Amputations

AMPUTATIONS

Indications

Dead (severe irreversible arterial occlusion)

Major blood vessels -

Atherosclerosis

Embolism

Small blood vessels -

Diabetes mellitus

Buerger's disease

Raynaud's disease

Deadly

Acute infections -

Moist gangrene

Gas gangrene

Chronic infections -

Osteomyelitis

Septic arthritis

Neoplasms

Arterio-venous fistulae

Dead Loss

Severe injury with fractures & partial amputation. (Microsurgery may be tied).

Rest pain without gangrene of an ischemic foot (because of relentless severe pain)

Deformity

Congenital

Acquired because of neurological disorders

Meningomyelocoele

Cerebral palsy

Poliomyelitis

Deficiencies (congenital)

Focal femoral defect

Thalidomide - amelia

Ring constriction

Absent Tibia / Fibula

Denervated

Brachial plexus injuries.

Trophic ulcer because of leprosy.

Aims

Rapid healing of the tissues through which amputation performed.

Adequate length of stump.

Use of residual part to maximum.

Rehabilitation of the patient.

Amputation Stump

Definition - The terminal segment which remains after the amputation.

Types

a.End bearing

Weight is taken by the stump

Solid bony end required

Scar is not terminal, anterior/posterior E.g.Syme's & Gritti-stokes

b.Non end bearing (proximal bearing)

Weight of the body is transmitted by way of the artificial limb socket to structures other than stump end. E.g. Above knee - by ischial tuberosities, thigh muscles

Below knee - Upper end of tibia and knee

Criteria for an ideal stump Stump

Optimum length

Firm and smoothly rounded.

Conical in shape, tapering distally.

Tip of the sectioned bone should be covered with periosteal flap and muscles to increase its vascularity and weight bearing property.

Muscle

Adequate flap, not too thin or bulky.

Good venous and lymphatic drainage.

Skin

Neatly cut and sutured

Adequate tension

No folds/puckering/dog ears

Freely movable on bone and subcutaneous tissue.

No inflammation/discoloration.

Scar

Well healed

Painless

Mobile

Not terminal in lower limb amputation.

Proximal Joint

Full range of movement

Types

A) Definitive Amputation - where no further operative procedure, expected. Primary suturing done.

End bearing

Cone bearing

B)Provisional Amputation - primary healing is unlikely to occur. Usually heals by granulation.

C)Revision Amputation - refashioning of provisional stump

Techniques

Closed amputation (elective)

Strict asepsis during surgery.

Use of tourniquet except if limb is ischemic, infective, or tumour present.

Level of Amputation - influenced by following -

a.Healing of stump - which depends on the collateral circulation, colour, and temperature of skin. Growth of hair, bleeding from skin and muscles during surgery suggests good vascularity.

b.Age - elderly - more proximal, in children - distal

c.Cosmesis

d.Return of function, which is better with below knee than above knee.

Skin flaps -

Single flap

Double flaps

Equal length - terminal scar

Unequal length — scar anterior / posterior

If limb is ischemic then flap with better blood supply should be longer.

E.g.-Syme's amputation - posterior flap longer

Below knee amputation - flaps of equal length

Above knee amputation, flaps of equal length

In PVD - posterior flap longer

Note - In order that the bone is adequately covered, the combined length of the 2 flaps /1 flap should be atleast 1.5 times the diameter of the limb at the level of bone section.

The shorter flap should be broader than the longer flap so that the skin edges to be sutured are of equal length. Distal part of the flap should have only skin and deep fascia.

Proximal part of the flap should have sufficient muscle to cover the bone end.

Muscle - cut just distal to the level of bone,

Myodesis - anchoring muscles to the bone.

Myop/asty - opposing muscles are joined together over the bone.

The above procedures help to achieve better control over the stump and decrease complications of phantom limb.

Nerves - are pulled down, cut cleanly with a blade and allowed to retract. Large nerves like sciatic nerve should be ligated with a fine suture before cutting.

Blood vessels - all major blood vessels are doubly ligated and the tourniquet released before closure to check for hemostasis.

Periosteum - cut at the level of bone. A sleeve of periosteum may be raised to close over the bony stump.

Bone - Transversely cut: Edges are beveled.

Post operative care

Immediate dressing and plaster of Paris cast

Immediate fitting of surgical prosthesis - Pilon. Advantages.

Edema decreases

Pain less

Improves shape of stump

Improves scar healing

Psychological advantage

After stump matures- permanent prosthesis.

Elastocrepe dressing

Rest

Limb elevation

Physiotherapy

Gait training

Open amputation (emergency) Types

Open circular (guillotine)

Open flap amputation (flaps sutured later)

Procedure

Circular skin incision

Incise fascia just above skin level.

Muscle is incised where fascia retracts.

Periosteum and bone is cut where muscle retracts.

Apply skin fraction with sticking plaster.

Skin may be closed later, after formation of granulation tissue. Tagging sutures may be taken initially to prevent skin from retracting.

Sites of amputation

Depends on

Muscle balance

Circulation

Function of amputed part.

Clinically - Colour, warmth, sensation, peripheral pulses, and growth of hair.

Laboratory - Arteriography, plethysmography, Doppler, thermography, oscillometry.

On table - bleeding

Toes

Amputation through the distal interphalangeal joint is not advised as remaining stump is of little use.

Even if a single toe is amputed, there is a tendency for deformity.

E.g. Hallux valgus after second toe amputation.

Ray excision of toe - done in diabetics with infected toe. Wound is not sutured.

Transmetatarsal

Diabetics with gangrene of 2 or more toes but in whom peripheral pulses are felt, Plantar flap kept long.

TarsometatarsaI

Not done nowadays because of high incidence of equinus and inversion deformity because of muscular imbalance.

Trans/Mid Tarsal (Chopart's)

Given up.as it causes equino valgus deformity.

After exposure, disarticulate talonavicular joint on the medial side and calcaneocubold joint on lateral side.

Pirogoff's amputation

Similar to Sime's amputation except that the calcaneum is bisected vertically, then rotated by 900.

Syme's amputation

Classical example of end bearing stump. Posterior flap (heel pad) longer to cover tibial lower end. Tibia incised just at the lower end and the fibula 1 inch proximal to tibial incision.

Disadvantages -

Bulbous stump

Heel pad has poor blood flow therefore ischemic necrosis.

Requires prosthesis called as Syme's prosthesis elephant boot.

Loss of length of lower limb.

Below knee

Ideally 5.5 inches/14 cm below line of knee joint (i.e leave behind 1/3 of tibia) Anterior flap

Short

Crosses the leg transversely.

Not more than 1 cm distal to the proposed site of tibial section.

Posterior flap

Long

Extends distally to the point where soleus and gastrocnemius become tendinous.

Disarticulation of knee joint

Good weight bearing stump. Preferred to above knee amputation, as - Better proprioception

Better circulation

Easy fitting of prosthesis.

Preferred in children, as lower femoral epiphysis is not disturbed. 2 lateral flaps of equal length used.

Gritti-Stokes (transcondylar)

Above knee amputation. Long posterior flap used.

Above kneetTransfemoral

Ideally 11 inches from tip of greater trochanter or 3 inches from line of knee joint (i.e. leave 2/3 of femur behind) Anterior and posterior flaps of equal length.

Note - Any amputation above this level is usually not successful because of muscle imbalance and improper leverage.

Hip disarticulation

Methods

1)Anterior racquet

2)Single posterior flap

Used in primary tumours of shaft of femur.

Hindquarter or hemipelvictomy

Used in tumours around hip joint. Lower limb + hipbone removed.

Thumb and fingers

Try to preserve maximum length.

Try to preserve index and ring fingers.

Disarticulation of wrist joint

Done at the radiocarpal joint so that pronation and supination is possible.

Transcarpal amputation

Pronation and supination preserved Flexion and extension preserved

Forearm Amputation

Ideally, seven inches from tip of olecranon process (i.e. junction of lower 1/3 and upper 2/3) Equal anterior and posterior length flaps are marked out with forearm pronated.

Minimum length of ulna required for efficient activation of prosthesis is 8cms. Try to preserve pronation and supination. '

Upper arm amputation

Ideally 8 inches from tip of olecranon, Shortest compatible length of stump is 15 cm.

Prosthesis and Orthosis

Orthosis is simply a brace meant only for support. Prosthesis - artificial restoration of function of body.

Lower limb prosthesis

Aim - comfortable ambulation with minimum expenditure of energy.

For Ankle joint

Syme's prosthesis -

It is a total contact prosthesis made up of plastic laminae. It can be made to fit the contour of the stump properly. Used in Syme's amputation.

It has a window. Lower end is given an artificial foot.

i)Solid Ankle Cushion Heels Foot- called as SACH foot

ii)Jaipur foot

MCR rubber

Especially for Indians, who walk barefoot on uneven ground and squat.

For Below knee

Patellar tendon brace -

Patellar tendon bracing total contact prosthesis. At the lower end SACH / Jaipur foot Better circulation

Less edema

Good knee joint functioning

Good proprioception

PTS - Patellar tendon supracondylar prosthesis. Supracondylar extension of patellar tendon brace.

Conventional - (Wooden/ aluminum) Below knee Hinge & bracing around stump & supporting mechanism.

For Above knee

Total contact socket - Socket for thigh (laminated plastic) + knee joint + below knee portion. Also has hip joint + pelvic belt.

Used elderly patients

Conventional - Pelvic belt + hip joint + knee joint + below knee portion

Suction socket prosthesis - One way valves. During swing phase a negative pressure is created & it remains in position (Air sucked in and expelled out)

For hip joint

Canadion hip disarticulation prosthesis.

Upper Limb prosthesis

For forearm

Plastic shell over the arms, steel bars on either side of elbow supported at the shoulders. Distal part looks like a hand.

There is a hook with a cable, which goes to opposite side shoulder. Shrug of the shoulder opens and closes the hook.

For arm

Digital parts same as above.

At elbow - elbow lock to fix the limb at a particular position.

Turn table for position.

Controlled by opposite shoulder.

lifyoelectrie prosthesis

Procedure Preoperation

Written informed consent

Psychological preparation of the patient.

Control the diabetes mellitus.

Correct anemia and fluid-electrolyte-imbalances.

Blood for grouping and cross matching.

Antibiotics

Assess the joint movements and rule out severe arthritis, contractures.

Shaving of private parts and lower limbs

Technique for below knee

Position - supine

Parts are prepared, painted and draped (infected lower limb covered with drape)

Anaesthesia

GA

SA

Ice anesthesia with tourniquet if GA contraindicated. (Macintosh rolled over ice which surrounds the thigh)

Flaps are raised such that the posterior flap is kept longer than the anterior flap at a distance of 15 cm from the tibial tubercle. So that the combined length of the flap =11/2 diameter of the leg at that level.

Subcutaneous tissue is incised.

Long and short saphenous veins are identified, ligated with linen and cut.

Deep fascia over the muscles is divided at the level of amputation.

Muscle groups, anteromedial, lateral and posterior (superficial & deep) are divided at the line of section. Hemostasis is achieved.

Neurovascular bundle (tibialis anterior) between tibia and fibula along the interosseous membrane is identified, ligated, cut. The ends are kept long.

The fibula is always divided before tibia as it acts as a kind of strut to the tibia. If the tibia is divided initially the leg tends to collapse and the fibula divides in a jagged manner at a higher level.

A Gigli's saw is used, to cut the bone at 45° to create optimum friction.

If other angle is used, the saw may be shredded.

Bone is divided at a higher level than the incision.

Check for homeostasis.

Approximate the muscles, with chromic catgut

Keep a drain under skin-suction drain

Skin is sutured with non-absorbable material.

Compression dressing is given.

Over this plaster of Paris slab applied.

Technique for above knee

Skin incision is marked and the skin is divided.

Subcutaneous tissue is incised

Identify the long saphenous vein, ligate and divide it.

Deep fascia is divided

Femoral artery in the Hunterial canal is identified and divided between ligatures.

Anterior and posterior group of muscles is divided at the level of incision.

Profunda femoris artery is identified and divided between ligatures.

Periosteum is divided at the line of incision.

The periosteal flaps are raised upto the site of section of the bone.

Divide the bone with Gigli's saw.

Sciatic nerve is identified, ligated and divided (cleanly cut) at a higher level

Post operation

Day 1

NBM for 6 hours.

TPR

Monitor urine output

Input/output chart

Antibiotics and analgesics

If diabetic- urine sugar and ketones every 8 hourly and treatment with plain insulin initially and later with lente/oral drugs.

Limb elevation - decreased edema

In below knee stump with splint /stab to prevent contraction and with sandbags on either side. (Hamstrings are powerful and they flex limb). Weighing amputation stump down.

Day 2

Amputation stump coned using elastocrepe bandage to prevent dog ear formation.

Some surgeons prefer application of prosthesis on 3/4 day to make rehabilitation simpler.

Mobilization of proximal joint.

Crutches for lower limb length (from anterior axillary fold to the heel of the foot)

Limb physiotherapy

Suture removal - 8-10 day

Complications

On table

Reactionary hemorrhage (+/- primary)

Cutting of inadequate stump

Late

Painful stump

Ring sequestrum

Hematoma

Therefore always drain kept

Aspirate with no 16 needle

Wound infection due to tracking of sepsis

Breaking of sutures

Fixed flexion deformity of lower limb due to contracture

Painful scar

Jacktitation neuroma

Phantom Limb - due to cortical representation present - the patient perceives the presence of the amputation limb. It is a psychological phenomenon.

Treatment -

Psychological treatment

Analgesics

Epidural analgesia