35
Principles of AMPUTATION Dr Arojuraye S.A National Orthopaedic Hospital Dala - Kano
| Date post: | 12-Jul-2015 |
| Category: |
Health & Medicine |
| Upload: | soliudeen-arojuraye |
| View: | 676 times |
| Download: | 3 times |
Principles of
AMPUTATION
Dr Arojuraye S.A
National Orthopaedic Hospital
Dala-Kano
OUTLINE
Introduction
Indications
Types
Preoperative evaluation
Operative techniques
Postoperative care
Complications
Conclusion
References
Introduction
Definition
Trans-osseous removal of a limb or part of it.
Most ancient surgical procedure
Multidisciplinary: Surgeon, Nurses,
Prosthetist, Physiotherapist, Occupational
therapists, Social worker & Psychologist.
Introduction…
Amputation: not a failure of Rx, but the 1st
step toward a patient's return to a more
comfortable & reproductive life.
The procedure should be planned &
performed with the same care & skill used in
any other reconstructive surgery.
Introduction…
Early surgical amputations ► limb was
severed from an unanesthetized patient.
Stump was dipped in boiling oil (hemostasis)
Stump was poorly suited for prostheses.
High mortality rate.
Introduction …
Introduction…
Hippocrates: first to use ligatures
1529: Popularized by Ambroise Paré
Paré also introduced the “artery forceps
He also designed sophisticated prostheses
1674: Morel's introduce tourniquet
1867: Lord Lister's introduce asepsis
Indication
Dead limb:
o Severe trauma
o Peripheral
vascular disease
o Burns
o Frostbite.
Indication…
Dangerous limb:
o Crush injury
o Malignancy
o Lethal sepsis
o Forgotten
tourniquet >6hrs.
Indication…
Damned nuisance:
o Gross deformity
o Recurrent sepsis
o Loss of function.
The only absolute
indication for
amputation is
irreversible ischaemia .
Types
Provisional amputation
o Circular or with flaps
o When primary healing is unlikely or
o Amputate as distal as aetiology will allow
o Skin flap is sutured loosely over a pack
o Re-amputation perform when stump is ok
Types…
Definitive end-bearing amputation
o Weight is taken through the end of the stump
o The scar should not be terminal
o Bone end must be solid (cut near the joint)
Definitive non-end-bearing amputation
o Commonest variety
o All upper limb & most lower limb amputations
o The scar can be terminal
Types…
Pre-operative Evaluation
History
o Aetiology
o Comorbidities
Physical examination
o CVS, Renal &
o Nervous system
Investigation
o Doppler indices
o Transcutaneous O2 tension
Pre-operative Evaluation…
Optimization:
Anaemia, hypotension, infection, nutrition
Consultations:
Nephrologist, Cardiologist, Neurologist
If vascular dx has progress to the point of amputation, most
patients also have concomitant dx process in the cerebral, renal &
coronary vasculatures.
Pre-operative Evaluation…
Counseling & consent
Procedure, anaesthesia, complications,
prosthesis & limitations.
MESS ≥ 7
Removes subjectivity from decision making
in trauma cases.
No scoring system can replace experience & good clinical judgment.
Principles of operative
techniques Anaesthesia
Regional, G.A
Antibiotics
Broad-spectrum, IV
Tourniquet
Except in arterial insufficiency
Principles of operative
techniques..
Principles of operative
techniques.. Skin flaps
o The combined length equals 1.5 times the
width of the limb at the site of amputation.
o Ant. & post. Flaps of equal length for UL &
A/K amputations. Long posterior flap for BK
amputation.
Principles of operative
techniques..
Principles of operative
techniques.. Muscles
o Divided distal to bone
o Myoplasty or Myodesis
Blood vessels
o Main vessels are doubly ligated individually
o Tourniquet is removed before closure
o Haemostasis is meticulously secured
Principles of operative
techniques.. Nerves
o Sharply cut & allow to retract
o Large nerves are ligated
Principles of operative
techniques.. Bone (site of election)
o A/K : 12cm above the joint
o B/K : 14cm below the joint
o B/E : 18cm from the olecranon
o A/E : 20cm from acromion
o sawn across @ proposed level
o Front of tibia is beveled
o Fibula is cut 2-3cm proximal to tibia
Principles of operative
techniques.. Other than site of election
o Gritti-Stokes
o Symes
o Pirogoff’s
o Chopart
o Lisfranc
o Krukenberg
the skill of the modern prosthetist has made it
possible to amputate at almost any site.
Principles of operative
techniques.. Closure
o Drain is placed
o Skin closed
without tension.
With modern total-contact
prosthetic sockets, the
location of the scar rarely is
important, but the scar
should not be adherent to
the underlying bone
Principles of operative
techniques.. Conical Dressing
o Soft dressing with crepe bandage
o Rigid dressing with POP• Rigid dressings prevent edema at the surgical site
• Enhance wound healing & early maturation of the stump
• Decrease postoperative pain
• Allow earlier mobilization & ambulation
• Prevent knee flexion contractures in B/K amputation
Principles of operative
techniques.. Ideal stump
o Conical
o Heal adequately
o Adequate stump
o Adequate muscle padding
o Thin scar not interfering with prosthesis
o Adjacent joint movements
o Adequate blood supply
Post-operative management
Analgesics
Antibiotics
DVT prophylaxis
Stump elevation (foot of the bed)
Avoid flexion contracture at knee & hip
Post-operative management…
Educate patient how to position the stump
Mobilize out of bed in 1DPO
Remove drain in 48hrs
Remove stitches in 2/52
Post-operative management…
Early physiotherapy
o Muscle setting exercises 1st
o Joint movement exercises
o Ambulation with parallel bars, then crutches
Prosthetic ambulation time depends on:
o Age of the patient
o Strength & agility of the patient
o Patient's ability to protect the stump
Post-operative
management…
Complications
Early
o Bleeding & haematoma
o Flap necrosis
o Surgical wound infection
o Gas gangrene
Complications …
Late
o Phantom pain
o Phantom limb
o Joint deformity
Conclusion
Amputation is the most ancient surgical
procedure
It should not be seen as a failure of Rx, but
rather as the first step towards a patient’s
return to a more comfortable & productive life
It does not end in the operating room; post op
care is equally important.
References Selvadurai Nayagam, David Warwick. Orthopaedic
operations; Apley’s system of orhtopaedics &
fractures, 9th Ed; 12:325-328.
Canale & Beaty: General principles of amputations:
Campbell's Operative Orthopaedics, 11th edition.
John Ebenezer: Amputations; Textbook of
Orthopaedics, 4th Edition; 60:787-791.
Tintle SM et. Al: Traumatic & trauma-related
amputations: Bone Joint Surg Am. 2010 Dec
15;92(18):2934-45.
