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1. Principles of Lower Limb
Amputation
By: Getye Bantayehu(OSRII )
Moderator :Dr Atakltie (Plastic &Reconstructive surgeon )
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2. Out lines
 Objective
 Introduction
 Epidemiology
 Anatomy of Lower Limb
 Indication /Contra indication
 Pre op evaluation
 Principles of amputation &post op management
 Summary
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3. Objective of Seminar
• At the end of this seminar we are expected to know
-Anatomy of lower Limb
-Indication & Contraindication of amputation
-Pre op preparation of patient for amputation
-Different intra op techniques &Level of amputation
-How to rehabilitate a patient with amputation
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4. Introduction
• Amputation is trans osseous removal of a limb or part
of it
• Is the most ancient surgical procedure.
• The procedure was associated with high mortality
rates
• The stump was poorly suited for prosthetic fitting.
• Know a days improvement in surgical technique&
availability of prosthesis decrease complication
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5. Epidemiology
• More than two million patients with amputations live
in the United States.
• > 185,000 amputations performed each year .
• More than 90% of amputations performed in the
Western world are 2nd to PAD
• In younger patients, trauma is the leading cause,
followed by malignancy.
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6. Anatomy of Thigh
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7. Anatomy of Knee
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8. Anatomy of Leg
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9. Anatomy of Ankle & Foot
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10. Pathophysiology
• Indication
Dead limp
• PAD
• Frost bite
• Burn
• Sever trauma
Dangerous limb
• Malignancy
• Uncontrolled infection
Damned nuisance
• Gross deformity
• Loss of function
• Contra Indication
-surgically unfit patient
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11. Pre op evaluation& Preparation
• ABC of life
• History
- Etiologies
- comorbidities
• Physical examination
-CVS, MSS ,CNS
• Investigation
-CBC, x ray , RBS
-TLC, serum albumen
-trans cutaneous oxygen
level,
-Doppler ultrasound,MRI
• Maximize medical
management
• Consult different
multidisciplinery team
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12. Surgical Principles of amputation
• Select level of amputation
• Follow intra op surgical techniques
• Reduce post op complications
• Is remaining limb fit for prostheses or not
• Make early return of patient to work and recreation
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13. Determine Level of Amputation
Preoperative assessment
of
skin color & Sensation
hair growth
 skin temperature
Trans cutaneous oxygen
level
Great toe pressure
Soft tissue status
 Ankle-brachial index
Metabolic demand
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14. Amputation vs Reconstruction
• LEAP study
- severe soft tissue injury
- plantar sensation
• SIP (sickness impact profile)
- Mangled foot and ankle injuries requiring free tissue
transfer have a worse SIP than BKA
• MESS score
• Surgeon decision &clinical experience
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15. Amputation Versus Reconstruction in Traumatic Defects of the Leg: Outcome and Costs
Hertel, R.; Strebel, N.; Ganz, R.
Author InformationJournal of Orthopaedic Trauma: May 1996 - Volume 10 - Issue 4 - p 223-229
BUY
Abstract
Summary
This retrospective study on reconstructive efforts to salvage severely injured legs.
18 lower leg amputation were compared to 21 patients microvascular reconstruction.
number of interventions was 3.5 for amputation and 8 for reconstruction (p < 0.009).
Total rehabilitation time was 12 months for amputation and 30 months for reconstruction
56 % amputees and 19% of the reconstructed patients were retrained to a different profession
44% amputees and 16% of the reconstructed patients were drawing an extremely costly and lifelong
invalidity pension.
there was no permanent social disintegration due to the long treatment.
Total costs (including pensions) for reconstruction were far lower than for amputation.
We conclude that for potentially salvageable legs reconstruction is advisable
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16. Metabolic Demand
• Consider Metabolic cost of walking preoperatively
- increases with more proximal amputations
-Inversely proportional to length of remaining limb
-Except Syme amputation which is more efficient
than midfoot amputation
-Higher in vascular &Bilateral amputation
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17. Intra operative surgical techniques
• Gentle handling of soft
tissues
• Remove necrotic tissue
• Harvest flap& Graft
from the amputated part
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18. CONT…………..
• SKIN AND MUSCLE
FLAPS
-flaps should be kept
thick.
-muscles stabilized by
myodesis or myoplasty
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19. HEMOSTASIS
• we have to use the a tourniquet .
-Except ischemic limbs
• have to exsanguinated the limb
- except for infections or malignancy.
• double ligate main vessels.
• Arteries and veins should be ligated separately
• deflate the tourniquet before closure
• Place a drain in most cases for 48 to 72 hours.
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20. NERVES
• A neuroma formation is inevitable after transaction
• Nerves should be isolated, pulled distally
divided with a sharp knife
• Large nerve should be ligated.
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21. Types of amputation
• Closed
• Open ( guillotine) types
of amputation
-For patent with septic
shock
- For mangled limb
• Approach depends on
the clinical status of the
patient and the quality
of the soft tissue
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22. BONE
• Avoid Excessive periosteal stripping .
• respected bone end should be rasped to form a
smooth contour.
• important in anterior aspect of the tibia, lateral
aspect of the femur.
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23. Different level of amputation in lower limb
• Hemipelvectomy
• Hip disarticulation
• AKA
• Knee disarticulation
• BKA
• Symes ,
• Boyd,Chopart,Lisfranc
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24. SYME AMPUTATON
• A weight-bearing
amputation through the
ankle
• involves removal of all
of the bones of the foot
• patent tibialis posterior
artery is required
• stable heel pad is most
important factor
• used successfully to
treat forefoot gangrene
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25. BKA For Non Ischemic Limb
• Equal anterior
&posterior flap
• We incise using fish
mouth technique
• We use it For non
ischemic limb
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26. BKA for Ischemic limb
• Long posterior flap and
a short anterior
one(BURGESS FLAP)
• Used for ischemic limb
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27. SKEW FLAP
• It uses Anteromedal
&PosteroLateral Flap
• Used for ischemic limb
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28. ERTL TECHNQUE
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29. Knee disarticulation
• Ambulatory patients
who cannot have a
trans tibial amputation
• Non-ambulatory
patients
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30. AKA FOR LIMB
• Ideal cut is 12 cm (10-
15cm) above knee joint
• 5-10 degrees of
adduction
• We can do adductor
myodesis
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31. DISARTICULATION OF THE HIP
• Hip disarticulation is
indicated for
- trauma
- decubitus ulcers
-bone or soft-tissue
sarcomas of the femur.
• accounts for 0.5% of
lower extremity
amputation
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32. Postoperative Care
• Requires a multidisciplinary team approach.
• Post op pain management
• Dressing(Soft vs Hard)?
• Positioning
• Drains usually are removed at 48 hours
• muscle-setting exercises to mobilize the joints
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33. complication
• Early
-Bleeding, hematoma formation, infection
-Dehiscence
-Skin necrosis
• Late
-Neuroma
-Contracture
-Phantom limb sensation
-Phantom limb pain
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34. INFECTION
• Should be treated with
debridement and
irrigation
• Antibiotics should be
started
• Follow Smith and
Burgess suggest closure
technique
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35. HEMATOMA
• Meticulous hemostasis before closure
• Put a drain and apply rigid dressing
• A hematoma serve as medium for bacterial infection.
• If a hematoma does form, it should be treated with a
compressive dressing.
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36. Wound necrosis
• Pre op evaluation of
-serum albumin level
and
- total lymphocyte count
• Avoid smoking tobacco
• If necrosis >1cm do
wedge resection
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37. Causes of post operative pain
• Residual limb pain
-Unfit prosthesis,
-Choking
- Neuroma
• Phantom limb pain
• Phantom limb sensation (it will be telescoped)
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38. Phantom limb pain
• Is the pain that persists
after complete tissue
healing
• Is characterized by
dysesthesia at the level of
the absent limb
• The most effective
treatments is mirror
therapy.
• We can give narcotic
drugs, anti-epileptic
medications
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39. Residual limb pain
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40. Phantom limb pain
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41. Post amputation Neuroma
• Occurs in 20-30% of amputees
• Proper nerve handling at the time of procedure
• Targeted muscle reinnervation
• If not neuroma excision
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42. AMPUTATIONS IN CHILDREN
• Amputations in children may be divided into two
general categories: congenital and acquired
• 60% of amputations are secondary to congenital and
40% are secondary to acquired conditions
• Considering general body growth and stump growth
are significant factors
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43. general principles of childhood
amputation surgery
• Preserve length,
• Preserve important growth plates,
• Perform disarticulation rather than transosseous
amputation
• Preserve the knee joint whenever possible
• Deal with issues in addition to limb deficiency in
children
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44. Post op rehabilitation
• Goal is to return the patient to a functional status
• Acute phase physical therapy includes
-pain &swelling control , joint mobilization
-isometric muscle training of the residual limb
• fabrication and application of prosthesis, usually
about 6 weeks after surgery
• occupational therapy for ADL
• cognitive therapy and psychological support
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45. Prosthesis
• Artificial substitute for a
missing part of the
body.
• Had different parts
• commonly used
prosthesis
-Quadrilateral socket
-Patellar tendon bearing
-Canadian syme prosthesis
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46. summary
• Pre op evaluation of patient important for
amputation
• We have to know anatomy of limb& Criteria for level
of amputation
• We have to follow important intra op surgical
techniques to decrease post op complication
• Rehabilitation is important after doing amputation
• Amputation is not a failure of treatment but saves life
of a patient’s &return a patient to a more comfortable
and productive life”
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47. References
Amputation Versus Reconstruction in Traumatic Defects of the
Leg: Outcome and Costs
Hertel, R.; Strebel, N.; Ganz, R.
Author InformationJournal of Orthopaedic Trauma: May 1996 -
Volume 10 - Issue 4 - p 223-229
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