الاساسيات الجراحية للبتر- Surgical principles of Amputation - البروفيسور فريح ابوحسان - استشاري جراحة العظام

11/7/2014Professor Freih Abuhassan -

University of Jordan1

Freih Odeh Abu Hassan,F.R.C.S(Eng),F.R.C.S(Tr.& Orth.)

Professor of Orthopedics

University of Jordan -Amman11/7/2014 2

Professor Freih Abuhassan -

University of Jordan

The skin is closed over the end

of the stump

11/7/2014 3Professor Freih Abuhassan -


(except in PVD)

* Highly desirable, makes the amputation

easier in Tourniquet with exsanguination.

* In infections or malignancy, inflation

of the tourniquet should be preceded

by elevation of the limb for 5 minutes.



* Use defined flaps electively with the

apex of the fish mouth at the level

of the bony resection.

* Use any available flaps in trauma to

preserve length.

Covering the stump with good skin is

of the utmost importance11/7/2014 5





The scarShould not be adherent to the underlying

bone because an adherent scar makes

prosthetic fitting extremely difficult and

because this type of scar often breaks

down after prolonged prosthetic use.



Equal ant + post

Equal med + lat

Long post - PVD



* Divide ~5 cm distal to level of bone resection

* Bevelling or contouring may be required

for good stump shape

*The conical shape is no longer necessary and is

even undesirable in fitting modern prosthetic

sockets.



1. Provides stump padding

2. Prevents atrophy

3. Improves function

4. Prevents bursa formation

5. these techniques improve the

function of the muscles and the

circulation in the stump and help

prevent phantom pain 11/7/2014 10



suture of flexors to the

extensors over bony stump



Direct suture of muscle to bone.

most useful in AK, AE and

disarticulations



Myodesis Contraindicated in PVD

or ischemia from other causes



* Divide cleanly under gentle tension

proximal to bone ends allow to retract

*Large nerves e.g Sciatic - ligate due to large

contained vessels





* Large A&V should be doubly ligated

*Haemostasis prior to closure.

The tourniquet should be released and

all bleeding points should be clamped

and ligated or coagulated



* Avoid excessive periosteal stripping

(prevent spur formation)

* Chamfer appropriately by raspe

to form a smooth contour





* Do not close under tension

* Use interrupted sutures



The drains or tubes are removed

48 - 72 hr after surgery.



An open amputation is one in which the

skin is not closed over the end of the

stump.



The wound is allowed to drain freely

and is usually ready to close secondarily

within 10 to14 days without shortening

the stump.

1- Open amputations with inverted

skin flaps.



11/7/2014 23



2-Circular open amputations.

* Healing of a circular open amputation

is quite prolonged and depends on the

use of constant skin traction that tends

to pull all of the soft tissues over the end

of the stump.

* Most often a stellate or convoluted scar

results that can be difficult to manage

prosthetically



1- A soft dressing program

or the rigid dressing concept.

2- Compression but not proximaly

3- with or without early prosthetic

ambulation.



*Wrapping of stump with extreme caution

hastens its healing, shrinkage, &

maturation

* Crutches when limb control achieved.

* Usually the wound is dressed and

the drains are removed at 48 hours.



* the sutures are removed at 10 to 14 days

* Definitive prosthesis at ~ 3 wks when

stump stabilised

Except when the patient is bathing, the stump

is kept snugly wrapped with an elastic bandage

until the prosthesis is fitted. Then the bandage

is used at night until the stump is mature.





Employs POP cast applied to the stump in

the OR at the conclusion of surgery

1- Prevents edema at the surgical site

= enhances wound healing

= early maturation of the stump

2- Decrease P.O pain, allow earlier

resumption of the erect posture

and ambulation with support



3- The hospital stay can be decreased and

the cost of care reduced accordingly

4-There is earlier fitting with a definitive

prosthesis and a documented higher

percentage of patients who are

successfully rehabilitated.



Use of the rigid dressing is continued until

definitive prosthetic fitting, which is usually

possible at 4 - 8 weeks after surgery.

The rigid dressing should be removed and

the surgical wound inspected in 7- 10 days.



Options1. Immediate

2. Prompt - ~7-10 days when evidence of

stump healing

3. Early - ~ 3 wks after stump has healed

4. Late - after stump is fully mature and

little chance of stump breakdown



Immediate postsurgical prosthesis fitted to below-elbow

amputation for trauma. Appearance on 13th postoperative day.



Immediate postsurgical prosthesis for the above-knee amputation



Immediate postsurgical prosthesis for the below-knee amputation.



Immediate postsurgical prosthesis for the hip-disarticulation

amputation



Immediate postsurgical prosthesis for the Syme amputation.



Immediate postsurgical prosthesis in knee disarticulation

for congenital anomalies.



1- Age, strength, and agility of the patient.

2- Patient’s ability to protect the amputation

stump from injury as a result of excessive

weight-bearing.



3- Availability of a well-trained team of

nurses,therapists, and prosthetists who

can consistently carry out a well-integrated

prosthetic treatment program;

4- The desire and willingness of the surgeon

to meticulously supervise such a treatment

program.



early unprotected weight-bearing can result

in sloughing of the skin or delayed healing

of the wound,

any weight-bearing ambulation allowed before

the wound has healed be strictly supervised

and that the stump be protected by the use

of crutches or a walker until the wound

has healed.



* Prone lying in AKA

* Muscle setting exercises followed by

exercises to mobilize the joints

* With BKA the patient is cautioned against

hanging the stump over the edge of the

bed or resting on crutch or lying or sitting

for a long time with the knee flexed.



Rehabilitation is not complete until

the patient has been fitted with

an appropriate prosthesis and

sufficiently trained in its use 11/7/2014 43





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الاساسيات الجراحية للبتر- Surgical principles of Amputation - البروفيسور فريح ابوحسان - استشاري جراحة العظام