PRINCIPLES OF AMPUTATION

Dr Umar M AminuDepartment of Surgery

ATBUTH Bauchi

Outline• Introduction

– Definition– History– Epidemiology

• Indications• Principles

– Preoperative– Intraoperative– Postoperative

• Amputation in Children• Complications• Prosthesis• Conclusion

Introduction

Definition• Removal of part of or an entire limb through

one or more bones

• When it is through a joint= disarticulation

Introduction

• Not a failure of surgery but a reconstructive procedure

• Goal is surgical reconstruction that maintains most functional limb possible

Introduction

History• Earliest reference in Babylonian code of

Hammurabi-1700BC• Hippocrates in De Articularis-385BC• William Cloves did first successful AKA-1588• Botallus and Fabricus Holdani describe use of

torniquet-16th century• Norman Kick used Guillotine amputation during

World War-1943

IntroductionHistory

Introduction

Epidemiology• 350,000-1 mil amputees• 20,000-30,000 new amputees a yr• >> age 50-75yrs • >> Lower limbs• >> Males

IntroductionEpidemiology• The estimated prevalence of extremity

amputation in Nigeria is 1.6 per 100,000• The most frequent indications for

amputation were trauma (34%); complication of traditional bonesetting (TBS)(23%); malignant tumours (14.5%); diabetic gangrene (12.3%); infections(5.1%); peripheral artery disease (2.1%); and burns (2.1%).

• The average age of the Nigerian amputee is 33 years.• Hospital mortality after amputation is 10.9%.

Extremity amputation in Nigeria a review of indications andmortality. Thanni LO , Tade AO. Surgeon. 2007 Aug;5(4):213-7.

IntroductionEpidemiology• 320 limb amputations were performed

on adults at the Ahmadu Bello University Hospital, Nigeria over a period of 10yrs.

• Major indication for upper limb amputation was trauma and post-fracture splintagegangrene (57%).

• In the lower limb the most common indication foramputation was advanced squamous cell carcinoma of the skin involving thebone.

• No case of peripheral vascular disease in these patientsother than diabetic ulcersMajor Limb Amputation in Adults,Zaria,Nigeria.Yakubu A , Muhammad I, Mabogunje OA. J R Coll Surg Edinb. 1996 Apr;41(2):102-4.

Introduction

Locally (Amputation in ABUTH)-• 37 cases• Commonest age group-10-19• Commonest indication-Gangrene• Commonest procedure- Below Knee

Amputation

Introduction

Gangrene39%

Malignancy19%

Trauma19%

DMFS19%

Burns3%

Indications for amputation in ATBUTH Jan-Sept 2015

GangreneMalignancyTraumaDMFSBurns

Introduction

BKA33%

Disarticulation22%

AKA17%

BEA11%

AEA11%

N A6%

Types of Amputations done in ATBUTH Jan-Sept 2015

BKADisarticulationAKABEAAEAN A

Classification

• Emergency/Traumatic/Elective• Provisional/Definitive• Open/Closed• End bearing/Cone bearing• Named/Eponymous amputation

– Gritti-Stoke– Syme– Progoff– Chopart (@ midtarsal joint)– Lisfranc (@ Tarsometatarsal joint)– Ray

Amputation levels ( upper limbs )• Hand & Partial-Hand Amputations

Finger, thumb or portion of the hand below the wrist

• Wrist DisarticulationLimb is amputated at the level of the wrist

• Transradial (below elbow amputations)Amputation occurring in the forearm, from the elbow to the wrist

• Transhumeral (above elbow amputations)Amputation occurring in the upper arm from the elbow to the shoulder

• Shoulder DisarticulationAmbutation at the level of the shoulder, with the shoulder blade remaining.

• Forequarter AmputationAmputation at the level of the shoulder in which both the shoulder blade and collar bone are removed

Amputation levels ( lower limbs )• Foot Amputations• Amputation of greater toes and other toes• Amputation through the metatarsal bones• Lisfranc`s operation : at the level of the

tarsometatarsal joints• Chopart`s operation : through the midtarsal

joints• Transtibial Amputations (below the knee)

Amputation occurs at any level from the knee to the ankle

• Knee DisarticulationAmputation occurs at the level of the knee joint

• Transfemoral Amputations (above knee )Amputation occurs at any level from the hip to knee joint

• Hip Disarticulation Amputation is at the hip joint with the entire thigh and lower portion of the leg being removed.

Indications

• Congenital/ Acquired

• 3 Ds

Indications

Congenital• Hemimalia • Polydactly• Congenital

pseudoarthrosis • PFFD• Gross congenital

malfiormations

Acquired– Trauma- Mangled limb,

Crush injury– Vascular- D M angiopathy,

PVD– Infectivce-COM, Clostridia

• Neoplasm- Osteosarcoma,

• Frost bite• Burns

Indications

3 Ds• Dead/ limb-Gangrene

• Dying/Deadly/Dangerous limb- Crush injury, Osteosarcoma, Melanoma

• Damn nuisance-Gross congenital anomalies,

Goals of amputation

• To get rid of all necrotic, infected & painful tissue.

• To have a wound that heals successfully.• To have an appropriate remnant stump that

is able to accommodate a prosthetic.

Pre-Operative Assessment

To:• Ascertain indication• Site of amputation• General medical condition• Rehabilitation potential• Counselling• Consent• Optimisation

Pre Operative Assessment

• Assessment of –– The affected limb– The unaffected limb &– The patient as a whole is conducted thoroughly.

• Assessment of physical, social & psychological status of the patient should be made.

Pre-operative Evaluation• History

o Aetiology o Comorbidities

• Physical examinationo MSS-MESS ≥ 7 Removes subjectivity from decision making in trauma

cases. No scoring system can replace experience & good clinical judgment.

o CVS, Renal &o Nervous system

Pre-operative Evaluation• Investigation

– To confirm Diagnosiso Dopplero X-Rayo FBSo Technitium 99 Pyrophosphate bone scan

– Capability of Wound Healingo Transcutaneous Oxygeno Hemoglobino Serum Albumino Absolute lymphocyte count

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.

Social assessment includes

• Family & friends supports• Living accommodation –

– Stairs, ramps, rails, width of door, wheelchair accessibility• Proximity of shops

Pre-operative Evaluation…• Counseling & consent Procedure, anaesthesia, complications,

prosthesis & limitations.

• Involvement of support groups

Intra-operative Principles

• Determine outcome of function and rehabilitation

• Meticulous attention to detail and careful soft tissue handling

• Effort to be directed at achieving ideal stump

Ideal stump

1) It should be of optimum length 2) The end of stump should be smooth & rounded3) It should be firm4) The opposing group of muscles should be

sutured together over the end of the bone.5) The muscles are sutured in such a way that

they will be converted into fibrous tissue & serve as an effective cushion.

Ideal stump

6) Vascularity of the flaps should be normal7) There should be no projecting spur of bone.8) The stump shouldn't’t be under tension.9) The position of the scar should be avoided of

pressure n should be transverse to avoid pulling up between 2 bones in ap scar.

10) In case of U.L the scar can be terminal, but in L.L a posterior scar is desirable to avoid pressure of weight of artificial limb.

Traditional Sites of Election

Upperlimb• A/E – 20cm from Acromion• B/E – 18cm from Olecranon

Lowerlimb• A/ K – 12cm from Joint line• B/ K – 14cm from Joint line

Site of Selection

Examination• Skin color• Hair growth• Lowest palpable pulse• Skin temperatureInvestigation• Doppler USS

INTRA - OPERATIVE

• Anaesthesia: GA or Regional

• Position: Supine

• Tourniquet +/_ Exsanguination

Intra-Operative Principles

Intra-Operative PrinciplesSkin Incisions•Fish mouth Vs Racquet

Intra-Operative Principles

Controlling Bleeding• Isolate and ligate

• Pinch ends of muscle

• Identify and cut btw sutures

Intra-Operative PrinciplesControlling Bleeding•Isolate and ligate

•Pinch ends of muscle

•Identify and cut btw sutures

Intra-Operative PrinciplesCutting Muscle•Transverse•5cm distal to site of bone section•With amputation knife

Intra-Operative Principles

Nerves• Isolated, gently pulled distally into wound and

divided sharply

• Large nerves should be ligated

• Prevent painful neuroma

Sawing Bone

•Reflect periosteorum 1-2cm distally

•Protect soft tissue with amputation shield

•Smoothen edges•Wash bone dust with saline

Intra-Operative Principles

Intra-Operative Principles

Closing the Wound• Hemostasis is secured • Opposing group of muscles are sutured across

both the ends with interrupted stitches.• Fascia & skin are sutured over the muscle without

tension.• Preferably a suction drain is placed.• Wound is covered with gauze & roller bandages

tightly from below upwards.

Intra-Operative Principles

Open Amputation• Indications-

• infected limb• Battle injuries• Soft tissue injury/contamination• Uncertain blood ss

• Types-– Inverted edges– Circular

Intra-Operative Principles

Wound Dressing• Soft vs Rigid• Rigid dressing : decreses edema, decreases post

operative pain, protect limb from trauma, early mobilsation. Good bandaging to mold the stump into Conical shape to accept the prosthesis

• Soft dressing concept: The stump is dressed with the sterile dressing & crepe bandage applied over it.

Post-operative Care

• General-» Analgesia» Antibiotics» DVT prophylaxis

• Specific-» Joint Positioning+excercise» Drain removal» Mobilisation» Rehabilitation-prosthetic fittiing, home, occupation &

hobby

Complications

• General vs Specific

• Early vs Late

Complications

General• Haemorrhage-

Reactionary/ 2o

• Infection

Specific• Flap breakdown• Flexion contracture• Residual pain• Stump ulceration• Phantom sensation• Phantom limb pain• Dermatologic

complications

Smith and Burgess method: the central one third of the wound is closed, and the remainder of the wound is packed open.

Phantom sensation

• The phantom is the sensation of the limb that is no longer there. The phantom, which usually occurs initially immediately after surgery, is often described as a tingling, burning, itching or pressure, sensation, sometimes a numbness.

• Phantom sensation may be painless although, most people find it uncomfortable & often report it as pain; it usually does not interfere with prosthetic rehabilitation.

(Physical rehabilitation;Susan B O’ Sullivan; 5th )

Phantom Limb Pain

• Phantom pain and sensations are defined as perceptions ranging from slight tingling to sharp, throbbing pain or aching that patients perceive relating to an extremity or an organ that is physically no longer a part of the body.

• It has been reported in various trials that the estimated prevalence of phantom pain varies from 49% to 83%.

Rehabilitation

• Residual Limb Shrinkage and Shaping• Limb Desensitization• Maintain joint range of motion• Strengthen residual limb• Maximize Self reliance• Patient education: Future goals and prosthetic

options

Psychological stress

• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms

– Depression– Anxiety– Crying spells– Insomnia– Loss of appetite– Suicidal ideation

AMPUTATIONS IN CHILDREN

• Amputations in children is divided into two general categories—congenital (60%) and acquired (40%)

Amputations In Children

Amputations In Children

Congenital Congenital deficiencies of

the long bones Amniotic band syndrome Exposure to teratogens

( thalidomide ) Polydactyly Macrodactyly Congenital pseudoarthrosis

of the tibia and fibula, radius and ulna

Acquired• Secondary to trauma • Neoplasm• Infection. • Vascular disease

• Preserve length • Preserve important growth plates• Perform disarticulation rather than transosseous

amputation whenever possible• Preserve the knee joint whenever possible • Stabilize and normalize the proximal portion of the

limb• Be prepared to deal with issues in addition to limb

deficiency in children with other clinically important conditions.

Principles Of Childhood Amputation

Because of growth issues and increased body metabolism, children often can tolerate procedures on amputation stumps that are not tolerated by adults, which includes • More forceful skin traction • Application of extensive skin grafts• Closure of skin flaps under moderate tension.

Advantages Of Amputation In Children In Comparison To Adults

Prosthetics

It is a replacement of substitution of a missing or a diseased part

Types of Prosthesis

BELOW KNEEKNEE

DISARTICULATION ABOVE KNEEHIP

DISARTICULATION

PROSTHETICSLOWER EXTREMITY

Ideal prosthesis

1. Fits comfortably 2. Function well 3. Looks presentable4. Fit as soon after the operation

TYPES

Temporary – •Used following amputationtill paient is fitted with permanent prosthesis eg;pylon

•Permanent prosthesis

Conclusion

• Goal is to achieve useful residual limb in an individual who is active with a positive attitude an continues to be a productive member of society

Reference

• Current Diagnosis & Treatment in Orthopedics 3rd edition: by Harry Skinner (Editor) Publisher: Appleton & Lange (June 20, 2003)

• Campbel Operative Orthopedics, 11th Edition

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