4. Introduction
• Not a failure of surgery but a reconstructive
procedure
• Goal is surgical reconstruction that maintains
most functional limb possible
5. Introduction
History
• Earliest reference in Babylonian code of
Hammurabi-1700BC
• Hippocrates in De Articularis-385BC
• William Cloves did first successful AKA-1588
• Botallus and Fabricus Holdani describe use of
torniquet-16th century
• Norman Kick used Guillotine amputation during
World War-1943
8. Introduction
Epidemiology
• The estimated prevalence of extremity
amputation in Nigeria is 1.6 per 100,000
• The most frequent indications for
amputation were trauma (34%); complication of traditional
bonesetting (TBS)(23%); malignant tumours (14.5%);
diabetic gangrene (12.3%); infections(5.1%); peripheral
artery disease (2.1%); and burns (2.1%).
• The average age of the Nigerian amputee is 33 years.
• Hospital mortality after amputation is 10.9%.
Extremity amputation in Nigeria a review of indications and
mortality. Thanni LO , Tade AO. Surgeon. 2007 Aug;5(4):213-7.
9. Introduction
Epidemiology
• 320 limb amputations were performed
on adults at the Ahmadu Bello University Hospital, Nigeria over a period of
10yrs.
• Major indication for upper limb amputation was trauma and post-fracture
splintage
gangrene (57%).
• In the lower limb the most common indication for
amputation was advanced squamous cell carcinoma of the skin involving
the
bone.
• No case of peripheral vascular disease in these patients
other than diabetic ulcers
Major Limb Amputation in Adults,Zaria,Nigeria.
Yakubu A , Muhammad I, Mabogunje OA. J R Coll Surg Edinb. 1996 Apr;41(2):102-
4.
14. Amputation levels ( upper limbs )
• Hand & Partial-Hand Amputations
Finger, thumb or portion of the hand
below the wrist
• Wrist Disarticulation
Limb is amputated at the level of the
wrist
• Transradial (below elbow
amputations)Amputation occurring in the
forearm, from the elbow to the wrist
• Transhumeral (above elbow
amputations)
Amputation occurring in the upper arm
from the elbow to the shoulder
• Shoulder Disarticulation
Ambutation at the level of the shoulder,
with the shoulder blade remaining.
• Forequarter Amputation
Amputation at the level of the shoulder in
which both the shoulder blade and collar
bone are removed
15. Amputation levels ( lower limbs )
• Foot Amputations
• Amputation of greater toes and other toes
• Amputation through the metatarsal bones
• Lisfranc`s operation : at the level of the
tarsometatarsal joints
• Chopart`s operation : through the midtarsal
joints
• Transtibial Amputations (below the knee)
Amputation occurs at any level from the knee
to the ankle
• Knee Disarticulation
Amputation occurs at the level of the knee
joint
• Transfemoral Amputations (above knee )
Amputation occurs at any level from the hip
to knee joint
• Hip Disarticulation
Amputation is at the hip joint with the entire
thigh and lower portion of the leg being
removed.
19. Goals of amputation
• To get rid of all necrotic, infected & painful
tissue.
• To have a wound that heals successfully.
• To have an appropriate remnant stump that
is able to accommodate a prosthetic.
20. Pre-Operative Assessment
To:
• Ascertain indication
• Site of amputation
• General medical condition
• Rehabilitation potential
• Counselling
• Consent
• Optimisation
21. Pre Operative Assessment
• Assessment of –
– The affected limb
– The unaffected limb &
– The patient as a whole is conducted thoroughly.
• Assessment of physical, social & psychological status
of the patient should be made.
22. Pre-operative Evaluation
• History
o Aetiology
o Comorbidities
• Physical examination
o MSS-MESS ≥ 7
Removes subjectivity from decision making in
trauma cases.
No scoring system can replace experience & good clinical judgment.
o CVS, Renal &
o Nervous system
23. Pre-operative Evaluation
• Investigation
– To confirm Diagnosis
o Doppler
o X-Ray
o FBS
o Technitium 99 Pyrophosphate bone scan
– Capability of Wound Healing
o Transcutaneous Oxygen
o Hemoglobin
o Serum Albumin
o Absolute lymphocyte count
24. Pre-operative Evaluation…
• Optimization:
Anaemia, hypotension, infection, nutrition
• Consultations:
Nephrologist, Cardiologist, Neurologist
If vascular dx has progress to the point of amputation, most patients also
have concomitant dx process in the cerebral, renal & coronary
vasculatures.
25. Social assessment includes
• Family & friends supports
• Living accommodation –
– Stairs, ramps, rails, width of door, wheelchair accessibility
• Proximity of shops
27. Intra-operative Principles
• Determine outcome of function and
rehabilitation
• Meticulous attention to detail and careful soft
tissue handling
• Effort to be directed at achieving ideal stump
28. Ideal stump
1) It should be of optimum length
2) The end of stump should be smooth &
rounded
3) It should be firm
4) The opposing group of muscles should be
sutured together over the end of the bone.
5) The muscles are sutured in such a way that
they will be converted into fibrous tissue &
serve as an effective cushion.
29. Ideal stump
6) Vascularity of the flaps should be normal
7) There should be no projecting spur of bone.
8) The stump shouldn't’t be under tension.
9) The position of the scar should be avoided
of pressure n should be transverse to avoid
pulling up between 2 bones in ap scar.
10) In case of U.L the scar can be terminal, but
in L.L a posterior scar is desirable to avoid
pressure of weight of artificial limb.
30. Traditional Sites of Election
Upperlimb
• A/E – 20cm from Acromion
• B/E – 18cm from Olecranon
Lowerlimb
• A/ K – 12cm from Joint line
• B/ K – 14cm from Joint line
31. Site of Selection
Examination
• Skin color
• Hair growth
• Lowest palpable pulse
• Skin temperature
Investigation
• Doppler USS
32. INTRA - OPERATIVE
• Anaesthesia: GA or Regional
• Position: Supine
• Tourniquet +/_ Exsanguination
41. Intra-Operative Principles
Closing the Wound
• Hemostasis is secured
• Opposing group of muscles are sutured across
both the ends with interrupted stitches.
• Fascia & skin are sutured over the muscle without
tension.
• Preferably a suction drain is placed.
• Wound is covered with gauze & roller bandages
tightly from below upwards.
45. Intra-Operative Principles
Wound Dressing
• Soft vs Rigid
• Rigid dressing : decreses edema, decreases
post operative pain, protect limb from
trauma, early mobilsation. Good bandaging
to mold the stump into Conical shape to
accept the prosthesis
• Soft dressing concept: The stump is dressed
with the sterile dressing & crepe bandage
applied over it.
50. Smith and Burgess method: the central one third of
the wound is closed, and the remainder of the wound
is packed open.
51. Phantom sensation
• The phantom is the sensation of the limb that is no
longer there. The phantom, which usually occurs
initially immediately after surgery, is often described as
a tingling, burning, itching or pressure, sensation,
sometimes a numbness.
• Phantom sensation may be painless although, most
people find it uncomfortable & often report it as pain;
it usually does not interfere with prosthetic
rehabilitation.
(Physical rehabilitation;Susan B O’ Sullivan; 5th )
52. Phantom Limb Pain
• Phantom pain and sensations are defined as
perceptions ranging from slight tingling to
sharp, throbbing pain or aching that patients
perceive relating to an extremity or an organ
that is physically no longer a part of the body.
• It has been reported in various trials that the
estimated prevalence of phantom pain varies
from 49% to 83%.
53. Rehabilitation
• Residual Limb Shrinkage and Shaping
• Limb Desensitization
• Maintain joint range of motion
• Strengthen residual limb
• Maximize Self reliance
• Patient education: Future goals and prosthetic
options
54. Psychological stress
• Up to 2/3 of amputees will manifest
postoperative psychiatric symptoms
– Depression
– Anxiety
– Crying spells
– Insomnia
– Loss of appetite
– Suicidal ideation
56. • Amputations in children is divided into two
general categories—congenital (60%) and
acquired (40%)
Amputations In Children
57. Amputations In Children
Congenital
Congenital deficiencies of
the long bones
Amniotic band syndrome
Exposure to teratogens (
thalidomide )
Polydactyly
Macrodactyly
Congenital pseudoarthrosis
of the tibia and fibula,
radius and ulna
Acquired
• Secondary to trauma
• Neoplasm
• Infection.
• Vascular disease
58. • Preserve length
• Preserve important growth plates
• Perform disarticulation rather than
transosseous amputation whenever possible
• Preserve the knee joint whenever possible
• Stabilize and normalize the proximal portion of
the limb
• Be prepared to deal with issues in addition to
limb deficiency in children with other clinically
important conditions.
Principles Of Childhood Amputation
59. Because of growth issues and increased body
metabolism, children often can tolerate
procedures on amputation stumps that are
not tolerated by adults, which includes
• More forceful skin traction
• Application of extensive skin grafts
• Closure of skin flaps under moderate tension.
Advantages Of Amputation In Children
In Comparison To Adults
60. Prosthetics
It is a replacement of
substitution of a missing or a
diseased part
61. Types of Prosthesis
BELOW KNEE
KNEE
DISARTICULATION ABOVE KNEE
HIP
DISARTICULATION
PROSTHETICS
LOWER EXTREMITY
62. Ideal prosthesis
1. Fits comfortably
2. Function well
3. Looks presentable
4. Fit as soon after the operation
63. Temporary –
•Used following amputation
till paient is fitted with
permanent prosthesis
eg;pylon
•Permanent prosthesis
64. Conclusion
• Goal is to achieve useful residual limb in an
individual who is active with a positive
attitude an continues to be a productive
member of society
65. Reference
• Current Diagnosis & Treatment in Orthopedics
3rd edition: by Harry Skinner (Editor)
Publisher: Appleton & Lange (June 20, 2003)
• Campbel Operative Orthopedics, 11th Edition
Leg Prosthesis (2 types):
An exoskeletal prosthesis has a hard outer shell made primarily of plastics and laminates.
An endoskeletal or modular prosthesis has the tube or pylon frame that acts as a type of “skeleton.”
A soft foam cover is usually applied over the prosthesis. The foam cover is shaped to match the remaining sound limb.
Arm:
A myoelectric arm, in which signals from muscles in the residual limb are sent via electrodes to the prosthetic hand to open or close it, is powered by a battery
The cheetah prosthetic which is pictured above has been riddled with controversy. Oscar Pistorius is a double below-knee amputee from South Africa who recently won the silver medal in the 400m at the South African senior athletics championships against an entirely able-bodied field. However, he may be excluded from further competing in "able-bodied" events because some feel that his artificial legs give him an unfair advantage by virtue of being longer then natural legs. Others say that his legs are a disadvantage, since unlike natural legs, they are merely akin to springs and can not generate energy like a natural leg.
It is important to consider culture and ethnic origin when discussing a prosthetic with patients. When I was in Haiti it was common for prosthetics to go unused as they were not made to match the skin tone of their wearer!