2. Lower Extremity Amputation
• The major cause of lower extremity amputation is
peripheral vascular disease (PVD), particularly
when associated with smoking and diabetes
• The second leading cause of amputation is
trauma, usually from motor vehicle accidents or
gunshot
• The incidence of amputation from osteogenic
sarcoma has been reduced by better limb salvage
3. Selection of Amputation Levels
• PVD
- Failed revascularisation
- Extensive tissue loss
- Unreconstructable
- Excess surgical risk
4. Selection of Amputation Levels
• Diabetes
- Overwhelming sepsis
- Extensive tissue loss
- Excess surgical risk
6. Level of Amputation
• Surgeon's selection of the level of amputation
is influenced by:
– Viability of the good tissues’
– Prosthesis
– Patients’ needs
• Occupation
• Cosmoses
• Age and gender
7. Surgical Process
Basic principles
• The surgeon’s goal is to amputate at the lowest
possible level compatible with healing
• Skin flaps are as broad as possible which depend on
the causes:
• Dysvascular or non-dysvascular.
• The scar should be pliable, painless, and
nonadherent.
8. Non-dysvascular
• For most transfemoral and non-dysvascular transtibial
amputations, equal length anterior and posterior flaps
are used, placing the scar at the distal end.
10. Healing Process
• Factors that may affect healing include
– Infection,
– Cigarette smoking,
– The severity of vascular problems,
– Diabetes,
– Renal disease,
– Other physiological problems such as cardiac
disease
11. The Major Outcomes of the
Postsurgical Period
1. Promote as high a level of independent function as
possible
2. Guide the development of necessary physical and
emotional level for eventual prosthetic rehabilitation
3. Independence in mobility and self-care
4. Independence in bed mobility and basic transfers
5. Supervised or independent mobility with crutches or
walker
6. Demonstrate knowledge of proper residual limb
positioning, bandaging, and care
12. The Major Outcomes of the
Postsurgical Program
1. Reduce postoperative edema and promote healing of
the residual limb
2. Prevent contractures and other complications
3. Maintain or regain strength in the affected lower limb
4. Maintain or increase strength in the remaining
extremities
5. Assist with adjustment to the loss of a body part
6. Demonstrate knowledge of basic residual limb
exercise
7. Learn proper care of the remaining extremity
8. Determine the feasibility of prosthetic fitting
13.
14. Conclusions
• Amputation is traumatic enough…poor level
selection can make it worse.
• Clinical judgement central to proper level
selection
• Patient factors are more important than
objective testing
17. Rehab Outcome and Level of
amputation
• The level of amputation and age of patient
affect the outcome
• Higher the amputation, more difficult the
rehab.
• Older/sicker the pt., more difficult the rehab.
19. Trans-pelvic amputation
Hind quarter amputation
(hemipelvectomy)
• Removing of the entire limb and part of ileum, pubis,
ischium and sacrum and leaving peritoneum muscles
and fascia to cover and support the internal organs.
• It’s a save life procedure.
20. Hip disarticulation (HD)
• Amputation of the
lower limb at the hip
joint, leaving the pelvis
intact.
• Mainly due to tumor
and rarely because of
vascular disease.
21. Trans-femoral amputation: above-knee
amputation (AK)
• Amputation of the lower limb
between the hip joint and the
knee joint.
• Surgeons must leave 11.5-12.5
Cm
• Long stump tend to flex and
adduct.
• Short stump tend to flex and
abduct.
22. Knee disarticulation (KD)
Gritti-Stokes Amputation
• Amputation of the lower limb at the knee
joint.
• An excellent weight-bearing stump.
• It is most often used in children and young
adults, but is nearly always avoided in the
elderly and patient with ischemic disease.
• Advantages include:
– A large end surface covered by skin and soft tissues
that is naturally suited for weight bearing.
– A long lever arm controlled by strong muscles.
– Increased stability of the patients prosthesis.
• Disadvantage
– Cosmetic (longer artificial leg)
23. Below Knee Amputation (BK)
• The ideal level for
amputation in the BKA
patient is approximately
at the mid-calf.
– The distal third relative
avascularity and lack of
sufficient soft tissue
padding at this level.
• The ideal BKA stump in
adults is 12.5 to 17.5cm.
24. The Symes amputation
• Disarticulation at the ankle
joint and removal of the
medial and lateral malleoli to
the level of articular surface of
the tibia. The heal pad being
sutured into the position over
the distal end of the tibia and
fibula.
• it creates an excellent end-
bearing stump and allows for
a functionally most
satisfactory prosthesis.
• Problems include posterior
migration of the heel pad, and
a bulky non-cosmetically
pleasing prosthesis.
28. Ray Amputation
• A ray amputation is a particular form of minor
amputation where a toe and part of the
corresponding metatarsal bone is removed.
29. Toes Amputation
• the fifth toe (the most commonly
amputated toe) is usually removed for
being overriding on the fourth toe.
• Complications of toe amputations with
regards to gait are minimal.
• This is true for amputation of the great
toe during standing or walking at a
normal pace. However, if the patient
walks rapidly a limp appears from the
loss of the normal push-off provided by
the great toe.
• Additional complications specific to the
toes include a severe hallux valgus
deformity seen in amputations of the
second toe.
