AMPUTATIONS

A GENERAL OVERVIEW

• INTRODUCTION• INDICATIONS• TYPES• LEVELS OF AMPUTATION• BASIC PRINCIPLES• AFTER TREATMENT• COMPLICATIONS

INTRODUCTION

• DEFN-REMOVAL OF THE DISEASED,NON FUNCTIONING,PROTRUDING BODY PART

• DERIVED FROM LATIN WORD “AMPUTARE” MEANING ‘CUTTING AROUND’

• INCIDENCE:AGE-50-75 YRS SEX-MALES[75%] LIMBS-LOWER LIMB[85%]

INDICATIONS

• POOR CIRCULATION -POVD, DIABETES• INJURY TRAUMA-3/5 STRUCTURES GROSSLY AND

IRRIVERSIBLY INJURED FROST BITE,BURNS• INFECTIONS FULMINANT GAS GANGRENE,C/C

OSTEOMYELITIS,INFECTED NON UNIONS,C/C INFECTED TROPHIC ULCER

• TUMOURS NOWADAYS DECREASED BECAUSE OF

SEVERAL LIMB SALVAGE TECHNIQUES• CONGENITAL ANOMALIES most common indication in children

TYPES

• CLOSED AMPUTATIONS FLAPS ARE FASHIONED AND ARE CLOSED PRIMARILY

ALONG WITH SURGERY.• OPEN AMPUTATIONS FLAPS ARE NOT CLOSED PRIMARILY LATER REVISED AMPUTATION, REAMPUTATION OR

PLASTIC REPAIR1.GUILLOTINE TECHNIQUE ALL THE TISSUES ARE CUT AT THE SAME LEVEL.IN

SEVERE CRUSH INJURIES AND SEVERE INFECTIONS.

• CIRCULAR AMPUTATION WITH FLAPS RETAINED FOR LATER

DELAYED SUTURING. OTHER TYPES• REVISION AMPUTATION-for ideal stump• REAMPUTATION

• EARLY AMPUTATION SO GROSS THAT THERE IS NO

ALTERNATIVE• INTERMEDIATE AMPUTATION AFTER TEMPORARILY SALVAGING THE LIMBS DEGREE OF DAMAGE JUSTIFY EARLY

AMPUTATION• LATE AMPUTATION PAINFUL SYMPTOMATIC MALUNION OR NON

UNION

LEVELS OF AMPUTATIONS

• HIGHER THE LEVEL OF AMPUTATION GREATER IS THE DIFF TO RESTORE ABILITY

• AMPUTATION STUMP SHOULD BE LONG ENOUGH

• IF A JOINT IS ARTHRODESED,SECTION AT JOINT LEVEL OR ABOVE

• POVD-LEVEL SHOULD BE BELOW THE DISTAL MOST ARTERIAL PULSATION

• IN ELDERLY FRAIL-BK AMPUTATION• OTHERWISE KNEE DISARTICULATION

• IN CLINICAL PRACTICE COLOUR AND TEMP OF THE SKIN BEFORE

SURGERY APPEARANCE OF FREE CAPILLARY BLEEDING

FROM CUT SURFACES ON OPERATION

UPPER LIMB

• SHOULDER DISARTICULATION• SHORT ABOVE ELBOW• STANDARD ABOVE ELBOW• LOW ABOVE ELBOW• ELBOW DISARTICULATION• SHORT BELOW ELBOW • MEDIUM BELOW ELBOW• LONG BELOW ELBOW• WRIST DISARTICULATION

LOWER LIMB AMPUTATIONS

BASIC PRINCIPLES

• ANAESTHESIA-GA OR SAB• TOURNIQUET CONTRA INDICATED IN ISCHAEMIC LIMB AND

ATHEROSCLEROSIS EXSANGUINATION PRIOR TO TOURNIQUET

APPLICATION-CONTRA INDICATED IN INFECTED LIMBS AND MALIGNANCIES

• SKIN FLAPS-GOOD COVERAGE,MOBILE,ADEQUATE LENGTH

• MUSCLES SECTIONED 5 CM DISTAL TO BONY SECTION 1.MYODESIS-SUTURING TO BONE (CI-ISCHAEMIC LIMB) 2.MYOPLASTY-OPPOSING MUSCLES ARE

SUTUREDADVANTAGES-• SHAPE OF THE STUMP GOOD

• INSULATE CUT NERVE ENDINGS• MUSCLES ORIGINATING PROXIMALLY

PROVIDE GOOD LEVERAGE• PHANTOM PAIN MAY BE PREVENTED• PREVENT RETRACTION &PAINFUL MUSCLE

CONTRACTION

• BLOOD VESSELS DOUBLE LIGATION AND CUT• NERVES PULLED AND CUT SO THAT IT RETRACTS INTO THE

STUMP• BONES PERIOSTEAL STRIPPING MINIMISED• DRAIN 48-72 HRS

AFTER PROGRAMME

• DRESSINGS1.RIGID DRESSING-POP CAST DECREASED STUMP EDEMA,EARLY

HEALING,LESS POST OP PAIN,TEMPORARY PROSTHETIC FITTING

2.SOFT DRESSING-SOFT BANDAGES AND ELASTOCREPE BANDAGES

REHABILITATION

• BEGIN ASAP• GOALS –REDUCE EDEMA, INCREASE

STRENGTH, PREVENT CONTRACTURES, MAXIMISE FUNCTIONAL INDEPENDENCE.

• BALANCE & COORDINATION ACTIVITIES FOR GAIT TRAINING.

• WALKING AIDS• ALSO VOCATIONAL TRAINING, PAIN MNGMT,

PSYCHO EDUCATION.

COMPLICATIONS

• HAEMATOMA• INFECTIONS• NECROSIS• CONTRACTURES• PAINFUL NEUROMAS• PHANTOM LIMB PREVENTED BY TREATMENT OF NERVES AT

THE SURGERY,MYOPLASTIC PROCEDURES AND PROPER STUMP BANDAGING AND STUMP EXERCISES.

STUMP

• IDEAL LENGTH• IDEAL SHAPE• MUSCULAR• GOOD POWER OF MUSCLES• NO FIXED DEFORMITY• FULL AND FREE MOVTS OF JOINT ABOVE• INFN FREE• NON ADHERENT INCISION SCAR• ABSENCE OF NEUROMA

CAN BE ACHIEVED BY• STUMP DRAINAGE• STUMP SPLINTING• STUMP BANDAGING• STUMP EXERCISES EARLY• STUMP HYGEINE

SYME’S AMPUTATION ANKLE DISARTICULATION,REMOVAL OF

MALLEOLI AND ANCHORING HEEL PAD TO THE WEIGHT BEARING AREA

• TWO POINTS 1.75 CM BELOW LAT MALLEOLUS AND 2.5 CM BELOW MED MALLEOLUS ARE JOINED INFRONT OF THE ANKLE AND ALSO VERTICALLY ACROSS THE HEEL PAD

• ANT INCISION DEEPENED-TALUS AND CALCANEUM REMOVED LEAVING ALL SOFT TISSUE IN THE FLAP

• MEDIAL AND LATERAL MALLEOLI ALONG WITH A THIN SLICE OF TIBIA REMOVED

• DON’T TRIM ‘’DOG EARS’’• ADV-PATIENT CAN WALK WITHOUT A

PROSTHESIS

LIS FRANCS AMPUTATION

• AMPUTATION THROUGH MIDDLE OF THE FOOT

• SEVERE EQUINUS DEFORMITY FRICTION IN ANTERO POSTERIOR PRT OF

STUMP

CHOPARTS AMPUTATION

• AMPUTATION THROUGH MID TARSAL JOINT• SUBTALAR FUSION AND ELONGATON OF

TENDO ACHILLES• DISCARDED BCOZ OF SAME REASON

PIGROFF’S AMPUTATION• ANT PART OF CALCANEUM IS CUT ACROSS AND RAW BONE IS FIXED TO THE RAW

UNDERSURFACE OF TIBIA• CALCANEAL TUBEROSITY -WEIGHT BEARING

AREA

BOYD’S AMPUTATION• TALUS IS EXCISED• CALCANEUM IS ADVANCED AND ATTACHED

TO THE RAW UNDERSURFACE OF TIBIA• STABLE LOAD BEARING SURFACE

THANK YOU