Amputations

• Dr. Guru prasad

• DNB orthopaedics

OUTLINEIntroduction

Indications

Types

Preoperative evaluation

Operative techniques

Postoperative care

Levels of amputations

Complications

Amputation in children

Amputation “Surgical removal of limb or part of the limb through a bone or multiple bones”

Disarticulation;-

“Surgical removal of whole limb or part of the limb through a joint”

Introduction …

– Most ancient of surgical procedure.

– Historically were stimulated by the aftermath of war.

– It was a crude procedure -limb was rapidly severed from unaesthetized patient.

– The open stump was then crushed or dipped in boiling oil to obtain hemostasis.

– Hippocrates was the first to use ligature.

– Ambroise Pare ( a France military surgeon) introduced artery forceps. He also designed prosthesis. Amputation of a leg without anaesthetic

Introduction

• As a punishment in Islam

– According to Islamic Sharia Law, the punishment for stealing is the amputation of the hand & after repeated offense, the foot (Quran 5:38)

– This controversial practice is still in practice today in countries like Iran, Saudi Arabia & Northern Nigeria.

Introduction • Other

– Sometimes professional athletes may choose to have digit amputated to relieve chronic pain & impaired performance.

– Australian footballer Daniel Chick elected to have his left ring finger amputated as chronic pain & injury was limiting his performance.

– Rugby player Jone Tawake also had a finger removed.

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Common causes

. Injury peripheral vasculardisease

Less common. Infection(fulminating gas gangrene). Malignancy. Nerve injury. Congenital anomalies. miscellaneous

Indications:

‘ DDD’ – Dead

– Dangerous

– Damned Nuisance

Indication

• Dead limb:

o Severe trauma

oPeripheral vascular disease

oBurns

o Frostbite.

Indication…

• Dangerous limb:

oCrush injury

oMalignancy

o Lethal sepsis

o Forgotten tourniquet >6hrs.

Indication…• Damned nuisance:

oGross deformity

oRecurrent sepsis

o Loss of function.

• The only absolute indication for amputation is irreversible ischaemia .

“The energy required for walking is inversely proportionate to the length of the remaining limb”

– Amputation of the lower extremity is often the treatment of choice for an unreconstructable or a functionally unsatisfactory limb

– The higher the level of a lower-limb amputation, the greater the energy expenditure that is required for walking

– As the level of the amputation moves proximally, the walking speed of the individual decreases, and the oxygen consumption increases

– In transtibial amputations, the energy cost for walking is not much greater than that required for persons who have not undergone amputations.

– For those who have undergone transfemoralamputations, the energy required is 50-65% greater than that required for those who have not undergone amputations .

Open

Guillotine

modified guillotine

Closed amputation

revised

planned

Aims

Return Patient to maximum level of independent function

Ablation of diseased tissue (tumor or infection)

Reduce morbidity & mortality (tumor or infection)

Considered first part of a Reconstruction to produce a physiological end organ .

Determination of level

• Zone of Injury (trauma)

• Adequate margins (tumor)

• Adequate circulation (vascular disease)

• Soft tissue envelope

• Bone and joint condition

• Control of infection

• Nutritional status

Pre Operative period

• Assessment

– Physical

– Social

– Psychological

• Training

• Re-assurance

Pre Operative Assessment

• Assessment of –

– The affected limb

– The unaffected limb &

– The patient as a whole is conducted thoroughly.

• Assessment of physical, social & psychological status of the patient should be made.

Physical Assessment

• Muscle strength of UL, trunk & LL apart from the affected limb before level of amputation.

• Joint mobility, particularly proximal to the amputation level.

• Respiratory function

• Balance reaction in sitting & standing

• Functional ability

• Vision & hearing status

Social assessment includes

• Family & friends supports

• Living accommodation –

– Stairs, ramps, rails, width of door, wheelchair accessibility

• Proximity of shops

Pre-operative Evaluation• History

oAetiology

oComorbidities

• Physical examination

oCVS, Renal &

oNervous system

• Investigation

oDoppler indices

o Transcutaneous O2 tension

Pre-operative Evaluation…• Optimization:

Anaemia, hypotension, infection, nutrition

• Consultations:

Nephrologist, Cardiologist, Neurologist

If vascular dx has progress to the point of amputation, most patients also

have concomitant dx process in the cerebral, renal & coronary vasculatures.

Pre-operative Evaluation…

• Counseling & consent

Procedure, anaesthesia, complications, prosthesis & limitations.

• MESS ≥ 7

Removes subjectivity from decision making in trauma cases.

No scoring system can replace experience & good clinical judgment.

Principles of operative techniques

• Anaesthesia

Regional, G.A

• Antibiotics

Broad-spectrum, IV

• Tourniquet

Except in arterial insufficiency

Principles of operative techniques..

Principles of operative techniques..

• Debridement of all Nonviable tissue and foreign material

• Several debridements may be required

• Primary wound closure often contraindicated

• High voltage, electrical burn injuries require careful evaluation because necrosis of deep muscle may be present while superficial muscles can remain viable

Techniques

Skin and Muscle Flaps

• Flaps should be kept thick.

• Unnecessary dissection should be avoided to prevent further devascularization of already compromised tissues.

Technical Aspects

• 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.

• 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

Myodesis

• 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.

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.

• 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.

• 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.

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.

Principles of operative techniques..

• Closure

oDrain is placed

o Skin closed without tension.

With modern total-contact prosthetic sockets, the location of the scar rarely is important, but the scar should not be adherent to the underlying bone

Principles of operative techniques..

• Conical Dressing

o Soft dressing with crepe bandage

oRigid dressing with POP• Rigid dressings prevent edema at the surgical site

• Enhance wound healing & early maturation of stump

• Decrease postoperative pain

• Allow earlier mobilization & ambulation

• Prevent knee flexion contractures in B/K amputation

Principles of operative techniques..

• Ideal stump

oConical

oHeal adequately

oAdequate stump

oAdequate muscle padding

o Thin scar not interfering with prosthesis

oAdjacent joint movements

oAdequate blood supply

Post-operative management

• Analgesics

• Antibiotics

• DVT prophylaxis

• Stump elevation (foot of the bed)

• Avoid flexion contracture at knee & hip

Post-operative management…

• Educate patient how to position the stump

• Mobilize out of bed in 1DPO

• Remove drain in 48hrs

• Remove stitches after wound evaluation

Post-operative management…• Early physiotherapy

oMuscle setting exercises 1st

o Joint movement exercises

oAmbulation with parallel bars, then crutches

• Prosthetic ambulation time depends on:

oAge of the patient

o Strength & agility of the patient

oPatient's ability to protect the stump

Post-operative management…

Surgical Principles• Level – sites of Election versus sites of Emergency

Amputation

LevelsOptimum Shortest Longest

Transradial

(forearm)

junction prox 2/3 &

distal 1/3

3cm below biceps

insertion

5cm above

wrist joint

Transhumeral

(arm)middle third

4cm below axillary

fold

10cm above

olecranon

Transfemoral (

thigh)middle third

8cm below pubic

ramus

15cm above

knee joint

Transtibial (leg)

8cm for every

metre of

height (12cm)

7.5cm below knee

joint

Amputation Level Nomenclature

Old Terminology Current Terminology

Partial hand Partial hand

Wrist disarticulation Wrist disarticulation

Below elbow Transradial

Elbow disarticulation Elbow disarticulation

Above elbow Transhumeral

Shoulder disarticulation Shoulder disarticulation

Forequarter Forequarter

Partial foot Partial foot

Syme’s Ankle disarticulation

Below knee Transtibial

Knee disarticulation Knee disarticulation

Above knee Transfemoral

Hip disarticulation Hip disarticualation

Hemipelvectomy Transpelvic

Levels of Amputation

Partial toe Excision of any part of one or more toes

Toe disarticulation Disarticulation at the MTP joint

Partial foot/ ray resection Resection of 3rd-5th metatarsal & digit

Transmetatarsal Amputation through the midsection of all metatarsals

Syme’sAnkle disarticulation with attachment of heel pad to distal of

tibia

Long transtibial (Below knee) More than 50% tibial length

Short transtibial (Below Knee) Between 20% and 50% of tibial length

Knee disarticulation Through knee joint

Long transfemoral ( Above knee) More than 60% femoral length

Transfemoral (above knee) Between 35% and 60% femoral length

Short transfemoral (Above Knee) Less than 35% femoral length

Hip disarticulation Amputation through hip joint, pelvis intact

Hemipelvectomy Resection of lower half of the pelvis

Hemicorporectomy/ Translumbar Amputation both lower limb & pelvis below L4-L5 level

Level of Amputation

• 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

Below Knee Amputations

Non ischemic limb Ischemic limb

Muscle flaps- both Myoplastyand Myodesis can be done

Myodesis is contra-indicated 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

Transtibial amputations can be divided into three levels

• 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.

Hindfoot and Ankle Amputations

SYME'S AMPUTATIONThe Syme's amputation provides an

end-bearing stump that in many

circumstances allows ambulation

without a prosthesis over short

distances. It is an excellent amputation

for children, in whom it preserves the

physes at the distal end of the tibia

and fibula (26).

The Syme's amputation works well for

tumors and trauma, assuming that the

heel flap has been spared from the

trauma. In the past, it has had a high

failure rate in ischemic limbs because

of failure of wound healing. Today, the

success of amputation at this level has

increased because local tissue

perfusion is preoperatively determined

with Doppler ultrasound measurement

of blood pressures, with radioactive 133Xe clearance tests, and with

measurement of oxygenation.

• Lisfranc’s Amputation- amputation at the level of tarsometatarsal joint.

• Chopart’s Amputation- amputation at the level of calcaneocuboid and talonavicular joint

• Boyd Amputation- talectomy, forward shift of the calcaneus, and calcaneotibial arthrodesis.

Midfoot Amputations

BOYD AMPUTATIONThe Boyd procedure provides a

broad weight-bearing surface of

the heel by creating an arthrodesis

between the distal tibia and the

tuber of the calcaneus

Compared to a Syme's

amputation, it provides more length

and better preserves the weight-

bearing function of the heel pad. Its

increased complexity and

morbidity have made it less used

now than the Syme's amputation.

The Pirogoff amputation removes

the anterior two thirds of the

calcaneus but has no advantage

over the Boyd amputation,

– The Boyd procedure provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus after talectomy

– Compared to a Syme’samputation, it provides more length and better preserves the weight-bearing function of the heel pad.

amputation of the foot by a midtarsal disarticulation.

Chopart’s amputation

amputation of the foot between the metatarsus and tarsus.

– More than 80 years ago, Krukenbergdescribed a technique that converts a forearm stump into a pincer that is motorized by the pronator teresmuscle. Indications for this procedure have been debated; however, they generally include bilateral upper-extremity amputations, in those who are also blind.

– not recommended as a primary procedure at the time of an amputation,

– To consider this surgical option, the ulna and radius must extend distal to the majority of the pronator teres (the motor for pinching) and an elbow flexion contracture of less than 70°.

• Krukenberg procedure

• Separate radial and ulna rays distally

• forming radial and ulna pincers capable of strong prehension and excellent manipulative ability

Complications

• Haematoma

• Infection

• Necrosis of stump end.

• Contractures (due to muscle imbalance)

• Neuroma at the cut nerve ending

• Phantom pain

• Terminal overgrowth (children)

Complication of amputation

• Haematomas

• Infections

• Necrosis

• Contractures

• Neuromas

• Stump pain

• Phantom sensation

• Hyperesthesia of stump

• Stump edema

• Bone overgrowth

• Causalgia

Amputation - Complications

• Phantom Limbs –

– Some amputees experience the phenomenon of Phantom

Limbs; they feel body parts that are no longer there.

– Limbs can itch, ache, & feel as if they are moving.

– Scientists believe it has to do with neural map that sends information to the brain about limbs regardless of their existence.

Amputation – Complications cont…

• In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb.

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.

Advantages Of Amputation In Children In Comparison To Adults

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.

• 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

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.

– Preserve the physis.

– Amputations through the metaphysis (such as above-knee or distal forearm level) or diaphysis are not recommended in children because of the progressive relative shortening of the residual limb. This is most critical in the femur, but it is applicable to other long bones as well.

– Disarticulate when possible. Disarticulation completely eliminates the problem of terminal overgrowth and subsequent revision surgery.

Preserve stump shape. The pediatric amputation stump becomes conical with growth, so preservation of bony architecture such as a short segment of proximal fibula or the distal condyles of the humerus will assist in subsequent rotational control of the prosthesis.

The split-thickness skin graft can hypertrophy and become sufficiently strong to withstand the shear forces of prosthesis use.

1. Preserve length 2. Preserve important growth plates3. Perform disarticulation rather than

transosseous amputation whenever possible4. Preserve the knee joint whenever possible 5. Stabilize and normalize the proximal portion

of the limb6. Be prepared to deal with issues in addition to

limb deficiency in children with other clinically important conditions.

Principles Of Childhood Amputation

After 12 months

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