4. INTRODUCTION
• Definition
– Amputation is the trans osseous removal of a limb or
part of a limb by trauma, prolonged constriction, or
surgery
• Statement of surgical importance
– Most ancients of surgical procedures
– Early surgical amputations were crude with
attendant high mortality
– Better outcomes and perception due to
advancements in surgical techniques and prosthetic
designs
5. INTRODUCTION
• Epidemiology
– More common in 50-75 years age group
– About 75% are in men
– Up to 85% involve lower limbs
– The estimated prevalence of extremity
amputation in Nigeria is 1.6 per 100,000
– In Nigeria, most studies reported trauma as the most
common cause of limb amputation
6. INTRODUCTION
• Epidemiology
– In Europe and USA 85-89% and 82% of amputations,
respectively, are as a result of vascular diseases
– Thanni and Tade reported 34% of amputations in Nigeria
to be due to trauma
– Diabetes has been reported as the most common cause
of non-traumatic amputation in Nigeria
– Nwadiaro H.C. et al found that 75% of amputations in
children below 16 years of age resulted from activity of
bone setters in Jos
7. INTRODUCTION
• Epidemiology
– The frequent indications for amputation in Nig.
• Trauma- 34%
• Complications of traditional bone setting (TBS)- 23%
• Malignant tumours- 14.5%
• Diabetic gangrene- 12.3%
• Infections- 5.1%
• Peripheral artery disease- 2.1%; and
• Burns- 2.1%
8. INDICATIONS
• Congenital
– Congenital deficiencies of the long bones
– Amniotic band syndrome
– Exposure to teratogens
– Polydactylyl
– Macrodactylyl
– Congenital pseudoarthrosis of the tibia and fibula,
radius and ulna
12. GENERAL PRINCIPLES
• Resuscitation
– Especially in trauma
– ATLS protocols
– IVF
– Blood transfusion
– Correction of anaemia
– Antibiotic and tetanus prophylaxis
– Control of blood sugar in diabetic patients
13. GENERAL PRINCIPLES
• Pre operative preparations
– Multidisciplinary
– Patient should be given time to come to terms with
the inevitability of amputation
– Aim:
• Ascertain indication
• Site of amputation
• General medical condition
• Rehabilitation potential
• Counselling
• Consent
• Optimization
14. GENERAL PRINCIPLES
• Pre operative preparations
– History
• Aetiology
• Co-morbidities
– Physical examination
• Assessment of –
– The affected limb
– The unaffected limb &
– The patient as a whole is conducted thoroughly
• Removes subjectivity from decision making in trauma cases
• No scoring system can replace experience & good clinical
judgment
15. GENERAL PRINCIPLES
• Pre operative preparations
– Social assessment
• Family & friends supports
• Living accommodation
– Stairs
– Ramps
– Width of door
– Wheelchair accessibility
• Proximity of shop/office
• Involvement of support groups
18. GENERAL PRINCIPLES
• Pre operative preparations
– Investigation
• Capability of Wound Healing
– Trans cutaneous Oxygen
– Haemoglobin
– Serum Albumin
– Absolute lymphocyte count
19. GENERAL PRINCIPLES
• Pre operative preparations
– Determination of level of amputation
• This is important especially in vascular disease
• Determining the most distal level for amputation with a
reasonable chance of healing can be challenging
• Demands of prosthetic design and local function also
deserve consideration
20. GENERAL PRINCIPLES
• Pre operative preparations
– Determination of level of amputation
• The selection of amputation level can be aided by
– Clinical
» Lowest palpable pulse
» Skin color
» Hair growth, and
» Skin temperature
– Doppler indices
» Ankle-brachial index >0.5
» Occlusion pressure at the calf and thigh > 65 mmHg
and 50 mmHg respectively
21. GENERAL PRINCIPLES
• Pre operative preparations
– Determination of level of amputation
– Transcutaneous oxygen tension 20-40mmHg
– Tissue uptake of intravenously injected fluorescein
– The tissue clearance of intradermally injected xenon-
133
22. GENERAL PRINCIPLES
• Pre operative preparations
– Optimization
• Correction of anaemia
• Correct hypotension
• Treat infection
• Nutritional support
– Consultations
• Vascular surgeon
• Nephrologist
• Cardiologist
• Neurologist
23. GENERAL PRINCIPLES
• Operative principles
– Goal
• To get rid of all necrotic, infected & painful tissue
• To have a wound that heals successfully
• To have an appropriate remnant stump that is able to
accommodate a prosthetic
– Meticulous attention to details and gentle soft tissue
handling play an important part in wound healing
24. GENERAL PRINCIPLES
• Operative principles
– Positioning
– Anaesthesia
• Regional or GA
– Antibiotic prophylaxis
– Tourniquet
• Except in arterial insufficiency
25. GENERAL PRINCIPLES
• Operative principles
– Skin flaps
• Good skin coverage of the stump is a very important
• Combined length equals 1.5 times the width of the limb at
site of amputation
• Types of skin flap
– Equal anterior and posterior flaps
– Longer posterior flap
– Lateral flaps
– Fish mouth flap
26. GENERAL PRINCIPLES
• Operative principles
– Skin flaps
• Recommendations
– Ant. & post. Flaps of equal length for UL & A/K
amputations
– Long posterior flap for BK amputation
• The skin should be mobile and sensitive
• Avoid redundant soft tissues and dog ears
• With modern total contact prosthetic sockets, the
location of the scar is rarely important
27. GENERAL PRINCIPLES
• Operative principles
– Muscles
• The muscles are divided at least 5 cm distal to the level of
intended bone section
• They may be stabilized by
– Osteomyodesis or
– Myoplasty
28. GENERAL PRINCIPLES
• Operative principles
– Advantages of muscles fixation/stabilization
• The shape of the stump is good
• The muscles insulate the cut nerve endings and bone from
prosthesis by producing a cushion end
• The muscles originating proximally to the joint produce
better stump mobility, and leverage is increased
• The muscles which are not acting on the joint above
contract isometrically and assist in venous return
29. GENERAL PRINCIPLES
• Operative principles
– Advantages of muscles fixation/stabilization
• Prevents retraction and painful muscle contractions
• Prevents atrophy
• Phantom pain may be prevented
30. GENERAL PRINCIPLES
• Operative principles
– Haemostasis
• Major blood vessels should be isolated and individually
doubly ligated
• Large arteries and veins are dissected and separately
ligated
• The tourniquet should be deflated before closure and all
bleeders ligated or cauterized for meticulous haemostasis
• Use of drain
31. GENERAL PRINCIPLES
• Operative principles
– Nerves
• Isolated, gently pulled distally into wound and divided
sharply
• Strong tension on the nerve should be avoided during this
manoeuver
• Large nerves should be ligated
32. GENERAL PRINCIPLES
• Operative principles
– Bone
• The bone is cut at least 5cm
above the level of muscle
section
• Reflect periosteum 1-2cm
distally
• Minimal periosteal stripping
to avoid formation of ring
sequestra or bony
overgrowth
• Protect soft tissues with
amputation shield
33. GENERAL PRINCIPLES
• Operative principles
– Bone
• Smoothen edges
• In trans-tibial amputations
– Anterior aspect of the tibia is usually bevelled and
smoothened
– The fibula is cut 3 cm shorter
34. GENERAL PRINCIPLES
• Operative principles
– Bone (site of election)
• A/K : 12cm above the joint
• B/K : 14cm below the joint
• B/E : 18cm from the olecranon
• A/E : 20cm from acromion
37. GENERAL PRINCIPLES
• Operative principles
– Wound closure
• Rigid dressing
– POP cast is applied to the stump over
the dressing after surgery
• Semi rigid dressing
• Soft dressing
– The stump is dressed with the sterile
dressing & elastocrepe bandage
applied over it
39. GENERAL PRINCIPLES
• Post operative care
– Multidisciplinary approach
– General
• Pain management
• Antibiotic therapy
• DVT prophylaxis
• Management of co-morbidities
40. GENERAL PRINCIPLES
• Post operative care
– Specific
• Prevent limb oedema
• Drain removal
• Mobilization
• Limb/stump positioning and exercise
• Removal of stitches
41. • Preserve length
• Preserve important growth plates
• Perform disarticulation rather than
transosseous amputation whenever possible
• Preserve the knee joint whenever possible
• Stabilize and normalize the proximal portion of
the limb
• Be prepared to deal with issues in addition to
limb deficiency in children with other clinically
important conditions.
PRINCIPLES OF CHILDHOOD
AMPUTATION
47. PROSTHESIS
• An artificial replacement for a body part, either
internal or external
• A prosthesis should be designed and assembled
according to the patient's appearance and
functional needs
• Early prosthesis were made of wooden and
metallic materials
• Subsequent introduction of thermoplastic and
other materials- polypropylene, plastic foam
49. PROSTHESIS
• Pre prosthetic assessment
– Check stump condition
– Pre morbid mobility level
– Strength and fitness
– Assess co morbidities
– Cognitive function
– Social situation
– Attitude and motivation
53. PROSTHESIS
• Ideal prosthesis
– Fits comfortably
– Function well
– Looks presentable
– Fit as soon after the operation
– Non toxic, non carcinogenic and non allergic
– Light in weight
54. • Includes lifelong prosthetic, functional, and
medical assessment and psychological support.
• Patients should be seen for follow-up by one of
the team members at least every 3 months for
the first 18 months, with physical follow-up
every 6 months
• Support groups
FOLLOW-UP
55. PECULIARITIES
• Patients have difficulty accepting amputation due to
culture
– Role of family
– Patients/family refusing
– Husband authority over wife
– Children never have authority
– Males usually decide
• Role of traditional bone setters
• Few specialist and specialist training centres
• Cost of prosthesis
56. CONCLUSIONS
• Amputation should not be seen as treatment
failure rather as the first step to patient’s return
to a more comfortable and productive live
• It does not end in the operating room, post
operative care is equally important
• Multidisciplinary: surgeon, nurse, prosthetist,
physiotherapist, occupational therapist, social
worker and psychologist
57. REFERENCES
• Selvadurai Nayagam; David Warwick;
Orthopaedic operations, in Apley’s System of
Orthopaedics and Fractures, 9th ed. 2010; 12:
325-328
• John Ebenezer; Amputations, in Textbook of
Orthopaedics, 5th ed. 2010; 60:787-791
• Patrick C. Toy; General principles of amputations
, in Campbell’s operative orthopaedics, 12th ed.
Vol. I, 2013; 14:598-611
58. REFERENCES
• AS Rao; Ramchandar Siwach; Amputations, in
Textbook of orthopaedics and trauma, 2nd ed.
Vol. 4, 2008; 386:3893-3916
• B.D Athani et al; Prosthetics and orthotics;
Introduction, in Textbook of orthopaedics and
trauma, 2nd ed. Vol. 4, 2008; 387:3919-3922
• Robert Sayer; Arterial disorders, in Bailey and
Love’s Short Practice of Surgery, 26th ed. 2013;
56: 891-893
59. REFERENCES
• H.C Nwadiaro et al; Outcome of traditional
bone setting in the middle belt of Nigeria, in
Nigeria Journal of Surgical Research vol. 8
No.1-2, 2006: 44-48
• W.O Okenwa et al; Amputation of the limbs:
10 years’ experience at Enugu state University
Teaching Hospital, in Oriental Journal of
Medicine vol.27 (1-2) Jan.-Jun. 2015; 40-45
