Successfully reported this slideshow.
Activate your 14 day free trial to unlock unlimited reading.
Amputation is the surgical removal of a limb or part of a limb
by cutting through the shaft of the bone.
It is the most ancient surgical procedures. Early surgical
amputation was a crude procedure by which a limb was
rapidly severed from an unanaesthesized patient,the open
stump was crushed or dipped in boiling oil to obtain
Hippocrates 1st to use ligature which was lost during the dark
1529:Pare reintroduced it & artery forceps.
1674:Morel introduced tourniquet.
With the introduction of general anaesthesia & antiseptic
technique in the late 19th century surgeons could now fashion
a functional stump.
More than 300,000 patients with amputations live in the U S
according to NCHS and about 65,000 amputations are
>90% of amputations performed in western world are
secondary to PVDx.
In younger patient trauma is the leading cause followed by
1965, AK : BK = 70 : 30
1980, AK : BK = 30 : 70.
In FMC Owerri,41 BKA were done in the last 2years with M
: F = 1.7 : 1.
Diabetic foot gangrene 88%, Trauma & TBS 5% each, others
1) Emergency or Elective.
2)Provisional or Definitive.
3)End bearing or Non end bearing.
Colloquially 3 D’s
Dead (or Dying) Dangerous limb
Gangrene Malignant tumours
Peripheral Vascular disease Osteosarcoma
Atherosclerosis Marjolins ulcer
DM Potentially lethal sepsis
Frost bite Recurrent Sepsis
Bone setters gangrene Severe loss of function
LEVEL OF AMPUTATION
Determined by : a) Disease process b) Viability of tissues and
c) Prosthesis available.
Determination of adequate blood flow: Clinical : i.)
lowest palpable pulse ii.)skin colour and
temperature iii)bleeding at surgery
.Doppler ultrasonography: Ankle : brachial index > 0.5.
Compression pressure at the calf >65mmHg.
Transcutaneous oxygen measurement >40mmHg.
Skin perfusion pressure measurement by infrared
thermography or laser doppler flowmetry.
Too short a stump may tend to slip out of prosthesis. Too long
a stump may have
inadequate circulation & can become painful or ulcerate.
Assessment and resuscitation
Investigate & address co-morbid conditions in consultation
with physicians, Anaesthetists &
FBC, FBS, Se/u/c, urinalysis, chest x-ray, ECG, serum
Informed consent –pathology, inevitability of amputation,
complications, availability of prosthesis
Determine the level of amputation. Goal of the
surgeon is to: a)Find a place where
healing is mostly to be complete.
b)To have an ideal stump for prosthesis fitting.
QUALITIES OF AN IDEAL STUMP
1)Should heal adequately.
2)Should have rounded, gently contour with adequate muscle
3)Should have sufficient length to bear prosthesis.
4)Should have thin scar which does not interfere with
5)Should have adequate adjacent joint movt.
ANAESTHESIA : GA/Spinal
POSITION : Supine
PREINCISION : prophylactic antibiotics, exsanguinate,
tourniquet, skin prep & draping.
incision to outline a long posterior flap & a short anterior
one --- combined length 1 ½ times the diameter of the leg at
the level of amputation.
Deepened to the bone. Periosteum raised.
Section tibia at level of incision, bevel anterior surface.
Fibular 2-3cm proximally. Smoothen round sharp margins.
Vessels isolated and double ligated,Nerves pulled down & cut
with a sharp knife & allowed to retract into the soft tissue.
Irrigation with N/S, Removal of tourniquet to meticulously
Myoplasty or Myodesis done over a drain after trimming the
muscle to size.
Close skin with interrupted non absorbable sutures.
Wound dressing- soft or rigid.
POSTOP CARE/ REHABILITATION
General care: Control of pain, prevention oedema,
prevention of infection, DVT prevention, care of concurrent
medical conditions., Suture removal.
Physiotherapy: Muscles exercised, joints kept mobile,
patients taught how to use crutches & prosthesis.
Stump dressing: .Soft
dressing: gauze, cotton wool, bandage. Teach patient or
relative stump bandaging. .Rigid dressing: POP cast
can be used with stump socks & padding. A jig could be
applied that allows attachment and alignment for early pylon
use where limited weight bearing with BAC is possible.
Cast changed every 5-7 days for skin care. Within 3-4 wks
rigid dressing can be changed to a removable temporary
Benefits: a)prevention of oedema b)enhanced
wound healing c)early maturation of
stump d)decreased post op pain
e)allow early ambulation f)position
stump to avoid contracture
Rehabilitation of the patient is a multidisciplinary approach.
Aim is to bring the patient to an optimum of physical ,
mental, emotional, social, vocational, & economic efficiency.
Is the substitution of a part of the body to achieve optimum
function. Eg BKA prosthesis A)patellar
tendon bearing B)solid ankle cushion
heel Advantages: i) Cosmesis
ii)Ambulation iii) Function of the part.
i)infection ii)pressure ulcer iii) cost
SITUATION IN OUR SUBREGION
Socio-cultural belief a)re-incarnation b)Husband
authority over wife c)Children never have
authority d)Males usually decides
Traditional bone setters
Few prosthetic centers
Few centers for microvascular surgeries.
Amputation should be done by surgeons who have
knowledge of amputation surgical principles,postop
rehabilitation, & prosthetic design.
Improved prosthetic design does not compensate for a poorly
performed surgical procedure.
Amputation should not be viewed as a failure
of treatment but rather as the 1st step towards a patient’s
return to a more comfortable & productive life.