Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Amputations by Dr. Sunny Agarwal


Published on

includes- etiology, amputation in children, b/k amputations, orthoses

Amputations by Dr. Sunny Agarwal

  1. 1. Dr. Sunny Agarwal DNB ( 2nd year ), Ortho St. Stephen’s Hospital
  2. 2. 1. Peripheral Vascular Disease 2. Trauma 3. Burns 4. Frostbite 5. Infections 6. Tumours
  3. 3.  Peripheral vascular disease with or without diabetes, which most frequently occurs in individuals age 50 to 75, is the most common indication for amputation.  If vascular disease has progressed to the point of requiring amputation, it is not limited to the involved extremity.
  4. 4.    Most patients also have concomitant disease processes in the cerebral vasculature, coronary arteries, and kidneys. Approximately half of amputations for peripheral vascular disease are performed on patients with diabetes. The most significant predictor of amputation in diabetics is peripheral neuropathy.
  5. 5.  • • • • Other documented risk factors include Prior stroke Prior major amputation Decreased transcutaneous oxygen levels Decreased ankle-brachial blood pressure index
  6. 6.  Before performing an amputation for peripheral vascular disease, a vascular surgery consultation is almost always indicated as improved techniques currently allow for revascularization of limbs that previously would have been unsalvageable.
  7. 7.  • • If amputation becomes necessary, Infection should be controlled Nutrition and Immune status should be evaluated. ( Risk for wound complications is greatly increased in patients whose serum albumin is less than 3.5 g/dL or whose total lymphocyte count is less than 1500 cells/mL).
  8. 8.    Trauma is the leading indication for amputations in younger patients More common in men because of vocational and avocational hazards. The only absolute indication for primary amputation is an irreparable vascular injury in an ischemic limb.
  9. 9.  • • • • • To predict which limbs will be salvageable, available scoring systems include :The The The The The predictive salvage index limb injury score limb salvage index mangled extremity syndrome index mangled extremity severity score.
  10. 10.    Of these, Mangled Extremity Severity Score is most useful as it is easy to apply, grades the injury on the basis of the energy that caused the injury, limb ischemia, shock, and the patient's age. The system was subjected to retrospective and prospective studies, with a score of 6 or less consistent with a salvageable limb. With a score of 7 or greater, amputation was the eventual result.
  11. 11.   Points × 2 if ischemic time exceeds 6 hours. Amputation of an injured extremity is necessary to preserve life as attempts to salvage a severely injured limb may lead to metabolic overload and secondary organ failure which is more common in patients with multiple injuries and in the elderly.
  12. 12.    Thermal or electrical injury to an extremity may necessitate amputation. The full extent of tissue damage may not be apparent at initial presentation, especially with electrical injury. Treatment involves early débridement of devitalized tissue, fasciotomies when indicated, and aggressive wound care, including repeat débridements in the operating room.
  13. 13.  Compared with early amputation, delayed amputation of an unsalvageable limb has been associated with increased risk of local infection, systemic infection, myoglobininduced renal failure, and death.
  14. 14.    Frostbite denotes the actual freezing of tissue in the extremities, with or without central hypothermia. This is a common problem for high-altitude climbers, skiers, and hunters. Also at risk are homeless, alcoholic, and schizophrenic individuals.
  15. 15.  When heat loss exceeds the body's ability to maintain homeostasis, blood flow to the extremities is decreased to maintain central body temperature. Actual tissue injury occurs through two mechanisms: 1. Direct tissue injury through the formation of ice crystals in the extracellular fluid 2. Ischemic injury resulting from damage to vascular endothelium, clot formation, and increased sympathetic tone 
  16. 16.    The first step in treatment is restoration of core body temperature. Treatment of the affected extremity begins with rapid rewarming in a water bath at 40°C to 44°C which requires parenteral pain management and sedation. After initial rewarming, if digital blood flow is still not apparent, treatment with tissue plasminogen activator or regional sympathetic blockade may be indicated.  Tetanus prophylaxis is mandatory
  17. 17.    Blebs should be left intact. Closed blebs should be treated with aloe vera. Silver sulfadiazine (Silvadene) should be applied regularly to open blebs. Low doses of aspirin or ibuprofen also should be instituted as oral anti-inflammatory medication and topical aloe vera help to stop progressive dermal ischemia mediated by vasoconstricting metabolites of arachidonic acid in frostbite wounds. Physical therapy should be started early to maintain range of motion.
  18. 18.    Amputation for frostbite routinely should be delayed 2 to 6 months. Clear demarcation of viable tissue may take this long. Even after demarcation appears to be complete on the surface, deep tissues still may be recovering.
  19. 19.    Despite the presence of mummified tissue, infection is rare if local wound management is maintained. Triple-Phase Technetium Bone Scan has helped to delineate deep tissue viability. Performing surgery prematurely often results in greater tissue loss and increased risk of infection.
  20. 20.  Amputation may be necessary for acute or chronic infection that is unresponsive to antibiotics and surgical débridement. Open amputation is indicated - two methods. 1. A guillotine amputation may be performed with later revision to a more proximal level after the infection is under control. 2. Amputation may be performed at the definitive level by initially inverting the flaps and packing the wound open with secondary closure at 10 to 14 days. 
  21. 21.    Kritter’s method for partial foot amputation with primary closure in patients with active infection. By this method, the wound is closed loosely over a catheter through which an antibiotic irrigant is infused. The constant infusion is continued for 5 days.
  22. 22.    The wound must be closed loosely enough to allow the fluid to escape into the dressings. The dressings must be changed frequently until the catheter is removed on postoperative day 5. This method may allow for primary wound healing, while avoiding a protracted course of wound healing by secondary intention.
  23. 23.   • • • • In the acute setting, the most worrisome infections are those produced by gas-forming organisms. Typically associated with Battlefield injuries Farm injuries Motor vehicle accidents Civilian gunshot wounds.
  24. 24.   • • Clostridial Myonecrosis- Gram-Positive Rods. Treatment – Immediate radical débridement of involved tissue, high doses of intravenous penicillin and hyperbaric oxygen. Emergency open amputation one joint above the affected compartments often is needed as a lifesaving measure, but may be avoided if treatment is initiated early.
  25. 25.  •  • Streptococcal Myonecrosis – Treatment - Debridement of involved muscle compartments, open wound management, and penicillin treatment usually allow preservation of the limb. Anaerobic Cellulitis - Causative organisms include clostridia, anaerobic streptococci, Bacteroides, and gram-negative rods. Treatment includes débridement and broadspectrum antibiotics. Amputation rarely is indicated.
  26. 26.  Four issues that must be considered when contemplating limb salvage instead of amputation, as follows: 1. Would survival be affected by the treatment choice? 2. How do short-term and long-term morbidity compare? 3. How would the function of a salvaged limb compare with that of a prosthesis? 4. Are there any psychosocial consequences?
  27. 27. 1. Would survival be affected by the treatment choice? • With the use of multimodal treatment, including surgery and chemotherapy, long-term survival for osteosarcoma patients has improved from approximately 20% to approximately 70%. • For osteosarcoma of the distal femur, the rate of local recurrence after wide resection and limb salvage is approximately 5% to 10%, which is equivalent to the local recurrence rate after a transfemoral amputation for osteosarcoma.
  28. 28. 2. How do short-term and long-term morbidity compare?   Amputation for malignancy may be technically demanding, often requiring nonstandard flaps, bone graft, or prosthetic augmentation to obtain a more functional residual limb. Limb salvage is associated with greater perioperative morbidity compared with amputation.
  29. 29.   Limb salvage involves a more extensive surgical procedure and is associated with greater risk of infection, wound dehiscence, flap necrosis, blood loss, and deep venous thrombosis. Long-term complications vary depending on the type of reconstruction which include periprosthetic fractures, prosthetic loosening or dislocation, nonunion of the graft-host junction, allograft fracture, leg-length discrepancy, and late infection.
  30. 30.   A patient with a salvaged limb is more likely to need multiple subsequent operations for treatment of complications. After initial successful limb salvage surgery, one third of long-term survivors ultimately may require an amputation.
  31. 31. 3. How would the function of a salvaged limb compare with that of a prosthesis?   With regard to function, the location of the tumor is the most important factor. Resection of an upper extremity lesion with limb salvage, even with sacrifice of a major nerve, generally provides better function than amputation and subsequent prosthetic fitting.
  32. 32.    Resection of a proximal femoral or pelvic lesion with local reconstruction generally provides better function than hip disarticulation or hemipelvectomy. Sarcomas around the ankle and foot frequently are treated with amputation followed by prosthetic fitting. Treatment for sarcomas around the knee must be individualized.
  33. 33.  • Osteosarcoma around the knee are treated with one of three surgical procedures— Wide Resection with Prosthetic Knee Replacement • Wide Resection with Allograft Arthrodesis • Transfemoral Amputation
  34. 34.  Patients who had undergone Resection and Prosthetic Knee Replacement showed higher self-selected walking velocities and a more efficient gait with regard to oxygen consumption than patients with Transfemoral Amputations.  Individuals with a Transfemoral Amputation functioned at more than 50% of their maximum aerobic capacity at free walking speeds, requiring anaerobic mechanisms to sustain muscle metabolism, which results in decreased endurance.
  35. 35.   Patients with an amputation had difficulty walking on steep, rough, or slippery surfaces, but were very active and were the least worried about damaging the affected limb. Patients with an arthrodesis performed the most demanding physical work and recreational activities, but they had difficulty with sitting, especially in the back seat of cars, theaters, or sports arenas.
  36. 36.   Determining the appropriate level of amputation requires an understanding of the tradeoffs between increased function with a more distal level of amputation and a decreased complication rate with a more proximal level of amputation. The energy required for walking is inversely proportionate to the length of the remaining limb
  37. 37.    Patients with amputations at the transfemoral, transtibial, and Syme levels secondary to trauma or chronic limb ischemia were evaluated. Compared with controls without amputations, the self-selected walking velocity for vascular amputees was 66% at the Syme level, 59% at the transtibial level, and 44% at the transfemoral level. For traumatic amputees, generally younger patients, the rates were 87% at the transtibial level and 63% at the transfemoral level.
  38. 38.     At self-selected walking velocities, the slower rates for amputees seem to be a compensatory mechanism to conserve energy per unit time. Patients tended to decrease their velocities to keep their relative energy costs per minute within normal limits. When energy expenditure per minute is not compensated, anaerobic mechanisms are summoned to sustain muscle function, and endurance is greatly compromised. Thus it becomes apparent that amputation should be performed at the most distal level possible if ambulation is the chief concern.
  39. 39.  If a patient has no ambulatory potential, wound healing with decreased perioperative morbidity should be the chief concern.
  40. 40.   • • - - Determining the most distal level for amputation with a reasonable chance of healing can be challenging. Preoperatively, Clinically - skin colour, hair growth, and skin temperature InvestigationsThermography or laser Doppler flowmetry as methods to test skin flap perfusion. Tissue uptake of intravenously injected fluorescein or the tissue clearance of intradermally injected xenon-133. Transcutaneous oxygen measurements
  41. 41.  Skin   and Muscle Flaps Flaps should be kept thick. Unnecessary dissection should be avoided to prevent further devascularization of already compromised tissues.
  42. 42.   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.
  43. 43.    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
  44. 44.   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.
  45. 45.  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. A drain should be used in most cases for 48 to 72 hours.
  46. 46.     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.
  47. 47.   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.
  48. 48.  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.
  49. 49.   An open amputation is one in which the skin is not closed over the end of the stump. Indicated in infections and in severe traumatic wounds with extensive destruction of tissue and gross contamination by foreign material.
  50. 50.    The operation is the first of at least two operations required to construct a satisfactory stump. It always must be followed by secondary closure, reamputation, revision, or plastic repair. The purpose of this type of amputation is to prevent or eliminate infection so that final closure of the stump may be done without breakdown of the wound.
  51. 51.    A wound vacuum-assisted closure ( VAC ) is applied to the open stump immediately after the initial débridement. Subsequent débridements are scheduled at 48-hour intervals. The VAC is reapplied after each débridement until the wound is ready for closure.
  52. 52.    It requires a multidisciplinary team approach All of the same precautions are followed as for any major orthopaedic surgery, including perioperative antibiotics, deep venous thrombosis prophylaxis, and pulmonary hygiene. Pain management includes the brief use of intravenous narcotics followed by oral pain medicine that is tapered as soon as tolerated.
  53. 53.   If weight bearing ambulation is not planned in the immediate postoperative period, the rigid dressing ( POP ) may be applied. If weight bearing ambulation in the immediate postoperative period is anticipated, a true prosthetic cast should be applied. A metal pylon with a prosthetic foot is attached to the cast and properly aligned for ambulation.
  54. 54.  Advantages of rigid dressing - Prevent edema at the surgical site - Protect the wound from bed trauma - Enhance wound healing and early maturation of the stump
  55. 55. - - - Decrease postoperative pain Allow earlier mobilization from bed to chair and ambulation with support. For transtibial amputations- prevent the formation of knee flexion contractures.
  56. 56.    Drains usually are removed at 48 hours. The stump is elevated by raising the foot of the bed, which helps manage edema and postoperative pain. The patient is cautioned against leaving the stump in a dependent position.
  57. 57.   With transfemoral amputations, the patient is cautioned against placing a pillow between the thighs or beneath the stump or otherwise keeping the stump flexed or abducted. These precautions are necessary to help prevent flexion or abduction contractures. Exercises (muscle-setting exercises followed by exercises to mobilize the joints ) for the stump are started under the supervision of a physical therapist the day after surgery. Patients should be mobilized from bed to chair on the first postoperative day.
  58. 58.    Early unprotected weight bearing can result in sloughing of the skin or delayed wound healing. If the wound is progressing well, weight bearing can progress in 25-lb increments each week. Supervision is especially important in patients with peripheral neuropathy who may have difficulty judging how much weight they are placing on their stumps.
  59. 59.    Regardless of when prosthetic ambulation is begun, the rigid dressing should be removed and the wound inspected in 7 to 10 days. Cast loosening, fever, excessive drainage, or systemic symptoms of wound infection are indications for earlier cast removal. If the wound is healing well, a new rigid dressing is applied, and ambulation with or without prosthetic foot is continued.
  60. 60.    The cast should be changed weekly until the wound has healed. After the wound is well healed, the rigid dressing may be removed for bathing and stump hygiene Use of the rigid dressing is continued until the volume appears unchanged from the previous week.
  61. 61.   At that time, the prosthetist may apply the first prosthesis. One or more socket changes frequently are required over the first 18 months
  62. 62. 1. Hematoma 2. Infection 3. Wound necrosis 4. Contractures 5. Pain 6. Dermatological problems
  63. 63.     Meticulous hemostasis before closure, the use of a drain, and a rigid dressing should minimize the frequency of hematoma formation. A hematoma can delay wound healing and serve as a culture medium for bacterial infection. If a hematoma does form, it should be treated with a compressive dressing. If the hematoma is associated with delayed wound healing with or without infection, it should be evacuated
  64. 64.    More common in amputations for peripheral vascular disease, especially in diabetic patients. Any deep wound infection should be treated with immediate débridement and irrigation and open wound management. Delayed closure may be difficult because of edema and retraction of the flaps.
  65. 65.   Smith and Burgess described a method whereby the central one third of the wound is closed, and the remainder of the wound is packed open. This method allows for continued open wound management, while maintaining adequate flaps for distal bone coverage.
  66. 66.     Necrosis of the skin edges less than 1 cm can be treated conservatively with open wound management. Severe necrosis with poor coverage of the bone end, wedge resection may be indicated. The basic principle of wedge resection is to regard the end of the amputation stump as a hemisphere. Resection of a wedge incorporating the full diameter of the stump would allow for reformation of the hemisphere, while minimizing local pressures
  67. 67.   Mild or moderate contractures of the joints of an amputation stump should be prevented by proper positioning of the stump, gentle passive stretching, and having the patient engage in exercises to strengthen the muscles controlling the joint. Severe fixed contractures may require treatment by wedging casts or by surgical release of the contracted structures.
  68. 68. 1. Mechanical low back pain has been shown to be more prevalent in amputees than in the general population. In addition to other accepted treatments for back pain, patients must be instructed on proper prosthetic ambulation to minimize abnormal stresses on the lumbar spine.
  69. 69. 2. Residual limb pain is caused by a. Poor fitting prosthesis b. Painful neuroma a. Poor fitting prosthesis- The stump should be evaluated for areas of abnormal pressure, especially over bony prominences. - Distal stump edema, often called ―choking,‖ may result if the end is not completely seated in the prosthesis, and ulceration or gangrene could result. - These problems can be avoided with socket modifications.
  70. 70. b. Painful neuroma -occurs when the nerve end is subjected to pressure or repeated irritation. - A painful neuroma usually can be prevented by gentle traction on the nerve followed by sharp proximal division, allowing the nerve end to retract deep into the soft tissue. - A painful neuroma usually is easily palpable and often has a positive Tinel sign. - Treatment initially consists of socket modification. - If this fails to relieve symptoms, simple neuroma excision or a more proximal neurectomy may be required.
  71. 71.    Patients should be instructed to wash their stumps with a mild soap at least once a day. The stump should be thoroughly rinsed and dried before donning the prosthesis. The prosthesis should be kept clean and should be thoroughly dried before donning.
  72. 72.  Contact dermatitis is common and causes skin inflammation which is associated with intense itching and burning when wearing the socket. Cause:-failure to rinse detergents from stump socks -nickel, chromates used in leathers -skin creams, antioxidants in rubber   Treatment consists of removal of the irritant, soaks, steroid cream, and compression.
  73. 73.     Bacterial folliculitis may occur in areas of hairy, oily skin. The problem may be exacerbated by shaving and by poor hygiene. Treatment initially consists of improved hygiene and possibly socket modifications to relieve areas of abnormal pressure. Occasionally, cellulitis develops that requires antibiotic treatment, or an abscess forms that requires incision and drainage.
  74. 74.   Epidermoid cysts develop at the socket brim. These frequently occur late and are best treated with socket modification. Excision may be required.
  75. 75.    Verrucous hyperplasia refers to a wartlike overgrowth of the skin at the end of the stump. It is caused by proximal constriction that prevents the stump from fully seating in the prosthesis. This ―choking,‖ as previously mentioned, causes distal stump edema followed by thickening of the skin, fissuring, ulceration, and possibly subsequent infection.
  76. 76.    Treatment initially is directed toward treating the infection. The skin should be treated with soaks and salicylic acid to soften the keratin. Socket modification is mandatory because pressure on the distal skin is essential to treat the problem and to prevent recurrences.
  77. 77.   • • • Amputations in children is divided into two general categories—congenital (60%) and acquired (40%) Causes of Acquired amputations:Secondary to trauma Neoplasm Infection.
  78. 78.   Motor vehicle accidents, gunshot wounds, and power tool injuries are the most common causes of limb loss from injury in older children; in young children, accidents with power tools, such as lawnmowers, and other household accidents are the most common causes. Dysvascular amputations in children are rare, but when they do occur, they usually are secondary to thrombotic or embolic events caused by another underlying problem.
  79. 79.          Causes of congenital amputations Amniotic band syndrome Exposure to teratogens ( thalidomide ) Polydactyly Syndactyly Macrodactyly Congenital pseudoarthrosis of the tibia and fibula, radius and ulna Constrictions of the leg Congenital deficiencies of the long bones
  80. 80. 1. 2. 3. 4. 5. 6. Preserve length Preserve important growth plates Perform disarticulation rather than transosseous amputation whenever possible Preserve the knee joint whenever possible Stabilize and normalize the proximal portion of the limb Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions.
  81. 81.   It is crucial as 75% of the growth of the femur occurs at the distal growth plate. Consequently, any transfemoral amputation performed in a young child would result in a very short stump as an adult. Conversely, even a very short transtibial stump in a young child may result in a functional stump as an adult if the growth plate is preserved.
  82. 82.    Disarticulation can provide a child with a well-balanced, sturdy stump capable of end weight bearing. Length and physes are preserved without the risks of terminal overgrowth. Prosthetic suspension is improved with a disarticulation secondary to preservation of the metaphyseal flares. This is important because of the high mechanical demands that children often place on their prostheses.
  83. 83.     It is a significant problem in a child amputee with a transosseous amputation. It does not occur after disarticulation. The overgrowth is caused by appositional new bone formation and is unrelated to the growth of the physis. The resulting bone is elongated and often pencil-shaped.
  84. 84.    It may cause swelling, edema, pain, and bursa formation and in severe cases may penetrate the skin. Overgrowth is more common after traumatic amputations than after amputations performed for other indications. It also is more common in younger children than in older children and occurs most often in the humerus and fibula and less often in the tibia, femur, radius, and ulna, in that order.
  85. 85.   Prevention of overgrowth can be done by capping the bone with an epiphyseal graft harvested from the amputated limb at the index procedure or by capping with tricortical iliac crest graft at a revision operation. It can be treated effectively with surgical resection of the excess bone.
  86. 86. A. B. C. Transtibial amputation in 2-year-old. Distal fibula from amputated leg is fashioned to fit into cut end of tibia. Fibula is press-fit into tibia.
  87. 87. 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.
  88. 88. 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.
  89. 89. • • 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
  90. 90. 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.
  91. 91. • • By the time children reach adolescence, they may begin to take advantage of the most sophisticated prostheses. Because of their activity level and growth, children with amputations must be observed closely for prosthetic repair, for frequent changes in the socket, and for fitting with new prostheses.
  92. 92.   • • 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
  93. 93. Non ischemic limb Ischemic limb Muscle flaps- both Myoplasty and Myodesis can be done Myodesis is contraindicated 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
  94. 94.  • • •  The optimal level of amputation has been chosen to provide :A stump length that allows a controlling lever arm for the prosthesis Sufficient ―circulation‖ for healing Sufficient ―soft tissue‖ for protective end weight bearing. The amputation level also is governed by the cause (e.g., clean end margins for tumor, level of trauma, and congenital abnormalities)
  95. 95.  • • A longer residual limb would have a more normal gait appearance, but it is not true for stumps extending to the distal third of the leg, as:There is less soft tissue available for weight bearing. The distal third of the leg is relatively avascular and slower to heal than more proximal levels.
  96. 96.     In adults, the ideal bone length for a below-knee amputation stump is to allow 2.5 cm of bone length for each 30 cm of body height. Stumps lacking quadriceps function are not useful. In a short stump whether fibula should be removed or preserved is controversial as fitting of the prosthesis depends on it. Transecting the hamstring tendons to allow a short stump to fall deeper into the socket also may be considered
  97. 97. A. Fashioning of equal anterior and posterior skin flaps, each one half anteroposterior diameter of leg at level of bone section.
  98. 98. B. Division and ligation of anterior tibial vessels and division of deep peroneal nerve.
  99. 99. C. Fashioning of posterior myofascial flap.
  100. 100. D. Suture of myofascial flap to periosteum anteriorly.
  101. 101. E. Closure of skin flaps.
  102. 102.     An immediate postoperative rigid dressing helps control edema, limits knee flexion contracture, and protects the limb from external trauma. Weight bearing is limited initially, with bilateral upper extremity support from parallel bars, a walker, or crutches. The cast can be changed every 5 to 7 days for skin care. Within 3 to 4 weeks, the rigid dressing can be changed to a removable temporary prosthesis which is later changed to a permanent prosthesis.
  103. 103. A. Fashioning of short anterior and long posterior skin flaps
  104. 104. B. Separation and removal of distal leg
  105. 105. C. Tailoring of posterior muscle mass to form flaps
  106. 106. D. Suture of flap to deep fascia and periosteum anteriorly.
  107. 107. E. Closure of skin flaps.
  108. 108.   The stump, in the initial stages, is usually unsuitable for prosthetic fitting due to stump oedema, and subsequent bandaging to reshape the stump causes a considerable delay in prosthetic fitting. Suture line passes over the distal end of the tibia which remains vulnerable to trauma due to the high pressure generated on this area while using the prosthesis.
  109. 109.    The principle of the skew flap technique is based on the observations that thermographic mapping of the leg shows a higher temperature profile on the anteromedial as well as the posterolateral aspect. It indicates a better blood flow of the anteromedial ( saphenous nerve artery) as well as the posterolateral (sural nerve artery) areas below the knee joint. This was also determined by the transcutaneous measurement of partial pressure of oxygen. The skew flap technique is based on these observations. The skin flaps correspond closely to the characteristic warm pattern of skin and underlying tissues.
  110. 110.    A circumferential marking was made 15 cm below the knee joint line. This was bisected equally, keeping one end at a point 2.5 cm lateral to the tibial crest, with the opposite point coming on the posteromedial aspect. Semicircular flaps were then marked from these points, keeping the length of the flaps at least one-quarter of the circumference
  111. 111. Marking of flaps. Jain S K Prosthet Orthot Int 2005;29:283-290 Copyright © by International Society for Prosthetics and Orthotics International
  112. 112.    If immediate prosthetic ambulation is not to be pursued, the stump can be dressed in a simple, well-padded cast that extends proximally to midthigh and is applied in such a manner as to avoid proximal constriction of the limb. The cast should be removed in 5 to 7 days, and if wound healing is satisfactory, a new rigid dressing or prosthetic cast is applied. If immediate prosthetic ambulation is pursued, a properly constructed prosthetic cast is best applied by a qualified prosthetist.
  113. 113. Advantages of skew flap amputation over conventional amputation • • Hazards of constricting bandages are avoided as there is less of stump edema. Early application and ambulation in a prosthetic cast. • Early healing of the skin incision • Lessened risk of wound breakdown
  114. 114.  Complications of skew flap amputation • Delayed wound healing • Re-amputation may be needed • Retrimming procedure may be needed
  115. 115.    Amputation of the great toe does not functionally affect standing or walking at a normal pace. If the patient walks rapidly or runs, however, a limp appears because of the loss of push-off normally provided by the great toe. Amputation of the second toe frequently is followed by severe hallux valgus because the great toe tends to drift toward the third toe to fill the gap left by amputation.
  116. 116.    Amputation of all toes causes little disturbance in ordinary slow walking, but is disabling during a more rapid gait and when spring and resilience of the foot are required. It interferes with squatting and tiptoeing. Usually, amputation of all toes requires no prosthesis, other than a shoe filler
  117. 117.    An insole is used for supporting the metatarsal to relieve weight from the metatarsal heads. A cavus support for the high arch. A cork or foam toe block is attached distally as a filler.
  118. 118.   A rocker sole may be necessary to replace the action of rocking forward on the foot. The sole can be stiffened with a long steel spring shank.
  119. 119.    Maintaining the base of the proximal phalanx often is preferable to metatarsophalangeal joint disarticulations. This allows for retention of some weight bearing properties, especially in the hallux, where 1 cm of proximal phalanx allows for some contribution by the flexor hallucis brevis and the plantar fascia. It also may slow the deviation of adjacent toes when one of the lesser digits is amputated
  120. 120.    The skin incision varies with the toe involved. A long posteromedial flap is desired for great toe. Begin the incision at the base of the toe in the midline anteriorly, and curve it distally over the medial and posteromedial aspects for a distance slightly greater than the anteroposterior diameter of the digit; extend it proximally across the plantar surface of the toe to the web.
  121. 121.   In the second, third, and fourth toes, amputation is performed through a short dorsal racquet-shaped incision. Begin the incision 1 cm proximal to the metatarsophalangeal joint, and pass it distally to the base of the proximal phalanx, dividing it to pass around the toe and across the plantar surface at the level of the flexor crease.
  122. 122.    In the fifth toe, fashion a lateral flap long enough to cover the defect left by the amputation. Raise the flaps to the level of the MTP joint. Identify the capsule of the MTP joint and, with the toe in acute flexion, incise its dorsal side first; straighten the toe, and expose and incise the remainder of the capsule after dividing the flexor tendons and neurovascular bundles.
  123. 123.     Removing the sesamoids in the insensate foot is recommended. Draw the tendons distally, divide them, and allow them to retract. Identify the digital nerves, and divide them proximal to the end of the bone, and divide and ligate the digital vessels. Close the skin edges with interrupted nonabsorbable sutures.
  124. 124.    Protected weight bearing with crutches or a walker for 5 to 10 days is indicated for comfort. When the sutures have been removed, the patient may need a shoe with an open toe box because of edema. When the edema has subsided, ambulation in a supportive, soft-soled, accommodating shoe is allowed.
  125. 125.   Amputation through the metatarsals causes loss of push-off in the absence of a positive fulcrum in the ball of the foot which is chiefly responsible for impairment of gait. No prosthesis is required other than a shoe filler.
  126. 126.    Lisfranc’s Amputation- amputation at the level of tarsometatarsal joint. Chopart’s Amputation- amputation at the level of calcaneocuboid and talonavicular joint Pirogoff’s Amputation- calcaneus is rotated forward to be fused to the tibia after vertical section through its middle
  127. 127.       Lisfranc or Chopart amputations often results in an equinus deformity because of loss of the foot dorsiflexor attacments. Dorsiflexors of the foot and their insertion- Tibialis anterior- medial cuneiform and base of 1st metatarsal bone EDL- extensor expansion of lateral four toes Peroneus tertius- base of 5th metatarsal bone EHL- base of the distal phalanx of great toe
  128. 128.    By performing tenotomy of tendoachilles, Roach and McFarlane were able to prevent early equinus deformities from becoming fixed. (Although push-off is compromised, the stump before lengthening of the Achilles tendon is not capable of much push-off in the presence of a fixed equinus deformity). Tendon transfers can be done The patient can be kept in a slight DF rigid dressing for 6 wks to prevent equinus deformity and allow for incorporation of the transferred ankle dorsiflexors
  129. 129. Tendon transfers:  Transfer the anterior tibial tendon to the neck of the talus, using a drill hole or by creating a trough in the talus and using suture or a staple to secure fixation.  Alternatives include i. Transferring the anterior tibial tendon to the neck of the talus and transferring the peroneus brevis to the anterior process of the calcaneus. ii. Anterior tibial and the EHL tendons can be transferred to the neck of the talus, and the EDL can be transferred to the anterior aspect of the calcaneus. 
  130. 130.   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.
  131. 131.  Boyd Amputation- talectomy, forward shift of the calcaneus, and calcaneotibial arthrodesis.
  132. 132.   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. The tough, durable skin of the heel flap provides normal weight bearing skin.
  133. 133.  i. Disadvantages : Posterior migration of heel pad ii. iii. Skin slough resulting from overly vigorous trimming of ―Dog ears‖. Cosmesis- the stump is large and bulky (bulbous) because of the flair of the distal tibial metaphysis which is covered with heavy plantar skin. ( not recommended for women)
  134. 134.  Begin the incision at the distal tip of the lateral malleolus, and pass it across the anterior aspect of the ankle joint at the level of the distal end of the tibia to a point one fingerbreadth inferior to the tip of the medial malleolus; extend it directly plantarward and across the sole of the foot to the lateral aspect, and end it at the starting point
  135. 135.  Place the foot in marked equinus, and divide the anterior capsule of the ankle joint + insert knife b/w medial malleolus and the talus and lateral malleolus and the talus to section the deltoid and calcaneofibular ligament
  136. 136.  Bone hook pulling talus distally, exposing distal articular surface of tibia and fibula
  137. 137.  Dissection of soft tissues from calcaneus (tendoachilles)
  138. 138.   Division of tibia and fibula just through dome of ankle joint centrally 0.6 cm proximal to the ankle joint. The plane of the transection should be such that the cut surfaces of the tibia and fibula are parallel to the ground when the patient is standing
  139. 139.  Holes drilled in anterior edge of tibia and fibula to anchor heel pad
  140. 140.  Edge of deep fascia lining heel pad is anchored to tibia and fibula
  141. 141.   Skin closure over drain, and application of above-knee cast. ―Dog ears,‖ are found at each end of the suture line; these should never be removed because they carry a large share of the blood supply to the heel flap and disappear later under bandaging.
  142. 142.   If ambulation is to be delayed until wound healing is assured, a simple well-padded cast is adequate. If early ambulation is preferred, or when subsequent prosthetic ambulation is to be instituted in the postoperative period, a true prosthetic cast should be applied.
  143. 143.  • • • Prosthetic cast Apply a light sterile dressing to the wound, and apply a sterile stump sock. Sterile felt pads are appropriately fashioned and skived by the prosthetist to relieve pressure over the tibial crest and the edges of the transected bones; the prosthetist glues these pads to the stump sock with medical adhesive and applies the plaster cast. Use elastic plaster of Paris in the initial wrap to provide good control of tension; reinforce this with conventional plaster.
  144. 144. • • • Gentle compression should be maximal over the end of the stump and gradually decrease proximally. The end of the rigid dressing is flattened for weight bearing by pressing a board against the wet plaster. The proximal part of the dressing is molded to create a patellar bar and a popliteal bulge, as in a patellar tendon–bearing prosthesis, to allow partial weight bearing by the patellar tendon and tibial condyles.
  145. 145. • • A filler block is added if needed to correct leg-length discrepancy, and a Syme prosthetic foot or a rubber walking heel is attached to the cast. A waist belt and suspension straps are used for additional suspension
  146. 146.    Wagner et al. popularised the technique and was used in diabetic patients with gross infection or gangrene of the forefoot who did not respond to conservative treatment. Had 95% success rate. Many authors believe that both stages can be safely combined when infection is not adjacent to the heel pad.
  147. 147.   1st stage- ankle disarticulation, preserving the tibial articular cartilage and the malleoli, and performing a Syme-type closure over a suction-irrigation system that allows installation of an antibiotic solution into the wound. Irrigation is continued until local and systemic signs of infection have resolved. 2nd stage-After 6 weeks, if the stump is healed, a second procedure is performed to remove the malleoli and narrow the stump for good prosthetic fitting.
  148. 148.  The prosthesis used for a classic Syme amputation consists of a molded plastic socket, with a removable medial window to allow passage of the bulbous end of the stump through its narrow shank, and a solidankle, cushioned-heel (SACH) foot prosthesis
  149. 149.  The socket, a sock or gel liner, a suspension system, a knee joint (articulating joint), the shank (a pylon), and a foot (terminal device)
  150. 150. Lower extremity prosthesis components
  151. 151.   • • • • The foot-ankle assembly is designed to provide a base of support during standing and walking, in addition to providing shock absorption and pushoff during walking on even and uneven terrain. Four general categories of foot-ankle assemblies are Non-articulated Articulated Elastic keel Dynamic-response
  152. 152.  • • • • • Prosthetic feet are classified into five types: The SACH foot Single axis foot The multi-axis foot The solid ankle flexible keel foot The energy storing foot
  153. 153.     Designed in 1958 by Eberhart and Radcliffe One of the most widely prescribed foot is the solid-ankle-cushion-heel (SACH) foot, due to its simplicity, low cost, and durability and light weight. It has a cushioned heel that compresses during heel strike,simulating plantar flexion, and a rigid anterior keel to roll over during the stance phase. It is prescribed for juvenile and geriatric amputees but may be inappropriate for active community ambulators and sports participants.
  154. 154.   • • • • • Madras foot is mainly used in the southern part of India It is composed of :Wooden keel Canvas rubber Hard rubber Soft rubber Swade lather.  Has the Advantage of bare foot walking, durability and cultural modifications like toe rings etc.
  155. 155. SACH foot SACH Foot doesn't look like a Normal Foot. SACH Foot requires a closed shoe to protect as well as hide it. Jaipur foot It looks like a Normal Foot. No such need or requirement with Jaipur Foot. But in case someone wants to wear a shoe, he can do it comfartably with a flat heel shoe. Wooden Keel is long enough to Metallic keel (carriage bolt) is restrict/limit movements in all confined to ankle only. So no direction and what so ever restriction of movement and all the movements take place they occur at movements take place at natural unnatural sites. sites. Squatting is not possible with SACH Squatting is easily achieved; as a foot as it requires dorsiflexion at sufficient range of dorsiflexion is ankle joint, which due to its rigid attainable comfortably. keel is not possible.
  156. 156. No cross- leg sitting is possible because it requires adduction at forefoot & transverse rotation of foot in relation to shank. Cross- legged sitting is possible because sufficient forefoot adduction & transverse rotation of foot in relation to shank is available. As there is almost no movement at sub-tarsal joint inversion or eversion is not possible; so SACH Foot is suitable only for walking on level ground. Walking on uneven grounds & rough terrain is very uncomfartable. As there is adequate inversion & eversion at subtarsal level, so walking on uneven ground and rough terrain is very comfortable. Bare-Foot walking is not possible. possible
  157. 157.   Single axis foot- has a single mechanical axis for PF and DF motion limited by anterior and posterior bumpers,allowing quicker foot flat,which results in a more stable knee. Multi axis foot- allows DF/PF, inversion/eversion and are good for walking on uneven ground or for an excessively scarred and sensitive residual limb,because of better shock absorption
  158. 158.   Solid ankle flexible keel foot- has a flexible anterior keel. Provides limited inv/eversion. Energy storing feet- stores and release energy as the limb is weighted and unweighted, giving a springy feeling, which results in a higher self selected walking speed
  159. 159.      The shank corresponds to the anatomical lower leg, and is used to connect the socket to the anklefoot assembly. In an endoskeletal shank, a central pylon, which is a narrow vertical support, rests inside a foam cosmetic cover. Endoskeletal systems allow for adjustment and realignment of prosthetic components. In an exoskeletal shank, the strength of the shank is provided by a hard outer shell that is either hollow or filled with lightweight material. Exoskeletal systems are more durable than endoskeletal systems; however, they may be heavier and have a fixed alignment, making adjustments difficult.
  160. 160.        Suspension devices should keep the prosthesis firmly in place during use and allow comfortable sitting. Several types of suspension exist, both for the transtibial and transfemoral amputation. Common transtibial suspensions include sleeve, supracondylar, cuff, belt and strap, thigh-lacer, and suction styles. Sleeves are made of neoprene, urethane, or latex and are used over the shank, socket and thigh. Supracondylar and cuff suspensions are used to capture the femoral condyles and hold the prosthesis on the residual limb. The belt and strap method uses a waist belt with an anterior elastic strap to suspend the prosthesis, while the thigh-lacer method uses a snug-fitting corset around the thigh. The suction method consists of a silicone sleeve with a short pin at the end. The sleeve fits over the residual limb and the pin locks into the socket.
  161. 161.      Types – PTB socket, soft and hard sockets,flexible sockets The socket enables the prosthesis to connect and fit to the stump (residual limb). This is the most important prosthetic component as a good fit is critical. A socket that is uncomfortable is a common reason why a prosthesis is rejected. Contoured sockets fit closer to the remaining bones, muscles, and soft tissues providing better support, and provide relief where it's needed for comfort