AFTER MID
SURGERY
DR.Ammar Al-yassiri
Orthopaedic
amputations
Dr. Ammar Al-yassiri
LECTURE 9
AMPUTATIONS
Learning outcomes
• Define amputation
• Realize the epidemiology of amputation
• Describe the indications of amputation
• Describe the varieties of amputation
• Explain the principles of techniques
• Describe the characteristics of the prosthesis
• Recognize the complications of amputation stumps
Definition
• Amputations is the removal of a body extremity by trauma, prolonged
constriction, or surgery.
• As a surgical measure, it is the most ancient of surgical procedures.
• Early surgical amputation was a crude procedure by which a limb was rapidly
severed from an unanesthetized patient.
• The open stump was crushed or dipped in boiling oil to obtain hemostasis.
Epidemiology
• It has been estimated that more than 300,000 patients with amputations live in
the United States.
• Greater than 90% of amputations performed in the Western world are secondary
to peripheral vascular disease.
• In younger patients, trauma is the leading cause, followed by malignancy.
Indications
the indications are summarized by 3D.s:
1. Dead,
2. Dangerous and
3. Damned nuisance:
• Dead (or dying)
• Peripheral vascular disease accounts for almost 90 % of all amputations.
• severe trauma,
• Burns, and
• frostbite.
• Dangerous 'Dangerous' disorders are
• malignant tumors,
• potentially lethal sepsis,
• crush injury: In crush injury, releasing the compression may result in renal
failure (the crush syndrome).
• Damned nuisance: Retaining the limb may be worse than having no limb at all.
– pain;
– gross malformation;
– recurrent sepsis or
– severe loss of function.
• The combination of deformity and loss of sensation is particularly trying, and in
the lower limb is likely to result in pressure ulceration.
Varieties
• A provisional amputation:
– necessary because primary healing is unlikely.
– The limb is amputated as distal as the causal conditions will allow.
– Skin flaps sufficient to cover the deep tissues are cut and sutured loosely
over a pack.
– Re-amputation is performed when the stump condition is favorable.
• A definitive end-bearing amputation
– performed when pressure or weight is to be borne through the end of a
stump.
– the scar must not be terminal,
– the bone end must be solid, not hollow, which means it must be cut
through or near a joint.
– Examples are through-knee and Syme's amputations.
• A definitive non-end-bearing amputation
– the commonest variety. All upper limb and most lower limb amputations
come into this category.
– Because weight is not to be taken at the end of the stump, the scar can be
terminal.
AMPUTATIONS AT SITES OF ELECTION
• Most lower limb amputations are for ischaemic disease and are performed
through the site of election below the most distal palpable pulse.
The selection of amputation level can be aided by
– Doppler indices; if the ankle/brachial index is greater than 0.5, or if the
occlusion pressure at the calf and thigh are greater than 65 mmHg and 50
mmHg respectively, then there is a greater likelihood the below-knee
amputation will succeed
– An alternative means is by using transcutaneous oxygen tension as a guide,
• The knee joint should be preserved if feasible .the energy expenditure for a trans-
tibial amputee is 10-30 % greater as compared to a 40-67 % increase in trans-
femoral cases.
• demands of prosthetic design and local function.
– Too short a stump may tend to slip out of the prosthesis
– Too long a stump may have inadequate circulation and can become painful,
or ulcerate; moreover, it complicates the incorporation of a joint in the
prosthesis.
• For all that, the skill of the modern prosthetist has made it possible to amputate
at almost any site.
Principles of technique
• A tourniquet is used unless there is arterial insufficiency.
• Skin flaps are cut so that their combined length = 1.5 times the width of the limb
at the site of amputation.
• Muscles are divided distal to the proposed site
• The bone is sawn across at the proposed level.
• Nerves are divided proximal to the bone cut
• The main vessels are tied.
• opposing muscle groups are sutured over the bone end to each other and to the
periosteum.
• The skin is sutured carefully without tension
• Suction drainage is advised.
AMPUTATIONS OTHER THAN AT SITES OF ELECTION
• interscapulo-thoracic (forequarter) amputation:
– mutilating operation
– traumatic avulsion of the upper limb
– eradicating a malignant tumour, or
– as palliation.
• disarticulation at the shoulder: This is rarely indicated .
• amputation in the forearm: The shortest forearm stump will stay in a prosthesis is
2.5 cm, measured from the front of the flexed elbow.
• Amputations in the hand
• Hemipelvectomy (hindquarter amputation): for malignant disease.
• disarticulation through the hip: rarely indicated.
• transfemoral amputations : it is usual to leave at least 12 cm below the stump for
the knee mechanism.
• around the knee (The Stokes-Gritti operation) the trimmed patella is apposed to
the trimmed femoral condyle.
• Transtibial (below-knee) amputations: the conventional stump length 14 cm.
• Above the ankle Syme's amputation .
• Pirogoff's amputation
• Partial foot amputation:
– through the mid-tarsal joints (Chopart), through the tarsometatarsal joints
(Lisfranc),
– through the metatarsal bones or
– through the metatarsophalangeal joints.
• In the foot: diabetic gangrene
PROSTHESES
• must fit comfortably.
• should function well and look presentable.
• Should be fitted soon after operation.
• In the upper limb, the distal portion of the prosthesis is detachable and it can be
changed.
• Electrically powered limbs are available for both children and adults.
COMPLICATIONS OF AMPUTATION STUMPS
• Early complications
– the complications of any operation (especially secondary haemorrhage).
– Breakdown of skin flaps: may be due to ischaemia, or suturing under excess
tension
– Gas gangrene: Clostridia and spores from the perineum may infect a high
above-knee amputation, especially if performed through ischaemic tissue
• Late complications
– Skin
• Eczema is common, and tender purulent lumps may develop in the
groin. A rest from the prosthesis is indicated.
• Ulceration is usually due to poor circulation, and re-amputation at a
higher level is then necessary.
– Muscle If too much muscle is left at the end of the stump, the resulting
unstable 'cushion' induces a feeling of insecurity that may prevent proper
use of a prosthesis; if so, the excess soft tissue must be excised.
– Blood supply Poor circulation gives a cold, blue stump that is liable to
ulcerate. often re-amputation is necessary
– Nerve:
• painful neuroma: occurs when the nerve end is subjected to pressure
or repeated irritation
• Prevention: by gentle traction on the nerve followed by sharp
proximal division, allowing the nerve end to retract deep into
the soft tissue.
• Treatment: initially socket modification. If this fails, simple
neuroma excision or a more proximal neurectomy.
• Phantom limb sensations: are so common that they should be
considered normal.
• management is simply to educate the patient regarding these
sensations so that they are not surprised by their presence.
• Phantom limb pain:
– far less common.
– More often present with proximal amputations, such as
forequarter and hindquarter amputations.
– some patients may benefit from massage, ice, heat, increased
prosthetic use, relaxation training, sympathetic blockade, local
nerve blocks, epidural blocks, ultrasound, transcutaneous
electrical nerve stimulation.
– Joint: the joint above an amputation may be stiff or deformed
• Above knee amputation: fixed flexion and fixed abduction .prevented
by exercises, treated by subtrochantric osteotomy
• Below knee amputation: fixed flexion
– Bone:
• a spure
• Osteoperosis
• Fracture
To take home message
• >90% of amputations performed in the Western world are secondary to
peripheral vascular disease.
• the indications are summarized by 3D.s
• Varieties of amputation
– Provisional
– Definitive End bearing
– Definitive Non end bearing
• It is possible to amputate at almost any site.
• Gas gangrene may complicate a high above-knee amputation, especially if
performed through ischaemic tissue
Done by : Murtedha Abbas