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AMPUTATIONS

DR THIT LWIN
FACULTY OF MEDICINE &
HEALTH SCIENCE
UCSI

Definition:

amputation is removal of part or


all of a body part enclosed by skin
Removal of an appendix would not be termed
amputation..
Amputation" is derived from the Latin word
"amputare" (to excise, to cut out).
. A person
who has undergone an amputation is called an
amputee.

INDICATIONS
Three

Ds: Dead, Dangerous, Danm nuisance.


Dead: peripheral vascular disease,(90%)
severe trauma
burns or frostbite.
The only absolute indication for amputation is
irreversible ischemia in a diseased or traumatized
limb.

Dangerous:

malignant tumour
potentially lethal sepsis (gas gangrene)
crushed injury (release of compression may
cause renal failure)
Danm nuisance: gross malformations
severe loss of functions


VARIETIES
1.

provisional amputations
2. definitive end-bearing amputations
e.g. through-knee and Symes
3. definitive non-end-bearing amputations
-scar can be terminal

Usual

site of election in lower limb


amputation.

Through-knee

and Symes amputation are

end-bearing:
the scars are not terminal:

Usual

site of election in upper limb


amputation.

Preoperative preparation

Control

diabetes, infection, dehydration,


anemia, shock, & cardiac insufficiency.
Prepared to withstand & survive surgical
trauma.
Preoperative clinical assessment of skin color,
hair growth, & skin temperature

Preoperative preparation

Skin flap perfusion- thermography, laser Doppler


flowmetry,
Transcutaneous oxygen measurements-2040mm Hg

Simple screening tests for nutritional status &


immunocompetence.
Serum albumin level >3.5g/dL
Total lymphocyte count 1500cells/mL

1) GUILLOTINE AMPUTATION

Emergency amputation done as a life saving


measure.
Done in cases of gross crush injuries of the limb.
Also indicated in cases of gas gangrene, as a life
saving procedure.
Incision is circular around the limb at the site of
bone section and all the tissues are cut at the same
level and the wound is left open to provide free
drainage
When infection controlled & patient stabilizedRevision amputation done

Two

types
a) Open amputation with inverted skin
flaps
b) Circular open amputation

a) Open amputation with


inverted skin flaps
Wound

allowed to drain fully


Interrupted suture through edges to create rolled
flaps
If no infection & sufficient granulation tissue
stump closed in 2 weeks.
Sutures removed & edges unrolled
ADV: No revision surgery
DISADV: Maceration
Difficult to maintain skin traction

guillotine amputation

Non-ischaemic limb
amputation

Ischaemic limb
amputation

General complications
chest infections,
angina, heart attacks and
strokes.
Because your mobility is restricted
after an amputation, pressure sores
can also develop

Local Complications:
- wound Infection
-Tissue necrosis
-Pain(phantom limb pain, neuroma pain)
-Dehiscence/wound breakdown
-Problems associated with the surrounding
skin(contracture)
-Bone erosion/osteomyelitis
-Haematoma
-Stump edema
-dermatological problems: contact dermatitis,
bacterial folliculitis, epidermoid cyst, verrucous
hyperplasia.

Three distinct gas-forming infections


Anaerobic
cellulitis

Closridial
myonecrosis

Streptococcal
myonecrosis

Tissue necrosis

COMMON LEVEL OF
AMPUTATIONS

A dehisced above knee amputation with exposed


femur bone

Above knee amputation

Below knee amputation

Through

knee amputations

Rays amputations

Amputated

blister

stump showing

Toe

amputation

Transmetartarsal amputation

Sims amputation

Rays amputation

Lisfranc amputation

Stump sinus masking underlying osteomyelitis

Ideal stump

Stump- Firm & smooth, tapering segment ,


with full range of movements whose
muscles can activate stump in all directions.
Skin- healthy free of scars with good
circulation with no in drawn scars or folds
or puckers
Scar- should be linear, fully mobile, preff
posterior in lower limb
Flaps- no undue tension / flabbiness

Basic principlesSKIN FLAP

Flaps should be kept thick.

Skin at ends should be mobile & normally


sensate

Unnecessary dissection should be avoided to


prevent further revascularization of already
compromised tissues.

Basic principles MUSCLE FLAP

Muscles usually are divided distally (at least 5 cm


distal to the intended bone resection)
Muscle flaps have to be stabilized.

Myodesis --suturing muscle or tendon to bone.


(contraindicated in PVD / severe ischemia)

Myoplasty --suturing muscle to periosteum or to


fascia of opposing musculature.
Advantages of myoplasty
Muscle function
Stump circulation
Phantom pain
Counterbalance antagonists
Prevent contracture

Basic principles5) Nerves

Nerves should be isolated, gently pulled distally


into the wound, and divided cleanly with a sharp
knife so that the cut end retracts well proximal to
the level of bone resection. If not neuroma forms
at the level of stump.

Large nerves such as the sciatic often contain


relatively large arteries and therefore should be
ligated

Basic principles5) Nerves

Strong tension on the nerve should


be avoided during this maneuver;
otherwise the amputation stump may
be painful even after the wound has
healed.

Crushing also should be avoided.

Basic principles6) BLOOD VESSELS


Major blood vessels should
be isolated and individually
ligated.
Larger vessels should be doubly
ligated.
Tourniquet should be deflated
before closure, and meticulous
hemostasis should be obtained.

Basic principles7) BONE:


Excessive

periosteal stripping is
contraindicated and may result in the
formation of ring sequestra or bony
overgrowth.
Bony prominences that will not be
well padded by soft tissue should
always be resected.
Remaining bone should be rasped to
form a smooth contour.

WOUND DRESSING
SOFT DRESSING
Snugly

applied, with elastic


bandage.
Stump elevated with foot end
elevation
Muscle setting exercises &
mobilization of joints

Wound Dressing
Hard dressing
Postoperative POP casts applied with appropriate
padding

Advantages
Prevent

edema
Promote wound healing
Early maturation of stump
Decrease postoperative pain
Allows early mobilization
Prevent contractures
Decreased stay
Physiological benefits
psychological benefits

Basic principles8) Drain


Drains

Cast

removed after 48 hours

loosening, excessive drainage, or


systemic symptoms, wound infection are
indications for early cast removal

Jigli saw

Amputation
saw

Amputations in Children
general principles of childhood amputation:
(1) preserve length,
(2) preserve important growth plates,
(3) perform disarticulation rather than transosseous
amputation whenever possible,
(4) preserve the knee joint whenever possible,
(5) stabilize and normalize the proximal portion of the
limb, and
(6) be prepared to deal with issues in addition to limb
deficiency in children with other clinically important
conditions.

A.Terminal overgrowth of a trans-humeral


amputation in a pediatric patient.
B, Stump capping procedure. The bone end has
been split longitudinally and capped with an
osteochondral graft.