This presentation provides an overview of amputation, including: 1) The history, indications, levels, preoperative evaluation, operative techniques, postoperative care, and complications of amputation. 2) Details on different amputation levels for the upper and lower extremities. 3) The importance of criteria for an ideal stump, including adequate length and muscle coverage, full range of motion in the proximal joint, and a healthy scar.

1. 1
WELCOME
TO THE DAILY TOPICS PRESENTATION
Dr Md Jobayer Al Mahmud
MS Phase B Resident

2. Amputation

4. Outline
• History
• Indication
• Levels of amputation
• Preoperative evaluation
• Operative techniques
• Technical aspects
• Postoperative care
• Complications
• References
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5. History
• The word amputation is derived from
from the Latin amputare, ‘to cut away’.
• The English word “amputation’’ was
first applied to surgery in 17th century
by Peter Lowe in 1612.
• Historically was given as punishment
• However stimulated by the aftermath
of war.
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6. History (cont…)
• It was a crude procedure by which limb was
rapidly severed from unanaesthesized patient.
• Hippocrates was the first to use ligature.
• Ambroise Pare ( a France military surgeon)
introduced artery forceps. He also designed
prosthesis.
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7. Indication
• Alan Apley encapsulated the
indications for amputation in
the ‘three Ds’:
1. Dead or dying limb
2. Dangerous limb
3. Damn nuisance
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8. Dead or dying limb
• Peripheral vascular disease
• Severe traumatised limb
• Burn
• Frost bite
Indications (cont…)

9. Dangerous limb
• Malignant tumour
• Lethal sepsis
• Crush injury
Indications (cont…)

10. Damn nuisance
Remaining the limb is more worse than
having no limb at all because of:
• Pain
• Gross malformation
• Recurrent sepsis
• Severe loss of function
Indications (cont…)

11. Level selection
Subjective measures
Clinical examination:
• Skin quality, extent of ischaemia/infection
• Presence of pulse immediately above the level of amputation
Local function:
• Joint and residual limb length salvage is directly correlated to
functional outcome.
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12. Level selection (cont…)
Prosthetic design:
• Short stump – Slips out from the prosthesis
• Long stump - Pain, ulceration, incorporate of the joint in the prosthesis
Objective test
Non invasive procedures :
• Doppler USG
• Skin perfusion pressure
•Transcutaneous oximetry
Invasive procedures:
• Angiography
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13. Level of amputation
Determination of level
• Zone of injury (trauma)
• Adequate margin (tumour)
• Adequate circulation (vascular disease)
• Soft tissue envelope
• Bone and joint condition
• Control of infection
• Nutritional status
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14. Pre operative evaluation
History
• Aetiology
• Co-morbidities
Physical examination
• CVS, renal and nervous system
Investigations
• Doppler indices
• Transcutaneuos O2 tension
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15. Pre operative evaluation (cont…)
Optimisation
• Anaemia, nutrition, hypotension, infection
Consultation
• Nephrologist, cardiologist, neurologist
Counselling and consent
• Procedure, anaesthesia, complications, prosthesis & limitations.
MESS score 7 or more
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16. Ganga Hospital Open Injury Score

17. Principles of amputation
• Adequate blood supply
• Skin incision should be marked properly
• Torniquet shouldn’t be used in case of vascular disease
• Proximal part of the flap contains muscle component and
distal flap should contain only skin & deep fascia
• Adequate flap length
• Nerve to be buried deep
• Proper dressing after surgery
• Postoperative active exercise should be given for proximal
joint

18. Criteria of ideal stump
• Length of the stump should be adequate.
• Muscle power should good in the stump and proximal joint.
• Full ROM in proximal joint.
• Healthy and non adherent scar.
• Adequate muscle covering over distal end and around the
stump.
• Normal skin sensation.
• No neuroma.
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19. Criteria of bad stump
• Small and inadequate size.
• Flabby musculature around the stump.
• Bony stump.
• Restricted ROM at proximal joint.
• Painful stump scar.
• Presence of neuroma.
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20. Technical aspects
Incision:
• Circular
• Elliptical
• Racquet
Skin flaps:
• Flap should be kept thick
• Tense sutures should be avoided
• Apex of fish mouth at the level of bony resection
• Total length of flap anterior + posterior = 1.5 times diameter
• Flap should be semicircular for conical stump

21. Technical aspects (cont..)
Muscles:
• Divided at least 5 cm distal to intended bone
resection
• Stabilised by myodesis or myoplasty
Nerves:
• Neuroma formation is inevitable after transaction
• Draw nerve distally, section it, allow to retract

22. Technical aspects (cont..)
Blood vessels:
• Large vessels should be double ligated
• Haemostasis achieved prior to closure
Bone:
• Avoid excessive periosteal stripping
• Bevel and smooth the bone end
Closure:
• Don’t close under tension
• Drains are necessary

23. Amputation levels
• Forequarter amputation:
Entire upper limb + scapula + clavicle (lateral 2/3rd)
• Shoulder disarticulation:
Done at the level of shoulder with shoulder blade remaining
• Transhumeral:
Done at any level between supracondylar region to axillary
fold
• Elbow disarticulation
• Transradial amputation:
Either proximal or distal

24. Amputation levels (cont..)
• Wrist disarticulation
• Krukenberg’s amputation:
Gap between radius & ulna like a claw.
• Wrist amputation
• Hand and partial hand amputation
• Hindquarter amputation:
Standard, anterior flap & conservative hemipelvectomy
5 cm above the ASIS to pubic tubercle
• Hip disarticulation:
5 cm distal to adductor muscle & ischial tuberosity, 8 cm distal to greater
trochanter

25. Amputation levels (cont..)
• Transfemoral amputation:
Short, medial & long transfemoral, supracondylar
Ideal length 25 from tip of greater trochanter
and minimum stump should be 10 cm
• Knee disarticulation
• Transtibial amputation:
Ideal length of the stump should be 12.5 cm to
17.5 cm

26. Amputation levels (cont..)
• Syme’s amputation:
Section of tibia-fibula 0.6 cm proximal to ankle retaining heel flap
• Chopart’s amputation:
Disarticulation of talonavicular & calcaneocuboid
• Lisfranc’s amputation:
Disarticulation of tarsometatarsal joint
• Gillies amputation (trans metatarsal)
• Ray amputation:
Amputation of toe + metatarsal head

27. Dressing
Rigid dressing:
• Decreases oedema & postoperative pain
• Protect limb from trauma
• Early mobilisation
• Temporary prosthetic fitting
Soft dressing:
• Sterile dressing & crepe bandages applied.

28. Complications
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Early complications:
• Bleeding and haematoma
• Flap necrosis
• Surgical wound infection
• Gas gangrene
Late complications:
• Phantom pain
• Phantom limb
• Dermatological complications
• Joint deformity

29. Post surgical rehabilitation
• Primary goal – Reduce pain & oedema, increase strength, prevent
contractures.
• Instructed not to lie on a overly soft mattress.
• Early mobilisation should be encouraged.
• Limb desensitisation.
• Maintain joint range of motion.
• Prosthesis may be fitted a minimum of 8-12 weeks after surgery.

30. Psychological stress
Up to 2/3rd amputee will manifest postoperative
psychiatric symptoms
• Depression
• Anxiety
• Crying spells
• Insomnia
• Loss of appetite
• Suicidal ideation

31. References
• Canale & Beaty: General principles of amputations:
Campbell's Operative Orthopaedics, 14th edition.
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• Selvadurai Nayagam, David Warwick. Orthopaedic operations;
Apley's system of orhtopaedics & fractures, 10th Ed; 12:325-328.
• John Ebenezer: Amputations; Textbook of Orthopaedics, 4th
Edition; 60:787-791.
• Internet