Amputation class


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Amputation class

  1. 1. Amputation is the complete removal of an injured or deformed body part
  2. 2. <ul><li>Peripheral vascular disease </li></ul><ul><ul><li>Peripheral Arterial occlusive disease </li></ul></ul><ul><ul><li>Acute occlusion due to embolism </li></ul></ul><ul><ul><li>Aneurysm </li></ul></ul><ul><li>Diabetic limb disease </li></ul><ul><li>Necrotising fasciitis </li></ul><ul><li>Trauma (severe tissue damage) - traumatic amputation </li></ul><ul><li>Infection (chronic disabling infection, Gas Gangrene) </li></ul><ul><li>Tumours (Malignant) </li></ul><ul><li>Nerve injury (trophic ulceration – insensitive limb) </li></ul><ul><li>Congenital anomalies </li></ul><ul><ul><li>(eg. extra digits) </li></ul></ul><ul><ul><li>Gross deformity (dysmelia) </li></ul></ul>
  3. 3. Amputation
  4. 4. Amputation
  5. 5. Amputation
  6. 6. Amputation
  7. 7. Polydactyly Amputation
  8. 8. Amputation
  9. 9. <ul><li>Damage to micro-vessels </li></ul><ul><li>Peripheral neuropathy, no sensation </li></ul><ul><li>Ulcers develop due to trauma, infection often ensues </li></ul><ul><li>Arterial blood supply is reduced </li></ul><ul><li>Ulcer becomes chronic with bouts of acute infection leading to loss of digits/foot/limb </li></ul>
  10. 11. <ul><li>Malignancy: squamous cell carcinoma </li></ul><ul><li>Cardiac disease: AF, CCF, MI, </li></ul><ul><li>Trauma: RTA, crushing injury, gunshot, bomb blast, industrial machinery and burns. </li></ul>
  11. 12. <ul><li>Return Patient to maximum level of independent function </li></ul><ul><li>Ablation of diseased tissue (tumor or infection) </li></ul><ul><li>Reduce morbidity & mortality (tumor or infection) </li></ul><ul><li>Considered first part of a Reconstruction to produce a physiological end organ . </li></ul>
  12. 13. <ul><li>Level – sites of Election versus sites of Emergency </li></ul>Amputation Levels Optimum     Shortest    Longest Transradial ( forearm )    junction prox 2/3 & distal 1/3    3cm below biceps insertion      5cm above wrist joint Transhumeral ( arm )   middle third    4cm below axillary fold    10cm above olecranon Transfemoral  ( thigh )  middle third    8cm below pubic ramus    15cm above knee joint Transtibial  ( leg )  8cm for every metre of height  (12cm)  7.5cm below knee joint
  13. 16. <ul><li>Zone of Injury (trauma) </li></ul><ul><li>Adequate margins (tumor) </li></ul><ul><li>Adequate circulation (vascular disease) </li></ul><ul><li>Soft tissue envelope </li></ul><ul><li>Bone and joint condition </li></ul><ul><li>Control of infection </li></ul><ul><li>Nutritional status </li></ul>Amputation
  14. 17. <ul><li>Debridement of all Nonviable tissue and foreign material </li></ul><ul><li>Several debridements may be required </li></ul><ul><li>Primary wound closure often contraindicated </li></ul><ul><li>High voltage, electrical burn injuries require careful evaluation because necrosis of deep muscle may be present while superficial muscles can remain viable </li></ul>Techniques Amputation
  15. 18. <ul><li>Nerve </li></ul><ul><ul><li>Prevent neuroma formation </li></ul></ul><ul><ul><li>Draw nerve distally, section it, allow it to retract proximally </li></ul></ul><ul><li>Skin </li></ul><ul><ul><li>Opportunistic flaps </li></ul></ul><ul><ul><li>Rotation flaps </li></ul></ul><ul><ul><li>Tension free </li></ul></ul><ul><ul><li>Skin grafts </li></ul></ul>Techniques Amputation
  16. 19. <ul><li>Bone: </li></ul><ul><ul><li>Choose appropriate level </li></ul></ul><ul><ul><li>Smooth edges of bone </li></ul></ul><ul><ul><li>Narrow metaphyseal flare for some disarticulations </li></ul></ul>Amputation Techniques
  17. 20. <ul><li>Goals of Postoperative Management </li></ul><ul><ul><li>Prompt, uncomplicated wound healing </li></ul></ul><ul><ul><li>Control of edema </li></ul></ul><ul><ul><li>Control of Postoperative pain </li></ul></ul><ul><ul><li>Prevention of joint contractures </li></ul></ul><ul><ul><li>Rapid rehabilitation </li></ul></ul>Techniques Amputation
  18. 21. <ul><li>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. </li></ul><ul><li>In postoperative prosthesis : early training with an IPOP is believed to increase the long term acceptance and use of prosthesis </li></ul><ul><li>Epidural analgesia </li></ul><ul><li>Cast to be appied at the end of the procedure, changed on the post op day 5 + IPOP </li></ul><ul><li>Cast changed weekly </li></ul><ul><li>Early prosthetic fitting . New prosthesis around 18 months </li></ul><ul><li>Avoid proximal compression of the limb. </li></ul><ul><li>Prevent contracture (by splinting and / or muscle exercises ) </li></ul>
  19. 22. <ul><li>Failure of wound to heal : gap if wider than 1cm needs revision </li></ul><ul><li>Infection : open – flaps retract / edematous </li></ul><ul><li>results in shortening the bone </li></ul><ul><li>Rx </li></ul><ul><li>close only central 1/3 for coverage of bone. </li></ul><ul><li>3. Phantom sensation : diminishes over time, telescoping </li></ul><ul><li>4. Pain and phantom pain : massage , cold packs, exercise and neuromuscular stimulation </li></ul><ul><li>TENS ( trans cutaneous electric nerve stimulation) : incorporated in a prosthesis </li></ul><ul><li>-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine </li></ul><ul><li>- Preioperative analgesia can prevent or decrease the later incidence of phantom pain .(Epiduralperineural) </li></ul>
  20. 23. <ul><li>5. Edema </li></ul><ul><li>mistakes :- 1) Too tightly applied cast </li></ul><ul><li>2) Soft spica cast – not applied in Transfemoral cast </li></ul><ul><li>“ Stump Edema Syndrome” </li></ul><ul><li>-Proximal constriction </li></ul><ul><li>-Blood in skin ,pain, Pigmentation </li></ul><ul><li>-Elevation </li></ul>
  21. 24. <ul><li>Children </li></ul><ul><li>Usually for congenital limb deficiencies </li></ul><ul><li>Try to retain limb if possible </li></ul><ul><li>Preserve length </li></ul><ul><li>Disarticulate if possible to preserve growth potential rather than trans-diaphyseal amputation (  bony overgrowth) </li></ul>
  22. 25. <ul><li>Complications </li></ul><ul><li>Haematoma </li></ul><ul><li>Infection </li></ul><ul><li>Necrosis of stump end. </li></ul><ul><li>Contractures (due to muscle imbalance) </li></ul><ul><li>Neuroma at the cut nerve ending </li></ul><ul><li>Phantom pain </li></ul><ul><li>Terminal overgrowth (children) </li></ul>
  23. 26. <ul><li>in the postoperative period- 3 sources, wound pain, back pain and phantom pain. Wound pain can be controlled with opiates in the immediate phase and, if needed, NSAID’s used. </li></ul><ul><li>between normal postoperative (ie, surgical) pain and phantom limb pain . </li></ul><ul><li>Surgical pain usually responds well to opioids. </li></ul><ul><li>Phantom limb pain usually is like a burning , stinging , electric pain , and it can be increased with anxiety and stress . </li></ul><ul><li>phantom pain is quite common initially, </li></ul><ul><li>if it is still present at 6 months postsurgery, the prognosis is unfavorable. </li></ul>
  24. 27. <ul><li>Phantom limb sensation also must be differentiated from phantom limb pain . </li></ul><ul><li>Phantom limb sensation is the sensation that the amputated limb is still present . </li></ul><ul><li>Patients usually report that the absent hand/arm/limb is itching , tickling , or moving through space. </li></ul><ul><li>Phantom sensation is perceived as a &quot;funny&quot; or &quot;different&quot; feeling but usually is not perceived as painful . </li></ul>
  25. 28. <ul><li>Three theories as to why patients experience phantom limb pain and sensation exist. </li></ul><ul><li>One theory is that the remaining nerves continue to generate impulses. </li></ul><ul><li>A second theory is that the spinal cord nerves begin excessive spontaneous firing in the absence of expected sensory input from the limb. </li></ul><ul><li>The third theory is that there is altered signal transmission and modulation within the somatosensory cortex . </li></ul>
  26. 29. <ul><li>Another common phenomenon is telescoping. </li></ul><ul><li>Telescoping is the sensation that the distal part of the amputated extremity has moved proximally up the arm. </li></ul><ul><li>A patient might report that it feels like the entire extremity has shrunk so that the hand is now up at the elbow. </li></ul><ul><li>This is a normal part of the nerve healing process and usually fades with time. </li></ul>
  27. 30. <ul><li>Residual limb - The preferred term for the remaining portion of the amputated limb ( Stump , while still used, is politically incorrect.) </li></ul><ul><li>Terminal device - Most distal part of the prosthesis used to do work (eg, hand) </li></ul><ul><li>Myodesis - Direct suturing of muscle or tendon to bone </li></ul><ul><li>Myoplasty - Suturing muscles to periosteum </li></ul><ul><li>Prehensile - Grasp </li></ul>
  28. 31. <ul><li>Forequarter Amputation </li></ul><ul><li>is the removal of the upper limb with the scapula </li></ul><ul><li>Mainly for malignancy </li></ul>
  29. 32. <ul><li>Krukenberg procedure </li></ul><ul><li>Separate radial and ulna rays distally </li></ul><ul><li>forming radial and ulna pincers capable of strong prehension and excellent manipulative ability </li></ul>
  30. 38. The Syme's amputation provides an end-bearing stump that in many circumstances allows ambulation without a prosthesis over short distances. It is an excellent amputation for children, in whom it preserves the physes at the distal end of the tibia and fibula (26). The Syme's amputation works well for tumors and trauma, assuming that the heel flap has been spared from the trauma. In the past, it has had a high failure rate in ischemic limbs because of failure of wound healing. Today, the success of amputation at this level has increased because local tissue perfusion is preoperatively determined with Doppler ultrasound measurement of blood pressures, with radioactive 133 Xe clearance tests, and with transcutaneous measurement of oxygenation.
  31. 40. <ul><li>The Boyd procedure provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus </li></ul><ul><li>Compared to a Syme's amputation, it provides more length and better preserves the weight-bearing function of the heel pad. Its increased complexity and morbidity have made it less used now than the Syme's amputation. </li></ul><ul><li>The Pirogoff amputation removes the anterior two thirds of the calcaneus but has no advantage over the Boyd amputation, </li></ul>
  32. 41. <ul><li>Amputation through the knee offers numerous advantages. The main advantage is the creation of an endbearing stump and preservation of the distal femoral physes, which is particularly desirable in children. Another advantage is the maintenance of a long active lever arm for control of the prosthesis, with excellent muscle attachments. The bulbous distal stump enhances suspension of the prosthesis. </li></ul><ul><ul><li>In elderly dysvascular patients, the longer stump helps prevent hip flexion contractures and it provides better balance for wheelchair activities. Knee disarticulation is most useful in young athletic amputees in whom a below-knee amputation is not feasible. </li></ul></ul>
  33. 42. <ul><li>Chopart's amputation   amputation of the foot by a midtarsal disarticulation. </li></ul><ul><li>closed amputation   one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone. </li></ul><ul><li>amputation in contiguity   amputation at a joint. </li></ul><ul><li>amputation in continuity   amputation of a limb elsewhere than at a joint. </li></ul><ul><li>double-flap amputation   one in which two flaps are formed. </li></ul>
  34. 43. <ul><li>Dupuytren's amputation   amputation of the arm at the shoulder joint. </li></ul><ul><li>elliptic amputation   one in which the cut has an elliptical outline. </li></ul><ul><li>flap amputation   closed a. </li></ul><ul><li>flapless amputation   guillotine a. </li></ul><ul><li>Gritti-Stokes amputation   amputation of the leg through the knee, using an oval anterior flap. </li></ul><ul><li>guillotine amputation   one performed rapidly by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing. </li></ul><ul><li>Hey's amputation   amputation of the foot between the tarsus and metatarsus. </li></ul><ul><li>interpelviabdominal amputation   amputation of the thigh with excision of the lateral half of the pelvis. </li></ul><ul><li>interscapulothoracic amputation   amputation of the arm with excision of the lateral portion of the shoulder girdle. </li></ul><ul><li>Larrey's amputation   amputation at the shoulder joint. </li></ul>
  35. 44. <ul><li>Lisfranc's amputation   </li></ul><ul><li>1. Dupuytren's a. </li></ul><ul><li>2. amputation of the foot between the metatarsus and tarsus. </li></ul><ul><li>oblique amputation   oval a. </li></ul><ul><li>open amputation   guillotine a. </li></ul><ul><li>oval amputation   one in which the incision consists of two reversed spirals. </li></ul><ul><li>Pirogoff's amputation   amputation of the foot at the ankle, part of the calcaneus being left in the stump. </li></ul><ul><li>pulp amputation   pulpotomy . </li></ul><ul><li>racket amputation   one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb. </li></ul><ul><li>root amputation   removal of one or more roots from a multirooted tooth, leaving at least one root to support the crown; when only the apex of a root is involved, it is called apicoectomy . </li></ul><ul><li>spontaneous amputation   loss of a part without surgical intervention, as in diabetes mellitus. </li></ul><ul><li>Stokes' amputation   Gritti-Stokes a. </li></ul><ul><li>subperiosteal amputation   one in which the cut end of the bone is covered by periosteal flaps. </li></ul><ul><li>Syme's amputation   disarticulation of the foot with removal of both malleoli. </li></ul><ul><li>Teale's amputation   amputation with short and long rectangular flaps. </li></ul>
  36. 48. <ul><li>Aim: to provide a useful, functional, well moulded, healthy stump to allow prosthetic attachment </li></ul><ul><li>Total excision of diseased tissue </li></ul><ul><li>Maintenance of sufficient blood supply to allow healing </li></ul><ul><li>Stump of sufficient length to allow prosthetic attachment </li></ul>
  37. 49. <ul><li>Patient should be prone with the stump flat at first, BKA patients will often have a brace in situ to prevent post popliteal tendon contracture. </li></ul><ul><li>Physio involvement is tentative at this stage to avoid wound problems </li></ul>
  38. 50. <ul><li>Sitting out of bed within 48 hrs </li></ul><ul><li>Wheelchair used to assist mobility </li></ul><ul><li>Practice in transferring, standing and early walking with crutches supervised with physio. </li></ul><ul><li>Use of the PPAM aid, inflatable tube in metal frame with rocker foot, used on parallel bars for support </li></ul>
  39. 51. <ul><li>Initial contact layer should be absorbent non-adherent and occlusive to avoid infection </li></ul><ul><li>Vacuum drains may be in place until drainage subsides sufficiently (48 hrs) </li></ul><ul><li>Padding should be applied for comfort and protection and bandaging should be firm but not restrictive </li></ul>
  40. 52. <ul><li>Ischaemia: poor perfusion, infection, wound breakdown, pain. </li></ul><ul><li>Flap tension: tightness of skin over bone causing tension in the wound </li></ul><ul><li>Oedema: Due to tissue damage, dependence and poor venous drainage </li></ul><ul><li>Infection:high risk due to ischaemia, particularly diabetic patients, poor healing, </li></ul>
  41. 54. <ul><li>Involvement of the multidisciplinary team is essential: physio for mobility, provision of stump board for wheelchair OT for home assessment and safety issues, social work, benefits, motability car, district nurse for wound checks and/or control of diabetes. </li></ul><ul><li>Involvement in local amputee groups </li></ul><ul><li>Medical follow up at o/p clinic </li></ul>
  42. 55. <ul><li>Two weeks after surgery, muscle-contraction exercises and progressive desensitization of the residual extremity are initiated. </li></ul><ul><li>Desensitization is started with a towel for distal residual extremity pressure, and distal-end bearing is started on a soft structure (usually a bed). </li></ul><ul><li>Prosthetic management is begun 6 weeks after surgery, depending on the condition of the extremity and wound. Some patients are not candidates for prosthetic limb replacement because of poor balance, weakness, or cognitive impairment. To avoid disappointment and expense, a permanent prosthesis should not be ordered for these patients. </li></ul>
  43. 56. <ul><li>External ramps required </li></ul><ul><li>Stair lift, railings. </li></ul><ul><li>Doors widened </li></ul><ul><li>Kitchen worktops and sinks adjusted </li></ul><ul><li>Shower on level, with chair access </li></ul><ul><li>Possible hoist for bath </li></ul><ul><li>Adapted furniture </li></ul>
  44. 59. <ul><li>Potentially greater psychological impact </li></ul><ul><li>Patient more likely to have been younger and fitter. </li></ul><ul><li>Wound may be left open until signs of oedema and signs of infection reduce </li></ul><ul><li>Psychosocial issues are often far reaching </li></ul>
  45. 60. <ul><li>. If a digit is hanging on by a small “bridge” of skin or muscle, attempt to bandage it without completing the separation. If the body part can be easily recovered and the victim can be brought to a hospital within 6 hours of the injury, do the following: 1. Gently rinse the body part if the cut end is contaminated with dirt. 2. Wrap the body part in clean cloth or gauze and keep the covering moist. The ideal solution is saline (not ocean water, because of infection risk), if that is available; if not, fresh water will do. Do not immerse the part in a bag of water; merely keep the covering moist. Keep the body part cool by placing it on ice after wrapping it securely in a bandage, cloth, or towel. To avoid a frostbite injury, do not apply ice directly to the body part or immerse it in ice water. 3. Bring the body part with the victim to the hospital. </li></ul>
  46. 61. <ul><li>Tissue </li></ul><ul><ul><li>Clinical - feel pulses, skin temperature, level of dependent redness </li></ul></ul><ul><ul><li>Doppler (U/S)– check limb circulation; inaccurate with calcified blood vessels </li></ul></ul><ul><ul><li>Arteriogram </li></ul></ul>
  47. 62. <ul><li>Systemic </li></ul><ul><ul><li>control diabetes </li></ul></ul><ul><ul><li>evaluate cardiac, renal + cerebral circulation </li></ul></ul><ul><ul><li>Preoperative calorie’s control in malnourished patient. </li></ul></ul><ul><li>Psychological </li></ul><ul><ul><li>early plan for return to function </li></ul></ul><ul><ul><li>preoperative counseling </li></ul></ul><ul><ul><li>amputee support groups </li></ul></ul><ul><li>Preoperative Pain Control </li></ul><ul><ul><li>Pain clinic review </li></ul></ul><ul><ul><li>Spinal anaesthesia </li></ul></ul>
  48. 63. <ul><li>Intralesional </li></ul><ul><li>Marginal </li></ul><ul><li>Wide resection </li></ul><ul><li>Radical resection </li></ul>
  49. 64. <ul><li>Skin flaps </li></ul><ul><ul><li>Use defined flaps, with the apex of the fish mouth at the level of the bony resection </li></ul></ul><ul><ul><li>Use any available flaps in trauma to preserve length </li></ul></ul><ul><ul><li>Tailor flaps at least as long as the diameter of the stump </li></ul></ul>
  50. 65. <ul><li>Muscles </li></ul><ul><ul><li>Divide ~5 cm distal to level of bone resection </li></ul></ul><ul><ul><li>Stabilisation of muscle mass by good suturing. </li></ul></ul><ul><ul><li>Adequate stump padding </li></ul></ul><ul><ul><li>prevents atrophy (Muscle exercises) </li></ul></ul><ul><ul><li>improves function </li></ul></ul><ul><ul><li>Myoplasty = involves suture of flexors to the extensors over bony stump </li></ul></ul><ul><ul><li>Myodesis = direct suture of muscle to bone - most useful in AK, AE and disarticulations </li></ul></ul>
  51. 66. <ul><li>Nerves </li></ul><ul><ul><li>Divide cleanly under gentle tension proximal to bone ends - allow to retract </li></ul></ul><ul><ul><li>Large nerves eg sciatic, median - ligate due to large contained vessels </li></ul></ul><ul><li>Blood vessels </li></ul><ul><ul><li>Large arteries & veins should be doubly ligated and haemostasis achieved prior to closure </li></ul></ul><ul><li>Bone </li></ul><ul><ul><li>Avoid excessive periosteal stripping (prevent spur formation) </li></ul></ul><ul><ul><li>Bevel & smooth the bone end </li></ul></ul>
  52. 67. <ul><li>Closure </li></ul><ul><ul><li>Do not close under tension </li></ul></ul><ul><ul><li>Interrupted sutures preferably </li></ul></ul><ul><li>Drains </li></ul><ul><ul><li>are necessary </li></ul></ul>
  53. 68. Crush Amputation
  54. 69. Techniques… Few examples Amputation
  55. 70. Techniques… Few examples Amputation
  56. 71. After 12 months Techniques… Few examples Amputation