GANGRENE &

AMPUTATION

GANGRENE• It is defined as a macroscopic form of necrosis with or without

super added putrefaction

• Necrosis- It is focal/microscopic death along with degradation of tissues by hydrolytic enzymes liberated by cells.

• Apoptosis- It is coordinated & internally programmed cell death.

TYPES OF GANGRENE• There are three main forms of gangrene –

dry, wet & gas gangrene.• In either type, coagulative necrosis

undergoes liquefaction by the action of putrefactive bacteria.

Dry gangrene

• Dry gangrene is caused by a reduction of blood flow through the arteries.

• It appears gradually and progresses slowly.• In most people, the affected part does not become

infected. • In this type of gangrene, the tissue becomes cold and

black, begins to dry, and eventually sloughs off.• Dry gangrene is commonly seen in people with

blockage of arteries (arteriosclerosis) resulting from increased cholesterol levels, diabetes, cigarette smoking, and genetic and other factors.

• Other causes include TAO, Raynaud’s disease, trauma.• It is usually seen in one of the toes which is farthest from

blood supply, containing so little blood supply that even invading bacteria find it hard to grow in the necrosed tissue.

• The gangrene spreads slowly upwards until it reaches a point where the blood supply is adequate to keep the tissue viable.

• The line of separation usually brings about complete separation, with eventual falling off of the gangrenous tissue if it is not removed surgically, also called autoamputation.

• MORPHOLOGIC FEATURES. Grossly, the affected part is dry, shrunken and dark black, resembling the foot of a mummy.

• It is black due to liberation of haemoglobin from haemolysed red blood cells which is acted upon by hydrogen disulfide (H2S) produced by bacteria resulting in formation of black iron sulfide

• Histologically, there is necrosis with smudging of the tissue.

• The line of separation consists of inflammatory granulation tissue

Wet gangrene

• Wet gangrene occurs in naturally moist tissues and organs such as the mouth, bowel, lung, cervix, vulva etc.

• Diabetic foot is another example of wet gangrene due to high sugar content in the necrosed tissue which favours growth of bacteria.

• Bed sores occurring in a bed-ridden patient due to pressure on sites like the sacrum, buttocks and heels are the other important clinical conditions included in wet gangrene.

• Wet gangrene usually develops rapidly due to blockage of venous, and less commonly, arterial blood flow from thrombosis or embolism or sometimes blockage of both arterial & venous system gets blocked.

• The affected part is stuffed with blood which favours the rapid growth of putrefactive bacteria.

• The toxic products formed by bacteria are absorbed causing profound systemic manifestations of septicaemia, and finally death.

• The spreading wet gangrene generally lacks clear-cut line of demarcation and may spread to peritoneal cavity causing peritonitis.

• MORPHOLOGIC FEATURES. Grossly, the affected part• is soft, swollen, putrid, rotten and dark. • The classic example is gangrene of bowel, commonly

due to strangulated hernia, volvulus or intussusception.

• The part is stained dark due to the same mechanism as in dry gangrene.

• Histologically, there is coagulative necrosis with stuffing of affected part with blood.

• There is ulceration of the mucosa and intense inflammatory infiltration.

• Lumen ofthe bowel contains mucus and blood.

• The line of demarcation between gangrenous segment and viablebowel is generally not clear-cut

Gas gangrene

• It is a special form of wet gangrene caused by gas-forming clostridia (gram-positive anaerobic bacteria) which gain entry into the tissues through open contaminated wounds, especially in the muscles, or as a complication of operation on colon which normally contains clostridia.

• Patients who are immunocompromised, diabetic or have malignant disease are at greater risk, particularly if they have wounds containing necrotic or foreign material, resulting in anaerobic conditions.

• Clostridia produce various toxins which produce necrosis and oedema locally and are also absorbed producing profound systemic manifestations.

• Gas gangrene wound infections are associated with severe local wound pain and crepitus (gas in the tissues, which

• may also be noted on plain radiographs). • The wound produces a thin, brown, sweet-smelling exudate, in

which Gram staining will reveal bacteria. • Oedema and spreading gangrene follow the release of collagenase,

hyaluronidase, other proteases and alpha toxin

• MORPHOLOGIC FEATURES. Grossly, the affected area is swollen, oedematous, painful and crepitant due to accumulation of gas bubbles within the tissues.

• Subsequently, the affected tissue becomes dark black and foul smelling.

• Microscopically, the muscle fibres undergo coagulative necrosis with liquefaction.

• Large number of gram-positive bacilli can be identified.

• At the periphery, a zone of leucocytic infiltration, oedema and congestion are found.

• Capillary and venous thrombi are common.

AMPUTATION

• Amputation = removal of a body extremity by surgery or trauma

• "to cut away", from ambi- ("about", "around") and putare ("to prune").

• Disarticulation is removing the limb through a joint.• It is one of the most ancient surgeries of all the

surgical procedures.• Chemotherapeutic agents & antibiotics have made it

possible to control invading infection & mortality rate has fallen.

Indications

1) Congenital – supernumerary digits ( polydactylism)

2)Traumatic – when the limb cannot be saved in anyway. Today an increasing tendancy towards conservatism has been developed with the advent of vascular surgery.3)Inflammatory – amputations from this condition have been considerably reduced with advent of anti-biotics.

• 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

Congenital limb deficiency

• So amputation is done only in cases of sepsis, destructive bone & joint, sometimes chronic infections like madura foot.

4) Vascular insufficiency – Majority of patients fall into this category. V.I caused by atherosclerosis or other forms of arterial disorders may lead to gangrene of the corresponding artery.

5) Malignant tumors – in malignant tumors like osteosarcoma, fibrosarcoma, chondrosarcoma.

6) Burns & frost bite

8)Misc – punishment as an indication– 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.

Age;- common in 50-75 yrs of age traumatic- common in young age Sex;- approx.. 75% male 25% female Limb;- approx.. 85% - lower limb 15% -- upper limb

INCIDENCE

Amputation levels ( upper limbs )• Hand & Partial-Hand Amputations

Finger, thumb or portion of the hand below the wrist

• Wrist DisarticulationLimb is amputated at the level of the wrist

• Transradial (below elbow amputations)Amputation occurring in the forearm, from the elbow to the wrist

• Transhumeral (above elbow amputations)Amputation occurring in the upper arm from the elbow to the shoulder

• Shoulder DisarticulationAmbutation at the level of the shoulder, with the shoulder blade remaining.

• Forequarter AmputationAmputation at the level of the shoulder in which both the shoulder blade and collar bone are removed

Amputation levels ( lower limbs )• Foot Amputations• Amputation of greater toes and other toes• Amputation through the metatarsal bones• Lisfranc`s operation : at the level of the

tarsometatarsal joints• Chopart`s operation : through the midtarsal

joints• Transtibial Amputations (below the knee)

Amputation occurs at any level from the knee to the ankle

• Knee DisarticulationAmputation occurs at the level of the knee joint

• Transfemoral Amputations (above knee )Amputation occurs at any level from the hip to knee joint

• Hip Disarticulation Amputation is at the hip joint with the entire thigh and lower portion of the leg being removed.

Relative % of causes of LL amputation

Developed world causes (%) Developing world causes (%)

PVD (approx. 25-50% diabetes mellitus) 85-90 Trauma 55-95

Trauma 9 Disease 10-35

Tumour 4 Tumour 5

Congenital deficiency 3 Congenital deficiency 4

Infection 1 Infection 11-35

Relative % of causes of UL amputation

Developed world causes (%) Developing world causes (%)

Trauma 29 Trauma 86

Disease 30 Disease 6

Congenital deficiency 15 Congenital deficiency 6

Tumour 26 Tumour 1

Classification of traumatic Amputations

• Primary amputation (within first 24 hours)

• Secondary amputation (7-8 days after injury)

• Re-amputation (repeated amputation)

• The goals of amputation are –1) To get rid of all necrotic, infected & painful

tissue.2) To have a wound that heals successfully.3) To have an appropriate remnant stump that

is able to accommodate a prosthetic.

Determination of level

Amputation

• Zone of Injury (trauma)• Adequate margins (tumor)• Adequate circulation (vascular disease)• Soft tissue envelope• Bone and joint condition• Control of infection• Nutritional status

2) Function of the stump –• The level at which amputation should be carried

out doesn’t entirely depend upon the disease.• Due consideration should be given to function

of the function of the stump which should be ideal for artificial limb fitting.

• The more proximal the amputation, the less likely a patient will be able to ambulate postoperatively.

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

Surgical Principles• Level – sites of Election versus sites of

Emergency Amputation Levels Optimum    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

Too short a stump slips out from the prosthesis

Too long a stump painful , ulcerate , complicates the incorporation of the joint in the prosthesis

• In the final analysis, amputation level selection is determined by the surgeon's clinical experience and judgment supplemented by laboratory data.

Ideal stump

1) It should be of optimum length 2) The end of stump should be smooth &

rounded3) It should be firm4) The opposing group of muscles should be

sutured together over the end of the bone.5) The muscles are sutured in such a way that

they will be converted into fibrous tissue & serve as an effective cushion.

6) Vascularity of the flaps should be normal7) There should be no projecting spur of bone.8) The stump shouldn’t be under tension.9) The position of the scar should be avoided

of pressure n should be transverse to avoid pulling up between 2 bones in ap scar.

10) In case of U.L the scar can be terminal, but in L.L a posterior scar is desirable to avoid pressure of weight of artificial limb.

Pre-operative assessment & preparation

Clinical assessment

• Tissue – Clinical - feel pulses, skin temperature, level

of dependent redness • Operative technique, the patient's nutritional status, and

the presence of infection also affect wound healing. • Clinical judgment by an experienced surgeon accurately

predicts healing of a BKA in approximately 80% of cases. • A palpable pulse at the level immediately proximal to the

proposed amputation essentially ensures healing; however, the converse is not true.

Investigations

• . Doppler ultrasonography - measure arterial pressure;– In approximately 15% of patients with PVD, the

results are falsely elevated because of the noncompressibility of the calcified extremity arteries.

– Doppler ultrasonography has been used in the past to predict wound healing.

A minimum measurement of 70 mm Hg is believed to be necessary for wound healing.

Ischemic index (II): - This index is the ratio of the Doppler

ultrasonography pressure at the level being tested to the brachial systolic pressure. An II of 0.5 or greater at the surgical level is necessary to support wound healing.

Ankle-brachial index: -The II at the ankle level is believed to be the best

indicator for assessing adequate inflow to the ischemic limb. An index less than 0.45 indicates incisions distal to the ankle will not heal.

- Thermography 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- Xray of the affected limb • DM, HTN, heart failure, infection, cholesterol levels

should be controlled• CBP,RFT, ECG, 2d echo, Chest X-ray

Preparation • Protein-calorie malnutrition should be

corrected.• The patient should be stopped from smoking.• Adequate analgesia, antibiotics.• Both the patient & their family members must

receive counselling & emotional support & consent regarding amputation should be taken

Types of amputation

1) Guillotine type(open method) – In this type all the structures of the limb are divided at the same level & the wound including the bone is left open.

• It is the most primitive amputation & now-a-days used in case of gas-gangrene where immediate amputation is required to save the patient from sepsis.

• in emergency situations for contaminated Wounds or infection as a quick means of removing diseased or damaged tissue & also in severe crush injuries.

• It is always followed by re-amputation at a higher level in a flap method to cover the bone end with soft tissues

Guillotine Amputation

2)Flap method(closed method)

• This type of amputation is mostly carried out nowadays.

a) Circular method – skin & muscles are divided circularly at a lower level than the bone, so that they provide a covering the bony stump.

• it has got special advantage in case of doubtful vascularity as the flaps are not long enough to be devatalised.

B)Elliptical or oval method• The upper end of ellipse is placed on the level

of bone section while the lower end should lie at a distance below this , equal to 1½ times the diameter of the limb

• The only advantage is that the scar is not terminal.

C) Racquet incision

• The incision for this type looks like a racquet with a straight incision resembling the handle of racquet & circular/elliptical incision continous with straight incision

D)Semicircular or rectangular method

• Most widely practiced incision.• Either 2 flaps of equal length or a single flap is

used.• When a single flap is used, length should be

1½ times the diameter of the limb at the level of bone section.

• When both flaps are used they should cover the same distance.

• Flap means skin, subcutaneous tissue along with deep fascia.

Technique of amputation

Tourniquet is used unless there is sever vascular insufficiency

Shaping the skin flaps – the skin flaps are first drawn on the skin by a skin pencil, keeping a provision for some amount of elastic shortening of the skin.• with a scalpel incision is made along the mark

through the skin, subcutaneous tissue & deep fascia.

Muscles• They are divided a little below the proposed level of bone section, so

that the opposing groups can be sutured over the bone end for proper round shape of the stump- myoplasty

• It acts as a barrier between scar & bone so that scar wouldn’t be adherent to the bone.

• Whenever opposing groups of muscles are not available in case of amputations of leg, one group of muscles should be taken over the end of the bone & sutured over the periosteum of the other side of the bone - myodesis

Myodesis

Blood vessels

– Large arteries & veins should be doubly ligated and haemostasis achieved prior to closure

Exposure and Ligation of Main Vessels

Nerves

• All large nerve trunks should be slightly pulled down & divided as short as possible, so that the ends will be retracted upwards & will not be involved in the scar.

• If they are involved in the scar tissue, continous pain or pain during movement of the limb will be intolerable to the patient.

Bone & the periosteum

• The bone should be cut through the proposed level of section whereas the periosteum is stripped only sufficient to expose the bare bone & to prevent development of ring sequestrum.

• Before a saw is used, the muscles should be well retracted either with a shield or with a towel.

• When the bone is subcutaneous, it should be bevelled so that the sharp edge will not project through the skin.

Treatment of Periosteum and Cutting of Bone

Closure of the wound

• First hemostasis is secured, then opposing group of muscles are sutured across both the ends with interrupted stitches.

• Fascia & skin are sutured over the muscle without tension.

• Preferably a suction drain is placed.• Wound is covered with gauze & roller

bandages tightly from below upwards.

Stitching of Soft Tissues above Bone Stump and Draining of Wound

Post operative care

• Amputation stump should be kept in rest by enclosing it in POP cast which should extend above the joint proximal to the stump.

• This will prevent flexion contracture of proximal joint.• Cast is kept for no less than 3 weeks.• Rigid dressing : decreses edema, decreases post operative

pain, protect limb from trauma, early mobilsation. Good bandaging to mold the stump into Conical shape to accept the prosthesis

• Soft dressing concept: The stump is dressed with the sterile dressing & elastocrepe bandage applied over it.

Figure 4. A, A patient with an elastic compression sock and an AirLimb IPOP system by AirCast B, Schematic of a cut away view of the AirLimb modular system with inflatable bladders to

accommodate for residual limb volume loss. Distal end pads help with tissue contact and

desensitization. Images courtesy of John Rheinstein, CP, FAAOP &

Lew Schon, MD

Advantages:limits dev’t of postoperative edema in residual limb.allows earlier ambu c attachment of pylon & footallows earlier fitting of permanent prosthesis

pylon- artificial LL

Disadvantages:expensiverequires special trainingneeds close supervision during early stage of healing

SOFT DRESSINGS

Advantages:

* Inexpensive

* Light weight

* Readily available

* Can be laundered

Disadvantages:

* Poor edema control

* Requires skill in application

* Needs frequent re-application

* Can slip and form tourniquet

ACE WRAPS

• Early ambulation & prosthesis placement• Epidural anaesthesia• Drain is usually taken off after 48 hours• Stitches are removed from 7 to 10 days when

wound is healthy.

Complications Early • Haematomas ( delays the wound healing and acts as

a culture media for the growth of the organism )• Infections ( more common in peripheral vascular

disease and DM )• DVT• Gas gangrene – source of infection – fecal

contamination

Late complications

• Adherent & painful scar.• Necrosis ( due to insufficient circulation )• Contractures ( preventable by positioning

the stump properly )• Causalgia ( Intense burning pain and

sensitivity to the slightest vibration or touch ) : - due to division of the peripheral nerve

• Phantom sensation ( pseudo feeling of the presence of the amputated limb ), seen in 50% of the cases

Phantom limb sensation also must be differentiated from phantom limb pain.

Phantom limb sensation is the sensation that the amputated limb is still present.

Patients usually report that the absent hand/arm/limb is itching, tickling, or moving through space.

Phantom sensation is perceived as a "funny" or "different" feeling but usually is not perceived as painful.

Phantom limb pain theories• Three theories as to why patients

experience phantom limb pain and sensation exist.

• One theory is that the remaining nerves continue to generate impulses.

• A second theory is that the spinal cord nerves begin excessive spontaneous firing in the absence of expected sensory input from the limb.

• The third theory is that there is altered signal transmission and modulation within the somatosensory cortex.

Telescoping• Another common phenomenon is

telescoping. • Telescoping is the sensation that the

distal part of the amputated extremity has moved proximally up the arm.

• A patient might report that it feels like the entire extremity has shrunk so that the hand is now up at the elbow.

• This is a normal part of the nerve healing process and usually fades with time.

• Stump neuroma – proliferation of nerve fibers at the point of nerve division.

• Unresolved infection> osteitis, sequestrum & sinus formation.

• Flexion contracture of the proximal joint.• Jactitation – intermittent spasm of the

amputation stump.• Ulceration due to pressure effets.

VARIOUS AMPUTATIONS BASED ON THE LOCATION

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’s Ankle 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

Foot And Ankle Amputations

• 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.

Toe Amputations

• 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

• 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

Amputation at the Base of the Proximal Phalanx

• 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.

Metatarsophalangeal Joint Disarticulation

• 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.

• 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.

• 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.

• 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.

Aftertreatment

• 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.

Transmetatarsal Amputations

Custom shoe insert for transmetatarsal amputation

• 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

Midfoot Amputations

Chopart’s amputation

• Lisfranc or Chopart amputations often results in an equinus deformity because of loss of the foot dorsiflexor attacments.

Severe equinus defromity after lisfranc’s amputation

• 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

• Disadvantages :i. Posterior migration of heel pad

ii. Skin slough resulting from overly vigorous trimming of “Dog ears”.

iii. 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)

• 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

Technique

• 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

• Bone hook pulling talus distally, exposing distal articular surface of tibia and fibula

• Dissection of soft tissues from calcaneus (tendoachilles)

Subperiosteal removal of calcaneus, leaving heel pad intact

• 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

• Holes drilled in anterior edge of tibia and fibula to anchor heel pad

• Edge of deep fascia lining heel pad is anchored to tibia and fibula

• 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.

amputation of the foot at the ankle, part of the calcaneus being left in the stump.

Pirogoff amputation

• Trans-tibial 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 Myoplasty and 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

• 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)

Nonischemic Limbs

• 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.

• 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

Ideal bone length

A. Fashioning of equal anterior and posterior skin flaps, each one half anteroposterior diameter of leg at level of bone section.

Procedure

B. Division and ligation of anterior tibial vessels and division of deep peroneal nerve.

C. Fashioning of posterior myofascial flap.

D. Suture of myofascial flap to periosteum anteriorly.

E. Closure of skin flaps.

• 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.

Aftertreatment

Long Posterior Myocutaneous Flap (Burgess)

A. Fashioning of short anterior and long posterior skin flaps

Procedure for ischemic limb

B. Separation and removal of distal leg

C. Tailoring of posterior muscle mass to form flaps

D. Suture of flap to deep fascia and periosteum anteriorly.

E. Closure of skin flaps.

• 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.

Disadvantages of long posterior flap

• 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.

• A modification of the long posterior myocutaneous flap technique is the skew flap technique.

• 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.

Skew flap

 

Marking of flaps.

Jain S K Prosthet Orthot Int 2005;29:283-290

Copyright © by International Society for Prosthetics and Orthotics International

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

Above knee amputation• Equal anterior and posterior fasciocutaneous flaps extending approximately

two thirds of the diameter of the leg in length are created. • The incision is then extended through the collateral, medial, lateral, and

cruciate ligaments and the hamstring tendons are transected. • The tibial nerve, the peroneal nerve, and the popliteal artery and vein

should then be identified. • The nerves should be transected proximally under tension to avoid

neuroma formation and the vessels should be suture ligated. • The patellar tendon can then be separated from the tibia and sutured to the

cruciate ligaments and hamstring tendons over the femoral condyles. The fascial layers are closed with absorbable sutures and the skin with interrupted nylon sutures.

• This technique is advocated for several reasons:• (a) minimal muscle is transected and therefore

postoperative bleeding and operative time are minimized; (b) it preserves more limb length than a transfemoral amputation for transfers;

• (c) although historically it has been a difficult prosthetic fit, use of the C-limb prosthesis has improved fitting dramatically; and

• (d) it avoids any flexion contractures. However, synovial fluid can accumulate and the flaps can break down due to tension from the underlying femoral condyles.

Upper vs Lower Limb

• Upper extremity nonweightbearing– Less durable skin acceptable– Decreased sensation better tolerated– Joint deformity better tolerated– Late amputations rare– Transplants now being performed

• Transcarpal amputation ;-

– At this level, supination and pronation of the forearm, as well as flexion and extension of the wrist,

– Ideally, a long full-thickness palmar and shorter dorsal flap should be created in a ratio of 2:1.

– Finger flexor and extensor tendons should be drawn, divided, and allowed to retract deep into the proximal wound. Conversely, wrist flexor and extensor tendons are identified and released from their distal insertions and reflected proximally out of the way.

– The wrist flexors and extensors should be anchored to the remaining carpus in line with their insertions to preserve active wrist motion

– providing a long lever arm and preserved supination and pronation.

– a technique to minimize postoperative pain from

neuroma formation, which involves extending the incisions proximally between the pronator teres and brachioradialis just distal to the elbow flexion crease and doubly ligating the median, ulnar, and superficial radial nerves at this level.

• Preserving the triangular fibrocartilage ,shortening of the radial styloid should be avoided that improves prosthetic suspension

• procedure of choice in children

Wrist disarticulation ;-

Forearm amputation

IT IS A REPLACEMENT OF SUBSTITUTION OF A MISSING OR A DISEASED PART

PROSTHESIS

ENDOPROSTHESIS- IMPLANTS USED IN

ORTHOPAEDIC SURGERY eg; AUSTIN MOORE

PROSTHESIS

EXOPROSTHESIS-EXTERNAL REPLACEMENT FOR

A LOST PART OF THE LIMB

CLASSIFICATION

TEMPORARY – USED FOLLOWING AMPUTATIONTILL PT. IS FITTED WITH PERMANENT PROSTHESIS

eg;PYLON

PERMANENT PROSTHESIS

46.2

TYPES

1-FOR DISARTICULATION OF HIP AND HEMIPELVECTOMY2-FOR TRANSFEMORAL AMPUTATION SUCTION SOCKETED .2 WAY VALVE MECHANISM

NEGATIVE PRESSURE .SNUGGLY FITS .USEUL IN YOUNG PT. .BEST FOR CILINDRICAL STUMPS

PROSTHESIS FOR LOWER LIMB

PROSTHESIS FOR BELOW KNEE AMPUTATION

PTB PROSTHESIS- SOCKET FITS EXACTLY OVER THE PATELLAR TENDON AND TIBIAL CONDYLES

-HAVE CLOSE SOCKETS OR OPEN SOCKETS

-FULL WIEGHHT BEARING OR MODIFIED END BEARING

PROSTHSIS FOR SYME’S AMPUTATION

-WHOLE FOOT IS OF VARIOUS LAYERS OF RUBBER WITH VARYING DENSITY -NO ANKLE JOINT-ABOVE ACTION ACHIEVED BY COMPRESSION OF WEDGE SHAPED RUBBER HEEL-ALL PLACED ON WOODEN INSERT FOR HEEL AND WOODEN SIDE KEEL

SACH(SOLID ACTION CUSHION HEEL) FOOT

-MADE OF RUBBER(WATERPROOF) ALUMINIUM(FOR LEG PIECE)-CHEAP ,STRONG,RUST FREE-ALLOWS SITTING , SQUATING,DOES NOT REQUIRE A SHOE

JAIPUR FOOT (INDIA’S PRIDE)

FOREQUARTER AMPUTATIONS- -PROSTHESIS MERELY

SERVES A COSMETIC PURPOSE -SLEEVE FITTER PROSTHESIS

WITH A PLASTOZOATE CAP PADDED INSIDE WITH FOAM AND RETAINING STRAPS IS USED Myoelectric

Prosthetics

PROSTHESIS FOR UPPER LIMB AMPUTATIONS

- SHOULDER PIECE EXTENDED CAP TO HOLD PROSTHESIS

- ELBOW PIECE CAN BE FLEXED B PULLING ON THE FLEXION CORD WITH THE PROTRACTORS

OF TH SHOULDER-HANDPIECE EITHER

COSMETIC OR SPLINT HOOK TYPE.

SHOULDER DISARTICULATION

SAME AS PROSTHESIS FOR SHOULDER DISARTICULATION EXEPTELBOW FLEXION IS STRONGER DUE TO ACTION OF ARM MUSCLESALONG THE PROTRACTORS

ABOVE ELBOW AMPUTATION

-THERE IS A COP SOCKET ATTACHED TO TERMINAL DEVICE

-TERMINAL DEVICE CAN BE ACTIVATED THROUGH A LOOP HARNESS

BELOW ELBOW AMPUTATION

-SPLIT SOCKET FOREARM AND A WRIST

ROTATION DEVICE IS PROVIDED

-A DEVICE CAN BE PROVIDED TO LOCK FOR SUPINATION AND PRONATION

FOR WRIST DISARTICULATION

Stump exercises

Follow-up

• Two weeks after surgery, muscle-contraction exercises and progressive desensitization of the residual extremity are initiated.

• Desensitization is started with a towel for distal residual extremity pressure, and distal-end bearing is started on a soft structure (usually a bed).

• Prosthetic management is begun 6 weeks after surgery, depending on the condition of the extremity and wound. Some patients are not candidates for prosthetic limb replacement because of poor balance, weakness, or cognitive impairment. To avoid disappointment and expense, a permanent prosthesis should not be ordered for these patients.

Adaptations to Home

• External ramps required• Stair lift, railings.• Doors widened• Kitchen worktops and sinks adjusted• Shower on level, with chair access• Possible hoist for bath• Adapted furniture

Care of the Stump – keep the stump clean, dry, and free from infection at all

times. – If fitted with a prosthesis, you should remove it before going

to sleep. – Inspect and wash the stump with mild soap and warm water

every night, then dry thoroughly and apply talcum powder. – do not use the prosthesis until the skin has healed. – The stump sock should be changed daily, and the inside of

the socket may be cleaned with mild soap.

Rehabilitations

– 1. Residual Limb Shrinkage and Shaping

– 2. Limb Desensitization – 3. Maintain joint range of

motion – 4. Strengthen residual limb – 5. Maximize Self reliance – 6. Patient education:

Future goals and prosthetic options

What can be done?

Cornerstones of Prevention

1. Regular inspection and examination of feet and footwear

2. Identification of the high-risk foot

• People with diabetes– Make sure you have your feet checked periodically by

a healthcare professional

What can be done?

• Healthcare professionals:

•Risk of neuropathy can be detected by using a 10g monofilament

•Palpation of foot pulses is the simplest means of identifying peripheral arterial disease

What can be done?

Cornerstones of Prevention

3. Education of people with diabetes, family members and healthcare workers

4. Appropriate footwear

5. Rapid treatment of all foot problems