Amputation, Disarticulation, Definition, stump, idea stump, types, methods,complication

1. Amputation and
Disarticulation
Indications, methods and complications
Dr Yash Oza

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-as the only step to give comfort
and prolong life.“
-Sir William Ferguson

3. Definition
• Amputation :
Removal of a part of limb
completely or partially proximal to the
lesion is called amputation.
• Disarticulation
It is the separation of two bones
at their joint, either traumatically by
way of injury or by a surgeon during
arthroplasty or amputation.

4. Indications
DEAD, DYING, DEVITALISED TISSUE
• Peripheral vascular disease (with or without
diabetes) is the commonest indication for
amputation. Gangrene due to atherosclerosis,
embolism, TAO, etc.
• Trauma is leading indication in young patients. To
save life in crush injuries
• Burns: thermal, chemical or electric may
necessitate amputation.
• Frostbite

5. • Infections. acute/chronic
infection which are
unresponsive to antibiotics and
surgical debridement. Most
worrisome of these are
infections causes by gas
forming organ isms which
typically result from battle field
injuries; farm injuries, severe
motor vehicle accidents and
gunshot wounds.
• Neoplasm : Osteosarcoma,
Marjoilin’s ulcer, melanomas
• Severe deformity : congenital or
acquired

6. Types of Amputation
Weight is taken up by the joint Weight is taken up by the body

7. Types of Amputation
Provisional
• Later final
amputation
is required
• temporary
Guillotine
• Emergency
conditions
• War
• Later final
amputation
is required
Formal
• It is a
definitive
procedure

8. Types of flaps
• Ex; below knee
amputation
Longer
Posterior
flap
• Ex; above knee
amputation
Equal Flap

9. 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 7.5 (minimum) to 12.5 cm from tibial tuberosity
• For above and below elbow 20 cm stump.For
• A-K 23 cm from greater trochanter.

10. • Should have thin scar which does not interfere with prosthetic
function.
• Should have adequate adjacent joint movement.
• Should have adequate blood supply.
• Scar should be in a place where it is not exposed to pressure.
• Scar should be freely mobile over underlying tissues, Skin and scar
should be freely mobile over the underlying bone. It is achieved only
if deep fascia is closed properly.
• Scar and skin should be free to achieve free movement of the
prosthesis. Socket of prosthesis with mobile skin creates a piston to
bone to move like a joint.
• Skin should not be unfolded.
• Redundant soft tissue should not be there.
• Stump should be free from tenderness and conical.

11. Principles in Amputation
• Adequate blood supply of the flap should be maintained.
• Tourniquet should not be used if amputation is done for vascular diseases.
• Proximal part of the flap contains muscle component but distal part should
contain only skin and deep fascia.
• Nerve should be pulled down and cut using a sharp knife and allowed to
retract into the soft tissue otherwise neuromas may develop.
• In crush injury/entrapment injury/sepsis guillotine amputation is done.
Later skin is pulled down by using skin traction, eventually to have better
skin coverage.
• Bone should be cut with beveling and all sharp margins should be rounded.
• Post-operatively active exercise should be given to the proximal joint so
that the prosthesis can be fitted properly.

12. • Myodesis :
muscle sutured to the bone via
drill holes
establish resting tension
provides better limb control, avoid
contracture
• Myoplasty :
muscle of opposing compartment
sutured to each other under tension
can achieve function as similar to
myodesis

13. Different Amputation

14. Amputation of Foot & Ankle

15. 1.Toe amputation : disarticulation of
toes from Interphalangeal joint
Single or multiple toes
2.Metatarsophalangeal disarticulation
3.Transmetatarsal amputation

16. 4. Lisfrank : at level of tarso-metatarsal
joint
5.Chopart’s : at level of midtarsal joint

17. 6. Syme amputation: through ankle at the
level just proxy mal to malleoli
- disadvantages include: poor cosmesis
(bulbous stump) and migration of heel pad
posteriorly).

18. 7. Boyd amputation is a modification of
Syme amputation. It involves talectomy
followed by calcaneo-tibial arthrodesis sis.
This preserves the heel pad for weight
bearing.
8. Pirogoff amputation involves sectioning
of calcaneus vertically. The remaining
posterior part of calcaneus is ro tated to
produce tibia calcaneal arthodesis.

19. 9. Ray amputation (lateral ray, middle rays and medial ray)

20. Amputation of lower limb

21. 1. Trans-tibial (below knee) amputation is the commonest level. The ideal
stump length in a below knee amputation is 12.5-17.5 cm depending on
the patient's height. (2.5 cm bone length for each 30 cm of body height).
Stump lacking quadriceps insertion are not useful.
A tibio-fibular synostosis (Ertl Procedure) creates wider stump and
removes fibular instability.

22. 2. Disarticulation of knee: is an excellent end bearing stump

23. • 3. Gritty-Stokes amputation:
the level is at the distal most
part of femoral condyles.
The advantage is good
fixation of muscle and skin to the
cancellous bone of distal femoral
condyles.
• 4. Trans-femoral (above knee)
amputation: The stump length
should allow adequate room
for fitting of prosthesis with
knee joint at same level with
the normal knee.
The longer stump results
in a distally placed prosthetic
knee which is undesirable.

24. 5. Disarticulation of hip : most
common indication are bone & soft
tissue sarcoma of femur or thigh
6. Hemipelvectomy : Sarcoma, life
threatening infection, arterial
insufficiency are common indication.
hemipelvectomy disarticulates
the symphysis pubis, sacroiliac joint
and ipsilateral limb

25. Amputation of hand
1. Finger tip amputation: a split thickness graft is sufficient if the bone
is only slightly exposed/ not exposed. Flaps/ full thickness grafts are
desirable for better sensation and durability. Flaps available for finger
tip cover include:
a. V-Y advancement flaps (Kutler/Atasoy)
b. Cross finger flap
c. Thenar flap
d. Island pedicle flap
e. Ulnar hypothenar flap

26. 2. Index/2nd ray amputation ideal level is through second metacarpal if
amputation is anticipated proximal to PIP.
3. Amputation of hand at wrist: grasp may be obtained by Krukenberg
reconstruction which converts forearm into a forceps where radial ray acts
against the ulnar ray.

27. 4. Thumb amputation reconstruction of thumb can be done by
pollicisation of 2nd digit (Buck-Gramcko). 2nd toe may be used with
micro-vascular technique to replace for thumb.

28. Amputation of Upper limb
1. Wrist Amputation : transcarpal amputation ( in between distal &
proximal row ) and disarticulation of hand are preferred to
amputation through distal forearm, because this preserves the
supination and pronation at forearm.

29. 2. Forearm amputation ( Transradial)
3. Elbow Disarticulation

30. 4. Transhumeral amputation
5. Disarticulation of shoulder

31. 6. Fore-quarter amputation: removes the entire upper extremity in
the interval between scapula & chest wall ( Tickhoff Limberg
procedure)

32. Complication
Early
Hemorrhage
Hematoma
Infection
Late
Pain
Ulceration of the stump
Ring sequestrum formation
Flap Necrosis
Painful ulcer
Phantom Limb

33. Early complication
Haematoma
• It is identified by pain, swelling over the stump underneath the flap.
• It is aspirated using a wide bore needle.
• Haematoma may delay healing; may precipitate infection or flap
necrosis due to pressure.
• After aspiration, pressure dressing is needed.
• If haematoma reforms after 2-3 aspirations, it should be drained by
opening the wound on one corner and inserting haemostat into the
wound.

34. Early complication
Infection of the Stump
• It may cause abscess formation, delay in wound healing, flap
necrosis, giving way of the wound.
• Removing few or all sutures to relieve pressure and draining the pus
underneath is needed.
• Infection may also lead to poor scar, adherent scar which causes
difficulty in placing the prosthesis.

35. Late complication
Flap Necrosis
• It is a common complication.
• Main causes for flap necrosis are poor blood supply, infection,
haematoma underneath, inadequate length of the flap causing
stretching of flap.
• Small area of necrosis can be excised.
• Wider area needs laying opening of the wound or revision of the
stump or higher level amputation.
• Anaemia, poor nutrition, nutritional deficiencies, diabetes mellitus,
immunosuppression, smoking, old age are other factors causing flap
necrosis.

36. Late complication
Stump Neuroma
• It can occur due to proliferation of the
nerve fibrils beyond the point of nerve
division and is usually due to failure of
cutting of the nerve more proximal to
the level of division of the bone.
• It causes pain and tenderness over the
stump. It is usually relieved by
analgesics, re-assurance and prosthesis.
• Occasionally, it may require re-
exploration of the wound, excision of
end neuroma and also cutting nerve
more proximally.

37. Late complication
Stump Pain after Amputation
• It is a common problem.
• Causes are-infection, poor blood supply, causalgia, stump neuroma,
phantom pain/limb, deep vein thrombosis, adherent scar, formation
of spurs and osteophytes at amputated bone end.
• Scar adhesion to bone is prevented by keeping adequate length of
deep fascia underneath intact.
• Spurs and osteophytes are confirmed by X-ray and needs removal
using bone nibbler after appropriate skin incision.

38. Late complication
Phantom Limb
• It is typical awareness of sensation that as if amputated part is still
present partly or in toto; often such part may be painful or
disturbing or hyperaesthetic.
• Exact cause is not known, but it is probably due to presence of
severe pain at the amputated part just prior to amputation making
brain area for that part in alert situation causing phantom limb.
• Reassurance, prosthesis, analgesics help to control the condition.
• It is said that it can be prevented by proper pain control for 24 hours
prior to amputation; but it is often difficult.
• It is common in upper limb.

39. Late complication
Ulceration over the stump
• It is not uncommon. It is due to necrosis, infection, lengthy bone
stump pressing on the summit of the flap, prosthesis, nutritional
deficiencies, diabetes mellitus, ischemic.
• Ulcer may be small/large; superficial/deep
• Callous chronic ulcer at the end of the stump is called as Douglas
ulcer.
• Small ulcer is later treated by regular dressings and suturing.
• Large ulcer needs flap to cover the defect.
• Osteomyelitis of the stump should be ruled out in chronic stump
ulcer. Ring sequestrum may be typical in such situation.
• Revision amputation is needed for the stump.

40. Late complication
Contracture of the Joint
• Contracture of the joint proximal to the amputated stump is
common.
• It is mainly due improper positioning after amputation due to pain,
poor exercise and occasionally due to inflammation of surrounding
soft tissues.
• Contracture interferes with proper fitting and functioning of the
prosthesis and delays rehabilitation.
• Proper positioning, passive stretching and exercises, strengthening
exercises with help to correct it.
• Rarely needs surgical release of the contracture.

41. Other Complications
• Scar hypertrophy,
• skin thickening,
• hyperkeratosis,
• papilloma,
• Eczema,
• Lymphoedema,
• boils,
• bursae over bony point
• Spur,
• osteophyte formation,
• causalgia,
• jactitation of the stump,
• stump aneurysm,
• stump fracture

42. Thank
you