peresentation general principle of amputation

1. GENERAL PRINCIPLES
OF
AMPUTATION
DR NIKHIL DROLIA
JR I

2. Amputation : Loss of a limb or part of a limb
 The word amputation is derived from the Latin word amputare, "to
cut away"
 Should not be viewed as a failure of treatment but as the first step
in Rehabilitation
 Should be performed by the most experienced surgeon in team

3. HISTORY
 Earliest amputation were done on unanesthetized patients &
haemostasis attained by crushing or dipping the open stump in
boiling oil
 Hippocrates was the first to use ligatures
 Morel’s introduced torniquet in 1674
 Lister’s introduced antiseptic technique in
reducing mortality

4. AMPUTATION
 Indications
 Scoring
 Surgical Principles
 Amputation level
 Technical Aspects
 Open Amputations
 Post operative care
 Amputation in children
 Complications

5. INDICATIONS
 Dead limb – Gangrene
 Deadly limb- Wet gangrene ,Spreading cellulitis ,
Arteriovenous fistula, Other (e.g. malignancy)
 ‘Dead loss’ limb -Severe rest pain , Paralysis ,Other(e.g.
contracture, trauma)

6.  Only absolute indication : irreversible ischemia in
diseased or traumatized limb
 Peripheral vascular disease
 Trauma
 Burns
 Frostbite
 Infections
 Tumors

7. PERIPHERAL VASCULAR DISEASE
 Most common age group 50 to 75 yrs
 Most patients have concomitant disease processes in cerebral
vasculature, coronary arteries & kidney.
 Co morbid conditions-diabetes, smoking, prior stroke, prior
major amputation, decreased transcutaneous oxygen levels,
decreased ankle-brachail blood pressure index, ulcers.
 Most significant predictor of amputation in diabetics is
peripheral neuropathy as measured by insensitivity to the
Semmes Weinstein 5.07 monofilament.
 Perioperative mortality rate-30 % & 40% die within 2 yrs.

8. TRAUMA
 Most common in young patients
 Male >Female
 Lange’s absolute indications for amputation in type III C tibial
injuries :
o Crush injury with warm ischemia time of > 6 hrs
 Relative indications :
o Serious associated injuries
o Severe ipsilateral foot injuries
 Decision as to a limb which can be saved , should be saved or not

9.  Early amputation and prosthetic fitting :
◦ Decreased morbidity
◦ Fewer operations
◦ Shorter hospital stay
◦ Decreased hospital costs
◦ Shorter Rehabilitation
◦ Earlier return to work
 Acute trauma : functional stump length of stump must be maintained
whenever possible

11.  Necessary for acute or chronic infections which are unresponsive to
antibiotics and surgical debridement
 Most worrisome infection produced by gas forming bacteria( eg.
Clostrdium,streptococcal)
 Disability from non healing trophic ulcer , chronic osteomyelitis ,
infected nonunion
 Squamous cell carcinoma from chronic discharging sinus
INFECTION

12.  Limb salvage vs. Amputation
◦ Would survival be affected by treatment choice
◦ Comparison of short term and long term morbidity
◦ Function of salvaged limb
◦ Psychosocial consequences
 Amputation for malignancy is technically demanding
 Limb salvage : Disadvantages
◦ More extensive surgical procedure
◦ Greater risk of infection
◦ Wound dehiscence
◦ Flap necrosis
TUMORS

13. ◦ Increased blood loss
◦ Deep venous thrombosis
 Late complications :
◦ Periprosthetic fractures
◦ Prosthetic loosening
◦ Graft host nonunion
◦ Allograft fractures
◦ Leg length discrepancy
◦ Late infection

14.  Increased function by increased length of stump vs. Increased complications with
shorter stump
 Revascularization may aid in increasing length of stump but peripheral bypass
surgery may compromise wound healing of a future transtibial amputation
 More proximal level of amputation promotes slower walking velocity in order to
conserve energy
 Amputation should be performed at most distal level if ambulation is main concern
 Potential for wound healing best measured by transcutaneous O2 measurement
LEVEL OF AMPUTATION

15. Ideal length of amputation stump
 Above knee amputation : 23-27 cm from greater trochanter or 12 cm from
knee
 Below knee amputation : 12 -17 cm stump length
2.5cm for every 30 cm of height
 Above elbow amputation : 20 cm from shoulder
 Below elbow amputation : 18 cm from olecranon

18. Factors affecting level of stump
 Section of bone above a joint may prevent use of best type of artificial joint
 Retention of limb remnants below joint which cannot move distal part is not
justified
 When B/K amputation not possible , disarticulation favored
 In ischaemic limbs , level just below distal most pulsation

19. Ideal stump
 Conical shape ( ideal shape )
 Ideal length
 Good muscle power
 Joint should be supple
 Non adherent scar
 No fixed deformity
 Absence of neuroma
 Bone well covered by muscles
 Muscular and not flabby
 Bone covered by muscles , free from infection

20. What a stump
should look like

21. What a stump should
not look like

22. Efforts should be aimed at
 Stump drainage and removal of drain in time
 Stump splinting
 Proper stump bandaging
 Early starting of stump exercises
 Stump hygiene and intermittent exposure to air

23.  Tourniquet : Advantageous, contraindicated in ischaemic limbs.
Exsanguinations contraindicated in infected limbs & tumors
Skin Flap
 Flaps should be kept thick
◦ Posterior skin flap should be => anterior skin flap
◦ With modern total contact prosthesis , location of scar not important
◦ Flap should not be adherent to the underlying bone
◦ Preferable to have atypical skin flap than higher level amputation
◦ Large dog ears are to be avoided
◦ Combined length of flaps should be 1/3 of circumference of limb at level of
amputation
SURGICAL TECHNIQUE

24. Muscles
◦ Muscles sectioned 5 cm distal to level of intended bone resection
◦ May be stabilized by myoplasty or myodesis
◦ Myoplasty : Suturing muscle to periosteum or fascia of opposing musculature
◦ Myodesis : Suturing muscle or tendon to bone
◦ Myodesis should be performed to have stronger insertion , help maximize
strength , minimize atrophy
◦ Myodesed muscle counterbalance antagonists and prevent contractures and
maximize residual limb function
◦ Myodesis contraindicated in severe ischemia due to increased risk of wound
breakdown

26. Advantages of Myoplasty/Myodesis
 Shape of stump is good
 Muscles insulate cut nerve endings and bone from prosthesis
 Muscles originating proximally to joint produce better stump mobility and increase
leverage
 Muscles not acting on joint contract isometrically and assist in venous return
 Prevent retraction and painful muscle contractions
 Phantom pain prevented

27. Blood vessels
 Larger vessels doubly ligated
 Tourniquet should be deflated before closure
 Drain preferable for 48-72 hrs

28. Nerves
 After nerve is divided it almost always forms neuroma
 Neuroma is painful if traumatized repeatedly
 Techniques to prevent neuroma formation : end loop anastomosis ,
perineural closure , Silastic capping , sealing epineurial tube with butyl-
cyanoacrylate , ligation , cauterization or burying nerve ends in muscle
/bone
 Strong tension should be avoided while stretching
 Larger nerves may need ligation for blood vessels

29. Bone
 Excessive periosteal stripping contraindicated
 May result in formation of ring sequestrum or bony overgrowth
 Bone should be rasped to form a smooth contour- over anterior aspect for below
knee , lateral aspect of femur and over radial styloid
 Fibula cut slightly proximally to produce conical stump

30.  Skin not closed over level of amputations
 First of the at least 2 surgeries used to create functional stump
 Required in :
 Extensive contaminated injuries
 Infection
 Guillotine amputations : all tissue from skin to bone cut at same level ;
wound left open for further management ; done as an emergency
procedure
 Open amputations with flaps where wound open , flaps covered later
OPEN AMPUTATIONS

31.  Treatment of stump crucial from time amputation is completed till definitive
prosthesis is fitted
 Gradual shift from conventional soft dressings to rigid dressing
 Rigid dressing :
POP cast applied to stump at conclusion of surgery
◦ Appropriate padding of all bony prominences
◦ Avoiding proximal constriction of ring
◦ Use of dependable cast suspension methods
 If immediate weight bearing intended , true prosthetic cast should be
applied by certified prosthetist
POST OPERATIVE CARE

32. Advantages of Rigid dressings
 Prevent edema at surgical site
 Protect wound from bed trauma
 Enhance wound healing
 Early maturation of stump
 Decrease postoperative pain
 Allow early mobilization from bed
 Prevent formation of knee flexion contractures
 Drains removed at 48 hrs post op
 Stump is elevated by raising foot end
`Avoid leaving stump in dependent position

33. RIGID DRESSING

35.  Prevent flexion or abduction contractures of hip
 2nd post op day : muscle setting and joint mobilization exercises begun
 Time for prosthesis application depends upon :
 Age
 Strength
 Agility
 Patient’s ability to protect stump from excessive weight bearing
 Early unprotected weight bearing may lead to sloughing of skin or
delayed wound healing
 Cast should be removed after 7-10 days
POST OPERATIVE CARE

36.  Hematoma
 Infection
 Wound Necrosis
 Contractures
 Pain
 Phantom limb sensation
 Dermatological problems
COMPLICATIONS

37.  Hematoma:
 Prevented by rigid dressing , meticulous hemostasis
 May delay wound healing
 Serve as nidus for infection
 Infection :
 More common in ischemic ,diabetic limbs
 Deep wound infection should be treated with immediate debridement
 Delayed closure may be difficult because of edema
 Smith and Burgess method of closing central 1/3 of wound and leaving rest
packed open
 Wound Necrosis:
 Nutritional supplementation , TLC , albumin counts
 Necrosis of skin edge < 1 cm can be treated conservatively
 Discontinue prosthetic until wound healed
 If severe necrosis with loss of bone coverage , wedge resection indicated

38.  Contractures:
 Prevented by proper stump positioning , gentle passive stretching , exercises
 Increased ambulation reduces contractures
 May need wedging casts or surgical release of contracted sutures
 Dermatological problems :
 Contact Dermatitis
 Bacterial folliculitis
 Epidermoid cysts
 Verrucous hyperplasia

39.  Pain :
 Phantom limb , Phantom pain, residual pain , pain from distant site
 Back ache more common in amputees
 Residual pain more often due to improper fitting
 Painful neuroma usually is easily palpable
 Phantom limb :
 Very common
 Usually not very bothersome
 Telescoping
 Phantom limb pain bothersome , present mostly in proximal level amputations
 Conservative measures tried

40. Infection Wound necrosis

41.  Most often due to trauma followed by neoplasms , infection
 General body growth and stump growth important
 Considerations :
 Preserve length as much as possible
 Preserve important growth plates
 Prefer disarticulation rather than amputation
 Preserve knee joint whenever possible
 Stabilize and normalize proximal portion of limb
 To prevent stump overgrowth , myodesis must be preferred at the time of
surgery
 Terminal overgrowth : appositional spike like new bone formation
 Regular prosthetic checking
AMPUTATIONS IN CHILDREN

42. REFERENCES
 Campbell
 Apley’s
 Google