AMPUTATION PRESENTATION Topic presented in AIIMS JODHPUR

1. AMPUTATION
ALL INDIA INSTITUTE OF MEDICAL SCIENCES
DEPARTMENT OF ORTHOPAEDICS

2. INDICATIONS
• DEAD :
• Peripheral Vascular
Disease
• Trauma
• DEADLY:
• Malignancy
• Infection
• Burns
• Frostbite
• Diabetes
• DEFORMED :
• Congenital deformities
• Neuropathic joints with
non healing ulcers

3. • PERIPHERAL VASCULAR DISEASE:
• Most common indication for amputation
• Incidence : 50-75 years
• Risk factors : Diabetes (m/c), prior stroke,
decreased oxygen levels, prior amputation
• TRAUMA:
• Leading indication for amputations in younger
patients
• More common in men
• The only absolute indication for primary amputation
is an irreparable vascular injury in an ischemic
limb

4. MESS (Mangled Extremity
Severity Score)
≥ 6 – Salvageable
limb
≤ 7 – Amputation

5. • BURNS: Thermal or
electrical injury
• FROSTBITE :
• Seen in high-altitude
climbers, skiers
• Tissue injury occurs
due to:
• Direct tissue injury
through formation of
ice crystals in
extracellular fluid
• Ischemic injury
resulting from damage
to vascular
endothelium, clot

6. SURGICAL PRINCIPLES OF
AMPUTATION
DETERMINATION OF AMPUTATION LEVEL:
• Must choose between increased function with a more
distal level of amputation and a decreased complication
rate with a more proximal level of amputation
• The energy required for walking is inversely
proportional to the length of the remaining limb
• Amputation should be performed at the most distal level
possible if ambulation is the chief concern.
• If a patient has no ambulatory potential, wound healing
with decreased perioperative morbidity should be the
chief concern.

7. SKIN FLAPS:
• Should be kept thick
• The scar should not be
adherent to the underlying
bone as an adherent scar
makes prosthetic fitting
extremely difficult and
often breaks down
• Types :
• Equal anterior and
posterior flap
• Equal medial and lateral
flap (scandinavian flap).
• Long posterior flap
(skewed flap).

8. MUSCLE FLAPS:
• Divided at least 5 cm
distal to bone
• Stabilized by –
• Myodesis (suturing muscle
or tendon to bone) –
increased strength,
minimise atrophy,
contraindicated in severe
ischemia
• Myoplasty (suturing muscle
to periosteum or to fascia
of opposing musculature)

9. NERVES:
Isolated, gently pulled distally into
the wound, and divided cleanly with a
sharp knife so that the cut end
retracts well proximal to the level of
bone resection.
HEMOSTASIS:
• Tourniquet should be used except in severely
ischemic limb
• Major blood vessels should be isolated and
individually ligated.
• Larger vessels should be doubly ligated.
• A drain should be used in most cases for 48 to
72 hours.
BONE:
• Avoid excessive periosteal stripping

10. POST-OPERATIVE CARE
• PAIN MANAGEMENT: Intravenous narcotics oral
pain medications
• RIGID DRESSING:
• Weight bearing not
planned – cast is
applied
• Weight bearing planned –
true prosthetic cast
with prosthetic foot
• Prevents edema, enhances
wound healing and
decreases pain
• Drains removed at 48

11. • Stump elevation
• Physiotherapy (to prevent flexion or abduction
contractures)
• Weight bearing: 25 pound increments every week.
Early unprotected weight bearing can result in
sloughing of the skin or delayed wound healing.
• Rigid dressing should be removed and the wound
inspected in 7 to 10 days.
• The cast is reapplied and changed weekly until
the wound has healed.
• After wound healing, first prosthesis is
applied.

12. COMPLICATIONS
HEMATOMA :
• Delays wound healing and
serve as a culture
medium for bacterial
infection
• If the hematoma is
associated with delayed
wound healing with or
without infection, it
should be evacuated
• Meticulous hemostasis
before closure, the use
of a drain, and a rigid
dressing should minimize
the frequency of
hematoma formation.

13. PHANTOM LIMB :
• Sensation of presence of
amputated part
• Cause – unablation of cortical
representation
• Destruction of sensory fibres
resulting in decreased
inhibitory control by reticular
activating system
• Tends to disappear with time
Treatment :
• Early use of prosthesis
• Drugs – carbamazepine, Beta-
blockers, phenytoin
• Sympathectomy
• Subcortical neurectomy

14. INFECTION :
• Commonly - Peripheral vascular disease, especially in
diabetics
• Treatment - Immediate debridement and irrigation and
open wound management.
• Delayed closure may be difficult because of edema and
retraction of the flaps
WOUND NECROSIS :
• >1 cm - conservative
• Severe necrosis – Wedge resection

15. WEDGE RESECTION :
• Principle – Regard end of
amputation stump as a hemisphere
• Resection of a wedge incorporating
the full diameter of the stump
would allow for reformation of the
hemisphere
CONTRACTURES:
Prevention – proper positioning and physiotherapy
Treatment –Wedging casts or surgical release
PAIN:
Mechanical low back pain – prevented by proper
prosthetic ambulation

16. Residual limb pain : Due to
a) Poor fitting prosthesis –
• Stump should be evaluated for areas of abnormal pressure.
• Choking (distal stump edema) and ulceration may occur
• Prevention – socket modifications
b) Painful neuroma –
• Due to irritation and pressure over nerve
• Prevention – gentle traction followed by sharp proximal
division
• Treatment – socket modifications  if fails  excision
DERMATOLOGICAL PROBLEMS :
• Contact dermatitis, bacterial folliculitis, epidermoid
cysts, verrucous hyperplasia

17. LOWER LIMB AMPUTATION
• HEMIPELVICTOMY
• HIP DISARTICULATION
• TRANSFEMORAL AMPUTATION
• KNEE DISARTICULATION
• TRANSTIBIAL AMPUTATION
• FOOT AMPUTATION

18. FOOT AMPUTATIONS
• Toe amputation or
disarticulation
• Metatarsal phalangeal
disarticulation
• Transmetatarsal amputation
• Lisfranc amputation
• Chopart amputation
• Syme amputation
• Boyd’s amputation

19. LISFRANC AMPUTATION
• Tarsometatarsal
disarticulation.
• Leads to severe equino-varus
deformity
• Prevention - preserve insertion
of tibialis anterior and
peroneus longus at medial
cuneiform and peroneus brevis
at the base of 5th metatarsal

20. CHOPART AMPUTATION
• Disarticulation of talo-
navicular & calcaneo-cuboid
joints.

21. SYME AMPUTATION
• Bone transection at distal
tibia and fibula 0.6 cm
proximal to periphery of
ankle joint and passing
through the dome of the
ankle centrally.
• Sarmiento modification -
Transecting tibia and fibula
1.3 cm proximal to ankle
joint and excision of medial
and lateral malleolus.
• It produces less bulbous
stump and allow use of more
cosmetic prosthesis.

22. BOYD AMPUTATION:
• Talectomy
• Excision of anterior part of
calcaneus, distal to peroneal
tubercle.
• Forward shift of calcaneus and
calcaneo-tibial arthrodesis by
using Steinmann pin or
cannulated screw
PIROGOFF AMPUTATION:
• Involves arthrodesis between
tibia and part of calcaneus.
• Calcaneus is sectioned
vertically, removing anterior
part and rotating posterior
portion with heel pad forward
and upward 90* to meet denuded

23. TRANSTIBIAL AMPUTATION
• Most common lower limb
amputation.
• Energy expenditure is an
important consideration in
choosing the level of
amputation.
• Ideal length 12.5 to 17.5 cm
distal to medial tibial
articular surface.
• Rule of thumb for selecting
level of bone section is to
allow 2.5 cm of bone length for
each 30 cm of body height.

24. NON-ISCHEMIC LIMB ISCHEMIC LIMB
• Refraining from use of
tourniquet.
• Long posterior flap and
short anterior
• Level of amputation- 8.8 to
12.5 cm.
• Tension myodesis is
contraindicating because it
causes further compromise
in marginal blood supply.
• Use of tourniquet advocated.
• Equal anterior and posterior
flap
• Level of amputation- 12.5 to
17.5 cm.
• Myoplasty is commonly done,
but in young age group
myodesis is advocated.

25. KNEE DISARTICULATION
• Excellent end bearing stump
• Stability of the prosthesis.
• Boyd, Splitter and McFaddin
technique

26. TRANSFEMORAL AMPUTATION
• Equal anterior and
posterior flap at the
level of amputation
• Myofascial flap fashioned
from quadriceps muscle and
fascia.

27. NON-ISCHEMIC LIMB
• Use of tourniquet advocated.
• Equal anterior and posterior
flap
• Level of amputation- 12 cm
from medial joint line or 18
cm from greater trochanter
tip.
• Myoplasty is commonly done,
but in young age group
myodesis is advocated.
ISCHEMIC LIMB
• Refraining from use of
tourniquet.
• Equal anterior and posterior
flap
• Level of amputation- 12 cm
from medial joint line or 18
cm from greater trochanter
tip.
• Tension myodesis is
contraindicating because it

28. HIP DISARTICULATION
• Boyd hip disarticulation
• Posterior flap method of
Slocum

29. HEMIPELVECTOMY
• STANDARD HEMIPELVECTOMY
• EXTENDED HEMIPELVECTOMY
• CONSERVATIVE
HEMIPELVECTOMY

30. UPPER LIMB AMPUTATION
• Wrist amputations
• Forearm amputations
(transradial)
• Elbow disarticulation
• Arm amputations
(transhumeral)
• Shoulder amputations
• Forequarter amputation

31. WRIST DISARTICULATION
• Incision - circumferentially
starting and ending 1.5cm
distal to the radial and ulnar
styloid processes respectively
(palmar flap and dorsal flap
made in a 2:1 ratio)
• Closure – full thickness palmar
flap and short dorsal flap

32. TRANSRADIAL AMPUTATION
• Preserve as much length as
possible to allow some
degree of pronation and
supination
• Distal third of the
forearm are less likely to
heal satisfactorily than
those at a more proximal
level
• Anterior and posterior
flaps are created at 1:1
ratio
• Preferable to preserve at
least 4cm of ulna for

33. ELBOW DISARTICULATION
• The elbow joint is an
excellent level for
amputation
• broad flare of the
humeral condyles -
grasped firmly by the
prosthetic socket
• humeral rotation -
transmitted to the
prosthesis. (In more
proximal amputations,
humeral rotation cannot
be transmitted)
• Posterior flap is

34. TRANSHUMERAL AMPUTATION
• Amputations are
typically made 4 cm
proximal to the elbow
joint to allow for the
prosthetic elbow lock
mechanisms
• Prosthesis must include
• Elbow-lock mechanism -
stabilize the joint in
full extension, full
flexion, or a position in
between
• Elbow turntable - humeral
rotation

36. SHOULDER DISARTICULATION
Indications –
• Malignant bone or soft
tissue tumors
• Arterial insufficiency
• Trauma
• Infection

37. FOREQUARTER AMPUTATION
• Removes the entire
upper extremity in the
interval between the
scapula and the chest
wall
• Indication – malignant
tumors
• Approaches –
• Anterior approach of
Berger
• Posterior approach of
Littlewood

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