1. Amputation is the complete removal of an injured or deformed body part

2.

Peripheral vascular disease

• Peripheral Arterial occlusive disease

• Acute occlusion due to embolism

• Aneurysm

Diabeticlimb disease

Necrotising fasciitis

Trauma (severe tissue damage) - traumatic amputation

Infection (chronic disabling infection, Gas Gangrene)

Tumours (Malignant)

Nerve injury (trophic ulceration insensitive limb)

Congenital anomalies

• (eg. extra digits)

• Gross deformity (dysmelia)

3. Amputation 4. Amputation 5. Amputation 6. Amputation 7. Polydactyly Amputation 8. Amputation 9.

Damage to micro-vessels

Peripheral neuropathy, no sensation

Ulcers develop dueto trauma, infection often ensues

Arterial blood supply is reduced

Ulcer becomes chronic with bouts of acute infection leading to loss of digits/foot/limb

10. 11.

Malignancy: squamous cell carcinoma

Cardiac disease: AF, CCF, MI,

Trauma: RTA, crushing injury, gunshot, bomb blast, industrial machinery and burns.

12.

Return Patient to maximum level ofindependent function

Ablationof diseased tissue (tumor or infection)

Reducemorbidity & mortality (tumor or infection)

Considered first part of aReconstructionto produce aphysiological end organ.

13.

Level sites ofElectionversus sites of Emergency

Amputation LevelsOptimum ShortestLongestTransradial ( forearm )junction prox 2/3 & distal 1/33cm below biceps insertion 5cm above wrist jointTranshumeral( arm )middle third4cm below axillary fold10cm above olecranonTransfemoral( thigh )middle third8cm below pubic ramus15cm above knee joint Transtibial( leg )8cm for every metre of height(12cm)7.5cm below knee joint 14. 15. 16.

Zone of Injury (trauma)

Adequate margins (tumor)

Adequate circulation (vascular disease)

Soft tissue envelope

Bone and joint condition

Control of infection

Nutritional status

Amputation 17.

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 18.

Nerve

• Prevent neuroma formation

• Draw nerve distally, section it, allow it to retract proximally

Skin

• Opportunistic flaps

• Rotation flaps

• Tension free

• Skin grafts

Techniques Amputation 19.

Bone:

• Choose appropriate level

• Smooth edges of bone

• Narrow metaphyseal flare for some disarticulations

Amputation Techniques 20.

Goals of Postoperative Management

• Prompt, uncomplicated wound healing

• Control of edema

• Control of Postoperative pain

• Prevention of joint contractures

• Rapid rehabilitation

Techniques Amputation 21.

Rigid dressing: decreses edema, decreases post operative pain, protect limb from trauma, early mobilsation. Goodbandagingto mold the stump intoConicalshape to accept the prosthesis.

Inpostoperative prosthesis: early training with an IPOP is believed to increase the long term acceptance and use of prosthesis

Epidural analgesia

Castto be appied at the end of the procedure, changed on the post op day 5 + IPOP

Cast changed weekly

Earlyprosthetic fitting . New prosthesis around 18 months

Avoidproximalcompressionof the limb.

Prevent contracture(bysplintingand / ormuscle exercises )

22.

Failure of wound to heal: gap if wider than 1cm needs revision

Infection: open flaps retract / edematous

results in shortening the bone

Rx

close only central 1/3 for coverage of bone.

3.Phantom sensation: diminishes over time, telescoping

4.Pain and phantom pain: massage , cold packs, exercise and neuromuscular stimulation

TENS ( trans cutaneous electric nerve stimulation) : incorporated in a prosthesis

-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine

- Preioperative analgesia can prevent or decrease the later incidence of phantom pain .(Epiduralperineural)

23.

5.Edema

mistakes :- 1) Too tightly applied cast

2) Soft spica cast not applied inTransfemoral cast

Stump Edema Syndrome

-Proximal constriction

-Blood in skin ,pain, Pigmentation

-Elevation

24.

Children

Usually for congenital limb deficiencies

Try to retain limb if possible

Preserve length

Disarticulate if possible to preserve growth potential rather than trans-diaphyseal amputation ( bony overgrowth)

25.

Complications

Haematoma

Infection

Necrosis of stump end.

Contractures (due to muscle imbalance)

Neuroma at the cut nerve ending

Phantom pain

Terminal overgrowth (children)

26.

in thepostoperativeperiod-3 sources, wound pain, back pain and phantom pain.Wound pain can be controlled with opiates in the immediate phase and, if needed, NSAIDs used.

betweennormal postoperative(ie, surgical) pain andphantom limb pain .

Surgical painusually responds well to opioids.

Phantom limbpain usually is like aburning ,stinging ,electric pain , and it can be increased withanxiety and stress .

phantom pain is quite common initially,

if it is still present at 6 months postsurgery, the prognosis is unfavorable.

27.

Phantom limb sensationalso must be differentiated fromphantom limb pain .

Phantom limbsensationis the sensation that the amputatedlimb is still present .

Patients usually report that the absent hand/arm/limb isitching ,tickling , ormovingthrough space.

Phantom sensation is perceived as a "funny" or "different" feeling but usually isnotperceived aspainful .

28.

Three theories as to why patients experience phantom limb pain and sensation exist.

One theory is that the remainingnervescontinue to generate impulses.

A second theory is that thespinal cordnerves beginexcessivespontaneous firing in the absence of expectedsensory inputfrom the limb.

The third theory is that there is altered signaltransmissionand modulation within the somatosensorycortex .

29.

Another common phenomenon is telescoping.

Telescoping is the sensation that the distal part of the amputated extremity hasmoved proximallyup the arm.

A patient might report that it feels like the entire extremity has shrunk so that the hand is now up at the elbow.

This is a normal part of the nerve healing process and usually fades with time.

30.

Residual limb- The preferred term for the remaining portion of the amputated limb ( Stump , while still used, is politically incorrect.)

Terminal device- Most distal part of the prosthesis used to do work (eg, hand)

Myodesis- Direct suturing of muscle or tendon to bone

Myoplasty- Suturing muscles to periosteum

Prehensile- Grasp

31.

Forequarter Amputation

is the removal of the upper limb with the scapula

Mainly for malignancy

32.

Krukenberg procedure

Separate radial and ulna rays distally

forming radial and ulnapincerscapable of strong prehension and excellent manipulative ability

33. 34. 35. 36. 37. 38. The Syme's amputation provides an end-bearing stump that in many circumstances allows ambulation without a prosthesis over short distances. It is an excellent amputation for children, in whom it preserves the physes at the distal end of the tibia and fibula (26). The Syme's amputation works well for tumors and trauma, assuming that the heel flap has been spared from the trauma. In the past, it has had a high failure rate in ischemic limbs because of failure of wound healing. Today, the success of amputation at this level has increased because local tissue perfusion is preoperatively determined with Doppler ultrasound measurement of blood pressures, with radioactive133 Xe clearance tests, and with transcutaneous measurement of oxygenation. 39. 40.

The Boyd procedure provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus

Compared to a Syme's amputation, it provides more length and better preserves the weight-bearing function of the heel pad. Its increased complexity and morbidity have made it less used now than the Syme's amputation.

The Pirogoff amputation removes the anterior two thirds of the calcaneus but has no advantage over the Boyd amputation,

41.

Amputation through the knee offers numerous advantages. The main advantage is the creation of an endbearing stump and preservation of the distal femoral physes, which is particularly desirable in children. Another advantage is the maintenance of a long active lever arm for control of the prosthesis, with excellent muscle attachments. The bulbous distal stump enhances suspension of the prosthesis.

• In elderly dysvascular patients, the longer stump helps prevent hip flexion contractures and it provides better balance for wheelchair activities. Knee disarticulation is most useful in young athletic amputees in whom a below-knee amputation is not feasible.

42.

Chopart's amputation amputation of the foot by a midtarsal disarticulation.

closed amputation one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone.

amputation in contiguity amputation at a joint.

amputation in continuity amputation of a limb elsewhere than at a joint.

double-flap amputation one in which two flaps are formed.

43.

Dupuytren's amputation amputation of the arm at the shoulder joint.

elliptic amputation one in which the cut has an elliptical outline.

flap amputation closed a.

flapless amputation guillotine a.

Gritti-Stokes amputation amputation of the leg through the knee, using an oval anterior flap.

guillotine amputation one performed rapidly by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing.

Hey's amputation amputation of the foot between the tarsus and metatarsus.

interpelviabdominal amputation amputation of the thigh with excision of the lateral half of the pelvis.

interscapulothoracic amputation amputation of the arm with excision of the lateral portion of the shoulder girdle.

Larrey's amputation amputation at the shoulder joint.

44.

Lisfranc's amputation

1.Dupuytren's a.

2.amputation of the foot between the metatarsus and tarsus.

oblique amputation oval a.

open amputation guillotine a.

oval amputation one in which the incision consists of two reversed spirals.

Pirogoff's amputation amputation of the foot at the ankle, part of the calcaneus being left in the stump.

pulp amputation pulpotomy .

racket amputation one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb.

root amputation removal of one or more roots from a multirooted tooth, leaving at least one root to support the crown; when only the apex of a root is involved, it is calledapicoectomy .

spontaneous amputation loss of a part without surgical intervention, as in diabetes mellitus.

Stokes' amputation Gritti-Stokes a.

subperiosteal amputation one in which the cut end of the bone is covered by periosteal flaps.

Syme's amputation disarticulation of the foot with removal of both malleoli.

Teale's amputation amputation with short and long rectangular flaps.

45. 46. 47. 48.

Aim: to provide a useful, functional, well moulded, healthy stump to allow prosthetic attachment

Total excision of diseased tissue

Maintenance of sufficient blood supply to allow healing

Stump of sufficient length to allow prosthetic attachment

49.

Patient should be prone with the stump flat at first,BKA patients will often have a brace in situ to prevent post popliteal tendon contracture.

Physio involvement is tentative at this stage to avoid wound problems

50.

Sitting outof bed within 48 hrs

Wheelchair used to assist mobility

Practice in transferring, standing and early walking with crutches supervised with physio.

Use of the PPAM aid, inflatable tube in metal frame with rocker foot, used on parallel bars for support

51.

Initial contact layer should be absorbent non-adherent and occlusive to avoid infection

Vacuum drains may be in place until drainage subsides sufficiently (48 hrs)

Padding should be applied for comfort and protection and bandaging should be firm but not restrictive

52.

Ischaemia: poor perfusion, infection, wound breakdown, pain.

Flap tension: tightness of skin over bone causing tension in the wound

Oedema: Due to tissue damage,dependence and poor venous drainage

Infection:high risk due to ischaemia, particularly diabetic patients, poor healing,

53. 54.

Involvement of the multidisciplinary team is essential: physio for mobility, provision of stump board for wheelchair OT for home assessment and safety issues,social work, benefits,motability car,district nurse for wound checks and/or control of diabetes.

Involvement in local amputee groups

Medical follow up ato/p clinic

55.

Two weeks after surgery, muscle-contraction exercises and progressive desensitization of the residual extremity are initiated.

Desensitization is started with a towelfor distal residual extremity pressure, and distal-end bearing is started on a soft structure (usually a bed).

Prosthetic management is begun 6 weeks after surgery, depending on the condition of the extremity and wound. Some patients are not candidates for prosthetic limb replacement because of poor balance, weakness, or cognitive impairment. To avoid disappointment and expense, a permanent prosthesis should not be ordered for these patients.

56.

External ramps required

Stair lift, railings.

Doors widened

Kitchen worktops and sinks adjusted

Shower on level, with chair access

Possible hoist for bath

Adapted furniture

57. 58. 59.

Potentially greater psychological impact

Patient more likely to have been younger and fitter.

Wound may be left open until signs of oedema and signs of infection reduce

Psychosocial issues are often far reaching

60.

. If a digit is hanging on by a small bridge of skin or muscle, attempt to bandage it without completing the separation. If the body part can be easily recovered and the victim can be brought to a hospital within 6 hours of the injury, do the following: 1. Gently rinse the body part if the cut end is contaminated with dirt. 2. Wrap the body part in clean cloth or gauze and keep the covering moist. The ideal solution is saline (not ocean water, because of infection risk), if that is available; if not, fresh water will do. Do not immerse the part in a bag of water; merely keep the covering moist. Keep the body part cool by placing it on ice after wrapping it securely in a bandage, cloth, or towel. To avoid a frostbite injury, do not apply ice directly to the body part or immerse it in ice water. 3. Bring the body part with the victim to the hospital.

61.

Tissue

• Clinical - feel pulses, skin temperature, level of dependent redness

• Doppler (U/S) check limb circulation; inaccurate with calcified blood vessels

• Arteriogram

62.

Systemic

• control diabetes

• evaluate cardiac, renal + cerebral circulation

• Preoperative calories controlin malnourished patient.

Psychological

• early plan for return to function

• preoperative counseling

• amputee support groups

PreoperativePain Control

• Pain clinic review

• Spinal anaesthesia

63.

Intralesional

Marginal

Wide resection

Radical resection

64.

Skin flaps

• Use defined flaps, with theapexof thefish mouthat thelevel of the bony resection

• Use any available flaps intraumato preserve length

• Tailor flaps at leastas long asthe diameter of the stump

65.

Muscles

• Divide ~5 cm distal to level of bone resection

• Stabilisation of muscle mass by good suturing.

• Adequatestump padding

• prevents atrophy (Muscle exercises)

• improves function

• Myoplasty = involves suture of flexors to the extensors over bony stump

• Myodesis = direct suture of muscle to bone - most useful in AK, AE and disarticulations

66.

Nerves

• Divide cleanly under gentle tensionproximal tobone ends - allow to retract

• Large nerves eg sciatic, median -ligatedue to large contained vessels

Blood vessels

• Large arteries & veins should bedoublyligatedand haemostasis achieved prior to closure

Bone

• Avoid excessive periosteal stripping (prevent spur formation)

• Bevel &smooththe bone end

67.

Closure

• Do not close under tension

• Interrupted sutures preferably

Drains

• are necessary

68. Crush Amputation 69. TechniquesFew examples Amputation 70. TechniquesFew examples Amputation 71. After 12 months TechniquesFew examples Amputation