Dr. Adarsh G. M.B.B.S. (M.S.

AMPUTATION

Amputation is the removal of a body extremity by trauma or Surgery

DEFINITION

Amputations have four aims: (1) The removal of all diseased tissue. (2) The relief of pain . (3) Primary healing of the amputation wound. (4) Construction of a stump that will permit the most useful function with or without prosthetic fitting.

AIM OF AMPUTATION

1. 2. 3. 4. 5. 6.

Peripheral Vascular disease Infection Osteomyelitis Trauma Frostbite Tumors

INDICATIONS

1. 2. 3. 4. 5.

Clinical Method Measurement of Blood pressure Oxygen tension measurement Measurement of Skin perfusion Arteriography

DETERMINATION OF LEVELS OF AMPUTATION

The presence of a palpable pulse in the major artery immediately above the amputation site indicates a high probability of amputation primary healing Absence of a palpable pulse in these locations

significantly reduces the likelihood of amputation healing.

CLINICAL METHOD

Does not adequately demonstrate collateral circulation Healing is common even when ankle pressures are extremely low or undetectable.

MEASUREMENT OF BLOOD PRESSURE

A transcutaneous PaO 2 of zero indicates a high probability that healing will be unsatisfactory A PaO 2 above 40 mm Hg indicates that good healing is likely. Disadvantages : 1.expense of the equipment

2.time required for examination (about 30 minutes per site).

OXYGEN TENSION MEASUREMENTS

1. 2. 3. 4.

Laser Doppler Studies Skin Fluorescence Skin Perfusion Pressure Skin Temperature

MEASUREMENT OF SKIN PERFUSION

Shows Anatomy, not physiology Shows feasibility of vascular reconstruction Not helpful in determining the level of amputation as it does not show skin perfusion

ARTERIOGRAPHY

1. Control of Diabetes, Heart failure 2. Control of infection 3. Improvement of nutritional status

PREPARATION FOR AMPUTATION

1. Acute Arterial Occlusion 2. Injury

URGENT OR EMERGENCY AMPUTATION

1. Most reliable sign of viability is the RIGOR of the muscle bed involved. 2. Degree of urgency determined by: Extent of ischemia Muscle bulk involved Degree of pain Presence of systemic toxicity

ACUTE ARTERIAL OCCLUSION

 Massively injure or Crushed Extremity Major nerve injury with bone, soft tissue and vascular injury

INJURY

TYPE OF AMPUTATIONS

Used : 1. To free a trapped victim in disasters 2. To remove tissue that is a source of life threatening infection

GUILLOTINE AMPUTATION

AMPUTATION THROUGH THIGH: 1. Most common type in emergencies 2. Equal anterior and posterior flaps are fashioned 3. 25cm of shaft is optimum 4. Bandaging should not be tight

LOWER LIMB AMPUTATIONS

GRITTI-STOKES AMPUTATION 1. End bearing longer stump 2. More useful in elderly 3. Should be done only when primary closure is possible 4. Anterior flap broader and longer 5. Transection at the femoral condyles 6. Articular surface of patella sawed off and fixed to lower end of femur

LOWER LIMB AMPUTATIONS

DISARTICULATION AT KNEE 1. Done in a child in whom amputation around the knee is necessary 2. Femoral condyles are retained to allow for growth

LOWER LIMB AMPUTATIONS

AMPUTATION OF LEG 1.15cm of tibia and fibula 2cm shorter 2. If shorter, patellar tendon is to be preserved: to fit the prosthesis 3. Long posterior flap with no anterior flap (BURGESS) 4. Interossious membrane preserved above the level of division of fibula

LOWER LIMB AMPUTATIONS

SYMES AMPUTATION 1. Patient can do without a prosthesis 2. Patients have the ground sensation 3. Result is good in children as growth at epiphyses not lost 4. Ulceration of stump is the disadvantage 5. Transection at the level of malleoli 6. Covered with heel flap

LOWER LIMB AMPUTATIONS

TRANSMETATARSAL AMPUTATION 1. Good vascularity necessary 2. Healing unlikely if foot Doppler pulse is absent and BP less than 90 in lower leg 3. Transection at the level of metatarsal necks 4. Gangrene of the dorsal flap is frequent, usually separates and heals by secondary intention 5. Progressive gangrene requires reamputation at a higher level

LOWER LIMB AMPUTATIONS

AMPUTATION OF TOES 1. Most common amputation 2. 1st metatarsal head is required for balance and should be preserved if possible 3. Toe or ray amputations should be carried out through shaft of the bone as joint fluid hampers healing 4. Ray amputation: toe with metatarsal head

LOWER LIMB AMPUTATIONS

Most commonly due to injury or malignancy As much length should be preserved as possible In trauma expectant management is more suitable, and one should wait till dead tissue sloughs off

UPPER LIMB AMPUTATIONS

HAND AMPUTATIONS 1. Volar flap should be longer than dorsal flap 2. Tip should be covered by volar skin and should be padded 3. Perfect hemostasis should be achieved before closing

UPPER LIMB AMPUTATIONS

WRIST AMPUTATION In transcarpal amputation, flexion extension at wrist joint should be preserved In wrist disarticulation radio-ulnar joint must not be disturbed

UPPER LIMB AMPUTATIONS

FOREARM AMPUTATION Preferable to elbow or above elbow amputations even if only a short stump can be left behind

UPPER LIMB AMPUTATIONS

TRANSHUMERAL AMPUTATION As much length as possible should be left behind Atleast the head should be left behind as it maintains the contour of the shoulder and cosmetically better

UPPER LIMB AMPUTATIONS

FOREQUARTER AMPUTATION Most commonly done for a malignant tumor Done most commonly by posterior approach Entire upper limb with clavicle is removed

UPPER LIMB AMPUTATIONS

LENGTH Trans-Femoral Trans-Tibial Symes Trans-Humeral Trans-Radial 25cm from crotch 12-15cm from knee 6cm ground clearance 8cm clearance from elbow 12-15cm from cubital fossa

IDEAL STUMP

SUTURE LINE OR SCAR Should be supple, non tender, not on high pressure regions RANGE OF MOVEMENTS Should be to full extent in the joint above MUSCULATURE Muscle tone should be normal, stump well padded SKIN OVER STUMP Should be healthy and sensations preserved TIP OF BONE Should be smooth, Should not protrude through skin

IDEAL STUMP

1. 2. 3. 4. 5. 6.

Sepsis Hematoma Thromboembolism Pain and Contractures Trauma to residual limb Ischemia to the residual limb

STUMP COMPLICATIONS

REHABILITATION

REHABILITATION