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Prepared by:
Dr. Abdullah K. Ghafour
2nd year IBFMS trainee
Supervised by:
Dr. Ali Abdulnabi Alwan
*AMPUTATION: Cutting of the extremity or part of
the extremity through the bone
While ………..
*DISARTICULATION: Cutting of t...
*Amputation surgery is an ancient procedure dating back to
prehistoric time.
*The word amputation is derived from the Lati...
*Cave-wall hand imprints have been found which
demonstrate that Neolithic humans had amputated
limbs.
*Earliest literature...
*1781 – John Warren – 1st successful shoulder amputation
*1806 – Walter Brashear –1st successful hip joint amputation
*182...
*In US 30,000 – 40,000 amputation are performed
annually.
*There were 1.6 million individuals living with
loss of a limb i...
77%
9%
8% 6%
UE amputation causes
Trauma 77%
Congenital 9%
Tumor 8%
Disease 6%
66%
26%
5% 3%
LE amputation causes
PVD 66%
...
Alan Apley encapsulated the indications for
amputation in the ‘three Ds’:
1. Peripheral vascular disease ( 60 -70 % in LE )
 DM (90%)
 Arteriosclerosis
 Thromboembolism
2. Severe traumatized li...
1. Malignant tumors
2. Lethal sepsis
3. Crush injury leading to crush syndrome
2D Dangerous limb:
Remaining the limb is more worse than having no
limb at all …. Because of :-
1. Pain
2. Gross malformation
3. Recurrent se...
When primary healing is unlikely
The limb amputate as distal as the causal factor will
allow
Skin flap suture loosely over...
When weight is taken through the end of the stump
The scar must not be terminal
Bone end must be solid (cut near the joint...
 Commonest variety
 All upper limb & most lower limb amputations are
come under this type
 The scar can be terminal
Def...
*Wagner et al (Journal of vascular surgery 1988):
[ clinical judgment is superior to objective
assessments. More distal am...
oskin quality, extent of ischemia/ infection
opresence of a pulse immediately above the level
of amputation – almost 100% ...
oDoppler Ultrasound pressures
oSkin perfusion pressures
otranscutaneous oximetry
oangiography
Invasive procedures
Non-inva...
oDoppler ultrasound pressures
 maybe unreliable in diabetics
 ankle pressures >60mm
--->50% chance of BKA healing
oSkin ...
otranscutaneous oximetry
 Tested under local hyperthermia
 Correlates with true PaO2
 Threshold value – 30mm
oInvasive ...
1. Interscapulo-thoracic (fore-quarter) amputation.
oTraumatic avulsion of the upper limb
oeradicating a malignant tumour
...
5. Transradial (forearm) amputation
ooptimal length is at the junction of the middle and
distal thirds of the forearm
oBot...
1. Hemipelvectomy (hindquarter amputation)
operformed only for malignant disease.
2. Disarticulation of the hip joint
opro...
1. Ankle disarticulation (Syme’s amputation)
ogives excellent function in children
obones are divided just above the malle...
* Tourniquet is used unless there is vascular
insufficiency
* Skin flaps are cut so that there combined
length equals 1.5 ...
*Nerves are divided proximal to the bone cut
*Saw is used to make the bone ends smooth ,
and for beveling the tibia interi...
*Skin flaps should be of full thickness
*Periosteal stripping should be sufficient
*Stable residual limb muscle mass can i...
Wrist joint disarticulation
*Guillotine amputation is used in emergency situations
for contaminated wounds or infection.
*Skin, muscle and bone are di...
*The metabolic cost of walking is increased with proximal-
level amputations and is inversely proportional to the
length o...
ocomplications of any operation (bleeding, pain,
infection, complications of anesthesia,…)
oBreakdown of skin flaps (may b...
oSkin; Eczema, tender purulent lumps in groin.
Ulceration due to poor circulation.
oMuscle; unstable ‘cushion’ stump If to...
oNerve; A cut nerve always forms a neuroma and
occasionally this is painful and tender.
oJoint; The joint above an amputat...
(Gitter and Bosker 2005):[Yet with appropriate
rehabilitation, many people can learn to walk or
function again and live hi...
oPassive
*Cosmetic
oBody Powered
*Harnesses and cables
oMyoelectric
*Surface EMG
*Perform most of functions
oNeuroprosthet...
*Amputation represents loss of
function, sensation and body image.
*(Gitter and Bosker 2005):[Limb loss
is one of the most...
*Up to 2/3 of amputees will manifest postoperative
psychiatric symptoms:
Depression
Anxiety
Crying spells
Insomnia
Loss of...
1 Preoperative
2 Immediate Postoperative
3 In-Hospital Rehabilitation
4 At-Home Rehabilitation
• Solomon L., Warwick D. , Nayagam S.,[2010] Apley’s System of Orthopaedics and Fractures, 9th ed.
Hodderarnold comp.,Lond...
Amputations of extremity
Amputations of extremity
Amputations of extremity
Amputations of extremity
Amputations of extremity
Amputations of extremity
Amputations of extremity
Amputations of extremity
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Amputations of extremity


AMPUTATION: Cutting of the extremity or part of the extremity through the bone


While ………..

DISARTICULATION: Cutting of the extremity or part of the extremity through the joint

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Amputations of extremity

  1. 1. Prepared by: Dr. Abdullah K. Ghafour 2nd year IBFMS trainee Supervised by: Dr. Ali Abdulnabi Alwan
  2. 2. *AMPUTATION: Cutting of the extremity or part of the extremity through the bone While ……….. *DISARTICULATION: Cutting of the extremity or part of the extremity through the joint
  3. 3. *Amputation surgery is an ancient procedure dating back to prehistoric time. *The word amputation is derived from the Latin amputare, "to cut away“. *The English word "amputation" was first applied to surgery in the 17th century by Peter Lowe in 1612. *amputation of the hands, feet or other body parts is or was used as a form of punishment for people who committed crimes. * In some cultures and religions, minor amputations are considered as a ritual accomplishment.
  4. 4. *Cave-wall hand imprints have been found which demonstrate that Neolithic humans had amputated limbs. *Earliest literature discussing amputation is the Babylonian code of Hammurabi 1700 BC *385 BC – Plato's symposium and Hippocrates De Articularis *1st century BC – cautery was used for large vessels *1588 – William Clove – first successful AKA *1674 – Morel – battle of Borodino – tourniquet *1679 – Younge – local flaps for wound closure (animal bladder used previously)
  5. 5. *1781 – John Warren – 1st successful shoulder amputation *1806 – Walter Brashear –1st successful hip joint amputation *1825 – Nathan Smith – described knee disarticulation *1870 – Stockes and Grittis procedure *1890 – Jaboulay and Girard – 1st successful hindquarter amputation *1943 – Norman Kirk – guillotine procedure in WWII
  6. 6. *In US 30,000 – 40,000 amputation are performed annually. *There were 1.6 million individuals living with loss of a limb in 2005. These expected to become 3.6 million by the year 2050 *Male : female ratio LE = 2:1 UE = 4:1 *majority in the 65 - 79 year age group * LE : UE ratio = 11:1 *10% perioperative mortality *3 year survival after BKA – 57%; after AKA – 39%
  7. 7. 77% 9% 8% 6% UE amputation causes Trauma 77% Congenital 9% Tumor 8% Disease 6% 66% 26% 5% 3% LE amputation causes PVD 66% Trauma 26% Tumor 5% Congenital 3%
  8. 8. Alan Apley encapsulated the indications for amputation in the ‘three Ds’:
  9. 9. 1. Peripheral vascular disease ( 60 -70 % in LE )  DM (90%)  Arteriosclerosis  Thromboembolism 2. Severe traumatized limb ( 75 – 80 % in UE) 3. Burns 4. Frostbite 1D Dead or dying limb
  10. 10. 1. Malignant tumors 2. Lethal sepsis 3. Crush injury leading to crush syndrome 2D Dangerous limb:
  11. 11. Remaining the limb is more worse than having no limb at all …. Because of :- 1. Pain 2. Gross malformation 3. Recurrent sepsis 4. Severe loss of function 3D Damn nuisance
  12. 12. When primary healing is unlikely The limb amputate as distal as the causal factor will allow Skin flap suture loosely over a pack Re-amputation perform when stump condition is favorable Provisional amputation
  13. 13. When weight is taken through the end of the stump The scar must not be terminal Bone end must be solid (cut near the joint) Definitive end-bearing
  14. 14.  Commonest variety  All upper limb & most lower limb amputations are come under this type  The scar can be terminal Definitive non-end-bearing
  15. 15. *Wagner et al (Journal of vascular surgery 1988): [ clinical judgment is superior to objective assessments. More distal amputations can be achieved with clinical measures over objective studies.] *Clinical judgment is central to amputation level selection.
  16. 16. oskin quality, extent of ischemia/ infection opresence of a pulse immediately above the level of amputation – almost 100% chance of healing ojoint- and residual-limb-length salvage is directly correlated with functional outcome oShort stump slips out from the prosthesis oLong stump  pain, ulceration, incorporate of the joint in the prosthesis oNow a day the skill of prosthetist make amputation possible at any level Subjective measures Clinical examination Local function Prosthetic design
  17. 17. oDoppler Ultrasound pressures oSkin perfusion pressures otranscutaneous oximetry oangiography Invasive procedures Non-invasive procedures Objective tests
  18. 18. oDoppler ultrasound pressures  maybe unreliable in diabetics  ankle pressures >60mm --->50% chance of BKA healing oSkin perfusion pressures  Radio isotope washout  Laser doppler velocimetry <20mm Hg – 89% failure of healing
  19. 19. otranscutaneous oximetry  Tested under local hyperthermia  Correlates with true PaO2  Threshold value – 30mm oInvasive – Angiographic scoring  Poor correlation
  20. 20. 1. Interscapulo-thoracic (fore-quarter) amputation. oTraumatic avulsion of the upper limb oeradicating a malignant tumour o aspalliation for intractable sepsis or pain. 2. Disarticulation of the shoulder oRare event 3. transhumeral (above-elbow)amputations o the appearance is much better oshortest arm stump is 2.5 cm 4. Elbow disarticulation Upper limb amputations:
  21. 21. 5. Transradial (forearm) amputation ooptimal length is at the junction of the middle and distal thirds of the forearm oBoth bones cut in same level 6. Wrist disarticulation 7. Amputations in the hand oPolydactyly oTraumatic amputation of fingers Upper limb amputations:
  22. 22. 1. Hemipelvectomy (hindquarter amputation) operformed only for malignant disease. 2. Disarticulation of the hip joint oprosthetic fitting is difficult 3. Transfemoral amputation oat least 12 cm 4. knee disarticulation &( Gritti-Stokes amp.) oassociated with poorer functional and psychological outcomes omain indication is in children 5. Transtibial (below knee) amputation oEven a 5–6 cm(optimum 12cm) stump may be fitted with a prosthesis oHave a good function and nearly normal gait Lower limb amputations:
  23. 23. 1. Ankle disarticulation (Syme’s amputation) ogives excellent function in children obones are divided just above the malleoli 2. & 3. Pirogoff’s and Boyd’s amputation oSimilar in principle to Syme’s oThe part of calcaneus is fixed onto the cut end of the tibia and fibula. Partial foot amputations 4. Mid-tarsal joint ( chopart amputation ) 5. Tarsometatarsal joint ( lisfranc amputation) 6. Transmetatarsal 7. Metatarsophlangeal 8. Transphalangeal Lower limb amputations:
  24. 24. * Tourniquet is used unless there is vascular insufficiency * Skin flaps are cut so that there combined length equals 1.5 the width of the limb at the site of the amputation. * Muscle cut at distal level from the level of the bone proposed. Osteomyodesis is done when the opposing muscle groups sutured together over the bone ends.
  25. 25. *Nerves are divided proximal to the bone cut *Saw is used to make the bone ends smooth , and for beveling the tibia interiorly oFibula is cut 3 cm shorter *The main vessels are meticulously ligated. *Remove the tourniquet and stop bleeding Suture the skin without tension Apply suction drain Bandage the stump tightly
  26. 26. *Skin flaps should be of full thickness *Periosteal stripping should be sufficient *Stable residual limb muscle mass can improve function by reducing atrophy and providing a stable soft tissue envelope over the end of the bone. *The nerve end should come to lie deep in a soft tissue envelope, away from potential pressure areas. *Rigid dressings (postoperative) help reduce swelling, decrease pain, and protect the stump from trauma. *Early prosthetic fitting is done within 5 to 21 days after surgery in selected patients.
  27. 27. Wrist joint disarticulation
  28. 28. *Guillotine amputation is used in emergency situations for contaminated wounds or infection. *Skin, muscle and bone are divided at the same level. *All bleeding vessels are tied and nerves are cut sharply while under gentle tension, allowing them to retract into the wound. *Debridement and lavage of the wound are done every 2–5 days until it is free of dead tissue and infection. At that point, definitive amputation and closure are performed.
  29. 29. *The metabolic cost of walking is increased with proximal- level amputations and is inversely proportional to the length of the residual limb and the number of functional joints preserved. *The higher the level of amputation ,the higher the oxygen consumption • BKA –10-40% increase in energy expenditure • AKA –50-70% extra energy expenditure
  30. 30. ocomplications of any operation (bleeding, pain, infection, complications of anesthesia,…) oBreakdown of skin flaps (may be due to ischemia or excessive suture tension ) oGas gangrene (especially AKA) EARLY COMPLICATIONS:
  31. 31. oSkin; Eczema, tender purulent lumps in groin. Ulceration due to poor circulation. oMuscle; unstable ‘cushion’ stump If too much muscle is left oBlood supply; Poor circulation gives a cold, blue stump that is liable to ulcerate. oPhantom limb; feeling that all or part of the amputated limb is still present oPhantom pain is a burning, painful sensation in the part having undergone amputation. LATE COMPLICATIONS:
  32. 32. oNerve; A cut nerve always forms a neuroma and occasionally this is painful and tender. oJoint; The joint above an amputation may be stiff or deformed. oBone; A spur often forms at the end of the bone, but is usually painless. Bones that not used may becomes osteoporotic and liable to fracture. LATE COMPLICATIONS:
  33. 33. (Gitter and Bosker 2005):[Yet with appropriate rehabilitation, many people can learn to walk or function again and live high quality lives.] 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 Rehabilitation
  34. 34. oPassive *Cosmetic oBody Powered *Harnesses and cables oMyoelectric *Surface EMG *Perform most of functions oNeuroprosthetics *Investigational at this time Prosthetics
  35. 35. *Amputation represents loss of function, sensation and body image. *(Gitter and Bosker 2005):[Limb loss is one of the most physically and psychologically devastating events that can happen to a person. Not only does lower limb amputation cause major disfigurement, it renders people less mobile and at risk for loss of independence.]
  36. 36. *Up to 2/3 of amputees will manifest postoperative psychiatric symptoms: Depression Anxiety Crying spells Insomnia Loss of appetite Suicidal ideation
  37. 37. 1 Preoperative 2 Immediate Postoperative 3 In-Hospital Rehabilitation 4 At-Home Rehabilitation
  38. 38. • Solomon L., Warwick D. , Nayagam S.,[2010] Apley’s System of Orthopaedics and Fractures, 9th ed. Hodderarnold comp.,London, UK. • Miller M. , Thompson S. , Hart J. ,[2012] REVIEW OF ORTHOPAEDICS [PDF], 6th ed. by Saunders, an imprint of Elsevier Inc. , Philadelphia, USA. • Canale S. , Beaty J. , [2007] Campbell’s Operative Orthopaedics [PDF], 11th ed. By Mosby, An Imprint of Elsevier , Tennessee, USA. • Matthew L., HMO2, [2011] Amputation and Limb Prostheses [PPT]. http://www.authorstream.com/ heier.barb-1256551-amputation2012..ppt (accessed nov. 22, 2011) • Arvind Lee , [2014] Lower Limb Amputations – Level Selection [PPT]. http://www.austpar.com/ portals/lowerlimbamputationlevelselection.ppt (accessed dec.2003) • Kovryha M. F., [2010] Basic Surgical Principles of Amputations and Disarticulations of the Upper and Lower Extremities [PPT]. http://www.slideshare.net/ xatcon/amputation-3286795.ppt. • Andrew H. Schmidt, David Ring, [2011] Upper Extremity Amputation [PPT].http://www.aota.org/ media/34684/U13_UE_Amputations-tfh-edited.ppt (accessed Feb. 2011) • Yousaf S., Kieffer W. [ 2013] Management of traumatic amputations at BSUH [PPT]. Brighton and Sussex medical school . Brighton, UK. • Der Eingriff . [2000] AMPUTATIONS & PROSTHETICS [E-Book].http://www.thieme.de/amputation/ 0000015919440/amputation_prothetics.pdf • M. Jason Highsmith, [2006] Epidemiology & Statistics associated with Limb Loss & Limb Deficiency [E-Book]. South Florida , USA. http://www.ncbi.nih.gov/pubmed/21140687/ Epidemiology - Statistics .pdf • Wikimedia Foundation, http://www.en.wikipedia.org/wiki/Amputation (last modified Nov, 2015)

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