amputations, types and principles

1. AMPUTATION
Dr. DINRAJ T V
JR 1, GENERAL SURGERY
AIMS

2. •AMPUTATION IS THE COMPLETE
REMOVAL OF AN INJURED OR
DEFORMED BODY PART

3. INDICATIONS
• PERIPHERAL VASCULAR DISEASE
 GANGRENE DUE TO ATHEROSCLEROSIS,
EMBOLISM, TAO
• DIABETIC LIMB DISEASE/ GANGRENE
• DEAD, DYING DEVITALISED TISSUE
• TRAUMA : LIFE SAVING IN CRUSH INJURIES
• INFECTION AND GANGRENE – TO SEPSIS
• MALIGNANCY
• DEVERE DEFORMITY : CONGENITAL/ ACQUIRED

4. AIM OF AMPUTATION
• RETURN PATIENT TO MAXIMUM LEVEL OF
INDEPENDENT FUNCTION
• ABLATION OF DISEASED TISSUE (TUMOR OR
INFECTION)
• REDUCE MORBIDITY & MORTALITY (TUMOR
OR INFECTION)
• PRODUCE A PHYSIOLOGICAL END ORGAN .

5. IDEAL STUMP
• PROPER HEALING
• ROUND, GENTLE CONTOUR WITH MUSCLE PADDING
• ADEQUATE BLOOD SUPPLY
• PROVISION FOR PROSTESIS
• THIN SCAR, SHOULD AFFECT PROSTESIS FUNCTION
• ADEQUATE ADJACENT JOINT MOVEMENT

8. 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

9. Preoperative evaluation
Hb, PCV
Correct anaemia
Control of infection : with antibiotics
Diabetic control
Level of amputation :
Arterial DOPPLER
R/o other cardiac conditions

10. Different Amputations
RAY AMPUTATION
TOE AMPUTATION
WITH HEAD OF METATARSAL
GILLIES’ AMPUTATION
TRANS METATARSAL
PROXIMAL TO NECK OF METATARSAL, DISTAL TO BASE

11. LISFRANC’S
TARSO METATARSAL AMPUTATION
DISARTICULATION
LONG VOLAR FLAP

12. CHOPART’S
MID TARSAL AMPUTATION
DISARTICULATION OF
TALO-NAVICULAR & CALCANEO CUBOID JOINTS
TIBIALIS ANTERIOR SUTURED TO TALUS
LONG VOLAR FLAP AND IMMOBILISATION – 6WKS

13. SYME’S AMPUTATION
REMOVAL OF FOOT WITH CALCANEUM
RETAINING HEEL FLAP
BONE AT TIBIA & FIBULA JUST ABOVE ANKLE JOINT
ELEPHANT BOOT

14. Pirogoff's amputation
Amputation of the foot at the ankle, part of the
calcaneus being left in the stump
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
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.

15. BELOW KNEE AMPUTATION
(BURGESS’ )
MIN. STUMP LENGTH :
8 CM FROM TIBIAL TUBEROSITY
(14-17 CM IS GOOD)
LONG POSTERIOR FLAP
SCAR ANTERIORLY
FIBULA TO BE DIVIDED BEFORE TIBIA AT A HIGHER LEVEL

16. • PEG LEG AMPUTATION
 5 CM STUMP
 ANTERIOR FLAP ROTATED POSTERIORLY
 NOT PRACTICED NOW

17. GRITTI STOKES
TRANS CONDYLAR AMPUTATION
FEMUR DEVIDED JUST ABOVE PATELLAR ARTICULAR
SURFACE
LONG POSTERIOR FLAP
NOT USED NOW
DUE TO NON UNION OF PATELLA WITH FEMUR

18. ABOVE KNEE AMPUTATION
EQUAL ANTERIOR AND POSTERIOR FLAP
FEMUR STUMP : IDEAL – 25 CM
NOT <10 CM

19. HIP DISARTICULATION
WHEN STUMP >10CM IS NOT POSSIBLE
SOLCUM’S APPROACH : SINGLE POSTERIOR FLAP
BOYD’S APPROACH : ANTERIOR RAACQUET INCISION

20. HIND QUARTER AMPUTATION
SIR GORDON TAYLOR’S AMPUTATION
HEMI PELVECTOMY
REMOVAL OF
 ONE SIDE PELVIS
 INNOMINATE BONE
 PUBIS
 MUSCLES AND VESSELS
RETAIN PART OF PUBIS, ILIUM
POSTERIOR FLAP : BY SUPERIOR GLUTEAL ARTERY

21. UPPER LIMB AMPUTATION
KRUKENBERG’S AMPUTATION
DONE IN TRAUMA
FOREARM AMPUTATION
GAP B/W RADIUS AND ULNA LIKE A CLAW

22. • UPPER LIMB AMPUTATION
 20 CM STUMP IS ADVICED IN BOTH ABOVE AND
BELOW ELBOW AMPUTATION
• FOREQUARTER AMPUTATION
 INTER SCAPULO THORACIC AMPUTATION
 UPPER LIMB WITH SCAPULA, LATERAL 2/3 OF
CLAVICLE,

23. TYPES OF AMPUTATION
• WEIGHT BEARING
• NON WEIGHT BEARING
• END BEARING/ CONE BEARING
• NON END BEARING/ SIDE BEARING
• FLAP CAN BE
 UNEQUAL/ EQUAL FLAPS

24. PRINCIPLES OF AMPUTATION
• Adequate blood supply
• No tourniquet during surgery
• Proper making of skin
• Proximal part of flap contain muscle and distal part only
skin
• Nerve to be buried deep
• Proper dressings after surgery

25. Incisions
• Circular incision amputation
• Elliptical/ oval incision
• Racquet incision

26. •SKIN FLAPS
 The apex of the fish mouth at the level of the bony resection
 Total length of flap anterior + posterior = 1.5 times diameter
 Flap should be semi circular for conical stump
 Use any available flaps in trauma to preserve length
 Tailor flaps at least as long as the diameter of the stump

27. •MUSCLES
 Divide ~5 cm distal to level of bone resection
 Stabilisation of muscle mass by good suturing.
 Adequate stump padding
 Prevents atrophy (muscle exercises)
 Improves function
 Myoplasty = involves suture of flexors to the extensors over bony
stump
 Myodesis = direct suture of muscle to bone - most useful in AK,
AE and disarticulations

28. Nerves
Divide cleanly under gentle tension proximal to bone ends -
allow to retract
Large nerves eg sciatic, median - ligate due to large contained
vessels
Blood vessels
Large arteries & veins should be doubly ligated and
haemostasis achieved prior to closure
Bone
Avoid excessive periosteal stripping (prevent spur formation)
Bevel & smooth the bone end

29. • Closure
 Do not close under tension
 Interrupted sutures preferably
• Drains are necessary

30. Goals of Postoperative Management
Prompt, uncomplicated wound healing
Control of edema
Control of Postoperative pain
Prevention of joint contractures
Rapid rehabilitation

31. WOUND CARE
ABSORBENT, NON-ADHERENT AND OCCLUSIVE
VACCUM DRAIN
PROPER PADDING FOR COMFORT AND PROTECTION
BANDAGING SHOULD BE FIRM BUT
NOT RESTRICTIVE

32. • PREVENT CONTRACTURE
 USE OF BRACE OR OTHER IMMOBILISER
 PHYSIOTHERAPY
 EARLY MOBILISATION OF PATIENT
 Sitting out of bed within 48 hrs
 Wheelchair used to assist mobility
 Practice in transferring, standing and early walking with
crutches supervised with physio.

33. Complications
 Early
 Haemorrhage & Haematoma
 Infection
 Late
 Necrosis of stump end.
 Ring sequestrum formation
 Contractures (due to muscle imbalance)
 Neuroma at the cut nerve ending
 Phantom pain
 Terminal overgrowth (children)

34. • Phantom limb sensation is the sensation that the
amputated limb is still present.
• Phantom limb pain usually is like a burning,
stinging, electric pain, and it can be increased with
anxiety and stress.
• Telescoping is the sensation that the distal part of
the amputated extremity has moved proximally up
the arm

35. “Stump Edema Syndrome” : associated with the use
of suction prosthesis.
-Proximal constriction
-Blood in skin ,pain, Pigmentation
-Elevation

36. COMPLICATIONS
1. Failure of wound to heal : gap if wider than 1cm needs revision
2. Infection : open – flaps retract / edematous
results in shortening the bone
Rx : close only central 1/3 for coverage of bone.
3. Phantom sensation : diminishes over time, telescoping
4. Pain and phantom pain : massage , cold packs, exercise and
neuromuscular stimulation
TENS ( trans cutaneous electric nerve stimulation) :
incorporated in a prosthesis
-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine

37. Follow up
2 weeks after surgery
Start muscle contraction exercises and physiotherapy
Desensitization is started with a towel for distal
residual extremity pressure
Prosthetic management to be started by 6weeks
Depending on the condition of the extremity and
wound
Some patients are not candidates for prosthesis

38. Thank you….