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    Amputation

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    jubaershimul
    Dr. Md Jobayer Al Mahmud presented on amputation, beginning with a brief history and then covering key topics such as indications, levels of amputation, preoperative evaluation, operative techniques, postoperative care, complications, and rehabilitation. The presentation outlined the principles and technical aspects of various amputation procedures and levels for both the upper and lower extremities. Postoperative goals include reducing pain and edema while encouraging early mobilization and prosthetic fitting to aid rehabilitation.

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    Amputation

    Uploaded by

    jubaershimul
    13 views32 pages
    Dr. Md Jobayer Al Mahmud presented on amputation, beginning with a brief history and then covering key topics such as indications, levels of amputation, preoperative evaluation, operative techniques, postoperative care, complications, and rehabilitation. The presentation outlined the principles and technical aspects of various amputation procedures and levels for both the upper and lower extremities. Postoperative goals include reducing pain and edema while encouraging early mobilization and prosthetic fitting to aid rehabilitation.

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    Amputation

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    Dr. Md Jobayer Al Mahmud presented on amputation, beginning with a brief history and then covering key topics such as indications, levels of amputation, preoperative evaluation, operative techniques, postoperative care, complications, and rehabilitation. The presentation outlined the principles and technical aspects of various amputation procedures and levels for both the upper and lower extremities. Postoperative goals include reducing pain and edema while encouraging early mobilization and prosthetic fitting to aid rehabilitation.

    Copyright:

    © All Rights Reserved
    Download as KEY, PDF, TXT or read online from Scribd
    Download as key, pdf, or txt
    13 views32 pages

    Amputation

    Uploaded by

    jubaershimul
    Dr. Md Jobayer Al Mahmud presented on amputation, beginning with a brief history and then covering key topics such as indications, levels of amputation, preoperative evaluation, operative techniques, postoperative care, complications, and rehabilitation. The presentation outlined the principles and technical aspects of various amputation procedures and levels for both the upper and lower extremities. Postoperative goals include reducing pain and edema while encouraging early mobilization and prosthetic fitting to aid rehabilitation.

    Copyright:

    © All Rights Reserved
    Download as KEY, PDF, TXT or read online from Scribd
    Download as key, pdf, or txt
    of 32

    WELCOME

    THE DAILY TOPICS PRESENTATION


    TO

    Dr Md Jobayer Al Mahmud
    MS Phase B Resident
    Amputation
    Outline
    • History

    • Indication

    • Levels of amputation

    • Preoperative evaluation

    • Operative techniques

    • Technical aspects

    • Postoperative care

    • Complications

    • References
    History
    • The word amputation is derived from
    from the Latin amputare, ‘to cut away’.

    • The English word “amputation’’ was


    first applied to surgery in 17 century
    th

    by Peter Lowe in 1612.

    • Historically was given as punishment

    • However stimulated by the


    aftermath of war.
    History (cont…)

    • It was a crude procedure by which limb was


    rapidly severed from unanaesthesized patient.

    • Hippocrates was the first to use ligature.

    • Ambroise Pare ( a France military surgeon)


    introduced artery forceps. He also designed
    prosthesis.
    Indication

    Alan Apley encapsulated the


    indications for amputation in
    the ‘three Ds’:
    1. Dead or dying limb

    2. Dangerous limb

    3. Damn nuisance
    Indications (cont…)
    Dead or dying limb
    • Peripheral vascular disease
    • Severe traumatised limb
    • Burn
    • Frost bite
    Indications (cont…)
    Dangerous limb
    • Malignant tumour
    • Lethal sepsis
    • Crush injury
    Indications (cont…)
    Damn nuisance

    Remaining the limb is more worse than having no


    limb at all because of:
    • Pain
    • Gross malformation
    • Recurrent sepsis
    • Severe loss of function
    Level selection
    Subjective measures
    Clinical examination:

    • Skin quality, extent of ischaemia/infection

    • Presence of pulse immediately above the level of amputation

    Local function:

    • Joint and residual limb length salvage is directly correlated to


    functional outcome.
    Level selection (cont…)
    Prosthetic design:

    • Short stump – Slips out from the prosthesis

    • Long stump - Pain, ulceration, incorporate of the joint in the prosthesis

    Objective test

    Non invasive procedures :

    • Doppler USG

    • Skin perfusion pressure

    •Transcutaneous oximetry

    Invasive procedures:

    • Angiography
    Level of amputation
    Determination of level

    • Zone of injury (trauma)

    • Adequate margin (tumour)

    • Adequate circulation (vascular disease)

    • Soft tissue envelope

    • Bone and joint condition

    • Control of infection

    • Nutritional status
    Pre operative evaluation
    History

    • Aetiology

    • Co-morbidities
    Physical examination

    • CVS, renal and nervous system


    Investigations

    • Doppler indices

    • Transcutaneuos O2 tension
    Pre operative evaluation (cont…)
    Optimisation

    • Anaemia, nutrition, hypotension, infection

    Consultation

    • Nephrologist, cardiologist, neurologist

    Counselling and consent

    • Procedure, anaesthesia, complications, prosthesis & limitations.


    MESS score 7 or more
    Ganga Hospital Open Injury Score
    Principles of amputation
    • Adequate blood supply

    • Skin incision should be marked properly

    • Torniquet shouldn’t be used in case of vascular disease

    • Proximal part of the flap contains muscle component and distal flap should
    contain only skin & deep fascia

    • Adequate flap length

    • Nerve to be buried deep

    • Proper dressing after surgery

    • Postoperative active exercise should be given for proximal joint


    Criteria of ideal stump
    • Length of the stump should be adequate.
    • Muscle power should good in the stump and proximal joint.
    • Full ROM in proximal joint.
    • Healthy and non adherent scar.
    • Adequate muscle covering over distal end and around the stump.
    • Normal skin sensation.
    • No neuroma.
    Criteria of bad stump
    • Small and inadequate size.

    • Flabby musculature around the stump.

    • Bony stump.

    • Restricted ROM at proximal joint.

    • Painful stump scar.

    • Presence of neuroma.
    Technical aspects
    Incision:

    • Circular

    • Elliptical

    • Racquet

    Skin flaps:

    • Flap should be kept thick

    • Tense sutures should be avoided

    • Apex of fish mouth at the level of bony resection

    • Total length of flap anterior + posterior = 1.5 times diameter

    • Flap should be semicircular for conical stump


    Technical aspects (cont..)
    Muscles:

    • Divided at least 5 cm distal to intended bone


    resection

    • Stabilised by myodesis or myoplasty


    Nerves:

    • Neuroma formation is inevitable after transaction

    • Draw nerve distally, section it, allow to retract


    Technical aspects (cont..)

    Blood vessels:

    • Large vessels should be double ligated

    • Haemostasis achieved prior to closure

    Bone:

    • Avoid excessive periosteal stripping

    • Bevel and smooth the bone end

    Closure:

    • Don’t close under tension

    • Drains are necessary


    Amputation levels
    • Forequarter amputation:

    Entire upper limb + scapula + clavicle (lateral 2/3rd)

    • Shoulder disarticulation:

    Done at the level of shoulder with shoulder blade remaining

    • Transhumeral:

    Done at any level between supracondylar region to axillary fold

    • Elbow disarticulation

    • Transradial amputation:

    Either proximal or distal


    Amputation levels (cont..)
    • Wrist disarticulation

    • Krukenberg’s amputation:

    Gap between radius & ulna like a claw.

    • Wrist amputation

    • Hand and partial hand amputation

    • Hindquarter amputation:

    Standard, anterior flap & conservative hemipelvectomy

    5 cm above the ASIS to pubic tubercle

    • Hip disarticulation:

    5 cm distal to adductor muscle & ischial tuberosity, 8 cm distal to greater


    trochanter
    Amputation levels (cont..)
    • Transfemoral amputation:

    Short, medial & long transfemoral, supracondylar

    Ideal length 25 from tip of greater trochanter and


    minimum stump should be 10 cm
    • Knee disarticulation
    • Transtibial amputation:

    Ideal length of the stump should be 12.5 cm to 17.5 cm


    Amputation levels (cont..)
    • Syme’s amputation:

    Section of tibia-fibula 0.6 cm proximal to ankle retaining heel flap

    • Chopart’s amputation:

    Disarticulation of talonavicular & calcaneocuboid

    • Lisfranc’s amputation:

    Disarticulation of tarsometatarsal joint

    • Gillies amputation (trans metatarsal)

    • Ray amputation:

    Amputation of toe + metatarsal head


    Dressing
    Rigid dressing:

    • Decreases oedema & postoperative pain

    • Protect limb from trauma

    • Early mobilisation

    • Temporary prosthetic fitting


    Soft dressing:

    • Sterile dressing & crepe bandages applied.


    Complications

    Early complications:

    • Bleeding and haematoma

    • Flap necrosis

    • Surgical wound infection

    • Gas gangrene

    Late complications:

    • Phantom pain

    • Phantom limb

    • Dermatological complications

    • Joint deformity
    Post surgical rehabilitation
    • Primary goal – Reduce pain & oedema, increase strength, prevent
    contractures.

    • Instructed not to lie on a overly soft mattress.

    • Early mobilisation should be encouraged.

    • Limb desensitisation.

    • Maintain joint range of motion.

    • Prosthesis may be fitted a minimum of 8-12 weeks after surgery.


    Psychological stress
    Up to 2/3rd amputee will manifest postoperative

    psychiatric symptoms

    • Depression

    • Anxiety

    • Crying spells

    • Insomnia

    • Loss of appetite

    • Suicidal ideation
    References
    • Selvadurai Nayagam, David Warwick. Orthopaedic
    operations; Apley's system of orhtopaedics & fractures,
    10 th
    Ed; 12:325-328.
    • Canale & Beaty: General principles of amputations:Campbell's Operative
    Orthopaedics, 14 edition.
    th

    • John Ebenezer: Amputations; Textbook of


    Orthopaedics, 4th Edition; 60:787-791.

    • Internet

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