3. INDICATIONS
• PERIPHERAL VASCULAR DISEASE
GANGRENE DUE TO ATHEROSCLEROSIS,
EMBOLISM, TAO
• DIABETIC LIMB DISEASE/ GANGRENE
• DEAD, DYING DEVITALISED TISSUE
• TRAUMA : LIFE SAVING IN CRUSH INJURIES
• INFECTION AND GANGRENE – TO SEPSIS
• MALIGNANCY
• DEVERE DEFORMITY : CONGENITAL/ ACQUIRED
4. AIM OF AMPUTATION
• RETURN PATIENT TO MAXIMUM LEVEL OF
INDEPENDENT FUNCTION
• ABLATION OF DISEASED TISSUE (TUMOR OR
INFECTION)
• REDUCE MORBIDITY & MORTALITY (TUMOR
OR INFECTION)
• PRODUCE A PHYSIOLOGICAL END ORGAN .
5. IDEAL STUMP
• PROPER HEALING
• ROUND, GENTLE CONTOUR WITH MUSCLE PADDING
• ADEQUATE BLOOD SUPPLY
• PROVISION FOR PROSTESIS
• THIN SCAR, SHOULD AFFECT PROSTESIS FUNCTION
• ADEQUATE ADJACENT JOINT MOVEMENT
6.
7.
8. 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
9. Preoperative evaluation
Hb, PCV
Correct anaemia
Control of infection : with antibiotics
Diabetic control
Level of amputation :
Arterial DOPPLER
R/o other cardiac conditions
13. SYME’S AMPUTATION
REMOVAL OF FOOT WITH CALCANEUM
RETAINING HEEL FLAP
BONE AT TIBIA & FIBULA JUST ABOVE ANKLE JOINT
ELEPHANT BOOT
14. Pirogoff's amputation
Amputation of the foot at the ankle, part of the
calcaneus being left in the stump
The Boyd procedure
Provides a broad weight-bearing surface of the heel by
creating an arthrodesis between the distal tibia and
the tuber of the calcaneus
Compared to a Syme's amputation, it provides more
length and better preserves the weight-bearing function
of the heel pad.
Its increased complexity and morbidity have made it
less used now than the Syme's amputation.
15. BELOW KNEE AMPUTATION
(BURGESS’ )
MIN. STUMP LENGTH :
8 CM FROM TIBIAL TUBEROSITY
(14-17 CM IS GOOD)
LONG POSTERIOR FLAP
SCAR ANTERIORLY
FIBULA TO BE DIVIDED BEFORE TIBIA AT A HIGHER LEVEL
16. • PEG LEG AMPUTATION
5 CM STUMP
ANTERIOR FLAP ROTATED POSTERIORLY
NOT PRACTICED NOW
17. GRITTI STOKES
TRANS CONDYLAR AMPUTATION
FEMUR DEVIDED JUST ABOVE PATELLAR ARTICULAR
SURFACE
LONG POSTERIOR FLAP
NOT USED NOW
DUE TO NON UNION OF PATELLA WITH FEMUR
19. HIP DISARTICULATION
WHEN STUMP >10CM IS NOT POSSIBLE
SOLCUM’S APPROACH : SINGLE POSTERIOR FLAP
BOYD’S APPROACH : ANTERIOR RAACQUET INCISION
20. HIND QUARTER AMPUTATION
SIR GORDON TAYLOR’S AMPUTATION
HEMI PELVECTOMY
REMOVAL OF
ONE SIDE PELVIS
INNOMINATE BONE
PUBIS
MUSCLES AND VESSELS
RETAIN PART OF PUBIS, ILIUM
POSTERIOR FLAP : BY SUPERIOR GLUTEAL ARTERY
22. • UPPER LIMB AMPUTATION
20 CM STUMP IS ADVICED IN BOTH ABOVE AND
BELOW ELBOW AMPUTATION
• FOREQUARTER AMPUTATION
INTER SCAPULO THORACIC AMPUTATION
UPPER LIMB WITH SCAPULA, LATERAL 2/3 OF
CLAVICLE,
23. TYPES OF AMPUTATION
• WEIGHT BEARING
• NON WEIGHT BEARING
• END BEARING/ CONE BEARING
• NON END BEARING/ SIDE BEARING
• FLAP CAN BE
UNEQUAL/ EQUAL FLAPS
24. PRINCIPLES OF AMPUTATION
• Adequate blood supply
• No tourniquet during surgery
• Proper making of skin
• Proximal part of flap contain muscle and distal part only
skin
• Nerve to be buried deep
• Proper dressings after surgery
26. •SKIN FLAPS
The apex of the fish mouth at the level of the bony resection
Total length of flap anterior + posterior = 1.5 times diameter
Flap should be semi circular for conical stump
Use any available flaps in trauma to preserve length
Tailor flaps at least as long as the diameter of the stump
27. •MUSCLES
Divide ~5 cm distal to level of bone resection
Stabilisation of muscle mass by good suturing.
Adequate stump padding
Prevents atrophy (muscle exercises)
Improves function
Myoplasty = involves suture of flexors to the extensors over bony
stump
Myodesis = direct suture of muscle to bone - most useful in AK,
AE and disarticulations
28. Nerves
Divide cleanly under gentle tension proximal to bone ends -
allow to retract
Large nerves eg sciatic, median - ligate due to large contained
vessels
Blood vessels
Large arteries & veins should be doubly ligated and
haemostasis achieved prior to closure
Bone
Avoid excessive periosteal stripping (prevent spur formation)
Bevel & smooth the bone end
29. • Closure
Do not close under tension
Interrupted sutures preferably
• Drains are necessary
30. Goals of Postoperative Management
Prompt, uncomplicated wound healing
Control of edema
Control of Postoperative pain
Prevention of joint contractures
Rapid rehabilitation
31. WOUND CARE
ABSORBENT, NON-ADHERENT AND OCCLUSIVE
VACCUM DRAIN
PROPER PADDING FOR COMFORT AND PROTECTION
BANDAGING SHOULD BE FIRM BUT
NOT RESTRICTIVE
32. • PREVENT CONTRACTURE
USE OF BRACE OR OTHER IMMOBILISER
PHYSIOTHERAPY
EARLY MOBILISATION OF PATIENT
Sitting out of bed within 48 hrs
Wheelchair used to assist mobility
Practice in transferring, standing and early walking with
crutches supervised with physio.
33. Complications
Early
Haemorrhage & Haematoma
Infection
Late
Necrosis of stump end.
Ring sequestrum formation
Contractures (due to muscle imbalance)
Neuroma at the cut nerve ending
Phantom pain
Terminal overgrowth (children)
34. • Phantom limb sensation is the sensation that the
amputated limb is still present.
• Phantom limb pain usually is like a burning,
stinging, electric pain, and it can be increased with
anxiety and stress.
• Telescoping is the sensation that the distal part of
the amputated extremity has moved proximally up
the arm
35. “Stump Edema Syndrome” : associated with the use
of suction prosthesis.
-Proximal constriction
-Blood in skin ,pain, Pigmentation
-Elevation
36. COMPLICATIONS
1. Failure of wound to heal : gap if wider than 1cm needs revision
2. Infection : open – flaps retract / edematous
results in shortening the bone
Rx : close only central 1/3 for coverage of bone.
3. Phantom sensation : diminishes over time, telescoping
4. Pain and phantom pain : massage , cold packs, exercise and
neuromuscular stimulation
TENS ( trans cutaneous electric nerve stimulation) :
incorporated in a prosthesis
-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine
37. Follow up
2 weeks after surgery
Start muscle contraction exercises and physiotherapy
Desensitization is started with a towel for distal
residual extremity pressure
Prosthetic management to be started by 6weeks
Depending on the condition of the extremity and
wound
Some patients are not candidates for prosthesis