AMPUTATION: Cutting of the extremity or part of the extremity through the bone While ……….. DISARTICULATION: Cutting of the extremity or part of the extremity through the joint

1. Prepared by:
Dr. Abdullah K. Ghafour
2nd year IBFMS trainee
Supervised by:
Dr. Ali Abdulnabi Alwan

2. *AMPUTATION: Cutting of the extremity or part of
the extremity through the bone
While ………..
*DISARTICULATION: Cutting of the extremity or
part of the extremity through the joint

3. *Amputation surgery is an ancient procedure dating back to
prehistoric time.
*The word amputation is derived from the Latin amputare, "to
cut away“.
*The English word "amputation" was first applied to surgery in
the 17th century by Peter Lowe in 1612.
*amputation of the hands, feet or other body parts is or was
used as a form of punishment for people who committed
crimes.
* In some cultures and religions, minor amputations are
considered as a ritual accomplishment.

4. *Cave-wall hand imprints have been found which
demonstrate that Neolithic humans had amputated
limbs.
*Earliest literature discussing amputation is the
Babylonian code of Hammurabi 1700 BC
*385 BC – Plato's symposium and Hippocrates De Articularis
*1st century BC – cautery was used for large vessels
*1588 – William Clove – first successful AKA
*1674 – Morel – battle of Borodino – tourniquet
*1679 – Younge – local flaps for wound closure (animal bladder
used previously)

5. *1781 – John Warren – 1st successful shoulder amputation
*1806 – Walter Brashear –1st successful hip joint amputation
*1825 – Nathan Smith – described knee disarticulation
*1870 – Stockes and Grittis procedure
*1890 – Jaboulay and Girard – 1st successful hindquarter
amputation
*1943 – Norman Kirk – guillotine procedure in WWII

6. *In US 30,000 – 40,000 amputation are performed
annually.
*There were 1.6 million individuals living with
loss of a limb in 2005. These expected to become
3.6 million by the year 2050
*Male : female ratio LE = 2:1
UE = 4:1
*majority in the 65 - 79 year age group
* LE : UE ratio = 11:1
*10% perioperative mortality
*3 year survival after BKA – 57%; after AKA – 39%

7. 77%
9%
8% 6%
UE amputation causes
Trauma 77%
Congenital 9%
Tumor 8%
Disease 6%
66%
26%
5% 3%
LE amputation causes
PVD 66%
Trauma 26%
Tumor 5%
Congenital 3%

8. Alan Apley encapsulated the indications for
amputation in the ‘three Ds’:

9. 1. Peripheral vascular disease ( 60 -70 % in LE )
 DM (90%)
 Arteriosclerosis
 Thromboembolism
2. Severe traumatized limb ( 75 – 80 % in UE)
3. Burns
4. Frostbite
1D Dead or dying limb

10. 1. Malignant tumors
2. Lethal sepsis
3. Crush injury leading to crush syndrome
2D Dangerous limb:

11. Remaining the limb is more worse than having no
limb at all …. Because of :-
1. Pain
2. Gross malformation
3. Recurrent sepsis
4. Severe loss of function
3D Damn nuisance

12. When primary healing is unlikely
The limb amputate as distal as the causal factor will
allow
Skin flap suture loosely over a pack
Re-amputation perform when stump condition is
favorable
Provisional amputation

13. When weight is taken through the end of the stump
The scar must not be terminal
Bone end must be solid (cut near the joint)
Definitive end-bearing

14.  Commonest variety
 All upper limb & most lower limb amputations are
come under this type
 The scar can be terminal
Definitive non-end-bearing

15. *Wagner et al (Journal of vascular surgery 1988):
[ clinical judgment is superior to objective
assessments. More distal amputations can
be achieved with clinical measures over objective
studies.]
*Clinical judgment is central to
amputation level selection.

16. oskin quality, extent of ischemia/ infection
opresence of a pulse immediately above the level
of amputation – almost 100% chance of healing
ojoint- and residual-limb-length salvage is directly
correlated with functional outcome
oShort stump slips out from the prosthesis
oLong stump  pain, ulceration, incorporate of
the joint in the prosthesis
oNow a day the skill of prosthetist make
amputation possible at any level
Subjective measures
Clinical examination
Local function
Prosthetic design

17. oDoppler Ultrasound pressures
oSkin perfusion pressures
otranscutaneous oximetry
oangiography
Invasive procedures
Non-invasive procedures
Objective tests

18. oDoppler ultrasound pressures
 maybe unreliable in diabetics
 ankle pressures >60mm
--->50% chance of BKA healing
oSkin perfusion pressures
 Radio isotope washout
 Laser doppler velocimetry
<20mm Hg – 89% failure of healing

19. otranscutaneous oximetry
 Tested under local hyperthermia
 Correlates with true PaO2
 Threshold value – 30mm
oInvasive – Angiographic scoring
 Poor correlation

20. 1. Interscapulo-thoracic (fore-quarter) amputation.
oTraumatic avulsion of the upper limb
oeradicating a malignant tumour
o aspalliation for intractable sepsis or pain.
2. Disarticulation of the shoulder
oRare event
3. transhumeral (above-elbow)amputations
o the appearance is much better
oshortest arm stump is 2.5 cm
4. Elbow disarticulation
Upper limb amputations:

21. 5. Transradial (forearm) amputation
ooptimal length is at the junction of the middle and
distal thirds of the forearm
oBoth bones cut in same level
6. Wrist disarticulation
7. Amputations in the hand
oPolydactyly
oTraumatic amputation of fingers
Upper limb amputations:

22. 1. Hemipelvectomy (hindquarter amputation)
operformed only for malignant disease.
2. Disarticulation of the hip joint
oprosthetic fitting is difficult
3. Transfemoral amputation
oat least 12 cm
4. knee disarticulation &( Gritti-Stokes amp.)
oassociated with poorer functional and psychological
outcomes
omain indication is in children
5. Transtibial (below knee) amputation
oEven a 5–6 cm(optimum 12cm) stump may be fitted with
a prosthesis
oHave a good function and nearly normal gait
Lower limb amputations:

23. 1. Ankle disarticulation (Syme’s amputation)
ogives excellent function in children
obones are divided just above the malleoli
2. & 3. Pirogoff’s and Boyd’s amputation
oSimilar in principle to Syme’s
oThe part of calcaneus is fixed onto the cut end of
the tibia and fibula.
Partial foot amputations
4. Mid-tarsal joint ( chopart amputation )
5. Tarsometatarsal joint ( lisfranc amputation)
6. Transmetatarsal
7. Metatarsophlangeal
8. Transphalangeal
Lower limb amputations:

24. * Tourniquet is used unless there is vascular
insufficiency
* Skin flaps are cut so that there combined
length equals 1.5 the width of the limb at the site of
the amputation.
* Muscle cut at distal level from the level of the bone
proposed. Osteomyodesis is done when the opposing
muscle groups sutured together over the bone ends.

25. *Nerves are divided proximal to the bone cut
*Saw is used to make the bone ends smooth ,
and for beveling the tibia interiorly
oFibula is cut 3 cm shorter
*The main vessels are meticulously ligated.
*Remove the tourniquet and stop bleeding Suture the
skin without tension Apply suction drain Bandage
the stump tightly

26. *Skin flaps should be of full thickness
*Periosteal stripping should be sufficient
*Stable residual limb muscle mass can improve function by
reducing atrophy and providing a stable soft tissue envelope
over the end of the bone.
*The nerve end should come to lie deep in a soft tissue
envelope, away from potential pressure
areas.
*Rigid dressings (postoperative) help reduce
swelling, decrease pain, and protect the stump
from trauma.
*Early prosthetic fitting is done within 5 to 21
days after surgery in selected patients.

32. Wrist joint disarticulation

35. *Guillotine amputation is used in emergency situations
for contaminated wounds or infection.
*Skin, muscle and bone are divided at the same
level.
*All bleeding vessels are tied and nerves are cut
sharply while under gentle tension, allowing them to
retract into the wound.
*Debridement and lavage of the wound are done every
2–5 days until it is free of dead tissue and infection. At
that point, definitive amputation and closure are
performed.

36. *The metabolic cost of walking is increased with proximal-
level amputations and is inversely proportional to the
length of the residual limb and the number of functional
joints preserved.
*The higher the level of amputation ,the higher the oxygen
consumption
• BKA –10-40% increase in energy expenditure
• AKA –50-70% extra energy expenditure

37. ocomplications of any operation (bleeding, pain,
infection, complications of anesthesia,…)
oBreakdown of skin flaps (may be due to ischemia
or excessive suture tension )
oGas gangrene (especially AKA)
EARLY COMPLICATIONS:

38. oSkin; Eczema, tender purulent lumps in groin.
Ulceration due to poor circulation.
oMuscle; unstable ‘cushion’ stump If too much muscle is
left
oBlood supply; Poor circulation gives a cold, blue stump
that is liable to ulcerate.
oPhantom limb; feeling that all or part of the amputated
limb is still present
oPhantom pain is a burning, painful sensation in the part
having undergone amputation.
LATE COMPLICATIONS:

39. oNerve; A cut nerve always forms a neuroma and
occasionally this is painful and tender.
oJoint; The joint above an amputation may be stiff
or deformed.
oBone; A spur often forms at the end of the bone, but is
usually painless. Bones that not used may becomes
osteoporotic and liable to fracture.
LATE COMPLICATIONS:

40. (Gitter and Bosker 2005):[Yet with appropriate
rehabilitation, many people can learn to walk or
function again and live high quality lives.]
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
Rehabilitation

41. oPassive
*Cosmetic
oBody Powered
*Harnesses and cables
oMyoelectric
*Surface EMG
*Perform most of functions
oNeuroprosthetics
*Investigational at this time
Prosthetics

42. *Amputation represents loss of
function, sensation and body image.
*(Gitter and Bosker 2005):[Limb loss
is one of the most physically and
psychologically devastating events
that can happen to a person. Not
only does lower limb amputation
cause major disfigurement, it
renders people less mobile and at
risk for loss of independence.]

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

44. 1 Preoperative
2 Immediate Postoperative
3 In-Hospital Rehabilitation
4 At-Home Rehabilitation

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