Amputation

1. Dr. GUNABHI RAM DAS
Assistant Professor of Surgery
A.M.C.H
27-Nov-22
Dr Gunabhi Ram das 1

2.  Amputation “Surgical removal of limb or
part of the limb through a bone or multiple bones”
 Disarticulation is removing the limb through a
joint.
27-Nov-22
Dr Gunabhi Ram das 2

3.  Early surgical amputations ► limb was
severed from an unanesthetized patient.
 Stump was dipped in boiling oil (hemostasis)
 Stump was poorly
suited for prostheses
 High mortality rate.
27-Nov-22 3
Dr Gunabhi Ram das

4.  Hippocrates: first to use ligatures
 1529: Popularized by Ambroise Paré
 Paré also introduced the “artery forceps
 He also designed sophisticated prostheses
 1674: Morel's introduce tourniquet
 1867: Lord Lister's introduce asepsis
27-Nov-22 4
Dr Gunabhi Ram das

5. 27-Nov-22
Dr.PR Khuman,MPT(Ortho & Sport) 5
Relative % of causes of LL amputation
Developed world
causes
(%)
Developing world
causes
(%)
PVD (approx. 25-
50% diabetes
mellitus)
85-
90
Trauma
55-
95
Trauma 9 Disease
10-
35
Tumour 4 Tumour 5
Congenital
deficiency
3
Congenital
deficiency
4
Infection 1 Infection
11-
35

6. 27-Nov-22
Dr.PR Khuman,MPT(Ortho & Sport) 6
Relative % of causes of UL amputation
Developed world
causes
(%)
Developing world
causes
(%)
Trauma 29 Trauma 86
Disease 30 Disease 6
Congenital
deficiency
15
Congenital
deficiency
6
Tumour 26 Tumour 1

7. Common causes
<50 yrs >50 yrs
. Injury peripheral vascular
disease
Less common
. Infection(fulminating gas gangrene)
. Malignancy
. Nerve injury
. Congenital anomalies
. miscellaneous
27-Nov-22 7
Dr Gunabhi Ram das

8.  Age;- Common in 50-75 yrs of age
Traumatic- common in younger age
 Sex;- Aprox. 75% male
25% female
 Limb;- Aprox. 85% - lower limb
15% -- upper limb
27-Nov-22 8
Dr Gunabhi Ram das

9. Indications
‘ DDD’
 Dead
 Deadly
 Dead loss
27-Nov-22 9
Dr Gunabhi Ram das

10.  A limb is dead when arterial
occlusive disease is severe
enough to cause infarction of
macroscopic portions of
tissue, i.e. gangrene.
 The occlusion may be in
major vessels (atherosclerotic
or embolic occlusions) or in
small peripheral vessels
(diabetes, Buerger’s disease,
Raynaud’s disease,
inadvertent intra-arterial
injection).
27-Nov-22 10
Dr Gunabhi Ram das

11. A limb is deadly when
the putrefaction and
infection of moist
gangrene spreads to
surrounding viable
tissues. Cellulitis and
severe toxaemia are the
result.
 Amputation is required
as a lifesaving operation
27-Nov-22
Dr Gunabhi Ram das 11

12. A limb may be deemed a dead loss
in the following circumstances:
 1. when there is relentless
severe rest pain without
gangrene and reconstruction is
not possible – amputation will
improve quality of life
 2. when a contracture or
paralysis makes the limb
impossible to use and renders it
a hindrance; and
 3. when there is major
unrecoverable traumatic damage
27-Nov-22
Dr Gunabhi Ram das 12

13.  Dead limb
Dry Gangrene
 Deadly limb
 Wet gangrene
 Spreading cellulitis
 Arteriovenous fistula
 Other (e.g. malignancy)
 ‘Dead loss’ limb
 Severe rest pain with unreconstructable critical leg ischaemia
 Paralysis
 Other (e.g. contracture, trauma)
27-Nov-22
Dr Gunabhi Ram das 13

14. L/E-≈20-30% of all amputations
U/E- 77%
In younger age group.
Men > women.
The only absolute indication for
primary amputation is an irreparable
vascular injury in an ischemic limb.
27-Nov-22 14
Dr Gunabhi Ram das

15. L/E 60-70% of amputations
U/E 6%
Arteriosclerosis
Thromboembolism
 +/-diabetes
 Most significant predictor of
amputation in diabetes:-
peripheral neuropathy
 Prior stroke
 decrease ankle-brachial blood
pressure index
 Vascular surgery , nephrology,
cardiology consultation must
27-Nov-22 15
Dr Gunabhi Ram das

16. Doppler USG
Ratio of systolic pressure
at the ankle to that in the
arm
Resting ABPI is normally
about 1.0
values
< 0.9 - some degree of
arterial obstruction and
< 0.3 - suggests imminent
necrosis
27-Nov-22
Dr Gunabhi Ram das 16

17. Gas gangrene.
Clostridial myonecrosis- within 24 hr.
bronze discoloration
serosanguineous exudates,
musty odor
Immediate radical debridement
I/V penicillin or clindamycin
Streptococcal myonecrosis- 3-4 days
Anaerobic cellulitis or necrotizing
fasciitis
-Acute or chronic infection that is
unresponsive to antibiotics and surgical
debridement.
- Open amputation
done
27-Nov-22 17
Dr Gunabhi Ram das

18.  L/E <3% of all amputations
U/E 9%
 Occurs in ≈1/2000 births
 Failure of partial or complete
formation of a portion of the
limb.
 Congenital extremity
deficiencies have been classified
as longitudinal, transverse, or
intercalary.
 Radial or tibial deficiencies are
referred to as preaxial, and ulnar
and fibular deficiencies are
referred to as postaxial
27-Nov-22 18
Dr Gunabhi Ram das

19.  L/E ≈5% of all amputations
U/E 8%
 Amputation is performed
less frequently with the
advent of advanced limb-
salvage techniques.
27-Nov-22 19
Dr Gunabhi Ram das

20. Burns : -
◦ delayed aputation – local infection
◦ -systemic infection
◦ - myoglobin induced renal failure
◦ - death
Frostbite :-
Typically occurs when one is trapped in
extreme cold conditions for extended
periods
◦ direct tissue injury- ice crystals in ECF
◦ Ischaemic injury- vascular endothelium
◦ clot formation
◦ inc sympathetic tone
◦ limb kept at 40-44 degree C
◦ wait 2-6 month demarcation
◦ Triple phase tecnetium bone scan
27-Nov-22 20
Dr Gunabhi Ram das

21. Open
Guillotine
modified guillotine
Closed amputation
revised
planned
27-Nov-22 21
Dr Gunabhi Ram das

22.  It is done as an emergency procedure.
◦ Severe life threatening infections
◦ Severe crush injuries
 After amputations, the wound is left open &
not closed.
 2 types depending upon the skin flaps:
◦ Open amputation with inverted skin flap
◦ Circular open amputation
27-Nov-22
Dr Gunabhi Ram das 22

23.  Rx following amputation:
◦ Rigid dressing concept (Pylon): POP cast
is applied to the stump over the
dressing after surgery.
◦ Soft dressing concept: The stump is
dressed with the sterile dressing &
elastocrepe bandage applied over it.
27-Nov-22
Dr Gunabhi Ram das 23

24.  It is done as an elective procedure.
 After amputations, the soft tissues are closed
primarily over the bony stump.
◦ E.g., above knee, below knee etc.
27-Nov-22
Dr Gunabhi Ram das 24

25.  Tourniquets: desirable except in ischemic limbs.
 Level of amputation: it is very important to fit the
prosthesis.
“The energy required for walking is inversely
proportionate to the length of the remaining
limb”
 Skin flaps: good skin coverage is important. Skin
should be mobile & sensitive.
 Muscle: is divided at least 5cm distal to the level of
intended bone section & sutured.
27-Nov-22
Dr Gunabhi Ram das 25

26.  Methods of Muscle Suture
◦ Myodesis – muscle is suture to bone
◦ Myoplasty – muscle is sutured to opposite muscle
group under appropriate tension.
27-Nov-22
Dr Gunabhi Ram das 26

27.  Nerves: cut proximally & allowed to
retract. Large nerves are ligated before
division.
 Blood vessels: doubly ligated separately &
cut. Then the tourniquet is released &
hemostasis is completed.
 Bone: section above level of muscle
section.
 Drains: removed after 48 – 72 hours.
27-Nov-22
Dr Gunabhi Ram das 27

28.  Compression dressing: Either elastic or a rigid
plaster dressing fitting immediately.
 Absolute bed rest with limb elevation: This is
acceptable for the conventional prosthesis
with adequate vascularity.
 Limb fitted: Conventional prosthesis is fitted a
minimum of 8 – 12 weeks after surgery. Rigid
dressing with temporary pylon prosthesis may
be elected as an alternative.
27-Nov-22
Dr Gunabhi Ram das 28

29. ◦ Hematocrit
◦ Creatinine levels should be monitored. In individuals with
muscle injury and necrosis, myoglobin enters the systemic
circulation and can lead to renal insufficiency and failure.
especially in individuals with thermal and electrical burns.
◦ Potassium and calcium levels should be monitored.
Elevated levels of these electrolytes may lead to cardiac
arrhythmias and seizures.
◦ White blood cell count, C-reactive protein , and ESR
Expect the C-reactive protein to be the first laboratory
value to respond to treatment,
◦ Platelets
27-Nov-22 29
Dr Gunabhi Ram das

30. ◦ X-ray AP & Lat view
◦ Computed tomography (CT) scanning and magnetic
resonance imaging (MRI) are performed for the patient
tumour workup or for osteomyelitis to ensure that the
surgical margins are appropriate.
◦ Technetium-99m (99mTc) pyrophosphate bone scanning
has been used to predict the need for amputation in
persons with electrical burns and frostbite.
A 94% sensitivity rate and a 100% specificity rate has been
reported in demarcating viable tissues from nonviable
tissues.
27-Nov-22 30
Dr Gunabhi Ram das

31. Doppler ultrasonography - measure arterial pressure;
◦ In approximately 15% of patients with PVD, the results are
falsely elevated because of the noncompressibility of the
calcified extremity arteries.
◦ Doppler ultrasonography has been used in the past to
predict wound healing.
A minimum measurement of 70 mm Hg is believed to be
necessary for wound healing.
Ischemic index (II): -
This index is the ratio of the Doppler
ultrasonography pressure at the level being tested to the
brachial systolic pressure. An II of 0.5 or greater at the
surgical level is necessary to support wound healing.
Ankle-brachial index: -
The II at the ankle level is believed to be the best indicator
for assessing adequate inflow to the ischemic limb. An
index less than 0.45 indicates incisions distal to the ankle
will not heal.
27-Nov-22 31
Dr Gunabhi Ram das

32. 27-Nov-22 32
Dr Gunabhi Ram das

33.  Anaesthesia
Regional, G.A
 Antibiotics
Broad-spectrum, IV
 Tourniquet
Except in arterial insufficiency
27-Nov-22 33
Dr Gunabhi Ram das

34. 27-Nov-22 34
Dr Gunabhi Ram das

35.  Skin flaps
oThe combined length equals 1.5 times
the width of the limb at the site of
amputation.
oAnt. & post. Flaps of equal length for
UL & A/K amputations.
oLong posterior flap for BK amputation.
27-Nov-22 35
Dr Gunabhi Ram das

36. 27-Nov-22 36
Dr Gunabhi Ram das

37.  Muscles
oDivided distal to bone
oMyoplasty or Myodesis
 Blood vessels
oMain vessels are doubly
ligated individually
oTourniquet is removed before
closure
oHaemostasis is meticulously
secured
27-Nov-22 37
Dr Gunabhi Ram das

38.  Nerves
oSharply cut & allow to
retract
oLarge nerves are ligated
27-Nov-22 38
Dr Gunabhi Ram das

39.  Bone (site of election)
oA/K : 12cm above the joint
oB/K : 14cm below the joint
oB/E : 18cm from the olecranon
oA/E : 20cm from acromion
osawn across @ proposed level
oFront of tibia is beveled
oFibula is cut 2-3cm proximal to tibia
27-Nov-22 39
Dr Gunabhi Ram das

40.  Other than site of election
oGritti-Stokes
oSymes
oPirogoff’s
oChopart
oLisfranc
oKrukenberg
 the skill of the modern prosthetist has made
it possible to amputate at almost any site.
27-Nov-22 40
Dr Gunabhi Ram das

41.  Closure
oDrain is placed
oSkin closed
without tension.
With modern total-contact
prosthetic sockets, the
location of the scar rarely is
important, but the scar
should not be adherent to
the underlying bone
27-Nov-22 41
Dr Gunabhi Ram das

42.  Conical Dressing
oSoft dressing with crepe bandage
oRigid dressing with POP
• Rigid dressings prevent edema at the surgical site
• Enhance wound healing & early maturation of the stump
• Decrease postoperative pain
• Allow earlier mobilization & ambulation
• Prevent knee flexion contractures in B/K amputation
27-Nov-22 42
Dr Gunabhi Ram das

43.  Ideal stump
oConical
oHeal adequately
oAdequate stump
oAdequate muscle padding
oThin scar not interfering with
prosthesis
oAdjacent joint movements
oAdequate blood supply
27-Nov-22 43
Dr Gunabhi Ram das

44.  Analgesics
 Antibiotics
 DVT prophylaxis
 Stump elevation (foot of the bed)
 Avoid flexion contracture at knee & hip
27-Nov-22 44
Dr Gunabhi Ram das

45.  Educate patient how to position the stump
 Mobilize out of bed in 1DPO
 Remove drain in 48hrs
 Remove stitches in 2/52
27-Nov-22 45
Dr Gunabhi Ram das

46. ◦ keep the stump clean, dry,
and free from infection at all
times.
◦ If fitted with a prosthesis,
you should remove it before
going to sleep.
◦ Inspect and wash the stump
with mild soap and warm
water every night, then dry
thoroughly and apply talcum
powder.
◦ do not use the prosthesis
until the skin has healed.
◦ The stump sock should be
changed daily, and the inside
of the socket may be cleaned
with mild soap.
27-Nov-22 46
Dr Gunabhi Ram das

47.  Haematomas
 Infections
 Necrosis
 Contractures
 Neuromas
 Stump pain
 Phantom sensation
 Hyperesthesia of
stump
 Stump edema
 Bone overgrowth
 Causalgia
27-Nov-22
Dr Gunabhi Ram das 47

48.  Phantom Limbs –
◦ Some amputees experience the phenomenon of
Phantom Limbs; they feel body parts that are no
longer there.
◦ Limbs can itch, ache, & feel as if they are moving.
◦ Scientists believe it has to do with neural map
that sends information to the brain about limbs
regardless of their existence.
27-Nov-22
Dr Gunabhi Ram das 48

49.  In many cases, the
phantom limb aids in
adaptation to a
prosthesis, as it permits
the person to experience
proprioception of the
prosthetic limb.
27-Nov-22
Dr Gunabhi Ram das 49

50.  Painful adhesive scar formation
◦ An adherent painful scar over the surgical incision
poses a problem in process of rehab.
◦ It may obstacle in fitting prosthesis.
◦ Early mobilization of the painful scar is
recommended with other therapeutic modalities.
27-Nov-22
Dr Gunabhi Ram das 50

51.  New bone formation at the amputation
sites
◦ It has been reported that new bone formation 5
weeks after electrical burn.
◦ The stump should be closely watch for any sing
& symptoms like – tenderness, warmth &
swelling (Helm & Walker, 1987)
◦ Such symptoms delayed fitting final prosthesis.
27-Nov-22
Dr Gunabhi Ram das 51

52.  Flexion Deformity
◦ Deformity complicates the
process of prosthetic fitting
& ambulation.
27-Nov-22
Dr Gunabhi Ram das 52

53.  Hyperesthesia of the stump:
◦ This is another annoying symptom that is difficult
to control.
◦ Re-amputation results only in reproducing the
symptom at a higher level.
27-Nov-22
Dr Gunabhi Ram das 53

54. Some special type of amputation
Dupuytren’s amputation ;- amputation of the arm at the
shoulder joint.
◦ elliptic amputation one in which the cut has an elliptical
outline.
 Gritti-Stokes amputation ;- amputation of the leg through
the knee, using an oval anterior flap.
 Hey’s amputation ;- amputation of the foot between the
tarsus and metatarsus.
 interpelviabdominal amputation ;- amputation of the
thigh with excision of the lateral half of the pelvis.
 interscapulothoracic amputation ;- amputation of the
arm with excision of the lateral portion of the shoulder
girdle.
 Larrey’s amputation;- amputation at the shoulder joint.
27-Nov-22 54
Dr Gunabhi Ram das

55.  spontaneous amputation;- loss of a part without
surgical intervention, as in diabetes mellitus
Sarmiento’s amputation- level is 1.3 cms proximal to
ankle joint line.
 Teale’s amputation;- amputation with short and long
rectangular flaps.
27-Nov-22 55
Dr Gunabhi Ram das

56.  disarticulation of the foot with
removal of both malleoli 0.6
cms proximal to joint line.
 amputation provides an end-
bearing stump that in many
circumstances allows
ambulation without a prosthesis
over short distances.
 It is an excellent amputation for
children, in whom it preserves
the physes at the distal end of
the tibia and fibula
27-Nov-22 56
Dr Gunabhi Ram das

57. ◦ The Boyd procedure provides
a broad weight-bearing
surface of the heel by
creating an arthrodesis
between the distal tibia and
the tuber of the calcaneus
after talectomy
◦ Compared to a Syme’s
amputation, it provides more
length and better preserves
the weight-bearing function
of the heel pad.
27-Nov-22 57
Dr Gunabhi Ram das

58. amputation of the foot
by a midtarsal
disarticulation.
27-Nov-22 58
Dr Gunabhi Ram das

59. amputation of the foot
between the
metatarsus and tarsus.
27-Nov-22 59
Dr Gunabhi Ram das

60. amputation of the foot at
the ankle, part of the
calcaneus being left in
the stump.
27-Nov-22 60
Dr Gunabhi Ram das

61.  Transcarpal amputation ;-
◦ At this level, supination and pronation of the forearm, as
well as flexion and extension of the wrist,
◦ Ideally, a long full-thickness palmar and shorter dorsal
flap should be created in a ratio of 2:1.
◦ Finger flexor and extensor tendons should be drawn,
divided, and allowed to retract deep into the proximal
wound. Conversely, wrist flexor and extensor tendons are
identified and released from their distal insertions and
reflected proximally out of the way.
 The wrist flexors and extensors should be anchored to the
remaining carpus in line with their insertions to preserve active
wrist motion
27-Nov-22 61
Dr Gunabhi Ram das

62. ◦ providing a long lever arm and
preserved supination and pronation.
◦ a technique to minimize postoperative
pain from neuroma formation, which
involves extending the incisions
proximally between the pronator teres
and brachioradialis just distal to the
elbow flexion crease and doubly
ligating the median, ulnar, and
superficial radial nerves at this level.
 Preserving the triangular
fibrocartilage ,shortening
of the radial styloid
should be avoided that
improves prosthetic
suspension
 procedure of choice in
children
27-Nov-22 62
Dr Gunabhi Ram das

63. 27-Nov-22 63
Dr Gunabhi Ram das

64. ◦ More than 80 years ago,
Krukenberg described a
technique that converts a
forearm stump into a pincer
that is motorized by the
pronator teres muscle.
Indications for this procedure
have been debated; however,
they generally include bilateral
upper-extremity amputations,
in those who are also blind.
◦ not recommended as a primary
procedure at the time of an
amputation,
◦ To consider this surgical
option, the ulna and radius
must extend distal to the
majority of the pronator
teres (the motor for
pinching) and an elbow
flexion contracture of less
than 70°.
27-Nov-22 64
Dr Gunabhi Ram das

65. IT IS A REPLACEMENT OF
SUBSTITUTION OF A
MISSING OR A DISEASED
PART
27-Nov-22 65
Dr Gunabhi Ram das

66. ENDOPROSTHESIS-
Implants used in orthopaedic
surgery
eg; Austin Moore prosthesis
EXOPROSTHESIS-
External replacement for
a lost part of the limb
27-Nov-22 66
Dr Gunabhi Ram das

67. TEMPORARY –
Used following
amputation till pt. Is
fitted with permanent
prosthesis eg;pylon
PERMANENT
PROSTHESIS 46.2
27-Nov-22 67
Dr Gunabhi Ram das

68. 1-FOR DISARTICULATION OF HIP
AND
HEMIPELVECTOMY
2-FOR TRANSFEMORAL
AMPUTATION
SUCTION SOCKETED
.2 WAY VALVE MECHANISM
NEGATIVE PRESSURE
.SNUGGLY FITS
.USEUL IN YOUNG PT.
.BEST FOR CILINDRICAL STUMPS
27-Nov-22 68
Dr Gunabhi Ram das

69. 27-Nov-22 69
Dr Gunabhi Ram das

70. SUCION SOCKETED
-LESS SKIN INFECTION
-FEEL OF CLOSE
CONTACT
WITH PROSTHESIS
-SOCKS ARE NOT
NECESSSARY
-NOT EASY TO WEAR
-LESS COMFORTABLE
NON SUCTION
SOCKETED
-MORE INCIDENCE OF
SKIN
INFECTION
-NOT SO
-NECESSARY
-EASY TO WEAR
-MORE COMFORTABLE
27-Nov-22 70
Dr Gunabhi Ram das

71. PTB PROSTHESIS-
SOCKET FITS EXACTLY OVER
THE
PATELLAR TENDON AND
TIBIAL
CONDYLES
27-Nov-22 71
Dr Gunabhi Ram das

72. CONVENTIONAL TYPE
PROSTHESIS-
CONSISTS OF
-THIGH CORSET
-SIDE STEELS
- KNEE JOINT
-SHIN PIECE
-ANKLE JOINT
-FOOT PIECE
27-Nov-22 72
Dr Gunabhi Ram das

73. -HAVE CLOSE
SOCKETS OR
OPEN SOCKETS
-FULL WIEGHHT
BEARING
OR MODIFIED END
BEARING
27-Nov-22 73
Dr Gunabhi Ram das

74. -WHOLE FOOT IS OF
VARIOUS LAYERS OF
RUBBER WITH VARYING
DENSITY
-NO ANKLE JOINT
-ABOVE ACTION
ACHIEVED BY
COMPRESSION OF WEDGE
SHAPED RUBBER HEEL
-ALL PLACED ON WOODEN
INSERT FOR HEEL AND
WOODEN SIDE KEEL
27-Nov-22 74
Dr Gunabhi Ram das

75. -MADE OF
RUBBER(WATERPROOF)
ALUMINIUM(FOR LEG
PIECE)
-CHEAP ,STRONG,RUST
FREE
-ALLOWS SITTING ,
SQUATING,DOES NOT
REQUIRE A SHOE
27-Nov-22 75
Dr Gunabhi Ram das

76. FOREQUARTER
AMPUTATIONS-
-PROSTHESIS MERELY
SERVES A COSMETIC
PURPOSE
-SLEEVE FITTER
PROSTHESIS WITH A
PLASTOZOATE CAP
PADDED INSIDE WITH
FOAM AND RETAINING
STRAPS IS USED Myoelectric
Prosthetics
27-Nov-22 76
Dr Gunabhi Ram das

77. - SHOULDER PIECE
EXTENDED CAP TO
HOLD PROSTHESIS
- ELBOW PIECE CAN BE
FLEXED B PULLING
ON THE FLEXION
CORD WITH THE
PROTRACTORS
OF TH SHOULDER
-HANDPIECE EITHER
COSMETIC OR SPLINT
HOOK TYPE.
27-Nov-22 77
Dr Gunabhi Ram das

78. SAME AS PROSTHESIS FOR
SHOULDER
DISARTICULATION EXEPT
ELBOW FLEXION IS
STRONGER DUE TO
ACTION OF ARM MUSCLES
ALONG THE
PROTRACTORS
27-Nov-22 78
Dr Gunabhi Ram das

79. -THERE IS A COP
SOCKET
ATTACHED TO
TERMINAL
DEVICE
-TERMINAL DEVICE
CAN
BE ACTIVATED
THROUGH
A LOOP HARNESS
27-Nov-22 79
Dr Gunabhi Ram das

80. -SPLIT SOCKET FOREARM
AND A WRIST
ROTATION DEVICE IS
PROVIDED
-A DEVICE CAN BE
PROVIDED TO LOCK
FOR SUPINATION AND
PRONATION
27-Nov-22 80
Dr Gunabhi Ram das

81.  Amputation is the most ancient surgical
procedure
 It should not be seen as a failure of Rx, but
rather as the first step towards a patient’s
return to a more comfortable & productive
life
 It does not end in the operating room; post
op care is equally important.
27-Nov-22 81
Dr Gunabhi Ram das

82.  Selvadurai Nayagam, David Warwick. Orthopaedic
operations; Apley’s system of orhtopaedics &
fractures, 9th Ed; 12:325-328.
 Canale & Beaty: General principles of amputations:
Campbell's Operative Orthopaedics, 11th edition.
 John Ebenezer: Amputations; Textbook of
Orthopaedics, 4th Edition; 60:787-791.
 Tintle SM et. Al: Traumatic & trauma-related
amputations: Bone Joint Surg Am. 2010 Dec
15;92(18):2934-45.
27-Nov-22 82
Dr Gunabhi Ram das

83. 27-Nov-22 83
Dr Gunabhi Ram das