Amputation is the most ancient of all surgical procedures. Neolithic man is known to have survived amputation as evidenced from the skeletons with amputated stumps and from the knives and saws made of stone used at that time. Even the murals of La Tene and the drawings on the Peruvian pottery depict human figures with amputated stumps. In the olden times, amputations were practiced not only for disease but also as a punishment for criminals and as rituals to appease Gods or even in the practice of Black Magic. It is considered that the first account of amputation as a purposeful medical procedure is found in the Hippocratic Treatise and it was concerned with amputation for vascular gangrene. Indications for amputations vary according to availability of skill, facilities and line of treatment adopted. Many limb cancers are treated by amputations, but in some advanced centers limb preservation surgeries are done. A severely traumatized limb where the circulation is good may be amputated if the facilities for reconstruction are not available. Although the designs and the usability of the prostheses continue to advance, a well performed amputation is necessary for optimum results. when the blood supply of a limb is irreparably destroyed or when the limb is so severely damaged that reasonable reconstruction is impossible, amputation of the limb is indicated. In injuries of limbs, if three or more out of the five components (blood vessels, nerves, skin, muscles and bones) are badly damaged, amputation can be considered . The amputation can be early, intermediate or late depending on the timing after injury as will be discussed later in type of amputation. Thermal burns, frostbite or electrical burns are other injuries that may require amputation. Residual short stump can have excellent function.1 In the past, amputation through specific levels was necessary for proper fitting of prosthesis. The accepted ideal stump lengths are 23–28 cm from greater trochanter in above-knee amputations, 13 cm from the tibial articular surface in below-knee amputations, 10 cm above elbow in amputations through arm, and 17 cm from olecranon in forearm amputations. With modern prosthetic fitting techniques, a prosthesis can be fitted to any well-healed nontender stump. Determining the level of amputation requires an understanding of the trade-offs between increased function with more distal level of amputation and a decreased complication rate with a more proximal level of amputation.

1. Principles Of Amputation
And
Differences Between Dysvascular And
Traumatic Amputation
MODERATOR:
Dr Sandeep Kumar Gupt
Assistant prof
DEPT OF PMR
KGMU
PRESENTED BY:
Dr Joe Antony
JR1
DEPT OF PMR
KGMU 1

2. Contents
1. Nomenclature and history
2. Definition of amputation
3. Epidemiology
4. Goals of amputation surgery
5. General principles of amputation
6. Diffrences between dysvascular and traumatic amputation
2

3. History and nomenclature
• 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.
• Most ancient of surgical procedure.
• Historically were stimulated by the aftermath of war.
• It was a crude procedure by which 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.
Campbells operative orthopedics 13th edition 3

4. Definition
• Amputation can be defined as “removal of diseased, protruding,
functioning unit of body”.
• Amputation surgical Removal or loss of limb through one or more
bones.
• Disarticulation—surgical Removal or loss of limb through a joint.
Kulkarni textbook orthopedics and trauma 4

5. Epidemiology
• Age-
• Sex- approx. 86% male
• Limb;- approx. 85% -
lower limb, 15% --
upper limb
Campbells operative orthopedics 13th edition
Ghosh Das Pooja et al
Prevalence and aetiology of amputation in India: A retrospective analysis
5

6. • 70 % of amputations accounts for trauma
• 27 % of amputations account for peripheral vascular disease
• Cancer accounts for 0.8% of the total amputations, and is the
most common cause in above 80 year old
Ghosh Das Pooja et al
Prevalence and aetiology of amputation in India: A retrospective analysis
6

7. Amputation : Loss of a limb or part of a limb
Causes
• Congenital
• Traumatic - Rail / Road accidents
- Agriculture / domestic accidents
- War / Industrial accidents
• Vascular - Atherosclerosis / alcoholism
- Burger’s disease /frost bite
- Diabetes
• Neoplastic - Malignant Tumors (Osteosarcoma)
• Infection - Leprosy, syphilis, septic gangrene
7

8. Goals and objectives of amputation
surgery
• Preserving life
• Preservation of function
• Early return to function
• Minimize energy
expenditure
• Preservation of Length
• Painless residual limb
• Prevention of symptomatic
neuromas
• Minimize phantom limb
pain
• Prevention of adjacent joint
contractures
• Early prosthetic fitting
Campbells operative orthopedics 13th
edition 8

9. Determination of level
• Zone of Injury (trauma)
• Adequate margins (tumor)
• Adequate circulation (vascular disease)
• Soft tissue envelope
• Bone and joint condition
• Control of infection
• Nutritional status
Campbells operative orthopedics 13th edition
Essentials of prosthesis and orthotics, Dr AK Agarwal 9

10. General Amputation Principles
• Skin
• Muscle
• Nerves
• Hemostasis
• Bone
10

11. Skin
• Flaps should be kept thick
• Unnecesary dissection
should be avoided
• Atypical flaps are preferable
for proximal level
• Tense sutures should be
avoided
• Painless and Non adherent
scar
• Removal of dog ear
Campbells operative orthopedics 13th edition
Grabs textbook of plastic and rehabilitative surgery
11

12. Muscle
Myofascial closure Minimal muscle
stabilization
Myoplasty Opposing muscle
groups
Myodesis Attached to bone
Tenodesis Tendon attached to
bone
12

13. • Jaegers et al. showed that
transected muscles atrophy 40%
to 60% in 2 years if they are not
securely fixed.
• If possible, myodesis should be
performed to provide a stronger
insertion, help maximize strength,
and minimize atrophy
• Myodesed muscles continue to
counterbalance their antagonists,
preventing contractures and
maximizing residual limb
function.
• Myodesis may be
contraindicated, however, in
severe ischemia because of the
increased risk of wound
breakdown
Campbells operative orthopedics 13th
edition 13

14. Non ischemic limb
Fashioning of equal anterior
and posterior skin flaps,
each one half
anteroposterior diameter of
leg at level of bone section.
Suture of myofascial flap to
periosteum anteriorly.
Fashioning of posterior myofascial
flap. 14

15. Ischemic limb
Fashioning of short anterior
and long posterior skin flaps
Separation and removal of distal leg Suture of flap to deep fascia and
periosteum anteriorly.
NO
TORNIQUET
15

16. • Classically, surgeons evaluate for final closure based on the ‘‘4
C’s’’—colour, consistency, contraction, and circulation.
• Traumatic amputations can be left open for serial debridement
procedures, while primary amputations done—
– those outside the zone of injury, infection, vascular compromise, or
tumor— can often be closed at the time of surgery.
16

17. Hemostasis
• Except in severely ischemic limbs, the use of a tourniquet is highly
desirable and makes the amputation easier.
• The limb may be exsanguinated by wrapping it with an Esmarch
bandage before the tourniquet is inflated.
• Contra indications- In amputations for infections or malignancy.
– In such instances, inflation of the tourniquet should be preceded by
elevation of the limb for 5 minutes.
• Major blood vessels should be isolated and individually ligated.
Arteries and veins should be ligated separately, and larger vessels
should be doubly ligated.
• The tourniquet should be deflated before closure, and meticulous
hemostasis should be obtained.
• A drain should be used in most cases for 48 to 72 hours.
Campbells operative orthopedics 13th
edition
17

18. Tourniquet
Brunners ten rules of tourniquet
• Venous tourniquet
– More useless than not having
tourniquet
Sharma JP, Salhotra R et al. Tourniquets in orthopedic surgery.
Indian J Orthop
18

19. Nerves
• A neuroma formation is inevitable after
transection since the axons are unable to locate
the distal nerve stump.
• A neuroma becomes painful if it forms in a
position where it would be subjected to repeated
trauma.
• Normal physiologic stimuli such as
– stretching,
– pressure,
– vascular pulsations
– may be painful and thus limit prosthetic usage.
19

20. • Special techniques have been tried in the hopes
of preventing the formation of painful neuromas.
These include
– end-loop anastomosis,
– peri- neural closure,
– Silastic capping,
– sealing the epineurial tube with butyl cyanoacrylate,
– ligation,
– cauterization,
– methods to bury the nerve ends in bone or muscle.
20

21. • Most surgeons currently agree that nerves should be
– isolated,
– gently pulled distally into the wound,
– divided cleanly with a sharp knife so that the cut end
retracts well proximal to the level of bone resection.
• Strong tension on the nerve should be avoided during
this maneuver; otherwise, the amputation stump may
be painful even after the wound has healed.
• Crushing also should be avoided.
• Large nerves, such as the sciatic nerve, often contain
relatively large arteries and should be ligated.
Campbells operative orthopedics 13th
edition 21

22. Bone
Minimize sharp edges – by Beveling/filing
Narrow metaphyseal flare/condyles
To Minimize bleeding
Minimize periosteal stripping
22

23. • A prominent distal fibula or
fibular head can cause pressure
related pain within the socket.
• If fibula is left longer than the
tibia, tenderness associated with
bursitis, occur frequently.
• GENU VALGUM- due to pull
of biceps femoris muscle
• Care should be taken to shorten
the fibula approximately 1 inch
more than tibia.
23

24. • In very short transtibial
amputation (within 5 cm
of the tibial tubercle)
proximal shaft and head
of fibula should be
excised.
24

25. TYPES OF AMPUTATION
GUILLOTINE MODIFIED
GUILLOTINE
REVISED PLANNED
OPEN CLOSED
25

26. Braddom physical medicine and
rehabilitatipn
26

27. Frantz and O'Rahilly classification
Nomenclature for congenital skeletal limb deficiencies, a revision
of the Frantz and O'Rahilly classification, Robert L.et al
27

28. Nomenclature for congenital
skeletal limb deficiencies, a
revision of the Frantz and
O'Rahilly classification,
28

29. Levels of amputations
• Around hip – Hemi-pelvectomy, Hip
Disarticulation
• Around knee –Transfemoral amputation,
Knee disarticulation Transtibial amputation
• Around ankle - Syme amputation
• At foot - Pirgof , Chopart (Mid tarsal)
Lisfranc (Tarsometatarsal), Boyd’s and
Disarticulation of toes
29

30. PARTIAL FOOT
AMPUTATIONS
30

31. Knee disarticulation
Benefits
• distal (or end) weight-bearing
, with potentially greater
comfort.
• The intact femur provides a
long mechanical lever
powered by strong muscles for
effective ambulation, better
sitting balance and leverage.
• Better proprioception from
subchondral bone, gives better
balance
Demerits
• The socket with distal
padding, attachment
brackets and knee
mechanism results in a
long “prosthetic thigh,”
which locates the
prosthetic knee axis lower
to the ground than that of
the sound knee. (Little
evidence exists, however,
that this knee level
difference is in fact
physiologically or
functionally harmful.)
31

32. Knee disarticulation
Benefits
• Growth plates at both
ends of the femur are
preserved, a particular
advantage for child
patients.
• bony overgrowth/spurs
common in children with
a transection is usually
eliminated
Demerits
• Bulbous distal end of
the residual limb
typically requires a
special socket design,
sometimes including
one or more cutout
openings for donning
32

33. Knee disarticulation
Benefits
• By preserving the femoral
condyles, a knee
disarticulation provides a
prominent base from
which to suspend the
prosthesis and help in
controlling unwanted
rotation.
Demerits
• With prosthesis applied,
the residual limb may
appear noticeably
larger than the
contralateral leg,
presenting a self-image
problem for some
people.
33

34. Standard Levels of Upper-Limb
Amputation
1. Transphalangeal
2. Transmetacarpal
3. Transcarpal
4. Wrist disarticulation
5. Transradial amputation
6. Elbow disarticulation
7. Transhumeral amputation—6.5 cm or
more proximal to the elbow joint
8. Shoulder disarticulation
9. Forequarter amputation
34

35. Ideal stump
• Length of the stump should be
adequate.
• Muscle power should good in the
stump and proximal joint.
• Full ROM in proximal joint
• Healthy and Non adherent scar
• Adequate muscle covering over
distal end and around the stump
• Normal skin sensation
• No Neuroma 35

36. Bad stump
• Small and inadequate
size.
• Flabby musculature
around the stump
• Bony stump
• Restricted ROM at
proximal joint.
• Painful stump scar.
• Presence of neuroma.
36

37. Postoperative goals
1. Adequate wound healing and Pain control
2. Preparation of residual limb for prosthetic fitting
3. Maintaining and optimizing ROM, especially in the remaining
proximal joints of the amputated extremity
4. Independent mobility
5. Independence in self-care and activities of daily living
6. Education about prosthetic fitting and care
7. Support for adaptations to the changes resulting from the
37

38. Diffrences between dysvascular and
traumatic amputation
PRE OP
Traumatic amputation
• Usually acute presentation
• Trauma zone and non
trauma zone will be easy to
identify
• Level of amputation can be
decided pre operatively in
most cases
• Vascular surgery reference
not necessary
Dysvascular amputation
• Chronic presentation
• Vascular zone and
dysvascular zone are a
complicated intra op
decision, and surgeon and
patient should be prepared
for intra op review of level
of amputation
• Vascular surgery reference
is necessary
38

39. INTRA OP
Traumatic amputation
• Usually patient will have
hemodynamic instability,
requiring surgeons to
proceed quickly
• May need to trade off
rehabilitative benefits for
immediate life saving
Dysvascular amputation
• Usually , can be managed
conservativily till patient is
optimized for surgery, and
surgeon can take best
surgical decisions for
rehabilitative benefits
39

40. INTRA OP
Traumatic amputation
• Tourniquet must be applied
• Equal posterior and anterior skin
flaps
• Long posterior myofascial flap
• Myodesis and myoplasty can be
done.
• Reconstructive flaps are an
option
Dysvascular amputation
• Tourniquet may harm the surgical
decisions in severly ischemic
limbs
• Long posterior myocutaneous
flap
• Myodesis and myoplasty should
be avoided in severely ischemic.
• Reconstructive flaps are usually
impractical due to non availability
of good recepeint vessels
40

41. IMMEDIATE POST OP
Traumatic amputation
• Limb elevation
• Compressive dressing to
control edema
• No need for anticoagulants
if otherwise not indicated
Dysvascular amputation
• Limb elevation is
controversial
• Compressive dressing not
recommended
• Anticoagulants and
vasodilators are
recommended in severely
ischemic limbs
41

42. PROSTHETIC PHASE
Traumatic amputation
• Hard sockets can be
accepted
Dysvascular amputation
• Soft inner lining must be
given
– Silicone lining is the ideal
– Ethoflex rubber
• Detailed cardiac evaluation
is necessary before lower
limb prosthetic training
• Wearing schedule must be
increased very slowly and
gradually
42

43. Thank you
• Refernces
– Campbells operative orthopedics 13th edition
– Kulkarni textbook of orthopedics and trauma
– Grabs textbook of plastic and rehabilitative surgery
– Ghosh Das Pooja et al ,Prevalence and aetiology of amputation
in India: A retrospective analysis
– Braddoms textbook of PMR
– Sharma JP, Salhotra R et al. Tourniquets in orthopedic surgery.
Indian J Orthopedics
– Nomenclature for congenital skeletal limb deficiencies, a
revision of the Frantz and O'Rahilly classification, Robert L.et al
– Essentials of prosthesis and orthotics, Dr AK Agarwal
43