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Dr. Yasir Jameel
Clinical Fellow
Orthopedic dept.
Bone and joint Centre
HMC
• Derived from the Latin amputare.
• "to cut away", from ambi- ("about", "around") and putare ("to prune").
• Amputation is the complete removal of an injured or deformed body part.
• The English word "amputation" was first applied to surgery in the 17th century.
Amputation
Nomenclature.
History• Most ancient of surgical procedure.
• Historically were stimulated by the aftermath of war.
• It was a crude procedure by which limb was rapidly severed from unanesthetized patient.
• The open stump was then crushed or dipped in boiling oil to obtain hemostasis.
• Hippocrates was the first to use ligature.
• Ambroise Pare ( a France military surgeon) introduced artery forceps. He also designed prosthesis.
• Morels – 1674 : introduced Tourniquet.
• Lord Listers – 1867 : introduced Antiseptic technique
Amputation
Incidence and Indications of amputation
• >90% amputations are due to PVD in aged
population.
• Trauma > Malignancy is more common in
younger pts.
• The only Absolute indication for
amputation is irreversible ischemia.
Incidence and Indications of amputation
Peripheral Vascular Disease
Trauma
Burns
Malignant Tumors
Neurologic Conditions
Infections
Congenital Deformities
Amputation
Amputation
Trauma
Amputation
Malignant Tumor
Amputation
Gangrene
Crush
Amputation
Amputation
Peripheral Vascular Disease
Polydactyly
Congenial Anomaly
Amputation
• the most common indication for amputation. with or without diabetes. Most frequently occurs in individuals age 50 to 75 years.
• If vascular disease has progressed to the point of requiring amputation, it is not limited to the involved extremity.
• Most patients also have concomitant disease processes in the cerebral vasculature, coronary arteries, and kidneys.
• Approximately half of amputations for peripheral vascular disease are performed on patients with diabetes.
• The most significant predictor of amputation in diabetics is peripheral neuropathy. (insensitive to Weinstein 5.07 monofilament)
1. Peripheral Vascular Disease
Amputation
Other documented risk factors include
I. Prior stroke
II. Prior major amputation
III. Decreased transcutaneous oxygen levels
IV. Decreased ankle-brachial blood pressure
index
Peripheral Vascular Disease
Amputation
• Before performing an amputation for
peripheral vascular disease, a vascular
surgery consultation is almost always
indicated as improved techniques currently
allow for revascularization of limbs that
previously would have been unsalvageable.
Peripheral Vascular Disease
Amputation
If amputation becomes necessary,
• Optimize the pt. for surgery
• Controlle the infection
• Nutrition and Immune status should be
evaluated. ( Risk for wound complications
greatly increases in patients whose serum
albumin is less than 3.5 g/dL or whose total
lymphocyte count is less than 1500 cells/mL).
Peripheral Vascular Disease
Amputation
• Trauma is the leading indication for
amputations in younger patients
• More common in men because of
vocational and avocational hazards.
• The only absolute indication for primary
amputation is an irreversible ischemia.
2. Trauma
Amputation
To predict which limbs will be salvageable,
available scoring systems include :-
The predictive salvage index
The limb injury score
The limb salvage index
The mangled extremity syndrome index
The mangled extremity severity score.
Trauma
Amputation
• Most useful score as it is easy to apply, grades the injury on the basis of the energy that caused the injury, limb ischemia, shock and the patient's age.
• Score of 6 or less = salvageable limb
• Score of 7 or greater = amputation
• Ischemia points × 2 if ischemic time exceeds 6 hours.
Trauma Mangled Extremity Severity Score
Amputation
Trauma Mangled Extremity Severity Score
• Amputation of an injured extremity is
necessary to preserve life as attempts to
salvage a severely injured limb may lead to
metabolic overload and secondary organ
failure which is more common in patients
with multiple injuries and in the elderly.
Trauma
Amputation
• Thermal or electrical injury to an extremity
may necessitate amputation.
• The full extent of tissue damage may not be
apparent at initial presentation, especially with
electrical injury.
• Treatment involves early débridement of
devitalized tissue, fasciotomies when
indicated, and aggressive wound care, might
need 2nd look procedure in OR.
3. Burns
Amputation
• Compared with early amputation, delayed
amputation of an unsalvageable limb has
been associated with increased risk of local
infection, systemic infection, myoglobin-
induced renal failure, and death.
Burns
Amputation
• Frostbite denotes the actual freezing of tissue in the extremities, with or without central hypothermia.
• This is a common problem for high-altitude climbers, skiers, and hunters.
• Also at risk are homeless, alcoholic, and schizophrenic individuals.
• When heat loss exceeds the body's ability to maintain homeostasis, blood flow to the extremities is decreased to maintain central body temperature.
4. Frostbite
Amputation
• Actual tissue injury occurs through two
mechanisms:
1. Direct tissue injury through the formation of
ice crystals in the extracellular fluid
2. Ischemic injury resulting from damage to
vascular endothelium, clot formation, and
increased sympathetic tone
Frostbite
Amputation
• Amputation for frostbite routinely should be delayed 2 to 6 months.
• Clear demarcation of viable tissue may take this long.
• Even after demarcation appears to be complete on the surface, deep tissues still may be recovering.
• Despite the presence of mummified tissue, infection is rare if local wound management is maintained.
Frostbite
Amputation
• Triple-Phase Technetium Bone Scan has
helped to delineate deep tissue viability.
• Performing surgery prematurely often
results in greater tissue loss and increased
risk of infection.
Frostbite
Amputation
• Amputation may be necessary for acute or chronic infection that is unresponsive to antibiotics and surgical débridement.
• Open amputation is indicated - two methods.
1. A guillotine amputation may be performed with later revision to a more proximal level after the infection is under control.
2. Amputation may be performed at the definitive level by initially inverting the flaps and packing the wound open with secondary closure at 10 to 14 days.
5. Infections
Amputation
• Kritter’s method for partial foot amputation
with primary closure in patients with active
infection.
• By this method, the wound is closed loosely
over a catheter through which an antibiotic
irrigant is infused.
• The constant infusion is continued for 5 days.
Infections
Amputation
• The wound must be closed loosely enough to
allow the fluid to escape into the dressings.
• The dressings must be changed frequently until
the catheter is removed on postoperative day 5.
• This method may allow for primary wound
healing, while avoiding a protracted course of
wound healing by secondary intention.
Infections Kritter’s method
Amputation
Kritter’s Method
Amputation
In the acute setting, the most worrisome
infections are those produced by gas-forming
organisms.Typically associated with:
• Battlefield injuries
• Farm injuries
• Motor vehicle accidents
• Civilian gunshot wounds.
Infections
Amputation
Infections
Clostridial myonecrosis: • Develop with in 24 hour,
• Acute onset of pain, swelling, Toxemia
• Wound bronze colour, serosanguineous exudate
with musty odor.
• Gram stain: gram +ive Rods
• Treatment: high dose of iv penicillin / clindamycin,
hyperbaric Oxygen, Amputation one joint above
the involed compartment as life saving.
Amputation
Infections
Streptococcal Myonecrosis• Develops over 3 to 4 days
• Swelling usually sever but pain not sever
• Wound with seropurulent discharge, small amount of gas,
• Treatment: involved muscle compartment debribment
Penicillin iv
Amputation
Infections
Anaerobic cellulitis• Develops after several days of wound closure
• Subcutaneous Emphysema may spread rapidly
• Pain, swelling and toxemia usually minimal
• Abundent gas with foul smell
• Treatment: debribment, broad-spectrum ABX, rarely
amputation
Amputation
• Four issues that must be considered when contemplating limb salvage instead of amputation, as follows:
1. Would survival be affected by the treatment choice?
2. How do short-term and long-term morbidity compare?
3. How would the function of a salvaged limb compare with that of a prosthesis?
4. Are there any psychosocial consequences?
6. Tumors
Amputation
1. Would survival be affected by the
treatment choice?
• Long-term survival for Osteosarcoma pts
improved from approximately 20% to
approximately 70% With the use of
multimodal treatment, including surgery and
chemotherapy
• Osteosarcoma: rate of local recurrence after
wide resection and limb salvage is 5% to 10%,
equivalent to the local recurrence rate after a
transfemoral amputation
Amputation
2. How do short-term and long-term
morbidity compare?
• Amputation in malignancy is often technically
demanding, requiring nonstandard flaps, bone
graft, or prosthetic augmentation to obtain a
more functional residual limb.
• Limb salvage is associated with greater
perioperative morbidity compared with
amputation.
Amputation
• Limb salvage requires a extensive surgical procedure with greater risk of infection, wound dehiscence, flap necrosis, blood loss, and deep venous thrombosis.
• Long-term complications vary depending on the type of reconstruction which include periprosthetic fractures, prosthetic loosening or dislocation, nonunion of the graft-host junction, allograft fracture, leg-length discrepancy, and late infection.
• A patient with a salvaged limb is more likely to need multiple subsequent operations for treatment of complications.
• After initial successful limb salvage surgery, one third of long-term survivors ultimately may require an amputation.
Tumors
Amputation
3. How would the function of a salvaged limb compare with that of a prosthesis?
• The location of the tumor is the most important factorwith regard to function.
• Resection of an upper extremity lesion with limb salvage, even with sacrifice of a major nerve, generally provides better function than amputation and subsequent prosthetic fitting.
• Resection of a proximal femoral or pelvic lesion with local reconstruction generally provides better function than hip disarticulation or hemipelvectomy.
• Sarcomas around the ankle and foot frequently are treated with amputation followed by prosthetic fitting
• Sarcomas around knee should be individualized.
Amputation
• Patients who had undergone Resection and Prosthetic Knee Replacement showed higher self-selected walking velocities and a more efficient gait with regard to oxygen consumption than patients with Transfemoral Amputations.
• Individuals with a Transfemoral Amputation functioned at more than 50% of their maximum aerobic capacity at free walking speeds, requiring anaerobic mechanisms to sustain muscle metabolism, which results in decreased endurance.
Tumors
Amputation
• Patients with an amputation had difficulty walking on steep, rough, or slippery surfaces, but were very active and were the least worried about damaging the affected limb.
• Patients with an arthrodesis performed the most demanding physical work and recreational activities, but they had difficulty with sitting, especially in the back seat of cars, theaters, or sports arenas.
Tumors
Amputation
Determination of Amputation level
• Understand tradeoff between increased
function with more distal amputation and
decreased complications with more
proximal amputation.
• The energy required for walking is
inversely proportionate to the length of the
remaining limb.
• Patients with amputations at the transfemoral, transtibial, and Syme levels secondary to trauma or chronic limb ischemia were evaluated.
• Compared with controls without amputations, the self-selected walking velocity for vascular amputees was 66% at the Syme level, 59% at the transtibial level, and 44% at the transfemorallevel.
• For traumatic amputees, generally younger patients, the rates were 87% at the transtibial level and 63% at the transfemoral level.
• At self-selected walking velocities, the slower rates for amputees seem to be a compensatory mechanism to conserve energy per unit time.
Determination of Amputation level
• Patients tended to decrease their velocities to keep their relative energy costs per minute within normal limits.
• When energy expenditure per minute is not compensated, anaerobic mechanisms are summoned to sustain muscle function, and endurance is greatly compromised.
• Thus it becomes apparent that amputation should be performed at the most distal level possible if ambulation is the chief concern.
• If a patient has no ambulatory potential, wound healing with decreased perioperative morbidity should be the chief concern.
Determination of Amputation level
Determination of Amputation level
Amputation
• Zone of Injury (trauma)
• Adequate margins (tumor)
• Adequate circulation (vascular disease)
• Soft tissue envelope
• Bone and joint condition
• Control of infection
• Nutritional status
Level of Amputation
• Debridement of all Nonviable tissue and foreign material
• Several debridements may be required
• Primary wound closure often contraindicated
• High voltage, electrical burn injuries require careful
evaluation because necrosis of deep muscle may be present
while superficial muscles can remain viable
Techniques
Amputation
Skin and Muscle Flaps
• Flaps should be kept thick.
• Avoid unnecessary dissection to prevent further devascularization of already compromised tissues.
• Scar should not be adherent to the bone as an adherent scar makes prosthetic fitting extremely difficult, and often breaks down after prolonged prosthetic use.
• Avoid redundant soft tissues or large “dog ears” to avoid problems with prosthesis
Techniques
• Muscles are usually divided at least 5 cm distal to
the intended bone resection.
• Myodesis (suturing muscle or tendon to bone) or
by Myoplasty (suturing muscle to periosteum or
to fascia of opposing musculature.
• Transected muscles atrophy 40% to 60% in 2
years if they are not securely fixed).
• Myodesis should be performed to provide a
stronger insertion, help maximize strength, and
minimize atrophy
Techniques
Myodesis
• Myodesed muscles continue to
counterbalance their antagonists, preventing
contractures and maximizing residual limb
function.
• Contraindicated in severe ischemia because
of the increased risk of wound breakdown.
Techniques
Hemostasis
• Use the tourniquet as it makes the amputation easier.(except for severely ischemic limb)
• Use Esmarch bandage (except infection and neoplasm)
• Major blood vessels should be isolated and individually ligated.( vein and artery separately)
• Doubly ligate larger vessels.
• Deflate tourniquet before closure, and do meticulous hemostasis.
• Use drain in most cases for 48 to 72 hours.
Techniques
Nerves
• Avoid formation of neuroma
• Neuroma becomes painful if it forms in a position where it would be subjected to repeated trauma.
• Isolate the nerve, gently pull distally and divide cleanly with a sharp knife so that the cut end retracts well proximal.
• Avoid crushing the nerve
• Ligate large nerves (sciatic nerve) to ligate accompanying vessels.
• Avoid strong tension on nerve, otherwise wound will be painfull.
Techniques
Bone
• Avoid excessive periosteal stripping as it may
result in the formation of ring sequestra or
bony overgrowth.
• Bony prominences that would not be well
padded by soft tissue always should be
resected, and the remaining bone should be
rasped to form a smooth contour.
Techniques
• Skin is not closed over the end of the stump.
• Indicated in infections and in severe traumatic wounds with extensive destruction of tissue and gross contamination.
• May require multipule surgeries
• Must be followed by secondary closure, reamputation, revision, or plastic repair.
• Vacuum-assisted closure ( VAC ) is applied to the open stump immediately after the initial débridement.
• Subsequent débridements are scheduled at 48-hour intervals.
• Reaply VAC after each debridement until the wound is ready for closure
Open Amputations
• Goals
• Prompt, uncomplicated wound healing
• Control of edema
• Control of Postoperative pain
• Prevention of joint contractures
• Rapid rehabilitation
Postoperative Care
Amputation
• Requires multidisciplinary team approach
• Perioperative antibiotics, DVT prophylaxis, and pulmonary hygiene.
• Pain management
• If weight bearing ambulation is not planned in the immediate postoperative period, the rigid dressing ( POP ) may be applied
• If weight bearing ambulation in the immediate postoperative period is anticipated, a true prosthetic cast should be applied.
Postoperative Care
• Dressing• Soft dressing (elastocreap)
• Rigid dressing (pop cast)
• Advantages of rigid dressing- Prevent edema at the surgical site
- Protect the wound from bed trauma
- Enhance wound healing and early maturation of the stump
- Decrease postoperative pain
- Allow earlier mobilization from bed to chair and ambulation with support
- For transtibial amputations- prevent the formation of knee flexion contractures
Postoperative Care
• Drains usually are removed at 48 hours.
• The stump is elevated by raising the foot of the bed, which helps manage edema and postoperative pain.
• The patient is cautioned against leaving the stump in a dependent position.
• Early unprotected weight bearing can result in sloughing of the skin or delayed wound healing.
• If the wound is progressing well, weight bearing can progress in 25-lb increments each week.
• Supervision is important in patients with peripheral neuropathy who may have difficulty judging how much weight they are placing on their stumps.
Postoperative Care
• Regardless of when prosthetic ambulation is begun, the rigid dressing should be removed and the wound inspected in 7 to 10 days.
• Cast loosening, fever, excessive drainage, or systemic symptoms of wound infection are indications for earlier cast removal.
• If the wound is healing well, a new rigid dressing is applied, and ambulation with or without prosthetic is continued.
Postoperative Care
• After the wound is well healed, the rigid
dressing can be removed for bathing and
stump hygiene
• Use rigid dressing until the stump volume
appears unchanged from the previous week.
• Then prosthetist may apply the first prosthesis.
• One or more socket changes frequently over
the first 18 months
Postoperative Care
1. Hematoma
2. Infection
3. Wound necrosis
4. Contractures
5. Pain
6. Dermatological problems
COMPLICATIONS
• Hemostasis before closure, use of drain, and a
rigid dressing should minimize hematoma
formation.
• Can delay wound healing and source of
bacterial infection.
• If formed, Should be treated with a
compressive dressing, evacuation.
1. Hematoma
• More common in amputations for PVD especially in diabetic patients.
• Any deep wound infection should be treated with immediate debridement and irrigation and open wound management.
• Delayed closure may be difficult because of edema and retraction of the flaps.
• Smith and Burgess method: the central one third of the wound is closed, and the remainder of the wound is packed open.
This allows for continued open wound management, while maintaining adequate flaps for distal bone coverage.
2. Infection
• skin edge necrosis less than 1 cm can be
treated conservatively
• Severe necrosis with poor coverage of the
bone end, wedge resection can be done.
• The basic principle of wedge resection is to regard
the end of the amputation stump as a hemisphere.
• Resection of a wedge incorporating the full
diameter of the stump would allow for reformation
of the hemisphere, while minimizing local
pressures
3. Wound Necrosis
• Mild or moderate contractures of the joints can be prevented by
• proper positioning of the stump,
• gentle passive stretching,
• engage in exercises to strengthen the muscles controlling the joint.
• Severe fixed contractures may require
• wedging casts
• surgical release of the contracted structures.
4. Contractures
1. Mechanical low back pain
2. Residual limb pain is caused by
Poor fitting prosthesis-
abnormal pressure, especially over bony prominences.
Distal stump edema “choking”
Treatment with socket modifications.
Painful neuroma
• due to pressure or repeated irritation of nerve end.
• usually palpable and positive Tinel sign.
Treatment initially socket modification
If not resolved then neuroma excision.
5. Pain
• Contact Dermatitis
• Bacterial Folliculitis
• Epidermoid cyst
• Verrucous hyperplaysia
To avoid such conditions • Wash the stump at least once a day.
• Stump should be thoroughly rinsed and dried before fitting prosthesis.
• keep the prosthesis clean and should be thoroughly dried before fitting.
• Treat infection and modify prosthesis as required
6. Dermatological problems
Techniques… Few examples
Amputation
Techniques… Few examples
Amputation
After 12 months
Techniques… Few examples
Amputation
Amputation
Rehabilitation and Prosthetics
Rehabilitations.
Amputation
• Residual Limb Shrinkage and Shaping
• Limb Desensitization
• Maintain joint range of motion
• Strengthen residual limb
• Maximize Self reliance
• Patient education: Future goals and prosthetic options
Psychological stress.
Amputation
• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms
• Depression
• Anxiety
• Crying spells
• Insomnia
• Loss of appetite
• Suicidal ideation
AMPUTATIONS IN
CHILDREN
• Amputations in children is divided into two general categories—congenital (60%) and acquired (40%)
• Causes of Acquired amputations:-
• Secondary to trauma
• Neoplasm
• Infection.
• Motor vehicle accidents, gunshot wounds, and
power tool injuries are the most common causes
of limb loss from injury in older children; in
young children, accidents with power tools, such
as lawnmowers, and other household accidents
are the most common causes.
• Dysvascular amputations in children are rare, but
when they do occur, they usually are secondary to
thrombotic or embolic events caused by another
underlying problem.
• Causes of congenital amputations
Amniotic band syndrome
Exposure to teratogens ( thalidomide )
Polydactyly
Syndactyly
Macrodactyly
Congenital pseudoarthrosis of the tibia and fibula, radius and ulna
Constrictions of the leg
Congenital deficiencies of the long bones
1. Preserve length
2. Preserve important growth plates
3. Perform disarticulation rather than transosseousamputation whenever possible
4. Preserve the knee joint whenever possible
5. Stabilize and normalize the proximal portion of the limb
6. Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions.
Principles Of Childhood Amputation
Because of growth issues and increased body
metabolism, children often can tolerate
procedures on amputation stumps that are
not tolerated by adults, which includes
• More forceful skin traction
• Application of extensive skin grafts
• Closure of skin flaps under moderate tension.
Advantages Of Amputation In
Children In Comparison To Adults
Complications after surgery tend to be less severe in children, which includes• Painful phantom sensations do not develop
• Neuromas rarely are troublesome enough to require surgery.
• Extensive scars usually are tolerated well.
Children use prostheses extremely well, and their proficiency increases as they age and mature.
• A progressive prosthetic program should be designed that parallels normal motor development.
• children function well with simple prostheses.
• As they grow, modifications may be made, such as the addition of a knee joint, a mobile elbow joint, or a mechanical hand.
Techniques… Few examples
Amputation
Techniques… Few examples
Amputation
After 12 months
Techniques… Few examples
Amputation
Amputation
Rehabilitation and Prosthetics
Rehabilitations.
Amputation
• Residual Limb Shrinkage and Shaping
• Limb Desensitization
• Maintain joint range of motion
• Strengthen residual limb
• Maximize Self reliance
• Patient education: Future goals and prosthetic options
Psychological stress.
Amputation
• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms
• Depression
• Anxiety
• Crying spells
• Insomnia
• Loss of appetite
• Suicidal ideation
Management of Amputee
Amputation
• Preparation
• Good Surgical Technique
• Rehabilitation
• Early Prosthetic Fitting
• Team Approach
• Vocational and Activity Rehabilitation