The document discusses various types of amputations and related considerations. It begins by describing the bones of the foot. It then discusses the three zones of the foot and indications for amputation including if part of the limb is dead, deadly, or a dead loss. Various types of lower and upper limb amputations are described along with techniques, preparation, postoperative care, complications and prosthetics. Key types discussed include Syme's amputation, below knee amputation, above knee amputation, hip disarticulation and forequarter amputation.

1. Amputations

2. 5 Metatarsal bones:
• They are numbered from medial (big toe)
to lateral.
• 1st metatarsal bone is large and lies
medially.
• Each metatarsal bone has a base
(proximal). a shaft and a head (distal).
14 phalanges:
• 2 phalanges for big toe (proximal & distal)
• 3 phalanges for each of the lateral 4 toes
(proximal, middle & distal)
• Each phalanx has base, shaft and a head.
BONES OF FOOT
1 2
3
4
5

3. • The foot and its bones may be considered in terms of
three anatomical and functional zones;-
• The hind foot: talus and calcaneus.
• The mid foot: navicular, cuboid, and cuneiforms.
• The forefoot: metatarsals and phalanges.

4. Amputation
• is the severing of a limb or part of a limb.
• Indication: Part of the limb becomes dead, deadly, or
dead loss.

5. Indication
1.Dead: arterial occlusion – gangrene and putrefaction.
• Occlusion: atherosclerosis, emboli, diabetes & ergotism.
2. Deadly: gangrene, putrefaction & infection.
• Infection spread: cellulitis, severe toxemia, systemic infection.
• locally unresectable malignancies.
• Rx = Amputation + BS antibiotics.
• Include: wet & gas gangrene.
Causing or capable of causing death

6. 3.Dead loss:
• Traumatic:- RTA or blast (not salvageable).
• Severe contracture , paralysis & poliomyelitis.
• Severe rest pain & gangrene in ischemic injury.

7. Indication
1. Gangrene due to atherosclerosis, embolism, TAO, diabetes,
ergots.
2. Gas gangrene.
3. Trauma: To save life in crush injuries.
4. Neoplasms: Osteosarcomas, Marjolin’s ulcer, melanomas.
5. Severe sepsis.
6. Occasionally severe elephantiasis, madura foot, when all
other methods have failed to help
7. Dead, dying, devitalised tissues
8. Severe deformity congenital or acquired.

8. Types of Amputation
• I Non end bearing/side bearing.
End bearing/cone bearing.
• II Weight bearing
Nonweight bearing.

9. 1.Conical bearing
• Here healing is by primary intention.
• Bone should not be projecting.
• Myoplastic.
• No neuroma.
• Scar should not be tender.
• Proximal joint should be supple.
Moving and bending with ease

10. Types of flaps
• Flaps = limber covering attached at one edge of wound.
• Long posterior flap= in below-knee amputation.
• Equal flaps = in above-knee amputation.

19. Ideal Stump
• Stump = The proximal part of a limb that remains standing after the distal has been
removed.
• Should heal adequately.
• Should have rounded, gentle contour, with adequate muscle padding.
• Should have sufficient length to bear prosthesis.
• For B-K 7.5 (minimum) to 12.5 cm from tibial tuberosity
• For A-K 23 cm from greater trochanter.
• For above and below elbow 20 cm stump.
• Should have thin scar which does not interfere with prosthetic function
• Should have adequate adjacent joint movement
• Should have adequate blood supply
Prosthesis= to put on it artificial foot
B-K= below knee

22. Evaluation of the Patients who need Amputation
• Haematocrit, control of anaemia by transfusing blood/packed
cells.
• Control of infection using antibiotics.
• Decision of level of amputation by skin temperature, arterial
Doppler.
• Informed consent should be taken.
• Plan for prosthesis and rehabilitation by physiotherapist and
rehabilitation team.

24. 1. lower limb amputation
Techniques
1. Major amputation
• Hip disarticulation.
• Above knee(A-K) amputation.
• Knee disarticulation.
• Below knee(B-K) amputation.
2. Foot amputations
• Mid and hind foot amputations.
• Transmetatarsal amputation (when multiple toes involved)
• Digit amputations.

25. Types of Amputation
• 1. Lower limb Amputations

26. Preparation
• Consent
• Medical risk
• Major amputations carry a significant risk
• ID of medical risk factors and appropriate pre- and
postoperative medical care
• may decrease the rate of perioperative complications.
• MI (most common cause of death ff amputation),
atelectasis, pneumonia, renal failure

27. Psychological evaluation
• Level of amputation
• The surgeon must be satisfied that sufficient arterial perfusion is present at
the proposed amputation level to sustain healing.
• determined by a combination of a thorough physical examination (palpable
pulse proximally) supplemented by investigation (Doppler U/S)
• Antibiotics
• broad spectrum perioperative antibiotics
• Thromboprophylaxis
• Patients undergoing major lower extremity amputation are at high risk for
thromboembolism due to the nature of the surgery

28. Post op care
• Wound care
• Stump pain - analgesia
• Weight bearing and ambulation
• Immediate postoperative prosthesis

29. Principles in Amputation
• Adequate blood supply of the flap should be maintained.
• Proper marking of the skin incision is essential.
• Tourniquet should not be used if amputation is done for vascular
diseases.
• Proximal part of the flap contains muscle component but distal
part should contain only skin and deep fascia.
• Flap length should be adequate; not short. It should be ideally
semicircular not rectangular to get a conical stump.

30. • Nerve should be pulled down and cut using a sharp
• knife and allowed to retract into the soft tissue
otherwise neuromas may develop
• In crush injury/entrapment injury/sepsis – guillotine
amputation is done. Later skin is pulled down by using
skin traction, eventually to have better skin coverage
• Bone should be cut with beveling and all sharp margins
should be rounded

31. • Postoperatively regular dressings are done.
• Patient is mobilised using axillary crutches.
• After 3 months, once scar has matured and stump has
become supple, proper prosthesis is fit.
• Berlamont first started immediate postoperative fitting of
prosthesis to leg for early mobilisation.
• Plaster pylon is applied to the stump and a prosthetic
extension is fit to facilitate partial weight bearing
immediately after surgery.

33. • It as got more stump complications and so it has not
become popular.
• Stumps can be side bearing (sutures are on the side); end
bearing/conical (sutures are on the end) or cylindrical.
• Postoperatively active exercise should be given to the
proximal joint so that prosthesis can be fit to it properly.
• If there is sepsis especially in gangrene limb, flaps should be
left open or loosely sutured otherwise flap necrosis occurs.
• Proper anatomy of muscles and neurovascular bundle
around should be known in all amputations

35. A. RAY amputation
• amputation of toe with head of metatarsal or
metacarpals.

37. 2. Gillies’ amputation
• Transmetatarsal amputation & Here amputation is
done proximal to the neck of the metatarsals, distal
to the base.

38. 3. Lisfranc‘s amputation
• Tarso metatarsal amputation.
• Here tarso metatarsal joint is disarticulated with a long volar flap.
• Chopart‘s amputation (Midtarsal amputation) – Here talonavicular
joint and calcaneo cuboid joints are disarticulated.
• Tibialis anterior muscle is sutured to drilled talus bone.
• A long volar flap is used and immobilised for 6 weeks after
surgery.

39. 4. Syme’s amputation
• It is removal of the foot with calcaneum and cutting of
tibia and fibula just above the ankle joint with retaining
heel flap (dividing both malleoli).
• Heel flap is supplied by medial and lateral calcaneal
vessels (branches of posterior tibial artery).
• Elephant boot is used for the limb after Syme’s which is
inexpensive.

40. • Many patients walk well with Syme’s stump without
difficulty.
• It is presently mainly used in trauma (crush injury) and
malignancies in distal part of the foot.
• In vascular diseases, calcaneal vessels may not be
adequate to maintain the viability of the flap.
• While raising the flap, knife should be very close to the
calcaneum so as to avoid injury to calcaneal vessels and
to maintain the viability of the flap.

42. 6. Modified Syme‘s amputation
• – Here heel flap is elliptical.
• Tibia and fibula are divided slightly higher. But
variation here is the elliptical flap

43. 7. Pirogoff‘s amputation
• – It is like Syme’s amputation except posterior part
of the calcaneum is retained along with heel flap.
• It provides longer stump than Syme’s amputation.

44. 8. Below-knee amputation
• – Here we use a long posterior
• flap with scar placed over anterior aspect is used.
• Prosthesis placement is better here with greater range
• of movements without limp and without support. It
• is also called as Burgess amputation. Fibula should be
• divided first, higher than the proposed site of cut of
• tibia otherwise its sharp end will press on the skin
• flap.

45. • Tibial stump should be beveled anteriorly.
• Posterior muscles are sutured across the bone end, to the
periosteum in front. In more proximal type of below knee
amputation, fibula often is removed to allow the proper
use of flap. Length of the flap should be 11/2 times the
circumference of the site (around 12 cm). Stump length is
14-17 cm from knee joint. Minimum length required for
prosthesis is 8 cm. If need to extend more proximally, it is
better to do above knee amputation. Modern artificial
limbs like suction socket prosthesis are used now.

49. 9. Peg-leg’ amputation
• ‘– It is amputation 5 cm below the knee level –
proximal most below knee amputation.
• It is not practiced nowadays. Here anterior flap is
rotated posteriorly like a hood and patient kneels
and bears weight which is well-accustomed to
pressure.
• It is done whenever prosthesis cannot be used
probably due to economic causes (in developing
countries).

51. 10. Transcondylar
• - Gritti-Stokes amputation with long posterior flap.
Femur is divided just above the articular surface
and patella is anchored to the divided femur. There
is risk of nonunion between patella and femur. This
procedure is no longer performed.

52. 11. Above-knee amputation
• – Usually equal anterior and posterior flaps are
used. Lower third and middle third level
amputations are done. Ideally the required length
of the femur as stump is 25 cm from the tip of the
trochanter. Femur length lesser than 10 cm is not
possible and here one needs to do hip
disarticulation. In children as growing epiphysis of
femur is in lower end, it is essential to preserve as
much length of femur as possible.

55. 12. Hip disarticulation
• – It is done whenever it is not possible to save the
minimum 10 cm length of the femur. Incision used
is either single posterior flap – Solcum’s approach
(better) or anterior racquet incision – Boyd’s
approach.
• Hind quarter amputation – Inter innominato
abdominal amputation (Sir Gordon Taylor’s
amputation):

56. • Removal of one side pelvis with innominate bone,
pubis, muscles and vessels. Original ligation of common
iliac artery is modified to individual ligations of external
and internal iliac vessels.
• Internal iliac artery is ligated beyond the origin of the
superior gluteal artery to keep the large posterior flap
viable. Now hind quarter name is replaced by
hemipelvectomy. It may be standard hemipelvectomy
with classic gluteal flap; extended hemipelvectomy
with removal of posterior part of the sacrum;
conservative hemipelvectomy with retaining part of the
pubis, ilium bones on that side. Internal
hemipelvectomy is new method wherein
hemipelvectomy is done with preserving the limb.

57. 13. Krukenberg’s amputation
• is done in upper limb following any trauma.
• Here forearm amputation is done in such a way
that it creates a gap between radius and ulna like a
claw to have a hold or grip.
•

58. 14. Forequarter amputation.
• Inter scapulo thoracic amputation (Little wood’s posterior approach or
Berger’s anterior approach):
• It is removal of entire upper limb with scapula and lateral 2/3rd of the
clavicle and muscles attached to it.
• It is done in malignancies involving scapula, upper part of humerus and
near shoulder joint.
• In emergency conditions like severe sepsis, gas gangrene and machinery
entrapment, Guillotine amputation is done without suturing.
• Suturing is done at later period. All tissues are divided at same level.

59. Postoperative Period
• Physiotherapy is advised.
• Regular dressings are done.
• Crutch is used initially, after 3 months prosthesis is
placed.
• Rehabilitation is important

62. Complication of Amputation
• Early:
1. Hemorrhage – return to OR
2. Hematoma – evacuation
3. Infection – usually from hematoma
4. Wound dehiscence
5. Gangrene
6. DVT, PE = heparin 500units, bid, for 2wks

63. • Late:
1. Pain: unresolved sinus, osteitis,
sequestrum, bone spur, scat
2. Phantom pain: feeling of amputated limb &
sometimes that is painful.
3. Ulceration.
4. Psychological stress
5. Ring sequestrum formation
6. Flap necrosis

64. • Painful scar
• Phantom Limb
• NB: Phantom Limb is feeling of amputated part in
toto or partially with pain over it. Reassurance,
analgesics, rehabilitation are the treatment. Control
of pain prior to amputation reduces the chances of
developing phantom limb. It is common in upper
limb.

66. Prosthesis
• It is the substitution to a part of the body to achieve its optimum
function.
• Syme’s amputation: Elephant boot, Canadian Syme’s prosthesis.
• Below-knee amputation: Patellar tendon bearing (PTB)
prosthesis and solid ankle cushion heel (SACH).
• Above-knee amputation: Suction type prosthesis.
• It is placed above the stump. It is better and well-tolerated.
• Nonsuction type prosthesis: It is placed at the ends.
• It requires additional support.
• Hind-quarter amputation: Tilting table prosthesis (TTP) or Canadian prosthesis
is used here.

67. A. Upper Limb amputation
1. Above elbow prosthesis is a high technology
prosthesis.
2. It is sophisticated device with harness,
socket, elbow joint unit, control cable,
forearm and wrist device.
3. Below elbow prosthesis
Krukenberg’s amputation does not require
any prosthesis.

68. 2. Upper Limb Amputations
• Hand Amputations
• Wrist Amputations
• Forearm (TransRadial) Amputations
• Elbow Disarticulation
• Arm(Transhumeral) Amputations
• Shoulder Disarticulation
• Forequarter Amputations

71. Advantages of Prosthesis
• Cosmetic
• Function of the part relatively can be got
• Ambulation in lower limb prosthesis
• Disadvantages
• Infection
• Pressure ulcers
• Joint disability

72. Prosthesis Types
• Exoskeletal prosthesis
• Endoskeletal prosthesis with modular
system
• Internal prostheses are one used inside. They
are placed by open surgery. They are
nonreactive, long durable materials, e.g. hip
prosthesis in total hip replacement.

73. THANKS