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LIMB AMPUTATION CLINICAL TREATMENT AND APPROACH.pptx

Discover more about limb amputation

Health & Medicine◦
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LIMB AMPUTATION Dr. Phillipo Leo Chalya M.D. ; M. Med. (Surg.) Consultant Surgeon & Senior Lecturer Dept Surgery BMC/CUHAS
DEFINITION  Limb amputation is defined as the surgical removal of a limb, or part of a limb through bone  Derived from latin word “amputare” meaning ‘cutting around
INDICATIONS  Amputation is indicated when part of a limb is dead, deadly (dangerous) or a dead loss (damn nuisance) • Dead (dying) limb  Peripheral vascular disease ( 90% )  Severe trauma  Burns  Frostbite • Deadly (dangerous) limb  Malignant tumors  Lethal sepsis  Crush injury leading to Crush syndrome • Dead loss (Damn nuisance) - retaning the limb is worse than having no limb at all …. because of :-  Pain  Gross malformation  Recurrent sepsis  Severe loss of function  The most common indications for amputation include:- • Congenital limb deformities • Acquired limb diseases
Congenital limb deformities  Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency)  Extra digits and/or limbs (e.g., polydactyly)  Amputation in utero (Amniotic band syndrome)  Congenital pseudoarthrosis of the tibia and fibula, and radius and ulna
Acquired limb diseases  Vascular diseases  Established gangrene due to peripheral vascular disease  Traumatic conditions  Severe limb injuries in which the limb cannot be saved or efforts to save the limb fail  Metabolic diseases  Diabetic foot
 Neoplastic  Bone tumors eg osteosarcoma, chondrosaroma, Ewing's sarcoma  Soft tissue tumors (e.g., fibrosarcoma, epithelioid sarcoma, Ewing's sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma)  Skin cancers (e.g. squamous cell carcinoma, malignant melanoma)  Infections  Fulminating gas gangrene  Bone infection (osteomyelitis)
CLASSIFICATIONS  According to etiology/indications • Therapeutic/surgical amputation  Amputation performed therapeutically to treat recurrent infection or gangrene in peripheral vascular disease; to remove malignant tumors; and to treat severe trauma • Traumatic amputation  Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat • Self amputation  In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated his or her own limb • Criminal amputation  Amputation is used as a legal punishment in a number of countries, among them Iran, Yemen, United Arab Emirates, Saudi Arabia, Sudan, and Islamic regions of Nigeria
 According to the purpose of amputation • Provisional amputation  Used when primary healing is unlikely or delayed because of infection, ischemia, or inadequate wound debridement  It is done as an emergency procedure, to save the life of the patient • Definitive amputation  In this type, amputation is done after provisional amputation as an elective surgery  In this, level is well- defined and thought out, with the ultimate prosthesis kept in mind
 According to the type of amputation • Major limb amputation  Major limb amputation is defined as any amputation at or proximal to the wrist and ankle • Minor limb amputation  Major limb amputation is defined as any amputation distal to wrist and ankle
 According to anatomical site • Upper limb amputation  Amputation through the bones of the upper limb • Lower limb amputation  Amputation through the bones of the lower limb  According to the levels of amputation  Levels of amputation in the lower limb  Levels of amputation in the upper limb
 Levels of amputation in the lower limb  Toe amputation  Ray’s amputation  Transmetatarsal amputation  Syme’s amputation  Below knee (transtibial) amputation  Amputation through knee joint  Above knee (transfemoral) amputation  Amputation through the hip  Hemipelvictomy (Hindquarter)/ transpelvic amputation
• Levels of amputation in the upper limb • Transcarpal amputation • Amputation through a wrist • Below elbow amputation (transradial) • Amputation through the Elbow • Above elbow amputation (transhumeral) • Amputation through shoulder • Forequarter amputation
 According to the timing of surgery • Emergency amputation  Amputation done on emergency setting • Elective amputation  Amputation done electively (i.e. planned amputation)  According to the type of amputation stump wound closure • Closed amputation  Closed amputation is one in which the skin of the amputation stump wound is closed primarily • Open / guillotine amputation  Open amputation is one in which the skin is not closed over the end of the stump  It is indicated in infection and severe traumatic wounds with extensive destruction of tissue and gross contamination by foreign materials
PRINCIPLES FOR AMPUTATIONS  The principles for amputations include the following:- • General principles  To save as much limb as possible while providing a residual limb that is able to tolerate the stress of the prosthesis and return to mobility • Surgical principles  The use of tourniquet is advised to obtain a bloodless field – except in ischemic conditions  Level of amputation – effort should be made to preserve all possible limb length, keeping in mind the prosthesis to be fit  The surgical principles for amputation surgery involve appropriate management of the skin, bone, nerves, and vessels
 Skin flap  The greatest skin length possible should be maintained for muscle coverage and a tension-free closure  Skin flaps are cut so that their combined length equals one and half times the width of the limb  As a rule:-  Anterior and posterior flaps of equal length for the upper limb and for transfemoral(AKA)  Long posterior flap for BKA  Muscles  Muscles should be divided at least 5 cm distal to the level of bone section
 Nerves  Nerves should be isolated, gently pulled distally into wound, and divided cleanly with a sharp knife so that the cut end retracts well proximal to the level of bone amputation  Ligation of large nerves can be performed when an associated vessel is present  Blood vessels  The larger arteries and veins are dissected and separately ligated  This prevents the development of arteriovenous fistulas and aneurysms
 Bone  Bone should be cut at least 5 cm proximal to the level of muscles division  Excessive periostrial stripping that may result in formation of ring sequestra or bone overgrowth should be avoided  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
PREOPERATIVE CARE  Requires a multidisciplinary approach involving general surgeons, orthopedic /trauma surgeons, physicians, anesthetists and physiotherapist  Investigate and treating co-morbid conditions in consultation with physicians, anesthetists and physiotherapist  Preoperative routine investigations such as complete blood count, blood grouping and cross matching, blood sugar, serum urea and creatinine, urinalysis, chest x-ray, ECG, serum albumin should be done  Determine the level of amputation  Informed written consent regarding the underlying pathology, inevitability of amputation, complications, availability of prosthesis
INTRA-OPERATIVE CARE  Intra-operative care for amputation include the following:- • Anesthesia: General/spinal • Position: supine • Pre-incision: prophylactic antibiotics, exsanguinate, tourniquet, skin preparation and drapping • Procedure • Should be done according to the principles for amputation  The goal of the surgeon is to:- • Adhere to the principles for amputation • Find a place where healing is mostly to be complete • To have an ideal stump for prosthesis fitting
The quality of an ideal stump for prosthesis  The stump should have sufficient length to bear the prosthesis  The end of the stump should be smoothly rounded and conical in shape with adequate muscle padding  The stump should be firm to accommodate the prosthesis  Should have thin scar which does not interfere with prosthetic function  The position of the scar should be such, as to avoid pressure  The resulting scar should be fully mobile and should neither be adherent nor be infolded  The stump should have adequate adjacent joint movement  The stump should have adequate blood supply i.e. vascularity of the flaps should be normal  The opposing groups of muscles should be sutured together over the end of the bone in such a way that they will be converted into fibrous tissue and will serve as an effective cushion, which protects the skin  There should be no projecting spur of bone
POSTOPERATIVE CARE  The post-operative care for amputation include the following:-  Pain management includes the brief use of intravenous narcotics followed by oral analgesics  Antibiotics  Deep venous thrombosis prophylaxisis  Stump elevation by raising the foot of the bed which help manage edema and pain
 Avoid flexion contracture at the knee and hip by:  proper positioning of the stump  Gentle passive-stretching exercises  Having the patient engage in exercise to strengthen the muscles controlling the joint  Severe contracture may require wedging casts or surgical release of the contracture  Mobilize out of bed in first postoperative day  Remove stitches in two weeks postoperatively
 Early physiotherapy  Muscle setting exercise first  Joint movement exercise  Ambulation with parallel bar, then crutches
COMPLICATIONS  Complications following limb amputations are classified as follows:-  Early complications  Late complications
Early complications  Hemorrhage  3 types  Primary hemorrhage  1st hge is one which occurs at the time of injury or operation  Reactionary hemorrhage  Reactionary hge is one which occurs within 24 hours of injury or operation  Such hge takes place due to dislodgement of blood clots or slipping of ligatures  Secondary hemorrhage  This occurs usually after 7 to 14 days of injury or operation  This is usually due to infection and sloughing of part of the arterial wall 
 Hematoma  Inadequate haemostasis, loosening of the ligature and inadequate wound drainage are the common causes  Hematoma results in delayed wound healing and infection  It should be aspirated and a pressure bandage given  Surgical site infection  The cause generally is an underlying peripheral vascular disease, diabetes or a hematoma  Wound breakdown and occasionally the spread of infection proximally may necessitate amputation at a higher level  A wound should not be closed whenever the surgeon is in doubt about the vascularity of the muscles or the skin at the cut end  Any discharge from the wound should be treated promptly
 Skin flap necrosis  A minor or major skin flap necrosis indicates insufficient circulation of the skin flap  It can be avoided by taking care at the time of designing skin flaps that as much subcutaneous tissues remain with the skin flap as possible  Small areas of flap necrosis may heel with dressings but for larger areas, redesigning of the flaps may be required
 Wound dehiscence  Wound dehiscence may occur when the wound is closed under tension or if there poor vascularity of the muscles or the skin at the cut end  Deep venous thrombosis  Amputation may be followed by deep vein thrombosis and pulmonary embolism in the early postoperative days  So subcutaneous heparin 5,000 units twice daily is strongly advised for several weeks after operation
 Stump ulceration  Ulceration of the stump may occur due to pressure effects of the prosthesis  Some patients may be troubled by cold and discoloured stump particularly during winter due to ischaemia
Late complications  Deformities of joints (Joint contracture/ stiffness)  These results from improper positioning of the amputation stump, leading to contractures  A mild or moderate contracture is treated by appropriate positioning and gentle passive-stretching exercises; severe deformity may need surgical correction  Causalgia (i.e. persistent painful stump scar)  Causalgia is defined as a persistent pain at the end of the amputation stump  This is mostly seen in case of amputation of digits
 Neuroma  Stump neuroma, which is proliferation of nerve fibre at the point of nerve division  It results from the nerve trauma and can be of two types:  Terminal neuroma which originates at the end of the nerve, being the pattern of nerve healing, often asymptomatic  Spindle neuroma which is far from the nerve extremity resulting from microtrauma due to stretching or compression by the localized scar tissue  Painful neuroma can usually be prevented by dividing the nerves sharply at a proximal level and allowing it to retract well proximal to the end of the stump to lie in normal soft-tissues  If it does form, it is to be excised at a more proximal level
 Phantom pain  Phantom pain is the awareness of pain in the amputated limb  Treatment is difficult  Phantom limb  All individuals with acquired amputations experience some form of phantom sensation, a sensation as if the amputated part is still present  This sensation is most prominent in the period immediately following amputation, and gradually diminishes with time
 Osteomyelitis  Osteomyelitis might occur by direct spread from a contiguous soft tissue infection, haematogenous dissemination or in a previous quiescent septic focus  Osteoporosis and tendency to fracture
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