1. Amputation is the surgical removal of a limb or part of a limb and is commonly performed due to trauma, vascular disease, tumors, infections, or other conditions.
2. The goals of amputation are to preserve functional residual limb length while providing well-healed, non-tender soft tissue reconstruction.
3. Major types of amputations include below knee amputations, above knee amputations, and forequarter (shoulder) amputations. Each type has specific surgical and rehabilitation considerations.
2. Outline
• Introduction and general principles
• Upper limb amputation
• Lower Limb amputation
• Rehabilitation
3. Definition
• Amputation:“Surgical removal of limb or part
of the limb through a bone or multiple
bones”
Versus
• Disarticulation:“Surgical removal of whole
limb or part of the limb through a joint”
4. History
• Most ancient of surgical procedure.
• Stimulated by the aftermath of war.
• Crude procedure - limb was rapidly
severed from unanesthetized
patient.
• The open stamp was then crushed or
dipped in boiling oil to obtain
hemostasis.
• Hippocrates was the first to use
ligature.
• Ambroise Pare ( a France military
surgeon) introduced artery forceps.
He also designed prosthesis
6. Etiology
• Trauma
• Peripheral Vascular Disease
• Malignant Tumors
• Burns
• Neurologic Conditions
• Infections
• Congenital Deformities
Dead
Deadly
Dam Nuisance
Put in order of frequency
7. Indications
• DEAD LIMB :
Gangrene
• DEADLY LIMB
Wet gangrene
Spreading cellulitis
Arteriovenous fistula
Other (e.g. malignancy)
• ‘DEAD LOSS’ LIMB
Severe rest pain with unreconstructable
critical leg ischaemia
Paralysis
Other (e.g. contracture, trauma)
8. Types
I. • Non end bearing/side bearing.
• End bearing/cone bearing.
II. • Weight bearing.
• Nonweight bearing.
Types of flaps
• Long posterior flap in below-knee amputation.
• Equal flaps in above-knee amputation.
12. Ideal stump
• It should be of optimum length.
• Should be rounded, smooth, with gentle
contour.
• Should be firm and heal adequately (thin
scar).
• The opposing groups of muscle sutured
together over the end of bone.
• The muscle are sutured in a such way that
they will be converted into fibrous tissue and
serve as in effective cushion.
13. Ideal stump….
• Vascularity of flap should be normal.
• There should be no projecting of spur bone.
• The stump should not be under tension.
• The position of scar should be avoided of
pressure and should be transverse to avoid
pulling up two bones in AP scar.
• In case of upper limb the scar can be terminal
, but in L.L. a posterior scar is desirable to
avoid pressure of weight of artificial limb.
14. Ideal stump…
• Adequate adjacent joint movement
• CONICAL BEARING:
healing (primary intention)
non projecting bone
myoplastic
No neuroma
Non tender scar
Proximal joint supple
15. Principles
• Preparation
• Good Surgical Technique
• Early Prosthetic Fitting
• Team Approach
• Vocational and Activity Rehabilitation
16.
17. Evaluation- Clinical history &
examination
• Thorough history , past history and co
morbidities
• GPE??- pallor, signs of sepsis etc
• Local examination:
??? Inspection (ulcer, gangrene, color),
palpation (temperature, motor n sensory), hand
held doppler if available
18. Evaluation- Lab studies
• Hemoglobin,Hematocrit (control of anemia)
• Creatinine levels should be monitored.
• Potassium and calcium levels should be
monitored. Elevated levels of these electrolytes
may lead to cardiac arrhythmias and seizures.
• White blood cell count, C-reactive protein , and
ESR . (control of infection using antibiotics)
• C-reactive protein to be the first laboratory value
to respond to treatment.
• Platelets ,Coagulation profile
• Myoglobinuria??
19. Imaging
• X-ray-AP & Lat view ????
• Usg doppler ( decision of level of amputation)
• Computed tomography (CT) scanning and magnetic
resonance imaging (MRI) -osteomyelitis to ensure
that the surgical margins are appropriate.
• Technetium-99m (99mTc) pyrophosphate -electrical
burns and frostbite. 94% sensitivity and 100%
specificity for demarcating viable tissues from
nonviable tissues.
• CT Angio and MR angiography
20. Imaging (Contd.)
Doppler ultrasonography–Blood pressure
• 15% of patients with PVD, pressure falsely elevated because of the
no compressibility of the calcified extremity arteries.
• Minimum 70 mm Hg is believed to be necessary for wound
healing.
Ischemic index (II): -
Site pressure/brachial pressure >=0.5 at the surgical level is
necessary to support wound healing.
Ankle-brachial index: -
The II at the ankle level is best indicator for assessing adequate
inflow to the ischemic limb.
An index less than 0.45 indicates incisions distal to the ankle will not
heal.
21. Pre operative preparation
• Informed written consent
• Identify patient and limb
• Appropriate preoperative antibiotics
• A tourniquet can be placed on the limb
prophylactically not in PAD
• Vascular and bone instruments are requested.
• An appropriate strength saw (gigly or
mechanical)for cutting bone
• Vessel ligatures are obtained.
22. Site of selection
• Examination :-
• skin colour
• hair growth
• lowest palpable pulse
• Skin temperature
• Investigation :- USG Doppler/ angiography
23. General Principles
• Adequate blood supply of flap should be
maintained
• Adequate flap length, ideally semicircular
• Proximal part of flap contains muscles but distal
should have only skin & deep fascia
• Skin-greatest skin length possible should be
maintained for muscle coverage and a tension-free
closure. (proper marking)
24. General Principles
• Muscle-Muscle is placed over the cut end of bones
via a myodesis, a long posterior flap sutured
anteriorly, or a well-balanced myoplasty (i.e.,
antagonistic muscle and fascia sutured together ).
25. General Principles(Contd.)
• Nerves –pulled distally, cut sharply (knife) &
allowed to retract.
Ligation of large nerves can be performed
when an associated vessel is present
• Arteries and veins- dissected and separately
ligated. Prevents the development of
arteriovenous fistulas and aneurysms.
26. General Principles(Contd.)
• Bone-Bony prominences around disarticulations
are removed with a saw, whereas for distal ends
cut with beveling anteriorly and filed smooth.
Maintaining the maximal extremity length
possible is desirable.
• Below-knee amputations are best performed 12-
18 cm below the joint line for non-ischemic limbs
• For ischemic limbs, a higher level of 10-12.5 cm
below the joint line is used because making limbs
longer than this can interfere with prosthetic use
and design
27. General Principles(Contd.)
• In crush injury/ entrapment injury/ sepsis-
Guillotine amputation should be done.
Later definitive closure is planned.
• Knowledge of anatomy of respective level of
limb is a must.
30. Goals of Post operative care
General :-
Analgesia
Antibiotics
DVT prophylaxis
Specific :-
Prompt, uncomplicated wound healing
Control of edema
Joint positioning and exercise
Drain removal
Mobilization
Rehabilitation
31.
32. Upper limb vs Lower limb
• Upper extremity non weight bearing
• Less durable skin acceptable
• Decreased sensation better tolerated
• Joint deformity better tolerated
• Late amputations rare
• Transplants now being performed
34. Trauma
• 90 % of Upper Extremity Amputation
• Male: Female = 4:1
• Most Amputations at level of Digit
• Major Limb Amputations less common
• Revascularization possible for incomplete
amputation
• Replantation possible for complete
amputation
35. Amputation vs Replantation
Poor Candidates for Replantation
1. Severely crushed or mangled parts
2. Multiple levels
3. Other serious injuries or diseases
4. Atherosclerotic vessels
5. Mentally unstable
6. > 6 hours ischemic time
7. Severe contamination
36. Decision Making
• Limb injury score
• Mangled Extremity Severity Score
• Attempts to salvage a severely injured limb may lead
to metabolic overload and secondary organ failure
• Injury severity score > 50 : contraindication to limb
salvage
Mangled Extremity Severity Score(M.E.S.S. )(Helfet,
CORR, 80, 1990) (most useful)
< 7 : Salvage
8-12 : Amputate
MESS >7
LSI >6
PSI >8
NISSSA
>11
HFS-
98 >11
37. • The five commonly used scoring systems are
the Mangled Extremity Severity Score
(MESS)1,3; the Limb Salvage Index (LSI)5; the
Predictive Salvage Index (PSI)2; the Nerve
Injury, Ischemia, Soft-Tissue Injury, Skeletal
Injury, Shock, and Age of Patient Score
(NISSSA)4; and the Hannover Fracture Scale-98
(HFS-98)6,
38. Mangled Extremity Severity Score
(MESS)
• A. Skeletal/Soft tissue injury
1. Low energy (stab wound, simple fracture, low-energy gunshot wound)
2. Medium energy (open or multiple fractures, dislocation)
3. High energy (high-speed motor vehicle collision or rifle gunshot wound)
4. Very high energy (above plus gross contamination)
• B. Limb ischemia*
1. Pulse reduced or absent but perfusion normal
2. Pulseless; paresthesia, diminished capillary refill
3. Cool, paralyzed, insensate, numb
• C. Shock
0. Systolic blood pressure always > 90 mm Hg
1. Systolic blood pressure transiently < 90 mm Hg
2. Systolic blood pressure persistently < 90 mm Hg
• D. Age (years)
0. <30
1. 30 -50
2. >50
• *Score doubled for ischemia time > 6 hours
39. Aim
• Preservation of functional residual limb
length
balanced with
• Soft tissue reconstruction to provide a well-
healed, non-tender, physiologic residual limb
40.
41. Technique: Determination of Level
• Zone of Injury (trauma)
• Adequate margins (tumor)
• Adequate circulation (vascular disease)
• Soft tissue envelope
• Bone and joint condition
• Control of infection
• Nutritional status
42. Technical Consideration
• Wrist Disarticulation vs. Transradial
• Disarticulation -better active pronation and supination of
forearm
• Disarticulation poor aesthetically
• Disarticulation more difficult to fit prosthetic
• Transradial -difficult to transmit rotation through
prosthesis
• Transradial needs to be done 2 cm or more proximal to
joint to allow prosthetic fitting
• Transradial usually favoured
43. Technical Consideration
• Transhumeral vs. Elbow Disarticulation
– Adults: Elbow disarticulation allows enhanced
suspension and rotation control of prosthesis
however retention of full length precludes use of
prosthetic elbow. Long transhumeral favoured
– Pediatrics: Transhumeral amputation results in
high incidence of bony overgrowth. Elbow
disarticulation is level of choice.
44. Technical Consideration
• Preservation of Elbow function is a priority
• Consider replantation/salvage of parts to maintain
elbow function
• 4-5 cm of proximal ulna necessary for elbow
function
• For very proximal amputations, it may be
necessary to attach bicep tendon to ulna
45. Krukenberg procedure
• More than 80 years ago,
Krukenberg described a
technique -a forearm stump
into a pincer motorized by the
pronator teres muscle.
• Used to be done for bilateral
upper-extremity amputations,
in those who are also blind.
• Not recommended as a primary
procedure at the time of an
amputation,
• To consider this surgical option,
the ulna and radius must extend
distal to the majority of the
pronator teres (the motor for
pinching) and an elbow flexion
contracture of less than 70°.
48. Pathophysiology
• As the level of the amputation moves proximally
o Greater the energy expenditure that is required
o Walking speed of the individual decreases
o Oxygen consumption increases
• Transtibial amputations- Energy cost for walking
similar to non amputee
• Transfemoral amputations-Energy required is 50-
65% greater than that required for those who
have not undergone amputations .
50. Minor amputation
• Toe amputation (through phalanx or entire toe)
• Distal metatarsophalangeal
• Ray amputation
• Transmetatarsal
• Lisfranc(tarsometatarsal)
• Chopart(midtarsal)
• Symes: Ankle disarticulation, through the
malleoli. It is a weight bearing amputation
because the heel pad is swung under the
tibia and fibula and attached.
52. Ray amputation
• Entire toe or finger with part
or complete metatarsal or
metacarpal respectively
• Very common
• Preservation of foot length and
cosmetically acceptable
55. Below Knee Amputation(BKA)-
Transtibial
• Most common secondary to PVD
• Different lengths
– Short (20% of tibia left)
– Standard (50% of tibia left)
– Long (90% of the tibia left)
56. Below Knee Amputation
• Ideal – 15 cm of tibia; if not possible, at least
7.5cm
• Anterior skin incision made; length of
posterior flap made 1.5 times the diameter
(circumference)of the limb at level of
amputation.
• Ant compartment muscles (TA, EHL, EDL) cut
• Ant tibial artery and vein ligated and divided
57. BKA contd….
• Tibia transected and bevelled anteriorly
• Fibula transected 1 cm more proximally
(removed completely in shorter BKA)
• Post tibial vessels identified, ligated and cut
• Muscle bulk reduced in the post flap to obtain
a tapered stump
• Ant and post fascia closed with 2-0 absorbable
sutures; skin closed with 3-0 nylon
62. Above knee amputation
• Relatively uncommon
• < 1½ inches of tibia is viable
• Intact femur results in good weight bearing surface
• Lengths
– Long (>60% of femur left)
– Standard (60%-35% of femur left)
– Short (<35% of femur left)
63. Above knee amputation
• Skin and subcutaneous tissue cut
• Ant femoral muscles (sartorius, quadriceps)
cut first, f/b medial femoral muscles (gracilis,
pectineus, adductor)
• Superficial femoral art and vein ligated and cut
• Post femoral muscles (biceps femoris,
semimembranosus, semitendinosus) cut
64. AKA contd…
• Sciatic nerve (b/w
adductor magnus and
biceps femoris) ligated
and cut
• Periostium stripped and
femur transected
• Ant and post fascia close
with 2-0 absorbable; skin
closed with 3-0 nylon;
drain±
69. Pain management
• Post op Pain:Analgesics+Limb elevation
watch for infection
• Pain after healing: treat cause+mechanical
Stimulation
• Prosthetic pain: best fit prosthesis
• Phantom Pain: Difficult to treat
70. Psychological adjustment
• Provide information
• Assess social support
• Address both the amputee and the family
• Peer Counselling and support groups
• Return to work and previous life roles.
71. Skin Care
Skin hygiene and lubrication Skin Inspection
Skin Mobilization Skin desensitization
72. Physiotherapy
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
76. Positioning
• Elevation of the residual limb on a pillow
following either transfemoral or transtibial
amputation can lead to hip/knee flexion
contractures and should be avoided.
77. Mobility
• Reaching for an object promotes weight shifting on/off the
prosthesis. Mirror reduces tendency to look at the floor.
82. Temporary Prosthesis
• Cosmetically unfinished
prosthesis that has been
fitted and aligned
• Used when amputee’s
ability to wear a prosthesis
is in doubt
• Can help shape limb better
rather than dressing
83. Part of Prosthesis
Strap or belt holding
prosthesis to stump
Soft Foam or silicone
Contact with the skin
Connects socket with foot
Contact with ground
85. Jaipur Foot
Bhagwan Mahavir Viklang Sahyata Samiti Dr. P. K . Sethi
•The articulation at the 'ankle' allows not only Inversion-
Eversion movements but also dorsiflexion(essential for
squatting, standing up from prone position etc.)
•A shorter keel helps achieve this. Also, the materials used
at the foot end are waterproof and moderately mimic a
real foot.
86. Conclusion
• Fewer procedure in surgery evoke more fear in
patient than a major amputation.
• Careful selection of level based on circulation
and functional issues, attention to detail in the
operating room, and careful perioperative
care are required to obtain good results.
• Surgeon who performs a major limb
amputation owes the patient debt of
rehabilitation
87. Amputation is not the end of life. It is the first day of
new beginning!!
Editor's Notes
Skeletal / soft-tissue injury Low energy (stab; simple fracture; pistol gunshot wound): 1 Medium energy (open or multiple fractures, dislocation): 2 High energy (high speed MVA or rifle GSW): 3 Very high energy (high speed trauma + gross contamination): 4 Limb ischemia Pulse reduced or absent but perfusion normal: 1* Pulseless; paresthesias, diminished capillary refill: 2 Cool, paralyzed, insensate, numb: 3* Shock Systolic BP always > 90 mm Hg: 0 Hypotensive transiently: 1 Persistent hypotension: 2 Age (years) < 30: 0 30-50: 1 > 50: 2
