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AMPUTATIONS
Dr. Ammar Talib Al-Yassiri
College of medicine/Baghdad
University
Learning outcomes
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Define amputation
Realize the epidemiology of amputation
Describe the indications of amputation
Describe the varieties of amputation
Explain the principles of techniques
Describe the characteristics of the prosthesis
Recognize the complications of amputation
stumps
definition
• Amputations is the removal of a body extremity by
trauma, prolonged constriction, or surgery.
• As a surgical measure, it is the most ancient of
surgical procedures.
• Early surgical amputation was a crude procedure by
which a limb was rapidly severed from an
unanesthetized patient.
• The open stump was crushed or dipped in boiling oil
to obtain hemostasis.
epidemiology
• It has been estimated that more than 300,000
patients with amputations live in the United States.
• Greater than 90% of amputations performed in the
Western world are secondary to peripheral vascular
disease.
• In younger patients, trauma is the leading cause,
followed by malignancy.
Indications
the indications are summarized by 3D.s:
• Dead,
• Dangerous and
• Damned nuisance:
• Dead (or dying)
– Peripheral vascular disease accounts for almost 90
% of all amputations.
– severe trauma,
– Burns, and
– frostbite.
• Dangerous 'Dangerous' disorders are
– malignant tumors,
– potentially lethal sepsis,
– crush injury: In crush injury, releasing the
compression may result in renal failure (the crush
syndrome).
• Damned nuisance: Retaining the limb may be
worse than having no limb at all.
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pain;
gross malformation;
recurrent sepsis or
severe loss of function.
• The combination of deformity and loss of
sensation is particularly trying, and in the lower
limb is likely to result in pressure ulceration.
Varieties
• A provisional amputation:
– necessary because primary healing is
unlikely.
– The limb is amputated as distal as the
causal conditions will allow.
– Skin flaps sufficient to cover the deep
tissues are cut and sutured loosely over a
pack.
– Re-amputation is performed when the
• A definitive end-bearing amputation
– performed when pressure or weight is to be
borne through the end of a stump.
– the scar must not be terminal,
– the bone end must be solid, not hollow,
which means it must be cut through or near a
joint.
– Examples are through-knee and Syme's
amputations.
• A definitive non-end-bearing amputation
– the commonest variety. All upper limb and most
lower limb amputations come into this category.
– Because weight is not to be taken at the end of
the stump, the scar can be terminal.
AMPUTATIONS AT SITES OF
ELECTION
• Most lower limb amputations are for ischaemic disease and
are performed through the site of election below the most
distal palpable pulse.
The selection of amputation level can be aided by
– Doppler indices; if the ankle/brachial index is greater than 0.5, or if the
occlusion pressure at the calf and thigh are greater than 65 mmHg and
50 mmHg respectively, then there is a greater likelihood the belowknee amputation will succeed
– An alternative means is by using transcutaneous oxygen tension as a
guide,
• The knee joint should be preserved if feasible .the energy
expenditure for a trans-tibial amputee is 10-30 % greater as
compared to a 40-67 % increase in trans-femoral cases.
• demands of prosthetic design and local
function.
– Too short a stump may tend to slip out of the prosthesis
– Too long a stump may have inadequate circulation and can
become painful, or ulcerate; moreover, it complicates the
incorporation of a joint in the prosthesis.
• For all that, the skill of the modern prosthetist
has made it possible to amputate at almost
any site.
Principles of technique
• A tourniquet is used unless there is arterial insufficiency.
• Skin flaps are cut so that their combined length = 1.5
times the width of the limb at the site of amputation.
• Muscles are divided distal to the proposed site
• The bone is sawn across at the proposed level.
• Nerves are divided proximal to the bone cut
• The main vessels are tied.
• opposing muscle groups are sutured over the bone end
to each other and to the periosteum.
• The skin is sutured carefully without tension
• Suction drainage is advised.
AMPUTATIONS OTHER THAN
AT SITES OF ELECTION
• interscapulo-thoracic (forequarter)
amputation:
– mutilating operation
– traumatic avulsion of the upper limb
– eradicating a malignant tumour, or
– as palliation.
• disarticulation at the shoulder: This is rarely
indicated .
• amputation in the forearm: The shortest
forearm stump will stay in a prosthesis is 2.5
• Hemipelvectomy (hindquarter amputation):
for malignant disease.
• disarticulation through the hip: rarely
indicated.
• transfemoral amputations : it is usual to leave
at least 12 cm below the stump for the knee
mechanism.
• around the knee (The Stokes-Gritti operation)
the trimmed patella is apposed to the
trimmed femoral condyle.
• Transtibial (below-knee) amputations: the
conventional stump length 14 cm.
• Above the ankle Syme's amputation .
• Pirogoff's amputation
• Partial foot amputation:
– through the mid-tarsal joints (Chopart), through
the tarsometatarsal joints (Lisfranc),
– through the metatarsal bones or
– through the metatarsophalangeal joints.
• In the foot: diabetic gangrene
PROSTHESES
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must fit comfortably.
should function well and look presentable.
Should be fitted soon after operation.
In the upper limb, the distal portion of the
prosthesis is detachable and it can be changed.
• Electrically powered limbs are available for
both children and adults.
COMPLICATIONS OF
AMPUTATION STUMPS
• Early complications
– the complications of any operation (especially
secondary haemorrhage).
– Breakdown of skin flaps: may be due to ischaemia,
or suturing under excess tension
– Gas gangrene: Clostridia and spores from the
perineum may infect a high above-knee
amputation, especially if performed through
ischaemic tissue
• Late complications
– Skin
• Eczema is common, and tender purulent lumps may
develop in the groin. A rest from the prosthesis is
indicated.
• Ulceration is usually due to poor circulation, and reamputation at a higher level is then necessary.
– Muscle If too much muscle is left at the end of the
stump, the resulting unstable 'cushion' induces a
feeling of insecurity that may prevent proper use
of a prosthesis; if so, the excess soft tissue must
be excised.
– Nerve:
• painful neuroma: occurs when the nerve end is
subjected to pressure or repeated irritation
– Prevention: by gentle traction on the nerve followed by sharp
proximal division, allowing the nerve end to retract deep into
the soft tissue.
– Treatment: initially socket modification. If this fails, simple
neuroma excision or a more proximal neurectomy.
• Phantom limb sensations: are so common that they
should be considered normal.
– management is simply to educate the patient regarding these
sensations so that they are not surprised by their presence.
• Phantom limb pain:
– far less common.
– More often present with proximal amputations,
such as forequarter and hindquarter amputations.
– some patients may benefit from massage, ice, heat,
increased prosthetic use, relaxation training,
sympathetic blockade, local nerve blocks, epidural
blocks, ultrasound, transcutaneous electrical nerve
stimulation.
– Joint: the joint above an amputation may be stiff
or deformed
• Above knee amputation: fixed flexion and fixed
abduction .prevented by exercises, treated by
subtrochantric osteotomy
• Below knee amputation: fixed flexion
– Bone:
• a spure
• Osteoperosis
• fracture
To take home message
• >90% of amputations performed in the
Western world are secondary to peripheral
vascular disease.
• the indications are summarized by 3D.s
• Varieties of amputation
– Provisional
– Definitive End bearing
– Definitive Non end bearing
• It is possible to amputate at almost any site.