This document provides information about amputation indications, surgical principles, and post-operative care. It discusses various types of amputations for both lower and upper limbs. The main indications for amputation include peripheral vascular disease, trauma, malignancy, infection, burns, and frostbite. The surgical principles focus on choosing an amputation level for optimal function, creating adequate skin and muscle flaps, and hemostasis. Post-operative care involves pain management, rigid dressings, physiotherapy, and prosthetic training to prevent complications like infection, contractures, and phantom limb pain.

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

38. THANK YOU