- 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
- Trauma (severe tissue damage) - traumatic amputation
- Infection (chronic disabling infection, Gas Gangrene)
- Nerve injury (trophic ulceration insensitive limb)
-
- Gross deformity (dysmelia)
3. Amputation 4. Amputation 5. Amputation 6. Amputation 7.
Polydactyly Amputation 8. Amputation 9.
- 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.
- Adequate circulation (vascular disease)
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.
-
- Prevent neuroma formation
-
- Draw nerve distally, section it, allow it to retract
proximally
Techniques Amputation 19.
-
- Narrow metaphyseal flare for some disarticulations
Amputation Techniques 20.
- Goals of Postoperative Management
-
- Prompt, uncomplicated wound healing
-
- Control of Postoperative pain
-
- Prevention of joint contractures
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
- Castto be appied at the end of the procedure, changed on the
post op day 5 + IPOP
- 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
- 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.
- mistakes :- 1) Too tightly applied cast
- 2) Soft spica cast not applied inTransfemoral cast
- -Blood in skin ,pain, Pigmentation
24.
- Usually for congenital limb deficiencies
- Try to retain limb if possible
- Disarticulate if possible to preserve growth potential rather
than trans-diaphyseal amputation ( bony overgrowth)
25.
- Contractures (due to muscle imbalance)
- Neuroma at the cut nerve ending
- 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
31.
- is the removal of the upper limb with the scapula
32.
- 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.
- 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.
- Kitchen worktops and sinks adjusted
- Shower on level, with chair access
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.
-
- Clinical - feel pulses, skin temperature, level of dependent
redness
-
- Doppler (U/S) check limb circulation; inaccurate with calcified
blood vessels
62.
-
- evaluate cardiac, renal + cerebral circulation
-
- Preoperative calories controlin malnourished patient.
-
- early plan for return to function
63.
64.
-
- 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.
-
- Divide ~5 cm distal to level of bone resection
-
- Stabilisation of muscle mass by good suturing.
-
- prevents atrophy (Muscle exercises)
-
- 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.
-
- Divide cleanly under gentle tensionproximal tobone ends - allow
to retract
-
- Large nerves eg sciatic, median -ligatedue to large contained
vessels
-
- Large arteries & veins should bedoublyligatedand
haemostasis achieved prior to closure
-
- Avoid excessive periosteal stripping (prevent spur
formation)
-
- Bevel &smooththe bone end
67.
-
- Do not close under tension
-
- Interrupted sutures preferably
68. Crush Amputation 69. TechniquesFew examples Amputation 70.
TechniquesFew examples Amputation 71. After 12 months TechniquesFew
examples Amputation