This document provides background information on lower limb amputations. It discusses the history of amputation dating back to ancient times and developments over centuries. It defines amputation, provides classifications, and outlines epidemiology, indications, investigations, surgical principles, complications and prognosis of lower limb amputations. The document discusses various types of foot, midfoot, hindfoot and above-knee amputations and their techniques.

1. Lower limb Amputations (PART I)
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

2. Outline
PART I -PRINCIPLES OF SURGERY
• Background
• Introduction
– Definition
– Etymology
– Classification
• Epidemiology
• Indications and contraindication
• Investigations
• Surgical principles
• Complications
• Prognosis

3. Outline
PART II- OPERATIVE SURGERY
• Foot amputations
– Forefoot Amputations
• Toe amputation
• Amputation at the base of
proximal phalanx
• Metatarsophalangeal
disarticulation
• Border Ray amputation
• Central Ray amputation
• Transmetatarsal amputation
– Midfoot amputations
• Lisfranc amputation
• Pirogoff amputation
• Chopart amputation
– Hindfoot (ankle) amputations
• Syme amputation
• Boyd amputation
• Transtibial (below-knee)
amputations
• Disarticulation of knee
• Transfemoral (above-knee)
amputations
• Disarticulation of Hip
• Hemipelvectomy

4. BACKGROUND
Amputation surgery is the most ancient of surgical procedures dating back to prehistoric times
Neolithic(New stone Age; 10,200 BC to 4500-2000 BC)
humans are known to have survived traumatic, ritualistic,
and punitive rather than therapeutic amputations.
Cave-wall hand imprints have been found that
demonstrate the loss of digits.
Unearthed mummies have been found buried with
cosmetic replacements for amputated extremities

5. BACKGROUND
The earliest literature discussing amputation is the
Babylonian code of Hammurabi*, inscribed on black
stone, from 1700 BC, which can be found in the Louvre**
In 385 BC, Plato's Symposium*** mentions therapeutic
amputation of the hand and the foot
Hippocrates provided the earliest description of
therapeutic amputation in De Articularis for vascular
gangrene
• Hippocrates describes amputation at the edge of the
ischemic tissue, with the wound left open to allow
healing by secondary intention
*6th Babylonian king, who enacted the code consisting of 282 laws of scaled
punishment(eye for eye, limb for limb)
** one of world largest museums and historic monument in Paris
*** Philosophical text concerned with genesis, purpose and nature of love

6. BACKGROUND
• The main risks described in the early
history of amputation surgery were
hemorrhage, shock, and sepsis
• Before the discovery of anesthesia, the procedure itself was quite
difficult/crude.
– Patient would be held down by a number of assistants and be given
alcohol (usually rum)
– Patient would essentially be awake and aware during the procedure
– Open stump was crushed or dipped in boiling oil to obtain hemostasis
– Associated with high mortality rate and poorly suited stump for
prosthesis in survivors
• Advancements in surgical technique and prosthetic design
historically were stimulated by the aftermath of war.

7. BACKGROUND
• Due to a lack of analgesics and narcotics the operation had to take
only a few minutes.
– Therefore the amputation was completed in one cut (i.e., detachment
of the skin, muscles, and bone at the same level).
– This technique, known as "classic circular cut”
• Petit recommended that we transect the skin first and the muscles
and bone more proximally ("two-stage circular cut," 1718), and
• Bromfield approved that the skin be cut first, the muscles more
proximally and the bone most proximal ("three-stage circular cut,"
1773).
• Lowdham (1679), Verduyn (1696), and Langenbeck (1810) changed
the operative technique in that they used a soft-tissue flap to cover
the bone without tension ("flap amputation").

8. BACKGROUND
1st
century
AC
Use of cautery for large vessels
(Celsus)
first mention of ligatures,
removal of gangrenous extremity
through the viable tissue edge with a
bone cut shorter than the soft tissues
1529 Ambroise Pare
(French military surgeon)
ligature reintroduced,
also thick ligature used as a tourniquet
(also introduced the artery forceps)
1588 William Cloves 1st successful above-knee amputation
1674 Morel
(Battle of Borodino)
tourniquet

9. BACKGROUND
1679 Younge and Lowdham introduction of local flaps for wound
closure without tension –flap
amputation
(animal bladders used previously)
1781 John Warren
Continental Army surgeon
(1753-1815) during the
America Revolutionary War
first successful shoulder amputation
1802 Dominique Jean-Larrey
French military
surgeon(1766-1842) in the
services of napoleon; he
introduced field hospitals,
first aid and ambulance
services
removal of 200 limbs in a 24-hour
period at the Battle of Beresina;
also, disarticulation of 11 shoulders in
24-hour period, with 9 complete
recoveries
1806 Walter Brashear first successful hip joint amputation

10. BACKGROUND
1825 Nathan Smith through-knee amputation described
1843 Sir James Syme Syme amputation
1857 Gritti •patella placed over the end of the
transected femoral condyles.
1870 Stokes Stokes and Grittis procedures modified
(ie, Gritti-Stokes amputation)
1890 Jaboulay and Girard first successful hindquarter amputation
1920 Ertl introduction of osteomyoplastic
technique and the flexible bone graft for
both transfemoral and transtibial levels
1943 Major General
Norman T. Kirk
indicated guillotine amputations in war
setting should be completed as distal as
possible and completed later under
calmer conditions
1960-
1980
Recommendation to salvage knee in
vascular amputations

11. Robert Liston(1794-1847)
• Pioneering Scottish surgeon.
• Famous for his skill in an era prior to anaesthetics, when speed made a difference in
terms of pain and survival.
• able to perform the removal of a limb in an amputation in 28 seconds
Liston's most famous case
• Amputated the leg in under 21⁄2 minutes
– Patient died afterwards in the ward from hospital gangrene
– He amputated in addition the fingers of his young assistant (who died afterwards in the ward
from hospital gangrene).
– He also slashed through the coat tails of a distinguished surgical spectator, who was so terrified
that the knife had pierced his vitals he dropped dead from fright.
– That was the only operation in history with a 300 percent mortality.

12. Robert Liston(1794-18477)
Second most famous case
– Amputated the leg in 21⁄2 minutes, but in his
enthusiasm the patient's testicles as well

13. BACKGROUND

14. BACKGROUND

15. J. McKnight, who lost his limbs in a railway accident in
1865, was the second recorded survivor of a
simultaneous triple amputation

16. Zil-e-Huma (21 February 1944 – 16 May 2014)
• Youngest of the 3 children of famed singer Noor Jehan
• Known case of Diabetes Mellitus and Chronic kidney Disease
• Leg amputated on 9 May 2014
• Died of Sepsis

17. Definition
Removal of an extremity or appendage from the body

18. Etymology
Derived from Latin amputare, "to cut away",
i.e. ambi- ("about", "around") and
putare ("to prune").
_____________________________________________
English word "amputation" was first applied to surgery in the 17th century, possibly first in
Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612)

19. Classification
In Utero Amputation Acquired amputation
ACCORDING TO ETIOLOGY
– Therapeutic/prophylactic
– Ritual
– Traumatic(war, RTA) (direct result of
accident)
– Self-amputation
– Auto-amputation
– Criminal(e.g. Hand amputation of theft in
Saudia/Iran/Yemen/Nigeria/Sudan)
ACCORDING TO SITE
– Lower limb
– Upper limb
– Facial (ear/nose/eye/teeth/tongue)
– Breast(Mastectomy)
– Genital (penis/scrotum/clitoris/foreskin)
– Hemicorporectomy (amputation at waist)
– Decapitation (amputation at neck)
• Constriction of fetal limbs
by fibrous bands of amnion
leading to strangulation of
limb
– Due to amniotic band
syndrome i.e. rupture of
inner amnion without rupture
of outer chorion
– ETIOLOGY: teratogenic drugs,
ionizing radiation, infections,
trauma

20. Self-amputation
• When a person has become trapped in a deserted place,
with no means of communication or hope of rescue
– 127 HOURS :
• 2010 British-American biographical survival drama film
• Film stars James Franco as real-life canyoneer Aron Ralston, who
became trapped by a boulder in an isolated slot canyon in Blue John
Canyon, southeastern Utah, in April 2003.
• Performed for criminal or political purposes:
– On March 7, 1998, Daniel Rudolph, the elder brother of the
1996 Olympics bomber Eric Robert Rudolph videotaped himself
cutting off one of his own hands with an electric saw to "send a
message to the FBI and the media”
• Body integrity identity disorder is a psychological condition
in which an individual feels compelled to remove one or
more of their body parts, usually a limb.

21. Self-amputation
REAL TIME STORY Body integrity identity disorder

22. Autoamputation
• Spontaneous detachment of an appendage from the body.
• Usually due to destruction of the blood vessels feeding an
extremity such as the finger tips
• Seen in
– Ainhum (dactylolysis spontanea)
• Painful constriction of the base of the fifth toe frequently followed by
bilateral spontaneous autoamputation a few years later.
– Cryoglobulinemia
– Thromboangiitis obliterans(Buerger Disease/presenile
gangrene)

23. Ainhum (dactylolysis spontanea)

24. Epidemiology(2008 data)
Estimates of Amputee Population
World population 6.7 billion
Incidence of amputation 1.5 per 1000
World population of amputees 10 million

25. ABSOLUTE INDICATION
Irreversible ischemia in a
diseased or traumatized
limb
RELATIVE INDICATIONS
Burns
Frostbite
Infection
Tumors
Certain congenital
anomalies(limb deficiencies)

26. Peripheral Vascular Disease
• Most common indication for amputation
• Most frequently occurs in individuals age 50-75
• About 50 % cases are diabetic
– Most significant predictor of amputation: Peripheral neuropathy
• that progresses to trophic ulcers and subsequent gangrene and osteomyelitis
– Others: prior stroke, prior major amputation, low transcutaneous oxygen levels, and
low ABI, smoking,
• PREVENTION:
– Foot care and shoe wear and frequent self examination
– Ulcers treated with off-loading, orthoses, total-contact casting, wound care,
and antibiotics
REMEMBER
If vascular disease has progressed to point of amputation, it is not limited to involved
extremity. So appropriate consultation is indicated to evaluate other systems( kidneys,
coronary and cerebral vasculature)

27. Peripheral Vascular Disease
• Pre-amputation vascular surgery consultation is ALMOST
ALWAYS indicated
– However, revascularization is not without risk
– MERIT: even if whole limb cant be salvaged, it may allow healing
of partial foot or ankle amputation instead of a transtibial
amputation
– DEMERIT: compromise wound healing of a future transtibial
amputation
• All effort must be expended to optimize surgical conditions
– Control of infection, evaluation of nutrition and immune status
– RISK FACTORS: albumin < 3.5 mg/dL, total lympocyte count <
1500 cells/mL (82 % healing rate if above 2 parameters normal)

28. Peripheral Vascular Disease
INDICATIONS
• Uncontrollable soft-tissue or bone infection,
• Nonreconstructable disease with persistent
tissue loss, or
• Unrelenting rest pain due to muscle ischemia.

29. Trauma
• Leading indication for amputation in younger
patients
– With profound effects on their lives
• More common in men because of vocational and
avocational hazards
– Otherwise healthy and productive
• ONLY ABSOULUTE INDICATION: irreparable
vascular injury in an ischemic limb

30. Lange’s Indications for primary amputation in trauma*
ABSOLUTE INDICATION
• Type III-C open tibial
fractures with
– complete disruption of tibial
nerve or
– crush injury with warm
ischemia time of > 6hours
RELATIVE INDICATION
• Serious associated injuries
• Severe ipsilateral foot
injuries
• Anticipated protracted
course to obtain soft-tissue
coverage and tibial
reconstruction
*DEMERIT: Involves Subjective Assessment

31. Mangled Extremity Severity Score(MESS)*
• Predictor of salvageable limb.
• Score 6 or less  salvageable limb
• Score 7 or more  amputation eventual result

32. Trauma
• No scoring system can replace experience and good clinical
judgment
– Attempts to salvage severely injured limb may cause reperfusion injury
syndrome and MOF
• More common in multiple injuries and in elderly with comorbid medical
conditions
• Once it is decided that limb can be saved, next step is decide
whether it should be saved
– Decision made in concert with patient
– Patient counseled about merits and demerits of salvage and
amputation
• Early amputation and prosthetic fitting are associated with decreased
morbidity, fewer operations, shorter hospital course, decreased hospital cost,
shorter rehabilitation and earlier return to work
• Treatment course and outcome more predictable in comparison to protracted
treatment course of limb salvage with high rate of complications and financial
burden and multiple salvages procedures ending in amputations

33. ………………………………………..
“Correct” decision are based on the patient as a
whole, not solely on the extent of the limb injury

34. Trauma
• Amputation in settings of acute trauma
– follow all standard principles of wound
management
• Debridement and irrigation of contaminated tissue
followed by open wound management
• Removal of all devitalized tissue
– Functional stump length should be maintained
wherever possible

35. Burns
• Thermal or electrical injury to an extremity
• Full extent of tissue damage may not be apparent at initial
presentation especially electrical injury
TREATMENT
• Early debridement of devitalized tissue
• Fasciotomies when indicated
• Aggressive wound care, including repeat debridements
REMEMBER
• Early amputation is preferred over Delayed amputation of an
unsalvageable limb (as already discussed with trauma)
• Performing inadequate debridement with hope to save limb put
patient in undue danger

36. Frostbite
• Denotes actual freezing of tissue in the extremities, with or
without central hypothermia
• Historically, most prevalent in wartime;
– but also seen in high-altitude climbers, skiers and hunters. Also
at risk are homeless, alcoholic and schizophrenic individuals
• Mechanism of tissue injury;
– Direct tissue injury through formation of ice crystals in the ECF
– Ischemic injury resulting from damage to vascular endothelium,
clot formation, and increased sympathetic tone
• Also due to decreased blood flow to extremities in order to maintain
central body temperature

37. Frostbite
TREATMENT
• Restoration of core body temperature
– Rapid rewarming of affected extremity in a water bath at 40oC to 44oC
• Requiring IV analgesia(low dose aspirin or ibuprofen*) and sedation
– Tissue plasminogen activator or regional sympathetic blockade
• Tetanus prophylaxis mandatory
• Systemic antibiotics- controversial
• Blebs left intact
– Closed blebs treated with aloe vera*
– Open blebs treated with silver sulfadiazine
• Physiotherapy
– Maitianence of range of motion
____________________________________________________________________________
* Help to stop progressive dermal ischemia mediated by vasoconstricting metabolites of AA in
frostbite wound

38. Frostbite
TREATMENT
• In stark contrast to traumatic, thermal or electrical injury,
amputation for frostbite routinely should be delayed 2 to 6
months
– Clear demarcation of viable tissue may take this long
– Deep tissues still may be recovering even after complete demarcation
• Triple-phase technetium bone scan help to delineate deep tissue viability
• Premature amputation often results in greater tissue loss and
increased risk of infection
– EXCEPTION: removal of a circumferentially constricting eschar

39. Infection
• Indicated for acute or chronic infection that is
unresponsive to antibiotics and surgical debridement
– Open amputation is indicated and performed using 1 of 2
methods
• Guillotine amputation with later revision to a more proximal level
after infection is under control
• Amputation at definitive level by initially inverting the flaps and
packing the wound open with secondary closure at 10-14 days
– Kritter partial foot amputation with primary closure
• Wound closed loosely over a catheter through which an antibiotic
irrigant is infused
• Constant infusion continued for 5 days
• Loose enough to allow fluid to escape into the dressings
• Dressing changed frequently till 5 day
• MERIT: Allow for primary wound healing, while avoiding
protracted course of wound healing by secondary intention

40. 3 distinct gas-forming infections must be differentiated
Factor Anaerobic cellulitis Clostridial
Myonecrosis
Streptococcal
Myonecrosis
Incubation >3 days
(several days after
closure of
contaminated
wound)
< 3 days
(within 24 hours of
closure of a deep
contaminated wound)
3-4 days
Onset Gradual Acute Subacute
Toxemia Slight Severe
(mental awareness of
impending death)
Severe(late)
Pain Absent Severe Variable
Swelling Slight Severe Severe
Skin Little change Tense, white/bronze Tense, copper colored
Exudate Slight Serosanguineous Seropurulent
Gas Abundant Rarely abundant Slight
Smell Foul Variable, mossy Slight
Muscle
involvement
No change Severe Moderate

41. Acute Infection
CLOSTRIDIAL MYONECROSIS
• Immediate radical debridement of involved tissue
• High doses of IV penicillin(clindamycin if allergic to
penicillin)
• Hyperbaric oxygen
• Emergency open amputation as a life-saving measure
– One joint above affected compartments

42. Acute Infection
STREPTOCOCCAL MYONECROSIS
• Debridement of involved muscle compartment
• Open wound management
• Penicillin treatment
– Allows preservation of the limb
ANAEROBIC CELLULITIS/NECROTIZING FASCITIS
• Debridement
• Broad spectrum antibiotics
• Amputation(rare)

43. Chronic Infection of limb
INDICATIONS FOR AMPUTATION
• Treatment of sepsis with vasoconstrictor agents leading to vessel
occlusion and subsequent extremity necrosis
• Systemic effects of a refractory infection
• Disability from a nonhealing trophic ulcer
• Chronic osteomyelitis
• Infected nonunion
• Chronic draining sinus with development of SCC

44. Amputation in Tumors
MERITS
• Limb salvage associated with
greater perioperative
morbidity
– High risk of infection, flap
necrosis, wound dehiscence,
blood loss and DVT
– Long term: periprosthetic
fractures/loosening/
dislocation, non union of graft-
host junction, allograft
fracture,leg length discrepency
and late infection
– and eventual ending in
amputation (1/3rd cases)
DEMRITS
• Technically demanding
– Need nonstandard flaps
– Bone graft
– Prosthetic augmentation

45. Amputation in Tumors
Location of tumor Procedure of choice
Upper extremity lesion Limb salvage better than amputation
(even with sacrifice of a major nerve)
Proximal femur or pelvic lesion Limb salvage better than disarticulation or
hemipelvectomy
Sarcoma around knee • Wide resection with prosthetic knee replacement
• Wide resection with allograft arthrodesis
• Transfemoral amputation
Sarcoma around ankle and foot Frequently treated with amputation followed by
prosthetic fitting

46. Amputation in Tumors
• Cancerous bone or soft tissue tumors
– Osteosarcoma
– chondrosaroma
– fibrosarcoma
– Epithelioid sarcoma
– Ewing's sarcoma
– synovial sarcoma
– sacrococcygeal teratoma
– Liposarcoma
• Melanoma

47. Amputation in tumors
INDICATIONS
• Palliative measure in metastatic disease and pain
refractory to standard surgical treatment, radiotherapy,
chemotherapy, and narcotic pain management
• Recurrent pathological fracture in which stabilization is
impossible
• Malignancy with massive necrosis, fungation, infection
or vascular compromise

48. Congenital Anomalies
• Indications
– Proximal femoral focal deficiency
– Polydactyly etc

49. CONTRAINDICATION
• Poor health that impairs the patient's ability to
tolerate anesthesia and surgery.
• BUT, the diseased limb is often at the center of
the patient's illness, leading to a compromised
medical status.
– i.e. removal of the diseased limb is necessary to
eliminate systemic toxins and save the patient's life.

50. INVESTIGATION
HEMATOLOGICAL
Hemoglobin(>10 g/dL), CRP , albumin(>3.5) ,
Lymphocyte count(>1500 cell/mL)
RADIOLOGICAL
• AP and lateral radiography of the involved extremity
• CT or MRI for tumor or osteomyelitis
– to ensure that the surgical margins are appropriate.
• Technetium-99m (99m Tc) pyrophosphate bone scanning
– to predict the need for amputation in persons with electrical burns and
frostbite
– 94% sensitivity and 100% specificity
• Doppler USG
• CT angiography

51. SURGICAL PRINCIPLES of amputation
• Determination of amputation level
• Technical Aspects
– Skin and Muscle flaps
– Hemostasis
– Nerves
– Bone
• Open amputations
• Postoperative Care

52. ………………………………………………..
The original surgical principles as described by Hippocrates remain
true today.
Refinements of surgical technique such as hemostasis, anesthesia,
and improved perioperative conditions have occurred,
but only relatively small technical improvements have been made

53. Determination of amputation level
• Involves balance between increased function with a more
distal level versus decreased complication rate with more
proximal level
– Patient’s overall well-being, general medical condition and
rehabilitation also important
– Adverse effect of malnutrition less detrimental in more proximal
amputations
• As the level of the amputation moves proximally, the
walking speed of the individual decreases, and the oxygen
consumption increases

54. Table: Energy expenditure for amputation
Amputation level Energy above
baseline, %
Speed, m/min Oxygen cost,
mL/kg/m
Long transtibial 10 70 0.17
Average transtibial 25 60 0.20
Short transtibial 40 50 0.20
Bilateral transtibial 41 50 0.20
Transfemoral 65 40 0.28
Wheelchair 0-8 70 0.16

55. Determination of amputation level

56. Determination of amputation level
• Preoperative clinical assessment of skin color, hair growth, and skin
temperature provides valuable initial information
• Preoperative arteriograms are of little help in determining potential for
wound healing
• Segmental SBP offer little useful information
– Falsely elevated owing to noncomplaint walls of arteriosclerotic vessels
• Measurement of skin perfusion pressures by
– Thermography OR laser Doppler flowmetry
– Tissue uptake of IV fluorescein
– Tissue clearance of Intradermally injected Xenon-133
– Transcutaneous oxygen measurement(MOST BENEFICIAL/RELIABLE and
SENSITIVE)
• 88 %sensiive and 84 % specific

57. Determination of amputation level
TRANSCUTANEOUS OXYGEN MEASUREMENT
• PROCEDURE
– insert a probe that is heated to 45OC for 10 minutes before
oxygen tension measured
– Allow for maximum vasodilatory response and more accurate
determination of perfusion potential
• INTERPRETATION
– 20-40 mmHg for “good” healing potential
• But NO absolute cutoff
• Falsely low in decreased diffusion: cellulitis or edema or venostasis
– Increase of 10 mmHg before and after inhalation of 100 % oxygen
– Decrease of greater than 15 mmHg after 3 minutes of elevation of
involved limb; poor prognostic indicator for healing

58. Technical Aspects
SKIN AND MUCLE FLAPS
• Flaps should be kept thick
– soft-tissue envelope of the residual limb becomes the proprioceptive end organ for the
interface between the residual extremity and the prosthesis.
– For effective ambulation, this envelope should consist of a sufficient mass of mobile
nonadherent muscle and full-thickness skin and subcutaneous tissue that can accommodate
axial and shear stress within the prosthetic socket.
• Avoid excessive pressure on skin edges with forceps
– skin is the most important tissue for healing of the amputation wound
• Avoid unnecessary dissection to prevent further devascularisation of already
compromised tissues
• Cover the end of the stump with sturdy soft-tissue envelop
• Atypical flaps always preferable to amputation at more proximal level
• Location of scar rarely important but should not be adherent to underlying bone
– Adherent scar makes prosthetic fitting extremely difficult, and often breaks down after
prolonged prosthetic use.

59. Technical Aspects
SKIN AND MUCLE FLAPS
• Redundant soft tissues or large “dog ears” also creates problems in prosthetic
fitting and may prevent maximal function of an otherwise well-constructed stump
• Greatest skin length possible should be maintained for muscle coverage and a
tension-free closure
• Muscles usually divided at least 5 cm distal to intended bone resection
• Muscles stabilized by myodesis(muscle sutured through drill holes in bone) or by
myoplasty(antagonistic muscle and fascia groups sutured together) or long
posterior flap sutured anteriorly
– 40-60 % chances of atrophy after 2 years in transected muscles not fixed
– MERIT: Myodesed muscle continue to counterbalance their antagonists, preventing
contractures and maximizing residual limb function
– Contraindicated in severe ischemia because of increased risk of wound breakdown

60. Technical Aspects
SPLIT THICKNESS SKIN GRAFT
• Sometimes used to complete wound coverage or decrease
tension on the wound closure, while maintaining the limb
length.
• When placed over soft tissue with avoidance of bone
scarring, these grafts can function quite well.
• However, most often these skin-grafted areas do not
tolerate the axial and shear stresses within the prosthesis
and may require removal at a later date

61. Technical Aspects
Hemostasis
• Except in severely ischemic limbs, use of tourniquet is highly desirable
• Limb exsanguinated by wrapping it with an Esmarch bandage before
tourniquet is inflated
– Avoid in infection or malignancy
• Do elevation of limb for 5 minutes
• Major blood vessels should be isolated and individually ligated
– To prevents the development of AV fistulas and aneurysms
• Larger vessels doubly ligated
• Tourniquet deflated before closure and meticulous hemostasis obtained
• Drain placed for 48 -72 hours

62. Technical Aspects
NERVES
• Neuroma ALWAYS form after a nerve is divided
– Become painful if at position where subjected to repeated trauma
• Nerves should be isolated, gently pulled distally into wound, and divided
cleanly with a sharp knife
– So that cut end retracts well proximal to the level of bone amputation in a
scar- and tension-free environment
– Avoid strong tension on nerve; otherwise amputation stump may be painful
even after wound has healed
– Avoid crushing
• Others techniques
– End-loop anastomosis, perineural closure, silastic capping, sealing the
epineurial tube with butyl-cyanoacrylate, ligation, cauterization, and burying
of nerve ends in bone or muscle
• Large nerves(e.g. Sciatic nerve) often contain relatively large arteries and
should be ligated

63. Technical Aspects
BONE
• Excessive periosteal stripping is contraindicated
– May result in formation of ring sequestra or bony overgrowth
• Bony prominences that would not well padded by soft
tissue and around disarticulation always be resected
– And remaining bone should be rasped to form a smooth contour
– Especially in locations such as anterior aspect of tibia, lateral
aspect of femur and radial styloid
• Diaphyseal transections can be covered with a local flexible
osteoperiosteal graft

64. OPEN AMPUTATIONS
• First of at least 2 operations required to construct a satisfactory
stump
• MUST be followed by secondary closure, reamputation, revision or
plastic repair
• INDICATION:
– Infections
– Severe traumatic wounds with extensive destruction of tissue and
gross contamination by FB
• PURPOSE: to prevent or eliminate infection so that final closure of
stump may be done without breakdown of wound

65. OPEN AMPUTATIONS
• Techniques:
– Inverted skin flaps
– Circular open amputations with post operative skin
traction
– VAC ( Vacuum-assisted closure)
• Applied to open stump immediately after initial debridement
• Subsequent debridements scheduled at 48-hour intervals
• VAC reapplied after each debridement until wound is ready for
closure

66. POSTOPERATIVE CARE
• Requires multidisciplinary team approach
– Bio-psycho-social model
– Surgeon, physical medicine specialist, physical therapist, occupational
therapist, psychologist, social worker, internist(DM, Coronary and cerebral
diseases), support groups
– Overcome the psychological stigma that society associates with the loss of a
limb. Persons who have undergone amputations are often viewed as
incomplete individuals
• Perioperative antibiotics
• DVT prophylaxis
• Pulmonary hygiene
• Pain management
– Brief use of IV narcotics followed by oral pain medicine
– Continuous postoperative perineural infusional anesthesia for several days

67. POSTOPERATIVE CARE
DRESSING
• Since 1970s, there has been a gradual shift from the use of
“conventional” soft dressings to use of rigid dressings(Plaster of
Paris cast applied to stump at end of surgery)
– Can be employed at all levels of amputations in lower and upper limbs
and in all age groups
• Early weight bearing is NOT an essential part of post-operative
management
.
OBJECTIVE CAST
If ambulation not planned rigid dressing applied
(standard cast application precautions observed)
If ambulation planned true prosthetic cast applied by certified prosthetist

68. 4 generic types of postoperative dressings
TYPE OF DRESSING DESCRIPTION
Soft dressings do not control postoperative edema
Soft dressing with pressure
wrap
require an even distribution of pressure to avoid possible limb
strangulation
Semi-rigid dressings include plaster splints and Unna Paste Bandages* held in
place with a stockinette
• same advantages of rigid dressings, except no immediate
postoperative prosthesis can be used
Rigid dressings MERIT (NEXT SLIDE)
DEMRIT: poor access to the wound and excessive pressure,
leading to wound necrosis.
*compression dressing, usually made of cotton, that contains zinc oxide paste (helps ease skin
irritation and keeps the area moist)

69. POSTOPERATIVE CARE
MERITS OF RIGID DRESSING
• Prevent edema at surgical site
• Protect wound from bed trauma
• Enhance wound healing
• Early maturation of stump
• Decrease postoperative pain, allowing earlier mobilization from bed
to chair and ambulation with support
– Physiological benefits to respiratory, CV, urinary and GI systems of
upright position
• Prevention of contractures( in transtibial amputation)
– Hence decreased hospital stay and cost of care with
– Earlier definitive prosthetic fitting possible and higher percentage of
patients successfully rehabilitated

70. POSTOPERATIVE CARE
• Drains usually removed at 48-72 hours
• Educate the patient about the proper position of stump
while in bed, while sitting, and while standing
– Stump elevated by raising foot of the bed, helps to manage
edema and post operative pain
– Cautioned against leaving stump in dependent position
– Cautioned against placing pillow between thighs or
beneath the stump i.e. Avoid keeping stump flexed or
abducted ( in transfemoral amputation)
• Help to prevent flexion or abduction contractures

71. POSTOPERATIVE CARE
• Exercises for stump started under supervision of
physical therapist the day after surgery or as soon as
tolerated
– Consist of muscle-setting exercises followed by exercises to
mobilize the joints
– Patient mobilized from bed to chair on 1st POD
– In case of Lower limb amputation, ambulation using
parallel bars followed by walker or crutches as soon as
patient can control limb and are comfortable enough

72. POSTOPERATIVE CARE
• Optimal time to begin prosthetic ambulation with protected weight
bearing depends on
– Age, strength, and agility of the patient and the patient’s ability to protect
stump from injury due to excessive weight bearing
• Gradual application of functional mechanical stress in appropriate
distribution can enhance wound healing
– Avoid early unprotected weight bearing resulting in sloughing of skin or
delayed wound healing
– Traumatic amputation above zone of injury begin 25-Ib partial weight
bearing immediately postoperatively
– Traumatic amputation through zone of injury or ischemic amputation should
wait until early wound healing is documented
– Weight bearing status checked with each subsequent cast change
– If wound progressing well  weight bearing can progress in 25-ib increments
each week
– Supervision required if patient has peripheral neuropathy, causing difficulty in
assessing weight bearing.

73. POSTOPERATIVE CARE
• Rigid dressing should be removed and wound inspected in 7-10
days
– Earlier cast removal in case of cast loosening, fever, excessive
drainage, or systemic symptoms of wound infection
– If wound healthy, apply new rigid dressing and ambulation continued
– Cast should be changed weekly until wound healed
– Once wound healed, rigid dressing may be removed for bathing and
stump hygiene
• Elastic stump shrinker at night or stump sock can also be used
– Rigid dressing continued until volume appears unchanged from
previous week
• This is the time when prosthesis can be first applied

74. • Hematoma
• Infection
• Wound necrosis
• Contractures
• Pain
• Dermatological Problems
• Edema
• Psychosocial Problems

75. Hematoma
• PREVENTION
– Meticulous hemostasis before closure
– Use of drain
– Rigid dressing
• Delays wound healing and serve as culture for bacterial
infection
• MANAGEMENT:
– Compressive dressing
– Evacuation (if associated with delayed wound healing with
or without infection)

76. Infection
• More common in amputations for peripheral vascular
disease, especially in diabetic patients than in trauma
or tumor amputations
• Deep wound infection
– Immediate debridement and irrigation
– Open wound management
– Antibiotics according to intraoperative cultures
– Smith and Burgess method
• Central one third of wound closed and remainder of wound is
packed open
• MERIT: Allows continued open wound management, while
maintaining adequate flaps for distal bone coverage

77. Wound Necrosis
• First step: reevaluate the preoperative selection of the amputation level
– Transcutaneous oxygen studies
– Serum albumin and lymphocyte count
– Immune and nutritional status
– Smoking cessation
• Necrosis of skin edges less than 1 cm
– Conservative: open wound management(local debridements)
– Discontinuing prosthetic use until wound has healed
• Necrosis of skin edges >1 cm
– Same as above
– Wedge resection( if poor coverage of bone end)
– Hyperbaric oxygen therapy
– Transcutaneous electrical nerve stimulation
– Revision of amputation(shortening of the bone, and closure without tension)

78. Contractures
• may occur at the time of surgery or postoperatively from lack
of activity and prolonged sitting or wheelchair ambulation
– Prevented by
• avoiding over tightening of the muscles and appropriate postoperative
positioning maintained.
– prolonged sitting with the hip and knee flexed should be avoided
– TRANSFEMORAL : lie in the prone position multiple times during the day to stretch
the hip musculature
• gentle passive stretching,
• Exercises to strengthen the muscles controlling the joint
– Managed by:
• Increased ambulation at knee joint
• Prosthetic modification
• Wedging casts or surgical release( severe fixed contracture)

79. Pain
• Residual limb pain
– Often caused by poorly fitting prosthesis
• Stump evaluated for areas of abnormal pressure, especially over
bony prominences
• Distal stump edema(=choking), ulceration, gangrene
• Prevented by socket modification
– Painful neuroma
• At the level of the amputation, which become adherent to skin,
muscle, and bone leading to
– direct nerve-end stimulation or pain from traction with extremity
motion.
– Continuous pulsatile arterial stimulation of the nerve occurs when the
neurovascular structures are ligated together
– compression of the nerve between the mobile fibula against the tibia
• Easily palpable with Tinel sign positive
• TREATMENT:
– desensitization therapy
– Socket modification

80. Pain
– Painful neuroma(TREATMENT)
• CONSERVATIVE
– desensitization therapy,
– progressive and continued prosthetic wear,
– intermittent compression,
– medications,
– transcutaneous nerve stimulation, or
– a trial of proximal nerve blocks.
• Reconstructive surgery
– to remove the neuromas and place them in an area free of
scarring and adhesions and
– to reorganize the tissues to the most anatomic position possible
through osteomyoplasty.
• Excision of neuroma or proximal neurectomy

81. Pain
• Residual Limb Pain(continued..)
– Osteoarthritis of hip
• Conservative, total hip arthroplasty
– Osteoarthritis of knee
• Add knee joint and thigh corset to the prosthesis to allow load haring
with thigh
– Miscellaneous Causes
• incompetent soft-tissue envelope,
• prominent bone ends and spurs with associated bursitis,
• deep tissue scarring, or
• ischemia in patients with vascular disease who have undergone
amputations

82. Pain
• Herniated lumbar disc referred pain
• Mechanical low back pain
• Instructed on proper prosthetic ambulation to minimize abnormal
stresses on the lumbar spine
• Phantom limb sensations
– So common that should be considered normal
– Education of patient
– Over 1st year after amputation, many patients experience a
phenomenon called “telescoping”, i.e. phantom limb
gradually shortens to end of residual limb

83. Pain
• Phantom limb pain
– more common than previously thought
– described as a painful burning sensation in the amputated
limb
– More often with proximal amputation
– More common in patients who felt pain in limb before
amputation
– Diverse measures: massage, ice, heat, increased prosthetic
use, relaxation training, biofeedback, sympathetic
blockade, local nerve blocks, epidural blocks, ultrasound,
TENS, and placement of dorsal column stimulator.
– No one specific method is universally beneficial

84. Dermatological Problems
• Wash stump with mild soap at least once a day
– Stump thoroughly rinsed and dried before donning prosthesis
– Prosthesis kept clean and dried before donning
• Contact dermatitis
– Intense itching and burning when wearing socket
– Due to failure to rinse detergents from stump socks thoroughly
– Other sensitizers: Nickel, chromates used in leathers, skin creams, antioxidants
in rubber, topical antibiotics, and topical anesthetics
– Treatment: Removal of irritant, soaks, steroid cream, and compression
• Bacterial folliculitis
– May occur in areas of hairy, oily skin
– Exacerbated by shaving and by poor hygiene
– TREATMENT:
• improved hygiene and possibly socket modifications to relieve areas of abnormal
pressure
• Antibiotics for cellulitis
• Incision and drainage of abscess

85. Dermatological Problems
• Epidermoid Cyst
– Develop late at socket brim
– TREATMENT:
• socket modification
• Excision
• Verrucous hyperplasia
– Wartlike overgrowth of skin at end of stump
– Caused by proximal constriction that prevents the stump from fully
seating in the prosthesis(=choking)
• Causes distal stump edema followed by thickening of skin, fissuring, ulceration and
possibly subsequent infection
– TREATMENT: directed toward treating infection
• Soaks and salicylic acid to soften the keratin
• Socket modification mandatory

86. Edema
• Postoperative bulbous swelling of the distal residual extremity
– due to tight proximal dressings or prosthesis too tight proximally or
medical problems
– leading to congestion(Verrucous hyperplasia), poor wound healing,
cellulitis and prosthetic-fitting difficulties
• PREVENTION:
– minimized by performing medullary canal closure by bone glue and
myoplasty.
• TREATMENT:
– total-contact socket with frequent alterations
as needed to accommodate volume changes

87. Psychosocial Problems
• Posttraumatic stress disorder,
• Sexual dysfunction,
• Depression(25-35 % cases),
• Social isolation and
• Job loss(financial problems)

88. AMPUTATIONS FOR PERIPHERAL VASCULAR DISEASE
PARAMETER MORTALITY RATE
Perioperative mortality rate 30 %
2 year mortality rate 40 %
Critical ischemia in remaining limb 30 % of remaining cases

89. …………..THANK YOU……….…
Amputation should not be viewed as a failure of
treatment, but rather as
• a reconstruction procedure,
• treatment of choice for an unreconstructable or a
functionally unsatisfactory limb and
• first step toward a patient’s return to a more
comfortable and productive life