This document provides information on amputations of the lower limb. It discusses the indications for amputation including peripheral vascular disease, trauma, burns, frostbite, infections, and tumors. It covers the surgical principles of amputation including determination of amputation level, techniques, postoperative care, and complications. It also provides specifics on transtibial (below knee) amputation techniques for both ischemic and nonischemic limbs.
2. Introduction
• Latin amputare, "to cut away”
• “Surgical removal of limb or part of the limb through a bone or
multiple bones”
• Should not be viewed as a failure of treatment but as the first step in
Rehabilitation
4. Peripheral Vascular Disease
• Most common indication for amputation
• Peripheral vascular disease with or without diabetes
• Age-50 to 75years
• Disease processes in the cerebral vasculature, coronary arteries, and
kidneys
5. • Vascular surgery consultation for improved techniques and
salvageable
• If amputation becomes necessary
• Infection and Nutrition and Immune status should be evaluated.
6. Trauma
• Leading indication in younger patients
• More common in men
• The only absolute indication for primary amputation is an irreparable
vascular injury
8. • Severely injured limb may lead to metabolic overload and secondary
organ failure
• Multiple injuries and in the elderly
9. BURNS
• Thermal or electrical injury
• Tissue damage may not be apparent, especially with electrical injury
• Treatment involves early débridement of devitalized tissue and
wound care
• Delayed amputation - increased risk of local infection, systemic
infection ,AKI
10. Frostbite
• Freezing of tissue in the extremities
• Common problem for high-altitude climbers, skiers, and hunters
• WHY IT HAPPENS
• Mechanisms:
1. Ice crystals in the extracellular fluid
2. Ischemic damage to vascular endothelium, clot formation, and increased
sympathetic tone
11. • Amputation for frostbite routinely should be delayed 2 to 6 months.
• Clear demarcation of viable tissue may take this long.
• Triple-Phase Technetium Bone Scan
12. Infection
• Acute or chronic infection that is unresponsive to antibiotics and
surgical débridement.
• Open amputation is indicated:
1. A guillotine amputation
2. Definitive level by initially inverting the flaps and secondary closure
at 10 to 14 days
15. • Clostridial Myonecrosis :
Radical débridement of involved tissue, high doses of intravenous
penicillin and hyperbaric oxygen , open amputation one joint above the
affected compartment.
• Streptococcal Myonecrosis:
Debridement , penicillin treatment , usually allow preservation of
the limb.
16. TUMOURS
• Would survival be affected by the treatment choice?
• Multimodal treatment - osteosarcoma patients has improved from
approximately 20% to approximately 70%.
• Osteosarcoma of the distal femur : recurrence is 5% to 10%
• Salvageable s better
17. How do short-term and long-term morbidity
compare?
• Amputation for malignancy may be technically demanding -
nonstandard flaps, bone graft, or prosthetic augmentation ,
periprosthetic fractures, prosthetic loosening
• Limb salvage involves a more extensive surgical procedure ,infection,
wound dehiscence, flap necrosis, blood loss, and deep venous
thrombosis , multiple subsequent operations , amputation
• Amputation s better
18. How would the function of a salvaged limb
compare with that of a prosthesis?
• The location most important factor
• Upper extremity lesion - limb salvage provides better function than
amputation
• Resection of a proximal femoral or pelvic lesion , better function than hip
disarticulation or hemipelvectomy
• Sarcomas around the ankle and foot frequently are treated with
amputation
19. Osteosarcoma around the knee
• Wide Resection with Prosthetic Knee Replacement
• Wide Resection with Allograft Arthrodesis
• Transfemoral Amputation
21. DETERMINATION OF AMPUTATION LEVEL
• Level of amputation : increased function with a more distal level of
amputation and a decreased complication rate with a more proximal
level of amputation
• The energy required for walking is inversely proportionate to the
length of the remaining limb
22. • At self-selected walking velocities : tended to decrease their velocities
• Compensatory mechanism to conserve energy per unit time
• Anaerobic mechanisms to sustain muscle function: endurance is
greatly compromised
23. • Thus most distal level AMPUTATION : If ambulation is the chief
concern
• No ambulatory potential : wound healing chief concern
• Level for amputation : Best healing can be challenging
• Thermography or laser Doppler flowmetry , tissue clearance of
intradermally injected xenon-133 and Transcutaneous oxygen
25. Skin and Muscle Flaps
• Flaps should be kept thick :Unnecessary dissection avoided
• The scar should not be adherent to the underlying bone : prosthetic
fitting difficult and scar breaks down
• Redundant soft tissues or large “dog ears” : prosthetic fitting problem
‖
26. • Muscles divided at least 5 cm distal to bone resection
• Stabilized by Myodesis :
1. stronger insertion, help maximize strength, and minimize atrophy
2. counterbalance their antagonists, preventing contractures
27.
28. Hemostasis
• Use of a tourniquet is desirable
• Larger vessels should be doubly ligated
• The tourniquet should be deflated before closure
• A drain should be used in most cases for 48 to 72 hours
29. Nerves
• Nerves isolated, pulled distally to the wound, and divided with a
sharp knife so that the cut end retracts well proximal to the level of
bone resection
• Strong tension on the nerve should be avoided
• Large nerves : contain relatively large arteries and should be ligated
• A neuroma always forms after a nerve has been divided
30. Bone
• Excessive periosteal stripping : Leads to ring sequestra or bony
overgrowth
• Bony prominences : well padded by soft tissue , remaining bone
rasped for smooth contour
31. OPEN AMPUTATION
• Skin is not closed at stump
• Indicated in infections and in severe traumatic wounds
• First operation is to remove devitalized structures
• vacuum-assisted closure : VAC is reapplied until the wound is ready
for closure
32. • Second sitting is to construct a satisfactory stump by secondary
closure, reamputation, revision, or plastic repair
33. POSTOPERATIVE CARE
• Multidisciplinary team approach
• Antibiotics , Analgesics ,DVT prophylaxis, pulmonary hygiene and
psychiatric help
• The stump is elevated by raising the foot of the bed : edema and
postoperative pain
• With transfemoral amputations : prevent flexion or abduction
contractures
34. • If non-weight bearing ambulation : rigid dressing ( POP ) applied.
• If weight bearing ambulation : true prosthetic cast with metal pylon
with a prosthetic foot
35. Advantages of rigid dressing
• Prevent edema at the surgical site
• Protect the wound from bed trauma
• Enhance wound healing
• Decrease postoperative pain
• Transtibial amputations : prevent knee flexion contractures
36. • Exercises, mobilized from bed to chair for the stump started on POD 1
• Regardless of when prosthetic ambulation is begun, the rigid dressing
should be removed and the wound inspected in 7 to 10 days
• Cast should be changed weekly
37. • rigid dressing is continued until the volume appears unchanged from
the previous week
• If the wound is progressing well, weight bearing can progress in 25-lb
increments each week
39. Hematoma
• Hemostasis before closure , use of a drain, rigid dressing has
minimized
• Delay wound healing and serve as a culture medium for bacterial
infection
• If it form : compressive dressing , evacuated if delaying wound healing
40. INFECTION
• More common in amputations for PVD, especially in diabetic patients.
• Deep wound infection : débridement and irrigation
42. WOUND NECROSIS
• Necrosis of the skin edges less than 1 cm can be treated
conservatively with open wound management
• Severe necrosis with poor coverage of the bone end, wedge resection
may be indicated.
• Basic principle of wedge resection : reformation of the hemisphere,
while minimizing local pressures
43.
44. CONTRACTURES
• Mild or moderate contractures of the joints of an amputation stump
treated by proper positioning of the stump, passive stretching, and
exercises
• Severe fixed contractures : wedging casts and surgical release
45. PAIN
• 1. Mechanical low back pain : more prevalent in amputees , proper
prosthetic ambulation to minimize abnormal stresses on the lumbar
spine.
• 2. Residual limb pain : a. Phantom Limb Pain
b. Poor fitting prosthesis
c. Painful neuroma
46. Phantom Limb Pain
• Silas Weir Mitchell (1829-1914) is credited with coining the term
phantom limb
• Caused by elimination or interruption of sensory nerve impulses
• PREVALENCE: 60% to 80%
• Not influenced by age in adults, gender, side, or level and cause of the
amputation
47. • TIME COURSE : First week after amputation
• The pain is usually intermittent
• MECHANISMS: Afferent C fibers , Stump neuromas
C fibers and Aδ afferents , NMDA receptor
Cortical reorganization
48. TREATMENT
• Amitriptyline: dose of 125 mg/day and tramadol
• Oral morphine: a significant reduction in phantom pain
• TNF – α antagonist : Etanercept
• Memantine at doses of 20 or 30 mg/day ????
• TENS , acupuncture , massage , Mirror therapy
49. Prevention
• Preoperative epidural blockade : lower incidence
• Catheter into the transected nerve sheath at the time of amputation
and infused bupivacaine for 72 hours
50. Poor fitting prosthesis
• Ill fitting with socket
• Stump should be evaluated for areas of abnormal pressure, especially
over bony prominences
• Distal stump edema, often called ―”choking” , may result if the end is
not completely seated in the prosthesis, and ulceration or gangrene
could result.
51. Painful neuroma
• Occurs when the nerve end is subjected to pressure or repeated
irritation
• A painful neuroma usually is easily palpable and often has a positive
Tinel sign
• Socket modification , neuroma excision or a more proximal
neurectomy
52. DERMATOLOGICAL
• Contact dermatitis : intense itching and burning
• Cause :
1.failure to rinse detergents from stump socks
2. nickel, chromates , antioxidants in rubber
Treatment : steroid cream , removal of the irritant
53. Bacterial folliculitis
• Areas of hairy, oily skin
• Exacerbate by poor hygiene.
• Improved hygiene and possibly socket modifications to relieve areas
of abnormal pressure
54. Verrucous hyperplasia
• Wartlike overgrowth of the skin at the end of the stump
• It is caused by proximal constriction that prevents the stump from
fully seating in the prosthesis
• This “choking”: causes distal stump edema followed by thickening of
the skin, fissuring, ulceration
55. • Salicylic acid to soften the keratin and Socket modification to prevent
recurrences
• Epidermoid cysts develop at the socket brim
• Treated with socket modification or Excision if required
56. AMPUTATION IN CHILDREN
• Divided into two general categories :
congenital (60%) and acquired (40%)
• Causes of congenital amputations:
Amniotic band syndrome
Exposure to teratogens ( thalidomide )
Polydactyly ,Syndactyly ,Macrodactyly
Congenital pseudoarthrosis of the tibia and fibula, radius and ulna
Congenital deficiencies of the long bones
57. Acquired amputations
• Secondary to trauma :
Power tool injuries are the most common
Motor vehicle accidents
• Neoplasm
• Infection
58. PRINCIPLES OF CHILDHOOD AMPUTATION
• Preserve length AND Preserve important growth plates
• Perform disarticulation rather than transosseous amputation
• Preserve the knee joint whenever possible
• Stabilize and normalize the proximal portion of the limb
59. Preserving length and growth plates
• 75% of the growth of the femur occurs at the distal growth plate :
transfemoral amputation performed in a young child would result in a
very short stump as an adult
• Conversely, even a very short transtibial stump in a young child may
result in a functional stump as an adult
60. Dysarticulation
• Provide well-balanced, sturdy stump capable of end weight bearing
• High mechanical demands that children place on their prostheses
• Secondary to preservation of the metaphyseal flares: Prosthetic
outcome is improved
61. TERMINAL BONE OVERGROWTH
• Appositional new bone formation and is unrelated to the growth of
the physis
• In a child amputee with a transosseous amputation
• More common in younger children : humerus and fibula
• Resulting bone is elongated and often pencil-shaped
• Swelling, edema, pain , may penetrate the skin
62. • It does not occur after disarticulation
• Prevention of overgrowth : capping by epiphyseal graft OR capping
with tricortical iliac crest graft
• Treated effectively with surgical resection of the excess bone
64. ADVANTAGES OF AMPUTATION IN
CHILDREN
• Children often can tolerate procedures on amputation stumps like
1. More forceful skin traction
2. Application of extensive skin grafts
3. Closure of skin flaps under moderate tension
65. Less severe Complications
• Painful phantom sensations do not develop
• Neuromas rare
• Extensive scars are tolerated well
• Psychological problems after amputation are rare in children
66. • Children use prostheses extremely well : High activity level
• Good growth potential: Prosthetic program should be designed that
parallels normal motor development
• Modifications may be made, such as the addition of a knee joint, a
mobile elbow joint
67. BELOW KNEE AMPUTATION
• Transtibial amputations are the most common amputations
performed for PVD
70. NONISCHEMIC LIMB AMPUTATION
• The optimal level of amputation determined by:
Level of trauma
clean end margins for tumor
Anatomical factors : stumps extending to the distal third of the leg
Less soft tissue for weight bearing
Distal third of the leg is relatively avascular and slower to heal
71. IDEAL
A stump length that allows a controlling lever arm for the prosthesis
i.e stump is to allow 2.5 cm of bone length for each 30 cm of body
height
Stumps lacking quadriceps function are not useful
Transecting the hamstring tendons
72. In a short stump whether fibula should be removed or preserved is
controversial as fitting of the prosthesis depends on it
Sufficient ―circulation‖ for healing and soft tissue‖ for protective end
weight bearing
73. PROCEDURE
• Fashioning of equal anterior and
posterior skin flaps
• Each one half anteroposterior
diameter of leg at level of bone
section
74. • Division and ligation of anterior
tibial vessels ,deep peroneal
nerve.
78. AFTERTREATMENT
• An immediate postoperative rigid dressing : control edema , limits
knee flexion contracture and trauma
• Mobilization with walker or crutches
• Cast can be changed every 5 to 7 days for skin care
• Within 3 to 4 weeks, prosthesis given
79. PROCEDURE FOR ISCHEMIC LIMB
• Fashioning of short anterior and
long posterior skin flaps
84. DISADVANTAGES OF LONG POSTERIOR FLAP
The stump, in the initial stages , unsuitable due to stump oedema :
delay in prosthetic fitting
Suture line passes over the distal end of the tibia: vulnerable to
trauma : due to the high pressure generated while using the
prosthesis
85. SKEW FLAP
The principle : thermographic mapping of the leg : higher
temperature on anteromedial AND posterolateral aspect
Indicates : Better blood flow
Anteromedial ( saphenous nerve artery)
Posterolateral (sural nerve artery)
87. Advantages of skew flap
• Less of stump edema : NO Hazards of constricting bandages
• Early healing of the skin incision
• Early application and ambulation in a prosthetic cast
• Lessened risk of wound breakdown
89. Syme’s Amputation
• Amputation at the distal tibia and fibula 0.6 cm proximal to the
periphery of the ankle joint and passing through the dome of the
ankle centrally
• The tough, durable skin of the heel flap provides normal weight
bearing skin
90. • Incision at the distal tip of the
lateral malleolus
• One fingerbreadth inferior to the
tip of the medial malleolus
• extend it plantarward and across
the sole of the foot to the lateral
aspect
91. • Foot in marked equinus
• Divide the anterior capsule of
the ankle joint
• b/w medial malleolus and the
talus and lateral malleolus and
the talus
• Deltoid and calcaneofibular
ligament
92. • Bone hook pulling talus distally,
• Exposing distal articular surface
of tibia and fibula
95. Division of tibia and
fibula just through dome
of ankle joint centrally
0.6 cm proximal to the
ankle joint
cut surfaces of the
tibia and fibula are
parallel to the ground
96. • Holes drilled in anterior edge of
tibia and fibula to anchor heel
pad
97. • Edge of deep fascia lining heel
pad is anchored to tibia and
fibula
98. • Skin closure over drain, and
application of above-knee cast
• “Dog ears”:never be removed
:they carry blood supply to the
heel flap
99.
100. SYME’S PROSTHESIS
• Molded plastic socket, with a
removable medial window
• solidankle, cushioned-heel
(SACH) foot prosthesis attached
to it
101. Disadvantages
Posterior migration of heel pad
Skin slough resulting from overly vigorous trimming of “Dog ears”
Cosmesis : the stump is large and bulky : Flair of the distal tibial
metaphysis which is covered with heavy plantar skin
102. Wagner’s Modification: Two stage procedure
• Diabetic patients with gross infection or gangrene
• 1st stage- Ankle disarticulation, preserving the tibial articular cartilage
and the malleoli , suction-irrigation system that allows installation of
an antibiotic solution into the wound
• 2nd stage-After 6 weeks , is performed to remove the malleoli and
narrow the stump for good prosthetic fitting
103. MIDFOOT AMPUTATIONS
Lisfranc’s Amputation- amputation at the level of tarsometatarsal
joint
Chopart’s Amputation- amputation at the level of calcaneocuboid
and talonavicular joint
Pirogoff’s Amputation- calcaneus is rotated forward to be fused to
the tibia after vertical section through its middle
105. ABOVE KNEE AMPUTATION
• Amputation through thigh s second in frequency to trans tibial
amputation
• Knee joint s lost : stump should be as long as possible to maintain
long lever arm
• Compuer assisted knee prosthesis : variable friction knee joints are
obtained
106.
107. NON ISCHEMIC LIMB
• At anticipated level of bone
section , anterior and posterior
flaps are made
• Half the AP diameter of thigh
• Incision from mid point of
medial thigh go distally in cure
fashion
108. • Divide quadriceps and fascia
along line of anterior incision
• Ligate femoral vessels in femoral
canal in medial aspect , cut
sciatic nerve beneath hamstring
muscles
• Poster muscles cut transversely
so it retracts at bone level
109. • Through drill holes in prox to cut
femur : adductors and
hamstrings are attached to bone
• Bring quadriceps and suture its
fascia to posterior fascia
• Skin closure
110. POST OP TREATMENT
• Rehabilitation progresses much slower and more causiously
• Major obstacle is loss of knee joint
• More energy requirement for locomotion with prosthesis
• Especially in cardiac and contralateral ischemic limb
111. KNEE DISARTICULATION
• Disarticulation result in large excellent end-bearing stump.
• New prosthesis provide sing phase control
• Benefits in children and young people
• Its use in elderly especially ischemic limb s controversial
112. Advantages
• Provides large end bearing stump for excellent weight bearing
function
• Long lever arm with strong muscles attached to it
• Stability of prosthesis
113. BATCH,SPITTLER AND MCADDIN
• From inferior pole of patella , a
long anterior flap equal to AP
diameter of knee placed in
curved fashion
• From popliteal crease fashion
posterior flap , half the AP
diameter of knee
114. • Deepening anterior incision ,
includes insertion of patellar
tendon and pes anserinus
115. • Expose knee joint by dissecting
anterior and lateral capsule
margins from tibia
• Divide cruciate ligament and
posterior capsule from tibia
117. • Patella not excised or sutured to
femoral condyles
• Suture patellar tendon to
cruciate ligament and
gastrocnemius to intercondylar
notch
118. MAZET-HENNESSY
• Remodelling femoral condyles
• Drive wide osteotome from
medial femoral condyle till
adductor tubercle
• Similarly for lateral condyles
• Posterior projecting parts
119. KJOBLE
• Ischemic limbs
• Medial and lateral flaps are
made , half the AP diameter of
knee
• From lower pole of patella to
tibial tuberosity in curved
fashion
