Amputation involves surgically removing a body part, such as a limb or extremity. It is used to treat conditions like gangrene, tumors, severe trauma, or infection in order to save the patient's life. Lower limb amputations are more common than upper limb amputations, usually due to issues like vascular disease, diabetes, or trauma. The appropriate type of amputation depends on factors like the location and condition of the affected body part. After amputation, rehabilitation focuses on wound healing, physiotherapy, fitting an appropriate prosthesis, and relearning daily activities.
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Amputations - A procedure no body wants or likes
1. AMPUTATIONS
Dr R S Dhaliwal
MBBS,MS,DNB(Surgery),M.Ch,DNB(CTVS),
FACS,FCCP,FICA,FNCCP,FIACS
Former Prof & HOD , CTV
Surgery,PGIMER,Chandigarh
2. Amputation is one of the meanest
yet one of the greatest operations
in surgery,i.e. mean- when resorted
to where better may be done,
Great â as the only step to give
comfort to patient and prolong life
- Sir William Ferguson
3. Amputation
⢠Amputation is the removal of a body part or
an extremity (or its part) by surgery or by
trauma or prolonged constriction . It is used
to control pain or a disease process in the
affected limb, such as malignancy or
gangrene. In some cases, it is carried out on
individuals as a preventative surgery for such
problems
4. Amputation: the surgical removal of a part of the body,
a limb or part of a limb for gangrene, tumours severe
trauma or infection for saving life of patient
5. Etiology
⢠Land mine injuries
⢠War & Terroism injuries
⢠Road side accidents
⢠Industrial trauma
⢠Criminal activity
⢠Punishment for crimes
⢠Surgical for dieases
6. Statistics
ďś Lower limb amputations are 4 times more common than upper limb
(infection) .
ďś While over 90% of amputations caused by vascular disease involve the
lower limb, nearly 70% of amputations caused by trauma involve the
upper limb For both males and females, risk of traumatic amputations
increased steadily with age, reaching its highest level among people age
85 or older
ďś Limb amputations resulting from cancer most commonly involved the
lower limb; above-knee and below-knee amputations alone accounted for
more than a third (36 percent) of all cancer-related amputations.
ďś There were no notable differences by sex or race in the age-specific risk of
cancer-related amputations, though rates of limb loss due to cancer were
generally higher among individuals other than African Americans.
ďś In all age groups, the risk of dysfunctional vascular related amputation
was highest among males and individuals who are African American
7. Indications for Amputation
⢠Dead limb - Gangrene
⢠Deadly limb - Wet gangrene
- Spreading cellulitis
- Multiple or huge AV fistula
- Bone or soft tissue tumour
. Dead loss limb â Severe rest pain
- Sever contracture or paralysis making it
impossible to use and it is a hinderance
-Major unrecoverable traumatic damage
8. Indications
⢠Gangrene due to atherosclerosis,embolism,
diabetes,Beurgerâs disease , ergots poisoning
⢠Trauma â Massive crush injury ,to save life
⢠Tumours â Bone and soft tissue tumours
(osteosarcoma, chonderosarcoma,melanoma,
Sq cell carcinoma(Marjolinâs ulcer)
⢠Gas gangrene . Severe sepsis
⢠Dead,dying, devitalised tissue
⢠Severe defformity âcongenital or acquired
9. Causative Factors of Amputations
ďśPeripheral arterial disease
ďśDiabetes Mellitus
ďśGangrene (due to the complication of fracture
or tight plaster cast ) .
ďśTrauma (crushing, frost bite, burns)
ďśCongenital deformities
ďśChronic Osteomyelitis
ďśMalignant Tumors
10.
11. General
⢠Amputation is considered as treatment when a
limb or its part is dead , deadly or is dead loss
⢠Dead limb â Occurs due to severe arterial
occlusive disease causing death of tissues i.e.
gangerene. The occlusion may be in major vessels
(atherosclerosis or embolic) or in small peripheral
vessels (diabetes,Buergerâs disease, Raynaudâs
disease or accidental intra arterial injection.If the
obstuction can not be reversed and symptoms
are severe, amputation is required.
12. General
⢠Deadly limb- Limb becomes deadly when
putrefaction and infection of moist gangrene
spreads to surrounding viable tissues leading to
cellulitis and severe toxaemia.It is dangerous to
life of patient .Massive broad spectrum antibiotic
cover is a must
⢠Dead loss limb â A limb may seem dead loss
when there is relentless, severe rest pain with out
gangrene, here amputation will improve quality
of life. When a limb is impossible to use and
becomes a hinderance in daily activity as in
paralysis or severe contracture or major
traumatic damage amputation is done to
improve quality of life
13. Pre-operative Assessment
ďśNeurovascular and functional status of extremity
ďśFunction and Condition of residual limb (in case of
traumatic amputation)
ďśCirculatory status and function of unaffected limb
ďśSigns & Symptoms of infection (culture required)
ďśNutritional Status
ďśConcurrent medical problems
ďśCurrent medications
14. Evaluation of Patients for amputation
⢠Check for anemia â correct it by blood or packed
cells transfusion
⢠Control of infection using antibiotics and dressings
⢠Informed consent for operation from patient or
his close family members (v.imp)
⢠Decide level of amputation by skin temp. and
arterial doppler study
⢠Psychological counciling of patient-very important
⢠Plan for prosthesis and rehabilitation by physio
therapist and rehabilitation team
16. Types of Amputations
⢠Major amputations-
- Transcondylar femoral level (Gritti
Stokes amputation )
- Above knee, below knee or through
knee amputation
- Symeâs ampuatation â below ankle
⢠Minor amputations -
Distal and transmetacarpal and metatarsal
amputations
17. Types
⢠Weight bearing
⢠Non weight bearing
It can be :
⢠Non- end bearing/ side bearing- Wt is taken up by
the joint
⢠End bearing/ cone bearing- Wt is taken up by the
body of patient
It can be - Provisional amputation with flap,
later finial formal amputation may be done
. Guillotine amputation- It always requires revision
formal amputation
. Formal amputation â It is deffinitive procedure
18. Amputations
⢠Types of Flaps-
-Long posterior flap in B/ K amputation
- Equal flaps in A/K amputation
⢠Ideal Stump-
-Should heal adequately by 1st intention
- Should have rounded gentle contour with
adequate muscle padding
⢠Should have sufficient length to bear prosthesis
> For B/K amputation 7.5 to 12.5 cms from
tibial tuberosity
> For A/K 23cms from greater trochanter
> For above and below elbow 20 cms stump
19. Different Amputations
⢠Ray amputation- Amputation of toe with head
of metatarsal or metacarpal
⢠Gillies ( Transmetatarsal ) âAmputation
proximal to neck ,distal to base of metatarsal
⢠Lisfrancâs( Tarsometatarsal) â The tarso meta
tarsal joint is disarticulated
⢠Chopartâs ( Mid tarsal)- Talonavicular and calca
neo cuboid joints are disarticulated
⢠Symeâs âTibia and fibula are cut just above
ankle joint to remove foot
20. Different Amputations
⢠Burgess (below âknee amputation) â Long
posterior flap is made so that scar is anterior
Stump length is 14-17 cms, minimum 8cms
⢠Peg- leg amputation - It is done 5 cms below
knee joint, anterior flap is rotated postly. Like
a hood. Pt kneels and bears wt on this.It is
only done when patient can not afford or bear
prosthesis limb.Uncommon
⢠Gritti- Stokes (transcondylar)- It is done
through knee joint, patella is anchored to
divided femur.Not done these days
22. Different amputations
⢠Above knee A/K amputation- Equal anterior and
posterior flaps, ideal femur stump should be 25 cms
long.Not done in children as growing epiphysis of femur
is in lower end. Minimum stump should be 10cms long.
It is technically easy, healing chances are better and
faster. Cosmetic results poor, prosthesis fitting is not
proper, pt limps while walking and need support
⢠Hip disarticulation- It is done when minimum 10cms
stump is not possible in A/K amputation. Single
posterior flap âSolcum approach(better) or anterior
racquet incision âBoydâs approach
⢠Hind quarter amputation or Hemipelvectomy-( Sir
Gordon Taylorâs amputation) One side pelvis with iliac
bone, pubis muscles and vessels along with lower limb
are removed. Internal and external vessels are
ligated.Internal hemipelvectomy is new method where
lower limb is saved
23. Different amputations
⢠Krukenbergâs amputation- Done in upper limb
through forearm. A claw like gap is left between
radius and ulna which is used for a grip or
holding some thing
⢠Forequarter amputation ( Interscapulothoracic
amputation)-It is removal of upper limb with
scapula and lateral 2/3rd of clavicle and muscles
.It is done for tumours of scapula,upper part of
humerus and near shoulder joint It can be done
through Littlewoodâs posterior approach or
Bergerâs anterior approach.
25. Post operative period & Complications
⢠Regular dressings are done
⢠Physiotherapy is started as early as possible
⢠Pt uses crutches for walking, Prosthesis is
fitted after 3 months
⢠Rehablitation is started
⢠Complications-
Early - Haemorrhage, hematoma, Infection
Late- Pain, Ulceration at stump, Flap
necrosis, Painful scar, Phantom limb â feeling
of amputated part partially or in toto with
pain over it.
26. Prosthesis or Artificial limbs
⢠A prosthesis a is an artificial device that
replaces a missing body part or a limb
( or its part ) lost due to trauma,
disease, or congenital conditions.
⢠These are devices to make shape and
function of the residual limb and help
patient readapt to his job and life style
27. Prosthesis or Artificial limbs
⢠In Lower Limb-
1 Symeâs amputation-Elephant boot,Canadian
Symeâs prosthesis
2. Below Knee amputation- Patellar tendon
bearing (PTB) prosthesis and solid ankle
cushion heel (SACH)
3.Above Knee amputation- Suction type
prosthesis, it is placed above the stump.It is
better and well tolerated
4.Nonsuction type prosthesis- It is placed at
the end.It requires additional support
5.Hind quarter amputation- Tilting table
prosthesis or Canadian prosthesis is used
28. Prosthesis
⢠Upper Extremity prosthesis-
a.Partial hand amputation- Cosmetic glove
b.Wrist disarticulation- Plastic laminate socket
with triceps cuff and wrist unit with terminal
device
c.Below elbow amputation- Same as wrist
disarticulation but with different socket confg.
d.Elbow disarticulation- cosmetically unde
sirable as outside locking elbow hinge is bulky
e.Above elbow amputation- The unit has internal
locking system and turn table which permits
passive control of rotation. Elbow joint lock is
controlled by shoulder depression and terminal
device is operated by scapular abduction or
shoulder flexion
29. Prosthesis
⢠Myoelectric prosthesis ( Externally powered
prosthesis)- It is self suspending unit with
electrodes embeded in the prosthetic socket.
Electrodes detect muscle action potential form
contracting muscles in residual limb.The signals
are amplified,rectified,modulated to run an
electric motor to do desired function. These
prosthesis are costly, weigh more and not
reliable. They provide only coarse movements
with out sensory feedback which is most
important function of hand
31. Lower limb prosthesis
⢠Toe amputation- Shoe with filler
⢠Partial foot amputation- Moulded plastic foot
support with toe filler and rigid extension in
the shoe
⢠Symeâs amputation- Prosthesis similar to B/K
amputation prosthesis( PTB)
⢠Below Knee B/K amputation- Patellar tendon
bearing (PTB) prosthesis made up of socket,
shin piece and SACH foot. It has a thigh corset
for suspension along with side knee joints
32. Types of Prosthesis
BELOW KNEE
KNEE
DISARTICULATION ABOVE KNEE
HIP
DISARTICULATION
PROSTHETICS
LOWER EXTREMITY
33. Lower limb prosthesis
⢠Jaipur foot- It is Indian modification for bare foot walking
made of vulcanized rubber and shaped like normal foot.It
is flexible and is helpful in walking on uneven surfaces
⢠SACH foot( Solid Ankle Cushioned Heel)- It is most
commonly used foot.It has no mechanicle ankle joint .The
cushioned heel stimulates the plantar flexion motion.
⢠Endoskeletal prosthesis- It uses aluminium, titanium,
graphite and tubular material to form central supporting
structure and have modular or interchange able
connectors and components like knee and feet.The
structural strength is derived from central skelton like
components.It is covered by foam material like skin.
⢠Exoskeletal prosthesis- there is outer plastic laminated skin
or shell with wood or poly urethane foam interiors.Here
strength is provided by outer lamination and shape is an
integral part of prosthesis
34. Lower limb prosthesis
⢠Above Knee prosthesis- It has four major parts
the socket, the knee system,the shank and foot
ankle system.A variety of sockets (quadri lateral,
ischial containment, CAD-CAM designed) knee
joints(constant friction, hydraulic, polycentric etc)
shanks( wood, metal ,composite),foot ankle
assembly(SACH,Jaipur foot,energing storing
foot,Madras foot etc).These can be combined to
make custom made.It does not permit squat or
sit cross legged on ground. AIIMS modification
allows these movements to patient.
35. Prosthesis or Artificial limb
⢠Patellar tendon bearing prostheiss (PTB
Prosthesis)- All the wt bearing is done below
knee, movement is controlled by his own knee
joint.Patellar tendon is main wt bearing area
within the socket.
⢠CAD âCAM made socket â It is an automated
processing method to make prosthesis.It is more
comfortable ,made of thermoplastic or laminated
plastic with polyethylene foam
⢠Suspension for B/K amputation prostheis is
leather cuff strap above femoral condyles.Exo or
endoskeleton is used.Endo skelton is preferred in
athletics
⢠SACH (Solid Ankle Cushion Heel) foot- Needs
minimal maintenance,preferred in old people
36.
37. Upper limb prosthesis
⢠Above elbow prosthesis is a high technology
prosthesis with harness, socket, elbow joint
unit ,control cable, forearm and wrist device.
⢠Below elbow prosthesis- Krukenbergâs
amputation does not require any prosthesis
Advantages of Prosthesis-
-Cosmetic - Function of the part is
gained to some extent - Ambulation in
lower limb prosthesis
38. Prosthesis or Artificial limb
⢠Disadvantages-
- Infection - Pressure ulcers
- Joint disability
⢠Prosthesis Types-
- Exoskeletal prosthesis-fixed with belts and
brces to remaining limb or stump
- Endoskeletal prosthesis with
modular system Internal prosthesis are used
inside body ,placed by open surgery.These are
non reactive long durable materials.e.g hip
prosthesis for hip replacement
39. There are 5 Stages of Rehabilitation:
1. Healing and Starting Physiotherapy
2. Visiting the Prosthetist
3. Choosing an Artificial Limb
4. Learning to Use your Artificial Limb
5. Life as a New Amputee
Amputation is the surgical removal of a part of the body, a limb or part of a limb to treat recurrent infection, gangrene in peripheral vascular disease; to remove malignant tumors; or to treat severe trauma. Amputation is used to relieve symptoms, improve function and save or improve the patients quality of life.
Stage 1: Healing and Starting Physiotherapy: Following the amputation, there will be a healing phase - during which time the incision and surrounding tissue will recover. This timeframe can vary between a matter of weeks, a couple of months or even more depending on the type of amputation, how much scar tissue may be involved and how the limb heals. In the hospital, the physiotherapist (PT) will teach exercises to improve muscle function and will show how to get around on crutches or a wheelchair (if it is required).
Stage 2: Visiting the Prosthetist: A prosthetist is the professional who makes the artificial limb (prosthesis). Once the clinic team is satisfied that the residual limb has healed well enough, a prosthesis can be fitted. A temporary prosthesis (more common for leg amputees) provides early mobility while allowing the residual limb to continue to shrink and change shape (which is normal following any amputation). Once the residual limb has settled into its final shape and the incision has healed, a "definitive" prosthesis (for permanent use) will be made.
Stage 3: Choosing an Artificial Limb(s): Factors to consider include level of activity, health, level of amputation, and importance of cosmetic look versus functionality.
Stage 4: Learning to Use Your Artificial Limb: The prosthetist or PT teach leg amputees how to walk with their artificial limb. This is called gait training. Arm amputees are trained by Ots and that may take longer and be more involved. OT also teach adaptive skills such as how to get dressed with one hand.
Stage 5: Life As a New Amputee: This stage is the return to their regular lifestyle and activities. Bigger stepping stones that many take longer to achieve include driving a car and returning to the work force.