amputation procedure

1. Welcome

3. Principles of
Below Knee Amputation
W S R to Trans tibiofibular Amputation
Presented by
Dr JayanthKumar.S
2nd yr PGScholar
Dept of PG Studies in ShalyaTantra
JSS AyurvedaMedicalCollege,
Mysuru-570028
Guided by
Dr SiddeshAradhyamath
Professor and Head
Dept of PG Studies in ShalyaTantra
JSS AyurvedaMedicalCollege, Mysuru-570028

4. CASE – 1
72yr Male
C/O Wound in the
B/L lower limbs
H/O crush injury *3
months
K/c/o DM

5. CASE-2
63yrs Female
C/O pain and
small crack
between the 1st
and 2nd toe
K/c/o DM

6. CASE- 3
53yrs Male
C/o pain in the
foot while
walking and
sitting
H/o Smoking
K/c/o DM

7. Contents
• History
• Definition
• Anatomy
• Incidence
• Surgical principles
• Types of amputation
• Types of flaps
• Levels of amputation
• Indication
• Pre-operative
• Operative
• Post-operative
• Complications
• Prosthesis
• Discussion
• Conclusion
• References

8. History
• Rig-Veda is the first recorded
document about a prosthesis
1:116:15
• The foot of Vispala, the wife of Khela,
was cut off like the wing of a bird and
Aswini Kumaras gave her a metallic
leg.

9. Neolithic humans –
(New stone Age 10,200 BC)
Plato's (Symposium)
(385 BC)
Hippocrates
(De Articularis)
400BC
Acharya Sushruta
800 BC

10. 282 laws of scaled punishment
Hummurabi-
1754BCE
Before the discovery of
Anaesthesia
classic circular cut

11. J. McKnight(1865)
recorded survivor of a simultaneous triple
amputation

12. Definition
• “Amputation is a procedure where a part of the limb is
removed through one or more bones ”
Disarticulation;-
• “Surgical removal of whole limb or part of the limb
through a joint”

13. Incidence
• Age
• Traumatic
• Gender
• Limb

14. ANATOMY

15. Bones

16. Muscles

17. Arteries

18. Veins

19. Nerves

20. Surgical principles
• Tourniquet
• Ex-sanguination
• Levels of amputation
• Skin flaps
• Muscles
• Muscle suturing
– Myodesis
– Myoplasty
• Nerves

21. Surgical Principles contd..
• Blood vessels
• Bone
• Drains
• Post operative procedures
• Dressing - Conventional or soft
• Positioning and elevation of the stump
• Exercise
• Wrapping
• Prosthetic fitting and gait training

22. Surgical principles according to Ayurveda
• Sushruta Samhita has given references on Amputation.
• Poorvakarma – Dhoopana, Shastra payana, Madyapaana
• Pradhanakarma – Chedana using Kharapatra
• Pashchat karma – in cases of Raktasrava – pouring of hot
Kshoudra ,Guda or Sneha over the stump to attain
hemostasis. Kosha bandha, followed by vranopachara.

23. छे द्या भगन्दरा ग्रन्थिः श्लैन्िकन्िलकालकिः ।
व्रणवर्त्ाार्बादानि अर्ा: चर्ाकीलोऽन्थिर्ाांसगर्् ॥
र्ल्यां जतबर्नण र्ाांससांघातो गलर्बन्िका ।
स्नायब र्ाांसनसराकोिो वल्मीक
ां र्तपोिकिः ॥
अध्रबषश्च उपदांर्श्च र्ाांसकन्ि अनिर्ाांसकिः ॥
(सब सू २५/३-४)
कोििः पूतीभाविः । डल्हण सब सू २५/४
अपाक
े षब तब रोगेषब कनििेषब न्थिरेषब च ।
स्नायब कोिानदषब तिा च्छे दिां प्राप्तर्बच्यते ॥
(सब नच १/३३)
सांनभन्न जजाररत कोष्ठनर्रिःकपाला ।
जीवन्ि र्स्त्रनिहतैश्च र्रीरदेर्ैिः ॥
नछन्नैश्च सन्िभबज पादकरैरर्ेषैिः ।
येषाां र्र्ासब क
ृ ता नवनविािः प्रहारािः ॥
(सब र्ा ६/३४)

24. • ततो गबग्गबलब अगरु सजारस वचा गौरसषापचूणणिः लवण निम्बपत्र नवनर्श्रैराज्ययबक्ैिः िूपयेत्,
आज्यर्ेषेण चास्य प्राणाि् सर्ालभेत ॥ (सब सू ५/१८)
• तेषाां पायिा नत्रनविा क्षारोदक तैलेषब । तत्र क्षार पानयतां र्रर्ल्यान्थि छे दिेषब, उदकपानयतां
र्ाांसछे दिपाटिेषब, तैलपानयतां नसराव्यिि स्नायबच्छे दिेषब ॥ (सब सू ८/१२)
• प्राक
् र्स्त्रकर्ाणश्चेष्टां भोजयेदातबरां नभषक
् ।
र्द्यपां पाययेन्मद्यां तीक्ष्णां यो वेदिाऽसहिः ॥ (सब सू १७/११)
• नछन्नाां नििःर्ेषतिः र्ाखाां दग्ध्वा तैलेि र्बन्िर्ाि् ।
र्ध्नीयात् कोर्र्िेि प्राप्तां कायं च रोपणर्् ॥ (सब नच २/३७)

25. Types of Amputation
Closed– Elective procedure.
• The Skin is closed primarily after amputation.

26. Open/Guillotine
• Emergency procedure
• The skin is not closed primarily and
later, any one of the closure methods
like secondary closure, reamputation or
plastic repair follows it
• Indication- severe infection
- severe crush injury

27. Skin flaps
• A skin flap is healthy skin and tissue that is partly detached and
moved to cover a nearby wound
Skewed flap Long posterior skin flap

28. Trauma
Peripheral
vascular disease
Infection
Burn Frostbite
Tumor

29. Determination of
Levels of Amputation

30. Clinically
• Disease progress
• Lowest palpable pulse
• Skin colour and temperature
• Prosthesis available
• Easy movement

31. Investigations
• X-ray
• USG Doppler or CT-Angiogram
• Ankle-brachial pressure index > 0.5.
• Compression pressure at the calf >65mmHg.
• Transcutaneous oxygen measurement >40mmHg.
• Skin perfusion pressure >40mmHg - laser doppler flowmetry.

32. • Pre-operative
• Operative
• Post-operative

33. • Assessment
• Investigation
• Consultation and physical fitness
• High risk consent
• Preparation of OT
• Preparation of patient
Pre-operative procedures

37. Operative
procedures

43. Post-operative
procedures

44. Qualities of an ideal stump
• Should heal adequately.
• Should have sufficient length to
bear prosthesis.
• Should have thin scar which does
not interfere with prosthetic
function.
• Should have adequate adjacent
joint movement.
• Should have adequate blood supply.

45. Hematoma
Skin flap necrosis
Deformity
Neuroma
Phantom limb
Infection

46. Prosthesis
Replacement or substitution of a missing or a diseased part
Classification
Endoprosthesis – implants used to replace joints
Exoprosthesis- replacement externally for part of the limb
Types
Temporary- used until the patient is fitted with permanent prosthesis
Permanent- used permanently

47. Prosthesis for below knee Amputation
• Patellar tendon bearing- socket is
made to fit exactly over the patellar
tendon and the side of the tibial
condyles
• Conventional type- consist
of thigh corset, side steel,
knee joint, shin piece, ankle
joint unit and footpiece

48. Jaipur Foot
• Rubber-based prosthetic leg
• inexpensive
• widely acceptable
• widely used in India.
• Dr. Pramod Sethi designed and manufactured artificial limbs, with the help of the skilled craftsmen Ram
Chandra Sharma designed and developed it in 1968.

49. Discussion
• The references related to amputation and use of prosthesis are found
since the Vedic period.
• Classics of Ayurveda gives the surgical principles of Amputation which
holds good even in the present era.
• The maintenance of Hemostasis by means of Agnikarma was in
practice as per Acharya Sushruta, which is now modified and achieved
by means of cauterization.
• Even though the crude instruments have given way to more
sophisticated ones now, the principles of amputation, achieving
hemostatsis and wound care remains the same even now.

50. • The cases presented here are of different aetiology and clinical
features, having Diabetes mellitus in common, ended up in Below
knee Amputation after all other measures of conservative
management failed.
• Hence this presentation was a humble attempt to throw light on
creating an awareness as how to approach a case, taking proper
history, clinical examinations and investigations helps a surgeon
to arrive at the right diagnosis, at the right time, to decide the
right level of amputation to save the life of the patient.
Discussion contd..

51. Conclusion
• Amputation should not be viewed as a failure of treatment rather as a
reconstructive surgery.
• Treatment of choice for an unreconstructable or a functionally unsatisfactory
limb and first step toward a patient’s return to a more comfortable and
productive life.
• Amputation may result in a psychological trauma of permanent disability to
the patient, which can be overcome by a holistic approach of treatment and
counselling.
• A major percent of the patients who underwent below knee amputation were
afflicted with Diabetes mellitus. Hence maintaining a euglycemic state,
lifestyle modifications and proper foot care throughout the life would reduce
the incidence of Amputations in coming days.

53. Sudha Chandran
Alex Zanardy

54. References

55. Thank you…!

56. Marma
Indrabasti Marma
• Location-middle of the leg(calfmuscle)
• Pramana-1/2angula
• Classification-
Shakha Gata
Mamsa marma
Kaalantara praanahara marma
(Gradual life taking )
• Effect of injury-haemorrhage leading to death