The document provides an overview of general principles and techniques for amputation. It discusses: 1. The definition of amputation and its historical development from ancient times to modern antiseptic techniques. 2. The common indications for amputation including peripheral vascular disease, trauma, infections, and tumors. 3. Surgical principles such as ideal stump shape and length, techniques for blood vessels, nerves, muscles and bone, and postoperative care including rigid dressings. 4. Potential complications like hematoma, infection, wound necrosis, contractures and phantom limb pain.

1. GENERAL PRINCIPLES
OF
AMPUTATION
DR NIKHIL DROLIA
JR I

2. Amputation : Loss of a limb or part of a limb
 The word amputation is derived from the Latin word amputare, "to
cut away"
 Should not be viewed as a failure of treatment but as the first step
in Rehabilitation
 Should be performed by the most experienced surgeon in team

3. HISTORY
 Earliest amputation were done on unanesthetized patients &
haemostasis attained by crushing or dipping the open stump in
boiling oil
 Hippocrates was the first to use ligatures
 Morel’s introduced torniquet in 1674
 Lister’s introduced antiseptic technique in
reducing mortality

4. AMPUTATION
 Indications
 Scoring
 Surgical Principles
 Amputation level
 Technical Aspects
 Open Amputations
 Post operative care
 Amputation in children
 Complications

5. INDICATIONS
 Dead limb – Gangrene
 Deadly limb- Wet gangrene ,Spreading cellulitis ,
Arteriovenous fistula, Other (e.g. malignancy)
 ‘Dead loss’ limb -Severe rest pain , Paralysis ,Other(e.g.
contracture, trauma)

6.  Only absolute indication : irreversible ischemia in
diseased or traumatized limb
 Peripheral vascular disease
 Trauma
 Burns
 Frostbite
 Infections
 Tumors

7. PERIPHERAL VASCULAR DISEASE
 Most common age group 50 to 75 yrs
 Most patients have concomitant disease processes in cerebral
vasculature, coronary arteries & kidney.
 Co morbid conditions-diabetes, smoking, prior stroke, prior
major amputation, decreased transcutaneous oxygen levels,
decreased ankle-brachail blood pressure index, ulcers.
 Most significant predictor of amputation in diabetics is
peripheral neuropathy as measured by insensitivity to the
Semmes Weinstein 5.07 monofilament.
 Perioperative mortality rate-30 % & 40% die within 2 yrs.

8. TRAUMA
 Most common in young patients
 Male >Female
 Lange’s absolute indications for amputation in type III C tibial
injuries :
o Crush injury with warm ischemia time of > 6 hrs
 Relative indications :
o Serious associated injuries
o Severe ipsilateral foot injuries
 Decision as to a limb which can be saved , should be saved or not

9.  Early amputation and prosthetic fitting :
◦ Decreased morbidity
◦ Fewer operations
◦ Shorter hospital stay
◦ Decreased hospital costs
◦ Shorter Rehabilitation
◦ Earlier return to work
 Acute trauma : functional stump length of stump must be maintained
whenever possible

11.  Necessary for acute or chronic infections which are unresponsive to
antibiotics and surgical debridement
 Most worrisome infection produced by gas forming bacteria( eg.
Clostrdium,streptococcal)
 Disability from non healing trophic ulcer , chronic osteomyelitis ,
infected nonunion
 Squamous cell carcinoma from chronic discharging sinus
INFECTION

12.  Limb salvage vs. Amputation
◦ Would survival be affected by treatment choice
◦ Comparison of short term and long term morbidity
◦ Function of salvaged limb
◦ Psychosocial consequences
 Amputation for malignancy is technically demanding
 Limb salvage : Disadvantages
◦ More extensive surgical procedure
◦ Greater risk of infection
◦ Wound dehiscence
◦ Flap necrosis
TUMORS

13. ◦ Increased blood loss
◦ Deep venous thrombosis
 Late complications :
◦ Periprosthetic fractures
◦ Prosthetic loosening
◦ Graft host nonunion
◦ Allograft fractures
◦ Leg length discrepancy
◦ Late infection

14.  Increased function by increased length of stump vs. Increased complications with
shorter stump
 Revascularization may aid in increasing length of stump but peripheral bypass
surgery may compromise wound healing of a future transtibial amputation
 More proximal level of amputation promotes slower walking velocity in order to
conserve energy
 Amputation should be performed at most distal level if ambulation is main concern
 Potential for wound healing best measured by transcutaneous O2 measurement
LEVEL OF AMPUTATION

15. Ideal length of amputation stump
 Above knee amputation : 23-27 cm from greater trochanter or 12 cm from
knee
 Below knee amputation : 12 -17 cm stump length
2.5cm for every 30 cm of height
 Above elbow amputation : 20 cm from shoulder
 Below elbow amputation : 18 cm from olecranon

18. Factors affecting level of stump
 Section of bone above a joint may prevent use of best type of artificial joint
 Retention of limb remnants below joint which cannot move distal part is not
justified
 When B/K amputation not possible , disarticulation favored
 In ischaemic limbs , level just below distal most pulsation

19. Ideal stump
 Conical shape ( ideal shape )
 Ideal length
 Good muscle power
 Joint should be supple
 Non adherent scar
 No fixed deformity
 Absence of neuroma
 Bone well covered by muscles
 Muscular and not flabby
 Bone covered by muscles , free from infection

20. What a stump
should look like

21. What a stump should
not look like

22. Efforts should be aimed at
 Stump drainage and removal of drain in time
 Stump splinting
 Proper stump bandaging
 Early starting of stump exercises
 Stump hygiene and intermittent exposure to air

23.  Tourniquet : Advantageous, contraindicated in ischaemic limbs.
Exsanguinations contraindicated in infected limbs & tumors
Skin Flap
 Flaps should be kept thick
◦ Posterior skin flap should be => anterior skin flap
◦ With modern total contact prosthesis , location of scar not important
◦ Flap should not be adherent to the underlying bone
◦ Preferable to have atypical skin flap than higher level amputation
◦ Large dog ears are to be avoided
◦ Combined length of flaps should be 1/3 of circumference of limb at level of
amputation
SURGICAL TECHNIQUE

24. Muscles
◦ Muscles sectioned 5 cm distal to level of intended bone resection
◦ May be stabilized by myoplasty or myodesis
◦ Myoplasty : Suturing muscle to periosteum or fascia of opposing musculature
◦ Myodesis : Suturing muscle or tendon to bone
◦ Myodesis should be performed to have stronger insertion , help maximize
strength , minimize atrophy
◦ Myodesed muscle counterbalance antagonists and prevent contractures and
maximize residual limb function
◦ Myodesis contraindicated in severe ischemia due to increased risk of wound
breakdown

26. Advantages of Myoplasty/Myodesis
 Shape of stump is good
 Muscles insulate cut nerve endings and bone from prosthesis
 Muscles originating proximally to joint produce better stump mobility and increase
leverage
 Muscles not acting on joint contract isometrically and assist in venous return
 Prevent retraction and painful muscle contractions
 Phantom pain prevented

27. Blood vessels
 Larger vessels doubly ligated
 Tourniquet should be deflated before closure
 Drain preferable for 48-72 hrs

28. Nerves
 After nerve is divided it almost always forms neuroma
 Neuroma is painful if traumatized repeatedly
 Techniques to prevent neuroma formation : end loop anastomosis ,
perineural closure , Silastic capping , sealing epineurial tube with butyl-
cyanoacrylate , ligation , cauterization or burying nerve ends in muscle
/bone
 Strong tension should be avoided while stretching
 Larger nerves may need ligation for blood vessels

29. Bone
 Excessive periosteal stripping contraindicated
 May result in formation of ring sequestrum or bony overgrowth
 Bone should be rasped to form a smooth contour- over anterior aspect for below
knee , lateral aspect of femur and over radial styloid
 Fibula cut slightly proximally to produce conical stump

30.  Skin not closed over level of amputations
 First of the at least 2 surgeries used to create functional stump
 Required in :
 Extensive contaminated injuries
 Infection
 Guillotine amputations : all tissue from skin to bone cut at same level ;
wound left open for further management ; done as an emergency
procedure
 Open amputations with flaps where wound open , flaps covered later
OPEN AMPUTATIONS

31.  Treatment of stump crucial from time amputation is completed till definitive
prosthesis is fitted
 Gradual shift from conventional soft dressings to rigid dressing
 Rigid dressing :
POP cast applied to stump at conclusion of surgery
◦ Appropriate padding of all bony prominences
◦ Avoiding proximal constriction of ring
◦ Use of dependable cast suspension methods
 If immediate weight bearing intended , true prosthetic cast should be
applied by certified prosthetist
POST OPERATIVE CARE

32. Advantages of Rigid dressings
 Prevent edema at surgical site
 Protect wound from bed trauma
 Enhance wound healing
 Early maturation of stump
 Decrease postoperative pain
 Allow early mobilization from bed
 Prevent formation of knee flexion contractures
 Drains removed at 48 hrs post op
 Stump is elevated by raising foot end
`Avoid leaving stump in dependent position

33. RIGID DRESSING

35.  Prevent flexion or abduction contractures of hip
 2nd post op day : muscle setting and joint mobilization exercises begun
 Time for prosthesis application depends upon :
 Age
 Strength
 Agility
 Patient’s ability to protect stump from excessive weight bearing
 Early unprotected weight bearing may lead to sloughing of skin or
delayed wound healing
 Cast should be removed after 7-10 days
POST OPERATIVE CARE

36.  Hematoma
 Infection
 Wound Necrosis
 Contractures
 Pain
 Phantom limb sensation
 Dermatological problems
COMPLICATIONS

37.  Hematoma:
 Prevented by rigid dressing , meticulous hemostasis
 May delay wound healing
 Serve as nidus for infection
 Infection :
 More common in ischemic ,diabetic limbs
 Deep wound infection should be treated with immediate debridement
 Delayed closure may be difficult because of edema
 Smith and Burgess method of closing central 1/3 of wound and leaving rest
packed open
 Wound Necrosis:
 Nutritional supplementation , TLC , albumin counts
 Necrosis of skin edge < 1 cm can be treated conservatively
 Discontinue prosthetic until wound healed
 If severe necrosis with loss of bone coverage , wedge resection indicated

38.  Contractures:
 Prevented by proper stump positioning , gentle passive stretching , exercises
 Increased ambulation reduces contractures
 May need wedging casts or surgical release of contracted sutures
 Dermatological problems :
 Contact Dermatitis
 Bacterial folliculitis
 Epidermoid cysts
 Verrucous hyperplasia

39.  Pain :
 Phantom limb , Phantom pain, residual pain , pain from distant site
 Back ache more common in amputees
 Residual pain more often due to improper fitting
 Painful neuroma usually is easily palpable
 Phantom limb :
 Very common
 Usually not very bothersome
 Telescoping
 Phantom limb pain bothersome , present mostly in proximal level amputations
 Conservative measures tried

40. Infection Wound necrosis

41.  Most often due to trauma followed by neoplasms , infection
 General body growth and stump growth important
 Considerations :
 Preserve length as much as possible
 Preserve important growth plates
 Prefer disarticulation rather than amputation
 Preserve knee joint whenever possible
 Stabilize and normalize proximal portion of limb
 To prevent stump overgrowth , myodesis must be preferred at the time of
surgery
 Terminal overgrowth : appositional spike like new bone formation
 Regular prosthetic checking
AMPUTATIONS IN CHILDREN

42. REFERENCES
 Campbell
 Apley’s
 Google