AMPUTATIONS

Statistics
185,000 amputations in the
US each year
 Around 80% of amputees are
over the age of 65
Lower extremity amputation
(LEA) = 87% of all
amputations performed in the
US and Europe
↑↑ complications in LEA for
disease-related causes with
50% dying within 5 years of
LEA
Definitions:
Amputation –removal of part
of the body, limb, or part of a
limb

Stump – Aka residual limb;

part of a limb that remains
after amputation

Purpose:
 Relieve symptoms
 Improve function
 Improve QOL
 Save life
Indication for Amputations
 Traumatic injury
 Progressive arterial disease: often a sequelae of diabetes
 Gangrene/infection
 Congenital deformities
 Chronic osteomyelitis
 Malignant tumor
 Traumatic Injury
Or partial laceration
Can be complete amputation
requiring surgical
from an accident
amputation
 Progressive Arterial
Disease
Often due to Diabetes

Can lead to ulcers that

may require amputation

Amputation is four times

more likely in diabetics
than non-diabetics
 Gangrene
May require staged
amputations
Initially a guillotine
amputation is done to
remove the necrotic and
infected tissue
Sepsis is treated with
systemic antibiotics
After the infection is
controlled and the
patient’s condition has
been stabilized, a
definitive amputation with
skin closure is performed
 Sites for Amputation
Upper limb:
Forequarter:
Shoulder disarticulation
Above-Elbow: Trans-
humeral
Elbow disarticulation
Below-Elbow :Trans-radial
Hand and wrist
disarticulation
Partial hand: Trans-carpal
Lower limb:
Hemipelvectomy
Hip disarticulation
Above-knee: Trans-femoral
Knee disarticulation
Below-knee: trans-tibial
Ankle disarticulation
Symes (Modified ankle
disarticulation)
Partial foot
Digits
ANESTHESIA
• Spinal anesthesia is commonly used for major
amputation of the lower extremities
• inhalation anesthesia for major amputations of
the upper extremities
• plexus block or local infiltration anesthesia for
amputation of the fingers and toes
POSITION
• In amputations of the upper extremity, the
patient is placed near the edge of the table with
the arm extended and abducted to the desired
position
• For amputations of the lower extremity, the leg
may be elevated with several sterile towels
under the calf.
OPERATIVE
PREPARATION

• elevation
• Tourniquet
– Contraindicated for arteriosclerosis
– Sterile elastic bandsminor amputation.

• Aseptic and antiseptic procedures

 Amputation,
Supracondylar
Femur
PREOPERATIVE
PREPARATION

• Careful evaluation :
– Arterial obstructionarteriography is essential
– infection
• bacterial cultures with drug sensitivities are obtained,
the appropriate antibiotic is administered.
• procedure is delayed until improvement is possible.
– advance infection guillotine or open amputation
POSITION
• Th e patient is placed with the hip on the
affected side out to the margin of the table to
allow full abduction of the thigh by an
assistant, and the calf or ankle may be elevated
with several sterile towels. Th e hair is shaved
or dipped at the operative level.
OPERATIVE
PREPARATION
• shaving carefully
• The foot is held in abduction while the leg from
below the knee to high in the groin is cleaned
with appropriate antiseptics
• A sterile sheet is placed beneath the thigh.
• The foot and lower leg up to the knee are
covered with a sterile sheet or plastic drape
• the extremity is elevated by the assistant to
encourage venous drainage
INCISION AND
EXPOSURE(1)
• The type of flap that is used varies. With
progressive infection of the lower leg, a circular
incision is made for a guillotine amputation.
However, when possible, anterior and posterior
flaps are outlined with a sterile marking pen,
ensuring an appropriate stump length
• Either equal anterior and posterior flaps are
used or, more commonly, a larger anterior flap
with a length 1½ times the diameter of the
thigh at the level of the division of the femur
INCISION AND
EXPOSURE(2)
• The surgeon stands on the inner side of the
thigh
• the skin incision must extend at least 15 cm
below the point where the bone is to be divided.
• Th e incision is carried through the skin and
subcutaneous tissue down to the fascia over the
underlying muscles
• All bleeding points are clamped and tied.
DETAILS OF PROCEDURE (1)
DETAILS OF PROCEDURE (2)
Postop Interventions
1.Wound care
1.Pain relief
2.Altered sensory perception
POSTOPERATIVE CARE
• Wound Dressing
– The stump is covered with a nonadherent dressing
and fluff s of sterile gauze and is encased in a dressing
that is snug but not too tight.
– changed in 24 hours, since the stump may swell,
resulting in pain as well as interference with the blood
supply
• insulin regulation in the diabetic
• elevation
• Splints may be applied at the time of surgery to
maintain extension and prevent flexion
contractures
 Wound Care – New
Amputation
non-tender stump with healthy
skin for prosthesis use
 Elevate limb for first 24-48 hr
 Assess color, temperature,
pulses, signs infection & skin
breakdown
 Cleansing
 Pain Relief

 Opioids, NSAID
 Position change, sandbag on
residual limb
 Evacuate hematoma
 2. Altered Sensory
Perception
 Phantom limb pain:
 60-80% of amputees
 Numbness, burning, tingling, cramping, feeling
that the missing limb is still there, crushed, or in
an awkward position
 Nonpharmacological Interventions:
 Activity
 Distraction
 Mirror therapy
 Pharmacological Interventions:
 Opioids, NSAIDS
How to wrap a below the knee
amputation
How to wrap an above the knee
amputation
 Complications

1. Hemorrhage
2. Infection
3. Skin breakdown
4. Joint contracture
5. Bony overgrowth
6. Phantom limb pain
 1. Hemorrhage
 Caused by
severed blood
vessels or
loosened sutures
 Keep a
tourniquet
handy!
2. Infection

 ↑↑ with traumatic
amputation due to
contaminated wound
3. Skin Breakdown

Erythema
Pressure sores
4. Joint Contracture
 PREVENT
 Proper positioning
 Early ROM
 Muscle strengthening
 5. Bony Overgrowth

 Required Revision
surgery