evaluation
• History
o Aetiology
o Comorbidities
• Physical examination
o MSS-MESS ≥ 7
Removes subjectivity from decision making in
trauma cases.
No scoring system can replace experience & good clinical judgment.
o CVS, Renal &
o Nervous system

23. Pre-operative Evaluation
• Investigation
– To confirm Diagnosis
o Doppler
o X-Ray
o FBS
o Technitium 99 Pyrophosphate bone scan
– Capability of Wound Healing
o Transcutaneous Oxygen
o Hemoglobin
o Serum Albumin
o Absolute lymphocyte count

24. Pre-operative Evaluation…
• Optimization:
Anaemia, hypotension, infection, nutrition
• Consultations:
Nephrologist, Cardiologist, Neurologist
If vascular dx has progress to the point of amputation, most patients also
have concomitant dx process in the cerebral, renal & coronary
vasculatures.

25. Social assessment includes
• Family & friends supports
• Living accommodation –
– Stairs, ramps, rails, width of door, wheelchair accessibility
• Proximity of shops

26. Pre-operative Evaluation…
• Counseling & consent
Procedure, anaesthesia, complications,
prosthesis & limitations.
• Involvement of support groups

27. Intra-operative Principles
• Determine outcome of function and
rehabilitation
• Meticulous attention to detail and careful soft
tissue handling
• Effort to be directed at achieving ideal stump

28. Ideal stump
1) It should be of optimum length
2) The end of stump should be smooth &
rounded
3) It should be firm
4) The opposing group of muscles should be
sutured together over the end of the bone.
5) The muscles are sutured in such a way that
they will be converted into fibrous tissue &
serve as an effective cushion.

29. Ideal stump
6) Vascularity of the flaps should be normal
7) There should be no projecting spur of bone.
8) The stump shouldn't’t be under tension.
9) The position of the scar should be avoided
of pressure n should be transverse to avoid
pulling up between 2 bones in ap scar.
10) In case of U.L the scar can be terminal, but
in L.L a posterior scar is desirable to avoid
pressure of weight of artificial limb.

30. Traditional Sites of Election
Upperlimb
• A/E – 20cm from Acromion
• B/E – 18cm from Olecranon
Lowerlimb
• A/ K – 12cm from Joint line
• B/ K – 14cm from Joint line

31. Site of Selection
Examination
• Skin color
• Hair growth
• Lowest palpable pulse
• Skin temperature
Investigation
• Doppler USS

32. INTRA - OPERATIVE
• Anaesthesia: GA or Regional
• Position: Supine
• Tourniquet +/_ Exsanguination

33. Intra-Operative Principles

34. Intra-Operative Principles
Skin Incisions
•Fish mouth Vs
Racquet

35. Intra-Operative Principles
Controlling Bleeding
• Isolate and ligate
• Pinch ends of muscle
• Identify and cut btw sutures

36. Intra-Operative Principles
Controlling Bleeding
•Isolate and ligate
•Pinch ends of muscle
•Identify and cut btw
sutures

37. Intra-Operative Principles
Cutting Muscle
•Transverse
•5cm distal to
site of bone
section
•With
amputation
knife

38. Intra-Operative Principles
Nerves
• Isolated, gently pulled distally into wound and
divided sharply
• Large nerves should be ligated
• Prevent painful neuroma

39. Sawing Bone
•Reflect periosteorum
1-2cm distally
•Protect soft tissue
with amputation
shield
•Smoothen edges
•Wash bone dust with
saline

40. Intra-Operative Principles

41. Intra-Operative Principles
Closing the Wound
• Hemostasis is secured
• Opposing group of muscles are sutured across
both the ends with interrupted stitches.
• Fascia & skin are sutured over the muscle without
tension.
• Preferably a suction drain is placed.
• Wound is covered with gauze & roller bandages
tightly from below upwards.

44. Intra-Operative Principles
Open Amputation
• Indications-
• infected limb
• Battle injuries
• Soft tissue injury/contamination
• Uncertain blood ss
• Types-
– Inverted edges
– Circular

45. Intra-Operative Principles
Wound Dressing
• Soft vs Rigid
• Rigid dressing : decreses edema, decreases
post operative pain, protect limb from
trauma, early mobilsation. Good bandaging
to mold the stump into Conical shape to
accept the prosthesis
• Soft dressing concept: The stump is dressed
with the sterile dressing & crepe bandage
applied over it.

47. Post-operative Care
• General-
» Analgesia
» Antibiotics
» DVT prophylaxis
• Specific-
» Joint Positioning+excercise
» Drain removal
» Mobilisation
» Rehabilitation-prosthetic fittiing, home, occupation &
hobby

48. Complications
• General vs Specific
• Early vs Late

49. Complications
General
• Haemorrhage-
Reactionary/ 2o
• Infection
Specific
• Flap breakdown
• Flexion contracture
• Residual pain
• Stump ulceration
• Phantom sensation
• Phantom limb pain
• Dermatologic
complications

50. Smith and Burgess method: the central one third of
the wound is closed, and the remainder of the wound
is packed open.

51. Phantom sensation
• The phantom is the sensation of the limb that is no
longer there. The phantom, which usually occurs
initially immediately after surgery, is often described as
a tingling, burning, itching or pressure, sensation,
sometimes a numbness.
• Phantom sensation may be painless although, most
people find it uncomfortable & often report it as pain;
it usually does not interfere with prosthetic
rehabilitation.
(Physical rehabilitation;Susan B O’ Sullivan; 5th )

52. Phantom Limb Pain
• Phantom pain and sensations are defined as
perceptions ranging from slight tingling to
sharp, throbbing pain or aching that patients
perceive relating to an extremity or an organ
that is physically no longer a part of the body.
• It has been reported in various trials that the
estimated prevalence of phantom pain varies
from 49% to 83%.

53. Rehabilitation
• Residual Limb Shrinkage and Shaping
• Limb Desensitization
• Maintain joint range of motion
• Strengthen residual limb
• Maximize Self reliance
• Patient education: Future goals and prosthetic
options

54. Psychological stress
• Up to 2/3 of amputees will manifest
postoperative psychiatric symptoms
– Depression
– Anxiety
– Crying spells
– Insomnia
– Loss of appetite
– Suicidal ideation

55. AMPUTATIONS IN CHILDREN

56. • Amputations in children is divided into two
general categories—congenital (60%) and
acquired (40%)
Amputations In Children

57. Amputations In Children
Congenital
 Congenital deficiencies of
the long bones
 Amniotic band syndrome
 Exposure to teratogens (
thalidomide )
 Polydactyly
 Macrodactyly
 Congenital pseudoarthrosis
of the tibia and fibula,
radius and ulna
Acquired
• Secondary to trauma
• Neoplasm
• Infection.
• Vascular disease

58. • Preserve length
• Preserve important growth plates
• Perform disarticulation rather than
transosseous amputation whenever possible
• Preserve the knee joint whenever possible
• Stabilize and normalize the proximal portion of
the limb
• Be prepared to deal with issues in addition to
limb deficiency in children with other clinically
important conditions.
Principles Of Childhood Amputation

59. Because of growth issues and increased body
metabolism, children often can tolerate
procedures on amputation stumps that are
not tolerated by adults, which includes
• More forceful skin traction
• Application of extensive skin grafts
• Closure of skin flaps under moderate tension.
Advantages Of Amputation In Children
In Comparison To Adults

60. Prosthetics
It is a replacement of
substitution of a missing or a
diseased part

61. Types of Prosthesis
BELOW KNEE
KNEE
DISARTICULATION ABOVE KNEE
HIP
DISARTICULATION
PROSTHETICS
LOWER EXTREMITY

62. Ideal prosthesis
1. Fits comfortably
2. Function well
3. Looks presentable
4. Fit as soon after the operation

63. Temporary –
•Used following amputation
till paient is fitted with
permanent prosthesis
eg;pylon
•Permanent prosthesis

64. Conclusion
• Goal is to achieve useful residual limb in an
individual who is active with a positive
attitude an continues to be a productive
member of society

65. Reference
• Current Diagnosis & Treatment in Orthopedics
3rd edition: by Harry Skinner (Editor)
Publisher: Appleton & Lange (June 20, 2003)
• Campbel Operative Orthopedics, 11th Edition

66. Thank you for Listening