overview of amputations and its various types n its complications n how it is different in children, for medicos ,postgraduates n physiotherapy

1. Amputations
• Dr. Guru prasad
• DNB orthopaedics

2. OUTLINE
Introduction
Indications
Types
Preoperative evaluation
Operative techniques
Postoperative care
Levels of amputations
Complications
Amputation in children

3. Amputation
“Surgical removal of limb or part of the limb
through a bone or multiple bones”
Disarticulation;-
“Surgical removal of whole limb or part of
the limb through a joint”

4. Introduction …

5. – Most ancient of surgical
procedure.
– Historically were stimulated by
the aftermath of war.
– It was a crude procedure -
limb was rapidly severed from
unaesthetized patient.
– The open stump was then
crushed or dipped in boiling oil
to obtain hemostasis.
– Hippocrates was the first to use
ligature.
– Ambroise Pare ( a France
military surgeon) introduced
artery forceps. He also
designed prosthesis.Amputation of a leg without anaesthetic

6. Introduction
• As a punishment in Islam
– According to Islamic Sharia Law, the punishment
for stealing is the amputation of the hand & after
repeated offense, the foot (Quran 5:38)
– This controversial practice is still in practice today
in countries like Iran, Saudi Arabia & Northern
Nigeria.

7. Introduction
• Other
– Sometimes professional athletes may choose to have
digit amputated to relieve chronic pain & impaired
performance.
– Australian footballer Daniel Chick elected to have his left
ring finger amputated as chronic pain & injury was
limiting his performance.
– Rugby player Jone Tawake also had a finger removed.
10-Apr-15 7

8. Common causes
. Injury peripheral vascular
disease
Less common
. Infection(fulminating gas gangrene)
. Malignancy
. Nerve injury
. Congenital anomalies
. miscellaneous

9. Indications:
‘ DDD’
– Dead
– Dangerous
– Damned Nuisance

10. Indication
• Dead limb:
o Severe trauma
o Peripheral
vascular
disease
o Burns
o Frostbite.

11. Indication…
• Dangerous limb:
o Crush injury
o Malignancy
o Lethal sepsis
o Forgotten
tourniquet >6hrs.

12. Indication…
• Damned nuisance:
o Gross deformity
o Recurrent sepsis
o Loss of function.
• The only absolute
indication for amputation is
irreversible ischaemia .

13. “The energy required for walking is inversely proportionate to the
length of the remaining limb”
– Amputation of the lower extremity is often the
treatment of choice for an unreconstructable or a
functionally unsatisfactory limb
– The higher the level of a lower-limb amputation, the
greater the energy expenditure that is required for
walking
– As the level of the amputation moves proximally, the
walking speed of the individual decreases, and the
oxygen consumption increases

14. – In transtibial amputations, the energy cost for walking is
not much greater than that required for persons who
have not undergone amputations.
– For those who have undergone transfemoral
amputations, the energy required is 50-65% greater than
that required for those who have not undergone
amputations .

15. Open
Guillotine
modified guillotine
Closed amputation
revised
planned

16. Aims
Return Patient to maximum level of
independent function
Ablation of diseased tissue (tumor or
infection)
Reduce morbidity & mortality (tumor or
infection)
Considered first part of a Reconstruction to
produce a physiological end organ .

17. 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

18. Pre Operative period
• Assessment
– Physical
– Social
– Psychological
• Training
• Re-assurance

19. Pre Operative Assessment
• Assessment of –
– The affected limb
– The unaffected limb &
– The patient as a whole is conducted thoroughly.
• Assessment of physical, social & psychological status
of the patient should be made.

20. Physical Assessment
• Muscle strength of UL, trunk & LL apart from the affected
limb before level of amputation.
• Joint mobility, particularly proximal to the amputation
level.
• Respiratory function
• Balance reaction in sitting & standing
• Functional ability
• Vision & hearing status

21. Social assessment includes
• Family & friends supports
• Living accommodation –
– Stairs, ramps, rails, width of door, wheelchair accessibility
• Proximity of shops

22. Pre-operative Evaluation
• History
o Aetiology
o Comorbidities
• Physical examination
o CVS, Renal &
o Nervous system
• Investigation
o Doppler indices
o Transcutaneous O2 tension

23. Pre-operative Evaluation…
• Optimization:
Anaemia, hypotension, infection, nutrition
• Consultations:
Nephrologist, Cardiologist, Neurologist
If vascular dx has progress to the point of amputation, most patients also
have concomitant dx process in the cerebral, renal & coronary
vasculatures.

24. Pre-operative Evaluation…
• Counseling & consent
Procedure, anaesthesia, complications,
prosthesis & limitations.
• MESS ≥ 7
Removes subjectivity from decision making in
trauma cases.
No scoring system can replace experience & good clinical judgment.

25. Principles of operative techniques
• Anaesthesia
Regional, G.A
• Antibiotics
Broad-spectrum, IV
• Tourniquet
Except in arterial insufficiency

26. Principles of operative techniques..

27. Principles of operative techniques..

35. • Debridement of all Nonviable tissue and foreign material
• Several debridements may be required
• Primary wound closure often contraindicated
• High voltage, electrical burn injuries require careful evaluation
because necrosis of deep muscle may be present while
superficial muscles can remain viable
Techniques

36. Skin and Muscle Flaps
• Flaps should be kept thick.
• Unnecessary dissection should be avoided to
prevent further devascularization of already
compromised tissues.
Technical Aspects

37. • The scar should not be adherent to the
underlying bone as an adherent scar makes
prosthetic fitting extremely difficult, and this type
of scar often breaks down after prolonged
prosthetic use.
• Redundant soft tissues or large “dog ears” create
problems in prosthetic fitting and may prevent
maximal function of an otherwise well-
constructed stump.

38. • Muscles usually are divided at least 5 cm distal to
the intended bone resection.
• They may be stabilized by Myodesis (suturing
muscle or tendon to bone) or by Myoplasty
(suturing muscle to periosteum or to fascia of
opposing musculature). (transected muscles
atrophy 40% to 60% in 2 years if they are not
securely fixed).
• If possible, myodesis should be performed to
provide a stronger insertion, help maximize
strength, and minimize atrophy

39. Myodesis

40. • Myodesed muscles continue to
counterbalance their antagonists, preventing
contractures and maximizing residual limb
function.
• Myodesis may be contraindicated, however, in
severe ischemia because of the increased risk
of wound breakdown.

41. Hemostasis
• Except in severely ischemic limbs, the use of a
tourniquet is highly desirable and makes the
amputation easier.
• Major blood vessels should be isolated and
individually ligated.
• Larger vessels should be doubly ligated.
• The tourniquet should be deflated before
closure, and meticulous hemostasis should be
obtained.

42. • Nerves
• A neuroma always forms after a nerve has
been divided.
• A neuroma becomes painful if it forms in a
position where it would be subjected to
repeated trauma.
• Nerves should be 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.

43. • Strong tension on the nerve should be
avoided during this maneuver; otherwise, the
amputation stump may be painful even after
the wound has healed.
• Large nerves, such as the sciatic nerve, often
contain relatively large arteries and should be
ligated.

44. Bone
• Excessive periosteal stripping is
contraindicated and may result in the
formation of ring sequestra or bony
overgrowth.
• Bony prominences that would not be well
padded by soft tissue always should be
resected, and the remaining bone should be
rasped to form a smooth contour.

45. Principles of operative techniques..
• Closure
o Drain is placed
o Skin 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

46. Principles of operative techniques..
• Conical Dressing
o Soft dressing with crepe bandage
o Rigid dressing with POP
• Rigid dressings prevent edema at the surgical site
• Enhance wound healing & early maturation of stump
• Decrease postoperative pain
• Allow earlier mobilization & ambulation
• Prevent knee flexion contractures in B/K amputation

47. Principles of operative techniques..
• Ideal stump
o Conical
o Heal adequately
o Adequate stump
o Adequate muscle padding
o Thin scar not interfering with prosthesis
o Adjacent joint movements
o Adequate blood supply

48. Post-operative management
• Analgesics
• Antibiotics
• DVT prophylaxis
• Stump elevation (foot of the bed)
• Avoid flexion contracture at knee & hip

49. Post-operative management…
• Educate patient how to position the stump
• Mobilize out of bed in 1DPO
• Remove drain in 48hrs
• Remove stitches after wound evaluation

50. Post-operative management…
• Early physiotherapy
o Muscle setting exercises 1st
o Joint movement exercises
o Ambulation with parallel bars, then crutches
• Prosthetic ambulation time depends on:
o Age of the patient
o Strength & agility of the patient
o Patient's ability to protect the stump

51. Post-operative management…

52. Surgical Principles
• Level – sites of Election versus sites of Emergency
Amputation
Levels
Optimum Shortest Longest
Transradial
(forearm)
junction prox 2/3 &
distal 1/3
3cm below biceps
insertion
5cm above
wrist joint
Transhumeral
(arm)
middle third
4cm below axillary
fold
10cm above
olecranon
Transfemoral (
thigh)
middle third
8cm below pubic
ramus
15cm above
knee joint
Transtibial (leg)
8cm for every
metre of
height (12cm)
7.5cm below knee
joint

54. Amputation Level Nomenclature
Old Terminology Current Terminology
Partial hand Partial hand
Wrist disarticulation Wrist disarticulation
Below elbow Transradial
Elbow disarticulation Elbow disarticulation
Above elbow Transhumeral
Shoulder disarticulation Shoulder disarticulation
Forequarter Forequarter
Partial foot Partial foot
Syme’s Ankle disarticulation
Below knee Transtibial
Knee disarticulation Knee disarticulation
Above knee Transfemoral
Hip disarticulation Hip disarticualation
Hemipelvectomy Transpelvic

55. Levels of Amputation
Partial toe Excision of any part of one or more toes
Toe disarticulation Disarticulation at the MTP joint
Partial foot/ ray resection Resection of 3rd-5th metatarsal & digit
Transmetatarsal Amputation through the midsection of all metatarsals
Syme’s
Ankle disarticulation with attachment of heel pad to distal of
tibia
Long transtibial (Below knee) More than 50% tibial length
Short transtibial (Below Knee) Between 20% and 50% of tibial length
Knee disarticulation Through knee joint
Long transfemoral ( Above knee) More than 60% femoral length
Transfemoral (above knee) Between 35% and 60% femoral length
Short transfemoral (Above Knee) Less than 35% femoral length
Hip disarticulation Amputation through hip joint, pelvis intact
Hemipelvectomy Resection of lower half of the pelvis
Hemicorporectomy/ Translumbar Amputation both lower limb & pelvis below L4-L5 level

58. Level of Amputation

60. • Transtibial amputations are the most common
amputations performed for peripheral
vascular disease.
• All technical procedures may be divided into
those used for
• Non-ischemic limbs
• Ischemic limbs
Below Knee Amputations

61. Non ischemic limb Ischemic limb
Muscle flaps- both Myoplasty
and Myodesis can be done
Myodesis is contra-indicated as
it may further compromise an
already marginal blood supply
Skin flaps- both anterior and
posterior skin flaps can be
equal
Long posterior flap and
short/absent anterior flap is
recommended as anteriorly the
blood supply is less abundant
than elsewhere in the leg

62. Transtibial amputations can be divided
into three levels

63. • Syme’s Amputation- amputation at the distal
tibia and fibula 0.6 cm proximal to the
periphery of the ankle joint and passing
through the dome of the ankle centrally.
• Modified Syme’s Amputation ( Sarmiento)-
transection of the tibia and fibula
approximately 1.3 cm proximal to the ankle
joint and excision of the medial and lateral
malleoli.
Hindfoot and Ankle Amputations

64. SYME'S AMPUTATION
The Syme's 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 (26).
The Syme's amputation works well for
tumors and trauma, assuming that the
heel flap has been spared from the
trauma. In the past, it has had a high
failure rate in ischemic limbs because
of failure of wound healing. Today, the
success of amputation at this level has
increased because local tissue
perfusion is preoperatively determined
with Doppler ultrasound measurement
of blood pressures, with radioactive
133Xe clearance tests, and with
measurement of oxygenation.

66. • Lisfranc’s Amputation- amputation at the
level of tarsometatarsal joint.
• Chopart’s Amputation- amputation at the
level of calcaneocuboid and talonavicular joint
• Boyd Amputation- talectomy, forward shift of
the calcaneus, and calcaneotibial arthrodesis.
Midfoot Amputations

68. BOYD AMPUTATION
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.
 The Pirogoff amputation removes
the anterior two thirds of the
calcaneus but has no advantage
over the Boyd amputation,

69. – 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.

70. amputation of the foot by a
midtarsal disarticulation.

71. Chopart’s amputation

72. amputation of the foot
between the metatarsus
and tarsus.

73. – 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°.

74. • Krukenberg procedure
• Separate radial and ulna rays distally
• forming radial and ulna pincers capable of
strong prehension and excellent manipulative
ability

80. Complications
• Haematoma
• Infection
• Necrosis of stump end.
• Contractures (due to muscle imbalance)
• Neuroma at the cut nerve ending
• Phantom pain
• Terminal overgrowth (children)

81. Complication of amputation
• Haematomas
• Infections
• Necrosis
• Contractures
• Neuromas
• Stump pain
• Phantom sensation
• Hyperesthesia of stump
• Stump edema
• Bone overgrowth
• Causalgia

82. Amputation - Complications
• 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.

83. Amputation – Complications cont…
• In many cases, the phantom
limb aids in adaptation to a
prosthesis, as it permits the
person to experience
proprioception of the
prosthetic limb.

84. 1. Because of growth issues and increased body
metabolism, children often can tolerate
procedures on amputation stumps that are not
tolerated by adults, which includes
• More forceful skin traction
• Application of extensive skin grafts
• Closure of skin flaps under moderate tension.
Advantages Of Amputation In Children
In Comparison To Adults

85. 2. Complications after surgery tend to be less
severe in children, which includes
• Painful phantom sensations do not develop
• Neuromas rarely are troublesome enough to
require surgery.
• Extensive scars usually are tolerated well.

86. • One or more spurs usually develop on the end
of the bone, but, in contrast to terminal
overgrowth, almost never require resection.
• Psychological problems after amputation are
rare in children

87. 3. Children use prostheses extremely well, and
their proficiency increases as they age and
mature.
• In general, a progressive prosthetic program
should be designed that parallels normal
motor development.
• At a young age, children function well with
simple prostheses.
• As they grow, modifications may be made,
such as the addition of a knee joint, a mobile
elbow joint, or a mechanical hand.

88. – Preserve the physis.
– Amputations through the metaphysis (such as above-
knee or distal forearm level) or diaphysis are not
recommended in children because of the progressive
relative shortening of the residual limb. This is most
critical in the femur, but it is applicable to other long
bones as well.
– Disarticulate when possible. Disarticulation completely
eliminates the problem of terminal overgrowth and
subsequent revision surgery.

89.  Preserve stump shape. The pediatric amputation stump
becomes conical with growth, so preservation of bony
architecture such as a short segment of proximal fibula
or the distal condyles of the humerus will assist in
subsequent rotational control of the prosthesis.
 The split-thickness skin graft can hypertrophy and
become sufficiently strong to withstand the shear forces
of prosthesis use.

90. 1. Preserve length
2. Preserve important growth plates
3. Perform disarticulation rather than
transosseous amputation whenever possible
4. Preserve the knee joint whenever possible
5. Stabilize and normalize the proximal portion
of the limb
6. Be prepared to deal with issues in addition to
limb deficiency in children with other clinically
important conditions.
Principles Of Childhood Amputation

93. After 12 months

94. Thank you