2. LOSS OF LIMB OR PART OF A LIMB
“AMPUTERE” meaning “to cut away”(latin)
First step in rehabilitation rather than failure of treatment
3. History
• Earliest amputations on unanesthetised patients or using opium and
hemostasis achieved by crushing or dipping the open stump in boiling
water
• Hippocrates – first to use ligatures
• Morel – tourniquet in 1674
• Lister – antiseptic technique in 1867
• Morton- ether in 1846
4. Indictations(3D)
• DEAD LIMB (absolute indication) – peripheral vascular disease,
trauma, burns, frostbite
• DEADLY LIMB (limb over life)-infections , arterioveinous fistula
,malignancy
• DEAD LOSS LIMB – severe rest pain, paralysed limb, contracture
5. Peripheral vascular disease
• Most common indication for amputation
• m/c 50-75yrs
• Risk factors – diabetes, , smoking, prior stroke, prior major
amputation, decreased transcutaneous oxyzen levels, decreased
ankle brachial blood pressure index.
• Vascular surgery consultation is must before amoputation to rule out
possibility of revascularization.
6. trauma
• m/c in young patient
• Male > females
• Absolute indication- irreparable vascular injury in an ischemic limb
1. guistello Anderson type 3C with complete disruption of tibial nerve
2. crush injury with “warm ischemia time” > 6 hrs
• Relative indication- severe ipsilateral foot injurues, anticipated protracted
course to obtain soft tissue coverage and tibial reconstruction.
• Predicting salvageable limbs – 1. mangled extremity severity score (MESS)
2. limb salvage index (LSI)
3. limb injury score (LIS)
7.
8. INFECTION
• Acute or chronic infections unresponsive to antibiotics and surgical
debridment.
• Infections threatening life – gas gangrene
• Disabllity of limb – chronic non healing ulcer, chronic osteomyelitis,
infected non union.
• Squamous cell carcinoma from non healing ulcers
9. TUMORS
• Limb salvage vs Amputation
• Would survival be affected by treatment choices
• Short term vs long term morbidity
• Function of salvaged limb
• Psychosocial consequences
• Amputation for malignancy is technical demanding surgery
• Limb salvage
• More extensive
• Greater risk of infection
• Wound dehiscence
• Flap necrosis
• Increased blood loss
• Deep vein thrombosis
10.
11. LEVELS OF AMPUTATIONS
• Increased function by increasing the length of stump
• More proximal level amputations promotes slower walking to
conserve energy
• If ambulation is concern amputation should be at most possible distal
level
12.
13.
14. FOREFOOT AMPUTATION
• Amputation of
• Great toe : limp while running(loss of push off)
• Second toe : severe hallux valgus
• Any other toe : little effect
• All toes :
• normal slow walking but disabling for rapid gait (loss of spring and resilience)
• Interferes with squatting and tiptoeing
• Requires only shoe filler prosthesis
• Terminal syme amputation:
• Removing distal aspect of distal phalanx retaining EHL and FHL insertion
• Done in hallux terminal ulceration, chronic ingrown nails etc
• Metatarsophalangeal disarticulation:
• Ray amputation
• Transmetatarsal amputation :
• Patient ambulates with shoe filler and steel shank with rocker shoes
• Limb length preserved
• Adequate vascularity is must for it to succeed
15. MIDFOOT AMPUTATIONS
• Lisfranc :
• at tarsometatarsal joints(Lisfrsanc joint)
• Can lead to sever equino varus deformity
• Prevented by preserving insertion of tibialis anterior and peroneus longus at
medial cunieformand peroneus brevis at base of mertatarsal.
• Chopart amputation:
• Disarticulation of TALO-NAVICULAR and CALCANEO-CUBOID joint
• Sevre equinovarus deformitry occurs prevented by
1. Transfer of one or more dorsiflexors
2. Decrease strength of ACHILLES tendon
3. position the stump in slight dorsiflexion and rigid dressing for weeks
17. HINDFOOT AND ANKLE AMPUTATION
• SYME Amputation:
• Bone transection at distal tibia and fibula 0.6 cm proximal to periphery of ankle joint
and passing through the dome of ankle centrally
• Tough durable skin of heel flap provides normal weight bearing
• Can be done in one stage or two stage
• BOYD Amputation:
• talectomy , excision of anterior part of calcaneus , forward shift of calcaneus and
calcaneotibial arthrodesis.
• PIROGOFF Amputation:
• Calcaneus is sectioned vertically, anterior part removed and its remaining posterior
part and heel flap are rotated forward and upward 90 degree until raw surface of
calcaneus meets denuded surface of distal end of tibia.
• Arthrodesis between tibia and part of calcaneus
19. TRANSTIBIAL APMUTATIONS
• Stumps extending to distal third of the leg suboptimal :
• Less soft tissue for weight bearing
• Relatively avascular – risk of flap necrosis
• Slower to heal
• Energy expenditure is an important consideration in
choosing level of amputation
21. Ideal length of amputation stump
• above knee amputation : 23-27 cms from greater trochanter or 12 cm
proximal to knee
• Below knee : 12-17 cm stump length or 2. cms for every 30 cm of
height
• Above elbow amputation : 20 cms from shoulder
• Below elbow amputation : 18 cms from olecranon
22.
23. Surgical principles
• Tourniqet : reduce blood loss ,keep surgical field clear,
contraindicated in ischemic limbs
• Skin flaps : thick, shouldn’t be adherent to bone, avoid dog ears,
save as much as possible(atypical flap > higher level of amputation)
• Muscles sectioned 5cm distal to the intended level of bone
• Nerves : always cut under tension to avoided painfull neuromas
in stump
• Blood vessels : double ligated and divided at slightly above the
bone cut
• Bone : mark before cutting, always smoothen the edges
24. Ideal stump
• Conical shape(prosthesis fitting)
• Ideal length
• Good muscle power
• Supple joints
• Non adherent scar
• No fixed deformity
• Absence of neuroma
• Bone well covered
• Muscular not flabby
• Free from infection
25. Myoplasty vs myodesis
myoplasty
• Muscles sutured to muscle of
opposing compartment or
periosteum under tension
• Both the flaps are equal in length
• Scar is formed at the end of
stump
myodesis
• Muscle sutured to bones via drill
holes
• Establish resting tension
• Provides better limb control
• Both flaps are unequal in length
• Scar is formed at the anterior of
the stump
• Avoided in severe ischeamic limbs
26. Post operative care
• Adequate antibiotic prophylaxis
• Stump drainage and removal of drain
• Stump splinting
• Early stump exercises
• Hygiene and intermittent exposure to air
• Early crutch mobilization
• Appropriate prosthesis
27. Open vs closed amputations
OPEN
• Skin not closed over level of
amputation
• First of atleast 2 stage surgery
• Indications
• Extensive contaminated injuries
• Infection
• Guillotine amputation : alltissue
from skin to bone cut at the
same level, wound left
open(emergency procedure)
• Open amputations with flap,
flaps are closed later
CLOSED
• skin closed over the level of
amputation after making proper
flaps
• One stage procedure
• Indications
• Routine/planned amputation
