Amputation- Indications, Types, Complications

1. Dr. Sanjib Kumar Das, Fellow PhDDr. Sanjib Kumar Das, Fellow PhD

2. AMPUTATION
• Amputation is a procedure where a part of the limb is removed
through one or more bones.
• Disarticulation where a part is removed through a joint.
• Amputation of lower limb is more commonly performed than
that of upper limb
• Partial amputation of fingers or hand is common in developing
countries, mainly as a sequelae of farm and machine injuries.

3. Indications for amputation
• Injury
• Peripheral vascular disease, including diabetes
• Infections e.g., gas gangrene
• Tumours
• Nerve injuries
• Congenital anomalies

4. TYPES-AMPUTATION
Guillotine or Open Amputation
• This is where the skin is not closed over the amputation stump, usually when
the wound is not healthy.
• The operation is followed, after some period, by one of the following
procedures for constructing a satisfactory stump:
• Secondary closure: Closure of skin flaps after a few days.
• Plastic repair: Soft tissues are repaired without cutting the bone and skin flaps
are closed.
• Revision of the stump: Terminal granulation tissue and scar tissue, as well as
a moderate amount of bone is removed and the stump reconstructed.
• Re-amputation: This is amputation at a higher level, as if an amputation is
being performed for the first time.

5. Closed Amputation
• This is where the skin is closed primarily (e.g., most elective
amputations).
SURGICAL PRINCIPLES – FOR CLOSED TYPE
• Tourniquet: Tourniquet is highly desirable except in case of an
ischaemic limb.
• Ex-sanguination: A limb should be squeezed (ex-sanguinated) by
wrapping it with a stretchable bandage (Esmarch bandage) before a
tourniquet is inflated.
• It is contraindicated in cases of infection and malignancy for fear of
spread of the same proximally.
TYPES-AMPUTATION

6. Nomenclature of amputation by levels

7. Nomenclature of amputation by levels

8. SURGICAL PRINCIPLES – FOR CLOSED TYPE
• Level of amputation- Principles guiding the level of amputations are as follows:
• The disease: Extent and nature of the disease/trauma, is an imp. consideration.
• One tends to be conservative with dry-gangrene (vascular) and trauma, but liberal
with acute life threatening infections and malignancies.
• Anatomical principles: A joint must be saved as far as possible. Artificial limbs is
fitted to a well healed, non-tender and properly constructed stump.
• Ideal length of the stump at AE or BE is 20cm, AK is 25-30cm, BK is 14cm.
• Suitability for the efficient functioning of the artificial limb: Sometimes, length is
compromised. For example, a long stump of an above knee amputee may hamper
with optimal prosthetic fitting.

9. • Skin flaps: The skin over the stump should be mobile and
normally sensitive.
• Muscles: Muscles should be cut distal to the level of bone. The
methods of muscle sutures:
 Myoplasty i.e., the opposite group of muscles are sutured to
each other.
 Myodesis i.e., the muscles are sutured to the end of the stump.
• Nerves are gently pulled distally into the wound, divided with
knife so that the cut end retracts well proximal to the level of
bone section.
SURGICAL PRINCIPLES – FOR CLOSED TYPE

10. • Major blood vessels should be isolated and ligated using non-
absorbable sutures.
• The tourniquet is released before skin closure and hemostasis should
be secured.
• Bone level: Bony prominences need to be well padded by soft tissues.
• Sharp edges of the cut bone to be resected and should be made
smooth.
• Drain: A corrugated rubber drain should be used for 48-72 hours post-
operatively.
SURGICAL PRINCIPLES – FOR CLOSED TYPE

11. COMPLICATIONS
• Haematoma: Loosening of the ligature and inadequate wound drainage are
the common causes.
• Haematoma results in delayed wound healing and infection. It should be
aspirated and a pressure bandage given.
• Infection: The cause generally is an underlying peripheral vascular disease,
diabetes or a haematoma.
• A wound should not be closed whenever the surgeon is in doubt about the
vascularity of the muscles or the skin at the cut end.
• Wound breakdown and occasionally spread of infection proximally may
necessitate amputation at a higher level.

12. • Skin flap necrosis: A minor or major skin flap necrosis indicates insufficient
circulation of the skin flap.
• It can be avoided at the time of designing skin flaps that as much subcutaneous
tissues remain with the skin flap as possible.
• Small areas of flap necrosis may heal with dressings but for larger areas,
redesigning of the flaps may be required.
• Deformities of the joints: These results from improper positioning of the
amputation stump, leading to contractures.
• A mild or moderate contracture is treated by appropriate positioning and gentle
passive-stretching exercises.
• Severe deformity may need surgical correction.
COMPLICATIONS

13. • Neuroma: A neuroma always forms at the end of a cut nerve.
• In case a neuroma is bound down to the scar because of adhesions, it becomes
painful.
• Painful neuroma can usually be prevented by dividing the nerves and allowing
it to retract well proximal to the end of the stump, to lie in normal soft tissues.
• If it does form, it is to be excised at a more proximal level.
• Phantom sensation: A sensation as if the amputated part is still present.
• This sensation is most prominent in the period immediately following
amputation, and gradually diminishes with time.
• Phantom pain is the awareness of pain in the amputated limb.
COMPLICATIONS

14. AFTER TREATMENT
• TRx from the time amputation is completed till the definitive
prosthesis fitted, is important if a strong and maximally
functioning stump is desired.
• Dressing: There are two types of dressings used after amputation
surgery:
1. Soft Dressing: This is conventional dressing using gauge, cotton
and bandage.
2. Rigid Dressing: In this type of dressing, after a conventional
dressing, a well moulded PoP cast is applied on to the stump at
the conclusion of surgery. This helps in enhancing wound
healing and maturation of the stump.
• In addition, the patient can be fitted with a temporary artificial
limb with a prosthetic foot (pilon) for almost immediate
mobilisation.

15. • Positioning and elevation of the stump: This is required to
prevent contracture and promote healing.
• Exercises: Stump exercises are necessary for maintaining
range of motion of the joint proximal to the stump and for
building up strength of the muscles controlling the stump.
• Wrapping the stump helps in its healing, shrinkage and
maturation. This can be done with a crepe bandage.
• Prosthetic fitting and gait training: This is started usually 3
months after the amputation.
AFTER TREATMENT

16. THANK YOU
Dr. Sanjib Kumar Das, MPT(Musculoskeletal),
Fellow Doctoral, NITIE-Ergonomics and Human Factors,
Amity University, Noida, India
Mail: sanjib_bpt@yahoo.co.in
Contact No. :+91 8879485847