AMPUTATIONS

Dr R S Dhaliwal
MBBS,MS,DNB(Surgery),M.Ch,DNB(CTVS),
FACS,FCCP,FICA,FNCCP,FIACS
Former Prof & HOD , CTV
Surgery,PGIMER,Chandigarh
 Amputation is one of the meanest
yet one of the greatest operations
in surgery,i.e. mean- when resorted
to where better may be done,
Great as the only step to give
comfort to patient and prolong life
- Sir William Ferguson
 Amputation
Amputation is the removal of a body part or
an extremity (or its part) by surgery or by
trauma or prolonged constriction . It is used
to control pain or a disease process in the
affected limb, such as malignancy or
gangrene. In some cases, it is carried out on
individuals as a preventative surgery for such
problems
Amputation: the surgical removal of a part of the body,
a limb or part of a limb for gangrene, tumours severe
trauma or infection for saving life of patient
 Etiology
Land mine injuries
War & Terroism injuries
Road side accidents
Industrial trauma
Criminal activity
Punishment for crimes
Surgical for dieases
 Statistics
Lower limb amputations are 4 times more common than upper limb
(infection) .

While over 90% of amputations caused by vascular disease involve the

lower limb, nearly 70% of amputations caused by trauma involve the
upper limb For both males and females, risk of traumatic amputations
increased steadily with age, reaching its highest level among people age
85 or older

Limb amputations resulting from cancer most commonly involved the

lower limb; above-knee and below-knee amputations alone accounted for
more than a third (36 percent) of all cancer-related amputations.

There were no notable differences by sex or race in the age-specific risk of

cancer-related amputations, though rates of limb loss due to cancer were
generally higher among individuals other than African Americans.

In all age groups, the risk of dysfunctional vascular related amputation

was highest among males and individuals who are African American
 Indications for Amputation
Dead limb - Gangrene

Deadly limb - Wet gangrene

- Spreading cellulitis
- Multiple or huge AV fistula
- Bone or soft tissue tumour
. Dead loss limb Severe rest pain
- Sever contracture or paralysis making it
impossible to use and it is a hinderance
-Major unrecoverable traumatic damage
 Indications
Gangrene due to atherosclerosis,embolism,
diabetes,Beurgers disease , ergots poisoning
Trauma Massive crush injury ,to save life
Tumours Bone and soft tissue tumours
(osteosarcoma, chonderosarcoma,melanoma,
Sq cell carcinoma(Marjolins ulcer)
Gas gangrene . Severe sepsis
Dead,dying, devitalised tissue
Severe defformity congenital or acquired
 Causative Factors of Amputations
Peripheral arterial disease
Diabetes Mellitus
Gangrene (due to the complication of fracture
or tight plaster cast ) .
Trauma (crushing, frost bite, burns)
Congenital deformities
Chronic Osteomyelitis
Malignant Tumors
 General
Amputation is considered as treatment when a
limb or its part is dead , deadly or is dead loss
Dead limb Occurs due to severe arterial
occlusive disease causing death of tissues i.e.
gangerene. The occlusion may be in major vessels
(atherosclerosis or embolic) or in small peripheral
vessels (diabetes,Buergers disease, Raynauds
disease or accidental intra arterial injection.If the
obstuction can not be reversed and symptoms
are severe, amputation is required.
 General
Deadly limb- Limb becomes deadly when
putrefaction and infection of moist gangrene
spreads to surrounding viable tissues leading to
cellulitis and severe toxaemia.It is dangerous to
life of patient .Massive broad spectrum antibiotic
cover is a must
Dead loss limb A limb may seem dead loss
when there is relentless, severe rest pain with out
gangrene, here amputation will improve quality
of life. When a limb is impossible to use and
becomes a hinderance in daily activity as in
paralysis or severe contracture or major
traumatic damage amputation is done to
improve quality of life
 Pre-operative Assessment
Neurovascular and functional status of extremity
Function and Condition of residual limb (in case of
traumatic amputation)
Circulatory status and function of unaffected limb
Signs & Symptoms of infection (culture required)
Nutritional Status
Concurrent medical problems
Current medications
Evaluation of Patients for amputation
Check for anemia correct it by blood or packed
cells transfusion
Control of infection using antibiotics and dressings
Informed consent for operation from patient or
his close family members (v.imp)
Decide level of amputation by skin temp. and
arterial doppler study
Psychological counciling of patient-very important
Plan for prosthesis and rehabilitation by physio
therapist and rehabilitation team
 Psychological Support

Emotional reaction to amputation

Circumstances surrounding amputation

(ie. Traumatic versus surgical)

Occupational and social Rehabilitation

 Types of Amputations
Major amputations-
- Transcondylar femoral level (Gritti
Stokes amputation )
- Above knee, below knee or through
knee amputation
- Symes ampuatation below ankle

Minor amputations -
Distal and transmetacarpal and metatarsal
amputations
 Types
Weight bearing
Non weight bearing
It can be :
Non- end bearing/ side bearing- Wt is taken up by
the joint
End bearing/ cone bearing- Wt is taken up by the
body of patient
It can be - Provisional amputation with flap,
later finial formal amputation may be done
. Guillotine amputation- It always requires revision
formal amputation
. Formal amputation It is deffinitive procedure
 Amputations
Types of Flaps-
-Long posterior flap in B/ K amputation
- Equal flaps in A/K amputation
Ideal Stump-
-Should heal adequately by 1st intention
- Should have rounded gentle contour with
adequate muscle padding
Should have sufficient length to bear prosthesis
> For B/K amputation 7.5 to 12.5 cms from
tibial tuberosity
> For A/K 23cms from greater trochanter
> For above and below elbow 20 cms stump
 Different Amputations
Ray amputation- Amputation of toe with head
of metatarsal or metacarpal
Gillies ( Transmetatarsal ) Amputation
proximal to neck ,distal to base of metatarsal
Lisfrancs( Tarsometatarsal) The tarso meta
tarsal joint is disarticulated
Choparts ( Mid tarsal)- Talonavicular and calca
neo cuboid joints are disarticulated
Symes Tibia and fibula are cut just above
ankle joint to remove foot
 Different Amputations
Burgess (below knee amputation) Long
posterior flap is made so that scar is anterior
Stump length is 14-17 cms, minimum 8cms
Peg- leg amputation - It is done 5 cms below
knee joint, anterior flap is rotated postly. Like
a hood. Pt kneels and bears wt on this.It is
only done when patient can not afford or bear
prosthesis limb.Uncommon
Gritti- Stokes (transcondylar)- It is done
through knee joint, patella is anchored to
divided femur.Not done these days
Levels of amputation in lower limb
 Different amputations
Above knee A/K amputation- Equal anterior and
posterior flaps, ideal femur stump should be 25 cms
long.Not done in children as growing epiphysis of femur
is in lower end. Minimum stump should be 10cms long.
It is technically easy, healing chances are better and
faster. Cosmetic results poor, prosthesis fitting is not
proper, pt limps while walking and need support
Hip disarticulation- It is done when minimum 10cms
stump is not possible in A/K amputation. Single
posterior flap Solcum approach(better) or anterior
racquet incision Boyds approach
Hind quarter amputation or Hemipelvectomy-( Sir
Gordon Taylors amputation) One side pelvis with iliac
bone, pubis muscles and vessels along with lower limb
are removed. Internal and external vessels are
ligated.Internal hemipelvectomy is new method where
lower limb is saved
 Different amputations
Krukenbergs amputation- Done in upper limb
through forearm. A claw like gap is left between
radius and ulna which is used for a grip or
holding some thing
Forequarter amputation ( Interscapulothoracic
amputation)-It is removal of upper limb with
scapula and lateral 2/3rd of clavicle and muscles
.It is done for tumours of scapula,upper part of
humerus and near shoulder joint It can be done
through Littlewoods posterior approach or
Bergers anterior approach.
Levls of amputation (proper stump)
Post operative period & Complications
Regular dressings are done
Physiotherapy is started as early as possible
Pt uses crutches for walking, Prosthesis is
fitted after 3 months
Rehablitation is started
Complications-
Early - Haemorrhage, hematoma, Infection
Late- Pain, Ulceration at stump, Flap
necrosis, Painful scar, Phantom limb feeling
of amputated part partially or in toto with
pain over it.
 Prosthesis or Artificial limbs
A prosthesis a is an artificial device that
replaces a missing body part or a limb
( or its part ) lost due to trauma,
disease, or congenital conditions.
These are devices to make shape and
function of the residual limb and help
patient readapt to his job and life style
 Prosthesis or Artificial limbs
In Lower Limb-
1 Symes amputation-Elephant boot,Canadian
Symes prosthesis
2. Below Knee amputation- Patellar tendon
bearing (PTB) prosthesis and solid ankle
cushion heel (SACH)
3.Above Knee amputation- Suction type
prosthesis, it is placed above the stump.It is
better and well tolerated
4.Nonsuction type prosthesis- It is placed at
the end.It requires additional support
5.Hind quarter amputation- Tilting table
prosthesis or Canadian prosthesis is used
 Prosthesis
Upper Extremity prosthesis-
a.Partial hand amputation- Cosmetic glove
b.Wrist disarticulation- Plastic laminate socket
with triceps cuff and wrist unit with terminal
device
c.Below elbow amputation- Same as wrist
disarticulation but with different socket confg.
d.Elbow disarticulation- cosmetically unde
sirable as outside locking elbow hinge is bulky
e.Above elbow amputation- The unit has internal
locking system and turn table which permits
passive control of rotation. Elbow joint lock is
controlled by shoulder depression and terminal
device is operated by scapular abduction or
shoulder flexion
 Prosthesis
Myoelectric prosthesis ( Externally powered
prosthesis)- It is self suspending unit with
electrodes embeded in the prosthetic socket.
Electrodes detect muscle action potential form
contracting muscles in residual limb.The signals
are amplified,rectified,modulated to run an
electric motor to do desired function. These
prosthesis are costly, weigh more and not
reliable. They provide only coarse movements
with out sensory feedback which is most
important function of hand
Elephant boot Crutches
 Lower limb prosthesis
Toe amputation- Shoe with filler
Partial foot amputation- Moulded plastic foot
support with toe filler and rigid extension in
the shoe
Symes amputation- Prosthesis similar to B/K
amputation prosthesis( PTB)
Below Knee B/K amputation- Patellar tendon
bearing (PTB) prosthesis made up of socket,
shin piece and SACH foot. It has a thigh corset
for suspension along with side knee joints
 Types of Prosthesis
PROSTHETICS
LOWER EXTREMITY

KNEE HIP
BELOW KNEE DISARTICULATION ABOVE KNEE DISARTICULATION
 Lower limb prosthesis
Jaipur foot- It is Indian modification for bare foot walking
made of vulcanized rubber and shaped like normal foot.It
is flexible and is helpful in walking on uneven surfaces
SACH foot( Solid Ankle Cushioned Heel)- It is most
commonly used foot.It has no mechanicle ankle joint .The
cushioned heel stimulates the plantar flexion motion.
Endoskeletal prosthesis- It uses aluminium, titanium,
graphite and tubular material to form central supporting
structure and have modular or interchange able
connectors and components like knee and feet.The
structural strength is derived from central skelton like
components.It is covered by foam material like skin.
Exoskeletal prosthesis- there is outer plastic laminated skin
or shell with wood or poly urethane foam interiors.Here
strength is provided by outer lamination and shape is an
integral part of prosthesis
 Lower limb prosthesis
Above Knee prosthesis- It has four major parts
the socket, the knee system,the shank and foot
ankle system.A variety of sockets (quadri lateral,
ischial containment, CAD-CAM designed) knee
joints(constant friction, hydraulic, polycentric etc)
shanks( wood, metal ,composite),foot ankle
assembly(SACH,Jaipur foot,energing storing
foot,Madras foot etc).These can be combined to
make custom made.It does not permit squat or
sit cross legged on ground. AIIMS modification
allows these movements to patient.
 Prosthesis or Artificial limb
Patellar tendon bearing prostheiss (PTB
Prosthesis)- All the wt bearing is done below
knee, movement is controlled by his own knee
joint.Patellar tendon is main wt bearing area
within the socket.
CAD CAM made socket It is an automated
processing method to make prosthesis.It is more
comfortable ,made of thermoplastic or laminated
plastic with polyethylene foam
Suspension for B/K amputation prostheis is
leather cuff strap above femoral condyles.Exo or
endoskeleton is used.Endo skelton is preferred in
athletics
SACH (Solid Ankle Cushion Heel) foot- Needs
minimal maintenance,preferred in old people
 Upper limb prosthesis
Above elbow prosthesis is a high technology
prosthesis with harness, socket, elbow joint
unit ,control cable, forearm and wrist device.
Below elbow prosthesis- Krukenbergs
amputation does not require any prosthesis
Advantages of Prosthesis-
-Cosmetic - Function of the part is
gained to some extent - Ambulation in
lower limb prosthesis
 Prosthesis or Artificial limb
Disadvantages-
- Infection - Pressure ulcers
- Joint disability
Prosthesis Types-
- Exoskeletal prosthesis-fixed with belts and
brces to remaining limb or stump
- Endoskeletal prosthesis with
modular system Internal prosthesis are used
inside body ,placed by open surgery.These are
non reactive long durable materials.e.g hip
prosthesis for hip replacement
There are 5 Stages of Rehabilitation:

1. Healing and Starting Physiotherapy

2. Visiting the Prosthetist

3. Choosing an Artificial Limb

4. Learning to Use your Artificial Limb

5. Life as a New Amputee

THANK YOU