This document provides information about amputation procedures. It describes the indications for amputation, including peripheral vascular disease, diabetic limb disease, trauma, infection, malignancy, and deformity. The goals of amputation are to return the patient to maximum function, ablate diseased tissue, reduce morbidity and mortality, and produce a physiological end organ. Different types of amputations are described for the toes, feet, legs, arms, and limbs. Principles for determining the amputation level and performing the procedure are outlined. Postoperative management focuses on wound healing, edema control, pain management, and rehabilitation to prevent contractures. Potential complications are also reviewed.

1. AMPUTATION
Dr. DINRAJ T V
JR 1, GENERAL SURGERY
AIMS

2. •AMPUTATION IS THE COMPLETE
REMOVAL OF AN INJURED OR
DEFORMED BODY PART

3. INDICATIONS
• PERIPHERAL VASCULAR DISEASE
 GANGRENE DUE TO ATHEROSCLEROSIS,
EMBOLISM, TAO
• DIABETIC LIMB DISEASE/ GANGRENE
• DEAD, DYING DEVITALISED TISSUE
• TRAUMA : LIFE SAVING IN CRUSH INJURIES
• INFECTION AND GANGRENE – TO SEPSIS
• MALIGNANCY
• DEVERE DEFORMITY : CONGENITAL/ ACQUIRED

4. AIM OF AMPUTATION
• RETURN PATIENT TO MAXIMUM LEVEL OF
INDEPENDENT FUNCTION
• ABLATION OF DISEASED TISSUE (TUMOR OR
INFECTION)
• REDUCE MORBIDITY & MORTALITY (TUMOR
OR INFECTION)
• PRODUCE A PHYSIOLOGICAL END ORGAN .

5. IDEAL STUMP
• PROPER HEALING
• ROUND, GENTLE CONTOUR WITH MUSCLE PADDING
• ADEQUATE BLOOD SUPPLY
• PROVISION FOR PROSTESIS
• THIN SCAR, SHOULD AFFECT PROSTESIS FUNCTION
• ADEQUATE ADJACENT JOINT MOVEMENT

8. DETERMINATION OF LEVEL
• Zone of Injury (trauma)
• Adequate margins (tumor)
• Adequate circulation (vascular disease)
• Soft tissue envelope
• Bone and joint condition
• Control of infection
• Nutritional status

9. Preoperative evaluation
Hb, PCV
Correct anaemia
Control of infection : with antibiotics
Diabetic control
Level of amputation :
Arterial DOPPLER
R/o other cardiac conditions

10. Different Amputations
RAY AMPUTATION
TOE AMPUTATION
WITH HEAD OF METATARSAL
GILLIES’ AMPUTATION
TRANS METATARSAL
PROXIMAL TO NECK OF METATARSAL, DISTAL TO BASE

11. LISFRANC’S
TARSO METATARSAL AMPUTATION
DISARTICULATION
LONG VOLAR FLAP

12. CHOPART’S
MID TARSAL AMPUTATION
DISARTICULATION OF
TALO-NAVICULAR & CALCANEO CUBOID JOINTS
TIBIALIS ANTERIOR SUTURED TO TALUS
LONG VOLAR FLAP AND IMMOBILISATION – 6WKS

13. SYME’S AMPUTATION
REMOVAL OF FOOT WITH CALCANEUM
RETAINING HEEL FLAP
BONE AT TIBIA & FIBULA JUST ABOVE ANKLE JOINT
ELEPHANT BOOT

14. Pirogoff's amputation
Amputation of the foot at the ankle, part of the
calcaneus being left in the stump
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
Compared to a Syme's amputation, it provides more
length and better preserves the weight-bearing function
of the heel pad.
Its increased complexity and morbidity have made it
less used now than the Syme's amputation.

15. BELOW KNEE AMPUTATION
(BURGESS’ )
MIN. STUMP LENGTH :
8 CM FROM TIBIAL TUBEROSITY
(14-17 CM IS GOOD)
LONG POSTERIOR FLAP
SCAR ANTERIORLY
FIBULA TO BE DIVIDED BEFORE TIBIA AT A HIGHER LEVEL

16. • PEG LEG AMPUTATION
 5 CM STUMP
 ANTERIOR FLAP ROTATED POSTERIORLY
 NOT PRACTICED NOW

17. GRITTI STOKES
TRANS CONDYLAR AMPUTATION
FEMUR DEVIDED JUST ABOVE PATELLAR ARTICULAR
SURFACE
LONG POSTERIOR FLAP
NOT USED NOW
DUE TO NON UNION OF PATELLA WITH FEMUR

18. ABOVE KNEE AMPUTATION
EQUAL ANTERIOR AND POSTERIOR FLAP
FEMUR STUMP : IDEAL – 25 CM
NOT <10 CM

19. HIP DISARTICULATION
WHEN STUMP >10CM IS NOT POSSIBLE
SOLCUM’S APPROACH : SINGLE POSTERIOR FLAP
BOYD’S APPROACH : ANTERIOR RAACQUET INCISION

20. HIND QUARTER AMPUTATION
SIR GORDON TAYLOR’S AMPUTATION
HEMI PELVECTOMY
REMOVAL OF
 ONE SIDE PELVIS
 INNOMINATE BONE
 PUBIS
 MUSCLES AND VESSELS
RETAIN PART OF PUBIS, ILIUM
POSTERIOR FLAP : BY SUPERIOR GLUTEAL ARTERY

21. UPPER LIMB AMPUTATION
KRUKENBERG’S AMPUTATION
DONE IN TRAUMA
FOREARM AMPUTATION
GAP B/W RADIUS AND ULNA LIKE A CLAW

22. • UPPER LIMB AMPUTATION
 20 CM STUMP IS ADVICED IN BOTH ABOVE AND
BELOW ELBOW AMPUTATION
• FOREQUARTER AMPUTATION
 INTER SCAPULO THORACIC AMPUTATION
 UPPER LIMB WITH SCAPULA, LATERAL 2/3 OF
CLAVICLE,

23. TYPES OF AMPUTATION
• WEIGHT BEARING
• NON WEIGHT BEARING
• END BEARING/ CONE BEARING
• NON END BEARING/ SIDE BEARING
• FLAP CAN BE
 UNEQUAL/ EQUAL FLAPS

24. PRINCIPLES OF AMPUTATION
• Adequate blood supply
• No tourniquet during surgery
• Proper making of skin
• Proximal part of flap contain muscle and distal part only
skin
• Nerve to be buried deep
• Proper dressings after surgery

25. Incisions
• Circular incision amputation
• Elliptical/ oval incision
• Racquet incision

26. •SKIN FLAPS
 The apex of the fish mouth at the level of the bony resection
 Total length of flap anterior + posterior = 1.5 times diameter
 Flap should be semi circular for conical stump
 Use any available flaps in trauma to preserve length
 Tailor flaps at least as long as the diameter of the stump

27. •MUSCLES
 Divide ~5 cm distal to level of bone resection
 Stabilisation of muscle mass by good suturing.
 Adequate stump padding
 Prevents atrophy (muscle exercises)
 Improves function
 Myoplasty = involves suture of flexors to the extensors over bony
stump
 Myodesis = direct suture of muscle to bone - most useful in AK,
AE and disarticulations

28. Nerves
Divide cleanly under gentle tension proximal to bone ends -
allow to retract
Large nerves eg sciatic, median - ligate due to large contained
vessels
Blood vessels
Large arteries & veins should be doubly ligated and
haemostasis achieved prior to closure
Bone
Avoid excessive periosteal stripping (prevent spur formation)
Bevel & smooth the bone end

29. • Closure
 Do not close under tension
 Interrupted sutures preferably
• Drains are necessary

30. Goals of Postoperative Management
Prompt, uncomplicated wound healing
Control of edema
Control of Postoperative pain
Prevention of joint contractures
Rapid rehabilitation

31. WOUND CARE
ABSORBENT, NON-ADHERENT AND OCCLUSIVE
VACCUM DRAIN
PROPER PADDING FOR COMFORT AND PROTECTION
BANDAGING SHOULD BE FIRM BUT
NOT RESTRICTIVE

32. • PREVENT CONTRACTURE
 USE OF BRACE OR OTHER IMMOBILISER
 PHYSIOTHERAPY
 EARLY MOBILISATION OF PATIENT
 Sitting out of bed within 48 hrs
 Wheelchair used to assist mobility
 Practice in transferring, standing and early walking with
crutches supervised with physio.

33. Complications
 Early
 Haemorrhage & Haematoma
 Infection
 Late
 Necrosis of stump end.
 Ring sequestrum formation
 Contractures (due to muscle imbalance)
 Neuroma at the cut nerve ending
 Phantom pain
 Terminal overgrowth (children)

34. • Phantom limb sensation is the sensation that the
amputated limb is still present.
• Phantom limb pain usually is like a burning,
stinging, electric pain, and it can be increased with
anxiety and stress.
• Telescoping is the sensation that the distal part of
the amputated extremity has moved proximally up
the arm

35. “Stump Edema Syndrome” : associated with the use
of suction prosthesis.
-Proximal constriction
-Blood in skin ,pain, Pigmentation
-Elevation

36. COMPLICATIONS
1. Failure of wound to heal : gap if wider than 1cm needs revision
2. Infection : open – flaps retract / edematous
results in shortening the bone
Rx : close only central 1/3 for coverage of bone.
3. Phantom sensation : diminishes over time, telescoping
4. Pain and phantom pain : massage , cold packs, exercise and
neuromuscular stimulation
TENS ( trans cutaneous electric nerve stimulation) :
incorporated in a prosthesis
-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine

37. Follow up
2 weeks after surgery
Start muscle contraction exercises and physiotherapy
Desensitization is started with a towel for distal
residual extremity pressure
Prosthetic management to be started by 6weeks
Depending on the condition of the extremity and
wound
Some patients are not candidates for prosthesis

38. Thank you….