Amputation (from campbell)
Dr Anurag Mittal
MS Ortho
UCMS & GTBH

Indication
• Trauma
• Ischaemia
• Peripheral vascular disease
• The most significant predictor of amputation in diabetics is peripheral
neuropathy as measured by insensitivity to the Semmes Weinstein 5.07
monofilament
• Tumour
• Congenital anomalies/non functional limb
• Uncontrollable infection
• Burns

risk for wound complications
• serum albumin is less than 3.5 g/dL or
• whose total lymphocyte count is less than 1500 cells/mL

Energy consumption
• The energy required for walking is inversely proportionate to the
length of the remaining limb.

Limb salvage vs Amputation
Limb salvage
• metabolic overload and secondary organ failure
• multiple operations to obtain bony union and soft-tissue coverage
and
• multiple operations on other areas to obtain donor tissue.
• External fixation may be necessary for several years, and
• complications, including infection, nonunion, or loss of a muscle flap,
may occur.
• Chronic pain and drug addiction
• multiple hospital admissions and surgery,
• isolation from their family and friends, and
• unemployment.
• In the end, despite heroic efforts, the limb ultimately could require
amputation, or
• a “successfully” salvaged limb may be chronically painful or
functionless.
Amputation
• decreased morbidity,
• fewer operations,
• a shorter hospital course,
• decreased hospital costs,
• shorter rehabilitation, and
• earlier return to work.
• The treatment course and outcome are
more predictable.
• Modern prosthetics often provide better
function than many “successfully”
salvaged limbs.

Frostbite
• Frostbite denotes the actual freezing of tissue in the extremities,
with or without central hypothermia
• When heat loss exceeds the body's ability to maintain homeostasis,
blood flow to the extremities is decreased to maintain central body
temperature.
• Actual tissue injury occurs through two mechanisms:
(1) direct tissue injury through the formation of ice crystals in the
extracellular fluid and
(2) ischemic injury resulting from damage to vascular endothelium,
clot formation, and increased sympathetic tone.

• The first step in treatment is restoration of core body temperature.
• Treatment of the affected extremity begins with rapid rewarming in
a water bath at 40°C to 44°C.
• parenteral pain management and sedation.
• After initial rewarming, if digital blood flow is still not apparent,
treatment with tissue plasminogen activator or regional
sympathetic blockade may be indicated.
• Tetanus prophylaxis
• prophylactic systemic antibiotics are controversial.

• Blebs should be left intact.
• Closed blebs should be treated with aloe vera.
• Silver sulfadiazine (Silvadene) should be applied regularly to open blebs.
• Low doses of aspirin or ibuprofen also should be instituted.
• Oral antiinflammatory medication and topical aloe vera help to stop progressive dermal
ischemia mediated by vasoconstricting metabolites of arachidonic acid in frostbite wounds.
• Physical therapy should be started early to maintain range of motion.
• In stark contrast to traumatic, thermal, or electrical injury, amputation for frostbite routinely
should be delayed 2 to 6 months.
• Clear demarcation of viable tissue may take this long.
• Even after demarcation appears to be complete on the surface, deep tissues still may be
recovering.
• Performing surgery prematurely often results in greater tissue loss and increased risk of
infection. An exception to this rule is the removal of a circumferentially constricting eschar.

Infection
• Any contaminated wound that is closed without appropriate
débridement is at high risk for the development of gas gangrene.

Treatment-clostridial
• associated with a mental awareness of impending death
• immediate radical débridement
• high doses of intravenous penicillin (clindamycin may be used if the
patient is allergic to penicillin), and
• hyperbaric oxygen.
• Emergency open amputation one joint above the affected
compartments often is needed as a lifesaving measure, but may be
avoided if treatment is initiated early.

Tumour
• Amputation
• technically demanding,
• often requiring nonstandard flaps,
• bone graft, or
• prosthetic augmentation to obtain a more functional residual limb
• Limb salvage
• greater risk of infection,
• wound dehiscence,
• flap necrosis, blood loss, and deep venous thrombosis.
• periprosthetic fractures, prosthetic loosening or dislocation,
• nonunion of the graft-host junction, allograft fracture,
• leg-length discrepancy, and
• late infection.

SURGICAL PRINCIPLES OF
AMPUTATIONs

Determination of Amputation Level
• clinical assessment
• skin color,
• hair growth, and
• skin temperature.
• skin perfusion pressures
• skin flap perfusion
• thermography or
• laser Doppler flowmetry.
• the tissue uptake of intravenously injected fluorescein or
• the tissue clearance of intradermally injected xenon-133.
• transcutaneous oxygen measurements to be most beneficial

Transcutaneous oxygen measurements
• probe that is heated to 45°C for 10 minutes - allows for a maximum vasodilatory
response.
• 20 to 40 mm Hg, “good” healing potential. however, no absolute cutoff
• The measurement can be falsely decreased in circumstances that decrease the
diffusion of oxygen, such as cellulitis or edema.
• The test can be improved by comparing the transcutaneous oxygen level before and
after the inhalation of 100% oxygen.
• An increase of 10 mm Hg at a particular level is a good indicator for healing potential.
• Accuracy also can be improved by comparing supine and elevation of the extremity
measurements in patients who fall into the 20 to 40 mm Hg gray zone.
• A decrease of greater than 15 mm Hg after 3 minutes of elevation of the involved limb
is a poor prognostic indicator for healing.
• this information must be used in light of other patient variables, including age,
concomitant medical problems, and ambulatory potential

Technical Aspects
• Skin
• Thick flap
• No unnecessary dissection
• Sturdy soft tissue envelop for stump
• No adherent scar
• No dog ears

• Muscles
• divided at least 5 cm distal to the intended bone resection.
• myodesis (suturing muscle or tendon to bone) :
• stronger insertion,
• help maximize strength, and minimize atrophy ,
• counterbalance their antagonists,
• preventing contractures and
• maximizing residual limb function
• myoplasty (suturing muscle to periosteum or to fascia of opposing
musculature).
• Myodesis may be contraindicated, however, in severe ischemia because of
the increased risk of wound breakdown.

• Nerves :preventing the formation of painful neuromas. These
include
• end-loop anastomosis,
• perineural closure,
• Silastic capping,
• sealing the epineurial tube with butyl-cyanoacrylate,
• ligation,
• cauterization, and
• methods to bury the nerve ends in bone or muscle
• 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.

• Bone :
• Excessive periosteal stripping is contraindicated -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.

Rigid dressing
• prevent edema ,
• protect the wound from bed trauma,
• enhance wound healing and
• early maturation of the stump, and
• decrease postoperative pain,
• allowing earlier mobilization from bed to chair and ambulation with support.
• For transtibial amputations, rigid dressings prevent the formation of knee flexion
contractures.
• The physiological benefits of upright posture to the respiratory, cardiovascular, urinary,
and gastrointestinal systems
• the hospital stay can be decreased and the cost of care reduced accordingly.
• Finally, earlier definitive prosthetic fitting is possible, and a higher percentage of
patients are successfully rehabilitated

Rehab
• A young patient with a traumatic amputation above the zone of
injury probably could begin 25-lb partial weight bearing
immediately postoperatively.
• A patient with a traumatic amputation through the zone of injury or
a patient with an amputation performed secondary to ischemia
probably should wait until early wound healing is documented
before gradually beginning partial weight bearing.
• Weight bearing status should be reevaluated with each subsequent
cast change.
• If the wound is progressing well, weight bearing can progress in 25-
lb increments each week

Complications
• Haemotoma
• Infection
• Wound necrosis
• Contractures
• Pain:phantom pain,mechanical low backache,residual limb
pain,neuroma(tinel sign)
• Dermatological problems

Local resection produces uneven tension; this is reduced and
evenly distributed after wedge resection

AMPUTATIONS IN CHILDREN
• congenital and acquired
• Krajbich general principles of childhood amputation
• (1) preserve length,
• (2) preserve important growth plates,
• (3) perform disarticulation rather than transosseous amputation
whenever possible,
• (4) preserve the knee joint whenever possible,
• (5) stabilize and normalize the proximal portion of the limb, and
• (6) be prepared to deal with issues in addition to limb deficiency in
children with other clinically important conditions

Terminal bone overgrowth
• In transosseous amputation
• does not occur after disarticulation.
• caused by appositional new bone formation and is unrelated to the
growth of the physis.
• bone is elongated and often pencil-shaped.
• swelling, edema, pain, and bursa formation and in severe cases may
penetrate the skin.
• Humerus>fibula> tibia> femur>radius>ulna.

• Treatment:
• surgical resection of the excess bone.
• Epiphysiodesis has been unsuccessful and is contraindicated.
• Capping the bone with a synthetic device -limited success and complicated
by infection or fracture of the implant or bone.
• capping the bone with an epiphyseal graft harvested from the amputated
limb at the index procedure
• capping with tricortical iliac crest graft at a revision operation.

Toe amputation
• Amputation of a single toe-little disturbance in stance or gait.
• Amputation of the great toe -a limp while runing because of the loss of push-
off.
• Amputation of the second toe -severe hallux valgus
• Treatment:second ray amputation and narrowing the foot then Screw fixation
• Amputation of any of the other toes causes little disturbance.
• 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
• Amputation of more than two rays often is more disabling than a
transmetatarsal amputation.

Midfoot amputation
• (1) Lisfranc amputation at the tarsometatarsal joints, -equinus
deformity -severe equinovarus deformity
• (2) Pirogoff amputation, in which the calcaneus is rotated forward
to be fused to the tibia after vertical section through its middle.

Preventing equinus
• Transfer of dorsiflexors
• Achillis tenotomy/tenectomy
• dorsiflexion rigid dressing for 6 weeks

Chopart
• “fish-mouth” flap that is slightly longer on the plantar surface. Begin
the incision at the transtarsal joints medially and laterally.
• Identify the transverse tarsal (calcaneocuboid and talonavicular)
joints, and disarticulate by releasing the dorsal and plantar
ligaments
• perform a tenotomy of the Achilles tendon. Excise 2 cm of tendon,
and attempt to preserve the sheath of the Achilles tendon
• Transfer the anterior tibial tendon/EHL to the neck of the talus
• peroneus brevis/EDL to the anterior process of the calcaneus

HINDFOOT AND ANKLE AMPUTATIONS
• Pirigoff
• arthrodesis between the tibia and part of the calcaneus;
• the calcaneus is sectioned vertically, its anterior part is removed, and its remaining
posterior part and the heel flap are rotated forward and upward 90 degrees until
the raw surface of the calcaneus meets the denuded distal end of the tibia.
• Boyd
• eliminates the problem of posterior migration of the heel pad
• talectomy, forward shift of the calcaneus, and calcaneotibial arthrodesis
• Syme
• Semiento modification of syme
• tibia and fibula approximately 1.3 cm proximal to the ankle joint and excision of
the medial and lateral malleoli.
• cosmetic

Boyd

Syme
• end-bearing stump,
• enough space between the end of the stump and the ground for the
construction of some type of ankle joint mechanism for the artificial
foot
• distal tibia and fibula 0.6 cm proximal to the periphery of the ankle
joint and passing through the dome of the ankle centrally
• Complications:
• posterior migration of the heel pad and
• skin slough resulting from overly vigorous trimming of “dog ears.”
• Non cosmetic:window required in prosthesis for bulbous end

prevent migration of the heel pad on the end
of the stump
• such as taping the heel flap to the leg with adhesive strips,
• skewering the heel flap to the bone with a Kirschner wire, or
• leaving a small sliver of calcaneus attached to the heel flap, which
fuses to the end of the tibia.
• The technique of Wagner is simple and has been effective in his
hands.
• Drill several holes through the anterior edge of the tibia and fibula, and
suture the deep fascia lining the heel flap to the bones through these holes
• “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.
,
•

TRANSTIBIAL (BELOW-KNEE)
AMPUTATIONS
• stumps extending to the distal
third of the leg have been
considered suboptimal because
• there is less soft tissue available
for weight bearing and
• less room to accommodate some
energy storage systems.
• The distal third of the leg also has
been considered relatively
avascular and
• slower to heal than more
proximal levels

Non ischemic limb
• ideal bone length stump :12.5 to 17.5 cm, depending on body height.
• 2.5 cm of bone length for each 30 cm of body height.
• the most satisfactory level is about 15 cm distal to the medial tibial
articular surface.
• A stump less than 12.5 cm long is less efficient.
• Stumps lacking quadriceps function are not useful.
• In a short stump of 8.8 cm or less, it has been recommended that the
entire fibula together with some of the muscle bulk be removed so that
the stump may fit more easily into the prosthetic socket.
• Many prosthetists find, however, that retention of the fibular head is
desirable because the modern total-contact socket can obtain a better
purchase on the short stump

• measure distally the desired length of bone, and mark that level
over the tibial crest with a skin marking pen.
• Outline equal anterior and posterior skin flaps, the length of each
flap being equal to one half the anteroposterior diameter of the leg
at the anticipated level of bone section
• Begin the anterior incision medially or laterally at the intended level
of bone section, and swing it convexly distalward to the previously
determined level and proximally to end at a similar position on the
opposite side of the leg

• When crossing the tibial crest, deepen the incision, and mark the
periosteum with a cut to establish a point for future measurement
• Divide the muscles in the anterior compartment of the leg at a point 0.6
cm distal to the level of bone section so that they retract flush with the
end of the bone
• Before sectioning the tibia, bevel its crest with a saw: begin 1.9 cm
proximal to the level of the bone section, and cut obliquely distalward to
cross this level 0.5 cm anterior to the medullary cavity.
• section the fibula 1.2 cm proximally
• Divide the muscles in the deep posterior compartment 0.6 cm distal to
the level of bone section
• bevel the gastrocnemius-soleus muscle mass so that it forms a myofascial
flap long enough to reach across the end of the tibia to the anterior fascia

ischemic limbs:burgess

• Because the skin's blood supply is much better on the posterior and
medial aspects of the leg than on the anterior or anterolateral sides,
transtibial amputation techniques for the ischemic limb are characterized
by skin flaps that favor the posterior and medial side of the leg.
• The long posterior flap technique popularized by Burgess is most
commonly used, but medial and lateral flaps of equal length as described
by Persson, skew flaps, and long medial flaps are being used.
• amputations performed in ischemic limbs are customarily at a higher
level (e.g., 10 to 12.5 cm distal to the joint line) than are amputations in
nonischemic limbs.
• Tension myodesis and the osteomyoplasty procedure of Ertl, which may
be of value in young, vigorous patients, are contraindicated

Amputation osteomyoplasty: Ertl procedure
• Amputation osteoplasty transforms the typical transosseous amputation
site into an end-bearing limb
• Advantages
• Decreased pain,
• better proprioception with ambulation,
• preservation of tissue quality and
• prevention of tibiofibular instability.
• The Ertl procedure consists of a periosteal sleeve sutured over the osseous
transections.
• This functions to seal the medullary canal and form a bone bridge between the tibia
and fibula.
• A modification of the technique has been described with use of a fibular
osteotomy rotated and fixed to the tibia.

Knee disarticulation
• Advantages
• 1) The large end-bearing surfaces of the distal femur covered by skin and
other soft tissues that are naturally suited for weight bearing are preserved,
• (2) a long lever arm controlled by strong muscles is created, and
• (3) the prosthesis used on the stump is stable
• ideal for nonambulating patients who require amputation because
additional length of the extremity provides adequate sitting support and
balance.
• Knee flexion contractures and associated distal ulcers common with
transtibial amputations also are avoided.

• from the inferior pole of the patella anterior flap about equal in length to
the diameter of the knee
• from the level of the popliteal crease, fashion a short posterior flap equal
in length to one half of the diameter of the knee.
• Place the lateral ends of the flaps at the level of the tibial condyles.
• Include in the flap the insertion of the patellar tendon and the pes
anserinus
• Do not excise the patella or attempt to fuse it to the femoral condyles. Do
not disturb the articular cartilage of the femoral condyles and patella.
Perform a synovectomy only if specifically indicated.
• Suture the patellar tendon to the cruciate ligaments and the remnants of
the gastrocnemius muscle to tissue in the intercondylar notch

• Mazet and Hennessy recommended a method that features
resection of the protruding medial, lateral, and posterior surfaces of
the femoral condyles for creating a knee disarticulation stump for
which a more cosmetically acceptable prosthesis can be
constructed.
• tolerances within the socket are greater,
• more adduction of the stump is permitted in the alignment of the
prosthesis, and
• the decreased bulk of the stump permits greater ease in the application and
removal of the prosthesis.

TRANSFEMORAL (ABOVE-KNEE)
AMPUTATIONS
• stump to be as long as possible to provide a
strong lever arm for control of the prosthesis.
• The conventional, constant friction knee joint
used in most above-knee prostheses extends 9 to
10 cm distal to the end of the prosthetic socket,
and the bone must be amputated this far
proximal to the knee to allow room for the joint.
• When the level of amputation is more distal than
this, the knee joint of the prosthesis is more distal
than the knee of the opposite limb, which is
cosmetically undesirable and is especially
noticeable when the patient is seated.
• Amputation stumps in which the level of bone
section is less than 5 cm distal to the lesser
trochanter function as and are prosthetically
fitted as hip disarticulations.

• Beginning proximally at the anticipated level of bone section,
outline equal anterior and posterior skin flaps.
• The length of each flap should be at least one half the
anteroposterior diameter of the thigh at this level
• Through several small holes drilled just proximal to the end of the
femur, attach the adductor and hamstring muscles to the bone with
nonabsorbable or absorbable sutures
• Bring the “quadriceps apron” over the end of the bone, and suture
its fascial layer to the posterior fascia of the thigh

• Gottschalk pointed out that in
the absence of myodesis of the
adductor magnus, most
transfemoral amputations
result in at least 70% loss of
adduction power.

Hip disarticulation
• The inguinal or iliac lymph nodes are not routinely removed with
hip disarticulation.
• The anatomical method of Boyd and
• the posterior flap method of Slocum

• anterior racquet-shaped incision
• the incision at the ASIS and curving it distally and medially almost
parallel with the Poupart ligament to a point on the medial aspect
of the thigh 5 cm distal to the origin of the adductor muscles
• continue the incision around the posterior aspect of the thigh about
5 cm distal to the ischial tuberosity and along the lateral aspect of
the thigh about 8 cm distal to the base of the greater trochanter.
• From this point, curve the incision proximally to join the beginning
of the incision just inferior to the anterior superior iliac spine

Hemipelvectomy
remove the inguinal and iliac lymph nodes
Types:
•employs a posterior or gluteal flap and disarticulates the symphysis pubis and
sacroiliac joint.
standard hemipelvectomy
•involves the posterior bony section passing through the sacrum.extended hemipelvectomy
•the bony section divides the ilium above the acetabulum, preserving the crest of
the ilium.
conservative hemipelvectomy,
Internal hemipelvectomy is a limb-sparing resection,
often achieving proximal and medial margins equal
to the corresponding amputation

Warm and cold ischaemia time
• Warm ischaemia time:time between the injury to putting the
amputated limb in ice
• Cold ischaemia time:from initiation of cold preservation solution to
restoration of warm circulation after transplantation
• These terms are mainly used for renal transplantation

With a score of 7 or greater, amputation was the eventual
result.

• Injuries with a score of 14 and below were recommended for salvage,
• those above 17 for amputation and
• those in between to be decided by an experienced team, depending
on the nature of injury and the expectations of the patient.

• The weighting for the injuries was given in such a way that scores ‘one’ and ‘two’
for any tissue meant that
• no special secondary procedures would be required for the repair and healing of that
particular structure and
• the ultimate outcome for the limb will not be poorly influenced by the injury of that
structure.
• A score of ‘three’ meant that some special procedure
• would be required for healing of that tissue, but
• a good functional outcome can be achieved with appropriate management.
• A score of ‘four’ or ‘five’ meant that the injury was of such severity, that it
• would involve multiple procedures for healing,
• would be a cause for prolonged hospital stay,
• would involve increased treatment costs,
• would negatively influence the healing of other components of the limb, and
• could ultimately lead to a poor functional outcome.