A short talk aboout amputaion and its principles

1. GENERAL PRINCIPLES OF
AMPUTATIONS
Nguyễn Quang Tôn Quyền

2. Crude procedure

3. • Sever limb
unanesthetically
• Dip open stump in
boiling oil
• High mortality
rate
• Resulting stump is
poorly suited
Oil on board by an unknown artist, mid nineteenth century amputation

4. HISTORY
• Ligature: Hippocrates first use => lost during
the Dark Ages => Ambroise Paré in 1529
• Ambroise Paré: artery forceps
• 1674: Morel - tourniquet
• 1867: Lister - antiseptic technique
• The late 19th century: chloroform and
ether for general anesthesia
• => for the first time could fashion sturdy and
functional stumps.

5. HISTORY
• Surgeons completely understand
• surgical principles
• postoperative rehabilitation
• prosthetic design
• Improved prosthetic design does not compensate for a poorly
performed surgical procedure.
• Amputation not a failure of treatment but the first step
toward a more comfortable and productive life.
• Planned and performed with the same care and skill as
other reconstructive procedure

6. INCIDENCE
• 300.000 amputations the United States.
• The number is increasing - an aging population.
• > 90% secondary to peripheral vascular disease.
• In younger patients: trauma > malignancy

7. INDICATIONS
• The only absolute indication irreversible
ischemia
• in a diseased limb
• or traumatized limb
• To preserve life in uncontrollable
infections
• Best option in some tumors
• Limb is not as functional as a
prosthesis, certain congenital anomalies
of the lower extremity
TRAUMA
PERIPHE
RAL
VASCULA
R
DISEASE
BURNS
FROSTBI
TE
INFECTIO
N
TUMORS

10. PERIPHERAL VASCULAR DISEASE
• Extracranial carotid and vertebral artery disease
• Renal Arterial Disease
• Mesenteric Arterial Disease
• Lower Extremity Arterial Disease
• Aneurysms of the Abdominal Aorta, Its Branch Vessels

11. Lower Extremity Arterial Disease
• LEAD has several different
presentations, categorized
according to the Fontaine or
Rutherford classifications -
• Critical Limb Ischemia

12. Critical Limb Ischemia
• Critical limb ischaemia
is the most severe
clinical manifestation
of LEAD, defined
• presence of ischaemic
rest pain,
• ischaemic lesions or
gangrene objectively
attributable to arterial
occlusive disease.

13. Critical Limb Ischemia

14. Critical Limb Ischemia
Indication of amputation
ACCF/AHA ESC
Patients unsuitable for revascularization
• Class I Level of Evidence: C

15. Critical Limb Ischemia
Indication of amputation
Neurologically impaired or non-ambulatory

16. Acute limb ischemia
• Acute limb ischemia is defined
as a rapid or sudden decrease in
limb perfusion that threatens
limb viability.
• The five “Ps” suggest limb
jeopardy: pain, paralysis,
paresthesias, pulselessness, and
pallor.
• The level of emergency and the
choice of therapeutic strategy
depend on the clinical
presentation, mainly the
presence of neurological
deficiencies

18. PERIPHERAL VASCULAR DISEASE
• Keep in mind: vascular disease has progressed to the
point of requiring amputation, not limited to the
involved extremity.
• Before performing an amputation for PAD, a vascular
surgery consultation is almost always indicated
• If amputation necessary, optimize surgical conditions:
albumin < 3.5 g/dL or lymphocyte <1500 cells/mL => 
complication

19. TRAUMA
• Whether the limb should
undergo salvage or
amputation?
• 8 studies
• Level III, Class IIb
• Gustilo IIIA fractures are unlikely to
require amputation
• Gustilo IIIB and IIIC fractures may require
amputation

20. • To remove subjectivity from the decision, available
scoring systems
• Mangled extremity severity score - most useful:
• easy to apply,
• grades the injury: the energy that caused the injury, limb isch-emia,
shock, and the patient’s age,
• ≤ 6 consistent with a salvageable limb, ≥ 7 amputation was the
eventual result

22. • No scoring system can replace experience and good clinical
judgment

23. • Might be necessary to preserve
life
• Salvage a severely injured limb
may lead to metabolic overload
and secondary organ failure
(multiple injuries the elderly)
• Injury severity score > 50:
contraindication limb salvage

24. Indication for amputation – lower limb

25. The tradeoffs - limb salvage
• Great cost.
• Multiple operations to obtain bony union , soft tissue
coverage, other areas to obtain donor tissue.
• External fixation may be necessary for several years
• Complications: infection, nonunion, or loss of a muscle flap.
• Chronic pain and drug addiction
• Isolation from family and friends, unemployment.
• The limb ultimately could require amputation,

26. The tradeoffs - early amputation
• Decreased morbidity, fewer operations, shorter hospital course,
decreased hospital costs, shorter rehabilitation, earlier return
to work.
• Modern prosthetics better function than many “successfully”
salvaged limbs.
• In long term studies, patients who have undergone amputation
and prosthetic fitting are more likely to remain working and are
far less likely to consider themselves to be “severely disabled”
than patients who have endured an extensive limb

27. DETERMINATION OF AMPUTATION LEVEL
• Tradeoffs
• more distal level of amputation → more function
• more proximal level of amputation → less complication
• Patient’s general medical condition
• A vascular surgery consultation: “Even if revascularization would
not allow for salvage of the entire limb, it may allow for healing
of a partial foot or ankle amputation instead of a transtibial
amputation”
• Simple screening tests

28. • Waters et al. studied
the energy cost of
walking for patients
with amputations
velocity
energy
100%
66%
59%
44%
87%
63%
normal Syme transtibial transfemoral transtibial
(trauma)
transfemoral
(trauma)

29. • If ambulation is the chief concern, amputation should be
performed at the most distal level possible
• If a patient has no ambulatory potential, wound healing
with decreased perioperative morbidity should be
the chief concern

30. DETERMINATION OF AMPUTATION LEVEL
• Determining the most distal level for
amputation with a reasonable chance
of healing can be challenging
• Transcutaneous oxygen measurements
• Different cutoff levels, ranging from 20
to 40 mm Hg, for “good” healing
potential

31. TECHNICAL ASPECTS
• SKIN AND MUSCLE FLAPS
• Flaps should be kept thick
• The scar should not be adherent to the underlying bone
• Muscles usually are divided at least 5 cm distal to
the intended bone resection and may be stabilized by
myodesis or myoplasty

32. TECHNICAL ASPECTS
• HEMOSTASIS
• Tourniquet
• Major blood vessels isolated and ligated
• A drain should be used in most cases for 48 to 72
hours

33. TECHNICAL ASPECTS
• NERVES
• A neuroma always forms
• Becomes painful if it forms in a position subjected to
repeated trauma.
• Nerves: gently pulled distally into the wound, divided
cleanly with a sharp knife so that the cut end retracts
proximal to the level of bone resection.

34. TECHNICAL ASPECTS
• BONE
• Excessive periosteal stripping is contraindicated.
• Bony prominences that would not be well padded
by soft tissue always should be resected
• The remaining rasped to form a smooth contour:
especially important the anterior aspect of the tibia,
lateral aspect of the femur, and radial styloid

35. TECHNICAL ASPECTS
• OPEN AMPUTATIONS
• infections severe traumatic wounds with extensive
destruction of tissue and gross contamination by
foreign material.
• open amputations with inverted skin flaps and
circular open amputations with postoperative skin trac-tion
• technique of vacuumassisted closure

36. POSTOPERATIVE CARE
• Requires a multidisciplinary team
approach
• Since the mid 1970s, there has been a
gradual shift from the use of
“conventional” soft dressings to the use
of rigid dressings

38. Rigid dressings - advantages
• prevent edema at the surgical site
• protect the wound from bed trauma
• enhance wound healing and early maturation of the stump
• decrease postoperative pain, allowing earlier mobilization
• transtibial amputations: prevent flexion contractures

39. POSTOPERATIVE CARE
• Position the stump properly
• Exercises for the stump
• Remove rigid dressing in 7 to 10 day
• Cast change weekly until the wound heal
• Continue until the volume appears unchanged from the previous
week
• At that time, the prosthetist may apply the first prosthesis.

40. THANK YOU