AMPUTATION AMPUTATION ETIOLOGY

- The surgical removal of all or part of a limb or extremity such as an arm, • Common causes:
leg, foot, hand, toe, or finger through a part of the bone - Less than 50 years: trauma/injury
- Stump – part of the limb that remains after amputation - More than 50 years: peripheral vascular disease
• Less common cause:
DISARTICULATION - Infection (gas gangrene)
- Removal of a limb thru a joint - Malignant tumors
- Nerve injuries
- Congenital anomalies
- Miscellaneous
AMPUTATION EPIDEMIOLOGY

- Each day, more than 500 individuals in the US undergo amputation

- There are more than two million people in the US living with upper and PERIPHERAL VASCULAR DISEASE
lower limb loss
- It is projected that there will be 3.6 million people living with upper or lower - LE 60-70% of amputations
limb loss in the US by 2050 - UE 6%
- Arteriosclerosis
- Thromboembolism
- +/- diabetes
AMPUTATION INCIDENCE
✓ Most significant predictor of amputation in diabetes
• Age: 50-75 years peripheral neuropathy
• Sex: - Prior stroke
✓ Male: 75%, female: 25% - Decrease ankle-brachial blood pressure index
• Limbs involved: - Vascular surgery consultation
✓ Upper limb: 15%
✓ Lower limb: 85%
• Age vs indication: TRAUMA
✓ Children: congenital anomalies
▪ Congenital anomalies of UE is more common than LE - 20-30% of all amputations
✓ Young adults: injuries - Leading indication for amputation in younger age group
✓ Elderly: peripheral vascular disease - Men > women
- 83% caused by blunt injury
- 51% caused by motor vehicle accidents and 19.4% caused by
machinery accidents
- The only absolute indication for primary amputation is an
irreparable vascular injury is an ischemic limb
AMPUTATION TYPES LOWER LIMB AMPUTATION (LLA)

1. Closed amputation: elective procedure HEMIPELVECTOMY

- Skin is closed after amputation
2. Open amputation: wound is left open over the amputation stump and is - Aka Hindquarter amputation or complete hip amputation
not closed - Whole of the lower limb with one side of the ilium removed
- Done as an emergency procedure in the case of life-threatening HIP DISARTICULATION
infection (severe infection, severe crush injury)
3. Myodesis: muscle is sutured to the bone - Complete hip amputation through trochanters and femoral neck
4. Myoplasty: muscle is sutured to the opposite muscle group under
ABOVE THE KNEE AMPUTATION
appropriate tension
- Aka transfemoral amputation
- Surgical procedure performed to remove the lower limb above
the knee joint when that limb has been severely damaged or
diseased

Above the knee amputation indications:

▪ Severe peripheral vascular disease not amenable to bypass
graft with popliteal pressures inadequate to heal BKA
• Failed revascularization and extensive tissue loss
▪ Chronic nonhealing BKA wound
▪ Non-reconstructable traumatic injury to the lower extremity
involving the knee joint or proximal tibia

Above the knee amputation level:

▪ Short AK – 3-4 inches below ischial tuberosity
▪ Middle AK – 10-12 inches below ischial tuberosity
1. Above knee ▪ Supracondylar amputation
2. Below knee
3. Partial foot Advantages:
4. UE amputation ▪ Healing rate is greater than for more distal amputations
Major amputation: above tarso-metatarsal joint ▪ The residual limb in many cases is easier to fit with a socket:
✓ Longer stump – better control and less surface
pressure
✓ Few bony prominences – less problem of socket
adaptation
✓ Medium length stumps with good end-cushioning are
ideal
 Disadvantages:
▪ Mortality is greater for more proximal amputations
▪ More surgical complications
▪ Cut muscle bellies retract, atrophy and loss their function;
myoplasty will prevent this problem
▪ Rehabilitation for prosthetic walking is less successful than with
more distal amputation
▪ No end-bearing possibilities as for knee disarticulation
▪ Need of a suspension (suction or belt)
▪ Mobility is reduced – increased energy is needed during gait
KNEE DISARTICULATION
- Complete leg amputation
- Gives an excellent end bearing stump. Large end bearing
surface of the distal femur is naturally suited for weight bearing
and prosthesis will be stable
BELOW THE KNEE AMPUTATION
- Aka transtibial amputation
- Surgical procedure performed to remove the lower limb below
the knee joint when that limb has been severely damaged or
diseased
- Optimum length: 14 cm from tibial tubercle
Below the knee amputation indication:
▪ Nonsalvageable lower extremity function
▪ Chronic nonhealing lower extremity wounds
▪ Acute lower extremity infection
▪ Trauma with vascular or neurologic injury; open tibia fracture
with posterior tibial nerve disruption or warm ischemia >6 hours
Advantages:
▪ Good prospect for prosthetic rehabilitation
▪ Longer stump – better control and less surface pressure
Disadvantages:
▪ Socket fit must be very accurate due to bony mapping
▪ No end-bearing possibility – reduced proprioception
▪ Very short stump – risk of stump – socket pseudoarthrosis
▪ Very long stump – distal stump is bony; acute risk of
abrasion/wound
ANKLE DISARTICULATION
- Complete tarsal amputation
PARTIAL FOOR AMPUTATION
- Parts of the frontal section of the foot are surgically removed
- Most common type of amputation in the US and occurs nearly
twice as frequently as either the transfemoral or transtibial
amputations
Range from:
▪ Removal of individual distal toes segments
▪ Disarticulations in the basal toe joint
▪ Removals in the mid-foot area such as metatarsal amputations
▪ Disarticulation in LISFRANC JOINT and CHOPART JOINT
▪ Amputations of the calcaneal part of the foot
TRANSMETATARSAL AMPUTATION
- Partial metatarsal amputation thru metatarsal bone
LISFRANC AMPUTATION
- Tarso-metatarsal disarticulation
Advantages:
▪ Good proprioception
▪ No PTB suspension/weight bearing
▪ Patient can walk short distance without prosthesis
 Disadvantages: SYME AMPUTATION
▪ Appearance of equino-varus deformity
▪ Prosthesis creates a leg length discrepancy - Amputation at the ankle articulation with removal of the malleoli
▪ Bony and sensitive stump – adaptation problems of the tibia and fibula 0.6 cm proximal to joint line
▪ Difficult to accommodate in standard shoes
Advantages:
CHOPART AMPUTATION ▪ End-bearing capabilities
▪ Self-suspension (bulbuous end)
- Talonavicular + calcaneo-cuboid disarticulation ▪ Long lever-arm – reduced surface pressure
▪ Good proprioception/control
Advantages: ▪ Possible to use standard foot and alignment
▪ Good proprioception
▪ No PTB suspension/weight bearing Disadvantages:
▪ Patent can walk short distance without prosthesis ▪ Poor healing
▪ Poor cosmetic, bulbuous contour of distal end
Disadvantages: ▪ Movement of distal stump-pad
▪ Appearance of equino-varus deformity ▪ Difficult donning and doffing of the prosthetics
▪ Prosthesis creates a leg length discrepancy
▪ Bony and sensitive stump – adaptation problems TOE AMPUTATION
▪ Difficult to accommodate in standard shoes
- Complete phalangeal amputation
PIROGOFF AMPUTATION - 2nd toe amputation results in severe hallux valgus

- Amputation at the ankle with part of the calcaneus left in the

stump
LLA PATHOPHYSIOLOGY
Advantages: “The energy required for walking is inversely proportionate to the length of the
▪ End-bearing capabilities remaining limb.”
▪ Self-suspension d/t bulbuous shape
▪ Good proprioception - Amputation of the LE is often the treatment of choice for an
▪ Long lever-arm – reduced surface pressure unreconstructable or a functionally unsatisfactory limb.
- The higher the level of a lower-limb amputation, the greater the
Disadvantages: energy expenditure that is required for walking
▪ Too-long to use standard foot - As the level of the amputation moves proximally, the waking
▪ No possibility to use standard prosthetic foot and alignment speed of the individual decreases, and the oxygen consumption
system increases
▪ Poor cosmetic - In transtibial amputations, the energy cost for walking is not
much greater than that required for persons who have not
undergone amputations
 - For those who have undergone transfemoral amputations the BELOW ELBOW AMPUTATION
energy required is 50-65% greater than that required for those
who have not undergone amputations - Amputation thru the forearm
- Aka transradial amputation
LLA PROGNOSIS - Optimum length: 20 cm stump from the tip of olecranon
- Minimum length: 7.5 cm
- 10% perioperative mortality
- Mortality rates were nearly twice as high for those with KRUKENBERG AMPUTATION
peripheral artery disease who had major LLA
- Individuals with more proximal limb loss (transfemoral) have a - A below elbow amputation done usually on both sides
higher risk of death compared to those with more distal locations - Here the forearm is split between the radius and ulna. This can
be like a fork and it provides a ‘pincer grip’. A below elbow
 3 years survival after BKA – 57%; after AKA – 38%
prosthesis or a ‘hook prosthesis’ can be put over the stump to lift
- For those who undergo partial foot amputation, between 15%
the heavy objects.
and 30% will die within 12 months.
WRIST DISARTICULATION

- Amputation through the radio-carpal joint

UPPER EXTREMITY AMPUTATION
METACARPOPHALANGEAL DISARTICULATION
FORE QUARTER AMPUTATION
- Amputation along the metacarpophalyngeal joint
- Carried out proximal to the shoulder joint
- Amputation of the scapula + lateral 1/3 of clavicle + whole of PHALANGEAL AMPUTATION
upper limb
- Amputation of the entire or parts of the finger
SHOULDER DISARTICULATION

- Removal thru the gleno-humeral joint

UEA PROGNOSIS
ABOVE ELBOW AMPUTATION
- Generally, the longer the residual stump, the greater the
- Amputation thru the arm residual function, with or without a prosthesis
- Aka transhumeral amputation
- Ideal length: 20 cm stump from the tip of the acromion

ELBOW DISARTICULATION

- Amputation thru the elbow

AMPUTATION COMPLICATIONS information. This area of brain is not removed during
limb amputation and still tries to process information
1. Hematomas – this delays the wound healing and acts as a culture media which is perceived as pain.
for the growth of the organisms
 Phantom Limb Pain (PLP) – classified as neuropathic pain, is
2. Infections – this is more common in peripheral vascular disease and
often more intense in the distal portion of the phantom limb and
diabetes
can be exacerbated or elicited by physical factors (pressure on
3. Necrosis of the skin flaps are usually d/t insufficient circulation and
the residual limb, time of day, weather) and physiological
require revision amputation
factors, such as emotional stress
4. Contractures – this is largely preventable by positioning the stump
✓ Commonly used descriptors include sharp, cramping,
properly
burning, electric, jumping, and crashing.
 Flexion contractures of hip and knee are very common
5. Abnormality of residual limb – dog ear appearance
6. Pain that may be caused by co-existing pathology
a. Vascular pain – such as exercise induced claudication or pain PRE-OPERATIVE INTERVENTIONS
caused by vascular disease Assess:
b. Musculoskeletal pain – pain form other injuries suffered during
traumatic amputation, musculoskeletal pain caused by abnormal ✓ Neurovascular and functional status of extremity
gait patterns, pain caused by normal aging processes, or - ROM, muscle power, condition of the skin, pulses
excessive wear and tear on the joints and soft tissue of the ✓ In traumatic amputation – function and condition of residual limb,
residual limb circulatory status and function of unaffected limb
c. Neuromas form always at the end of a cutaneous nerve and ✓ Nutritional status – healing = ↑protein and vitamin requirements
any pain from a neuroma is usually caused by traction on a ✓ Psychological status – determine emotional reaction to amputation
nerve when it is embedded within the scar tissue ✓ Current medications – especially corticosteroids, anticoagulants,
d. Causalgia – intense burning pain and sensitivity to the slightest vasoconstrictors, vasodilators
vibration or touch (d/t division of the peripheral nerve)
X-rays of extremity in 2 views
7. Pain resulting from the trauma of the surgery
 Post-amputation pain – pain at the wound site Doppler ultrasonography or angiography to determine perfusion
 Residual Limb Pain (RLP)/Stump Pain – pain or sensations in
the areas adjacent to the amputated body part. It is often Prepare for client for surgery:
confused with and its intensity is often positively correlated with
✓ Post-op expectations
PLP
✓ Psychological preparation
 Phantom limb sensations – this is a pseudo feeling of the
presence of the amputated limb
✓ It could be painless or painful variety
✓ Cause: first the nerves have been severed, causing
injury to the nerve tissue, and thus pain messages are
sent to the brain. Secondly, the brain has an area of
tissue dedicated to that part and will expect sensory
The pre-operative training by a PT involves:
✓ Prevention of thrombosis by maintaining circulation through movements
✓ Prevention of chest complications by deep breathing, coughing, and PD
✓ Pressure mobility of the joints
✓ Improve mobility of trunk, pelvis, and shoulder girdle
✓ Teach method to be adopted for mobility and limb positioning in bed
✓ Teach techniques of transfers, monitoring the wheelchair, single limb
standing and balancing
2.
EARLY POSTOPERATIVE STAGE
RIGID DRESSING CONCEPT
• POP cast is applied to the stump over the dressing after surgery
• Advantage:
✓ Prevents edema
✓ Enhance wound healing
✓ Decrease postoperative pain
✓ Reduce hospital stay
✓ Helps in early temporary prosthetic fitting
SOFT DRESSING CONCEPT
• Stump is dressed with a sterile dressing and elastocrepe bandage are
applied over it
• Bed is elevated to facilitate venous drainage and prevent stump edema
• Suture are removed after 10 to 14 days and muscle exercise are
commenced
• Prosthetic fitting is taken up as the last step
1. Pain management and prevention of infection
pain management:
✓ Analgesics
✓ Pain and phantom pain:
- Massage, cold packs, exercise and neuromuscular
stimulation
- TENS: incorporated in a prosthesis
Prevention of infection:
✓ Antibiotics
Prevention of contracture and deformities
▪ Shoulder – adduction and rotation contracture
▪ Elbow – flexion contracture
▪ Hip – flexion and abduction contracture
▪ Knee – flexion contracture
▪ Ankle – plantar or equinus
Methods to prevent contracture and deformities:
✓ Early identification – characterized by a tight feeling with pain at
end range of passive antagonist movement
- Bilateral amputee is more prone to develop hip and
knee contracture d/t decrease mobility.
✓ Postural guidance – the posture which keeps the tightness
prone area stretched should be emphasized. Moreover, posture
promoting development of contracture should be discouraged
- For trans tibial: avoid as much as possible long
position with a knee flexion (cushion under the knee
for example)
- For trans femoral: avoid position with hip flexion and
abduction (cushion under the stump for example)
✓ Use of traction – sustained sessions of gentle traction to stretch
the contracture developing areas
✓ Use of corrective splint – velcrostraps and broadcuffs can be
extremely useful
✓ AVOID long periods of sitting and soft mattresses that can
presdispose to development of flexion contracture
✓ Repeated sustained isometrics of extensors and repeated
periods of prone lying can prevent development of hip flexion
contracture
3. Maintenance of strength and mobility ✓ Frequent periods of prone lying with attempted hip extension
▪ The patient should be encouraged to move in bed by pushing up with strong and sustained contraction of gluteus maximus are
the body on the arms. This push up exercise strengthens the valuable
muscles which may be necessary or using ambulation aid later ✓ Repeated sustained isometrics for muscles of stump especially
on especially in bilateral amputee two joint muscles which originate above the joint proximal to the
▪ Vigorous strengthening exercises should be given amputation
▪ Bed activities like bridging, rolling, etc. can be useful to initiate 7. Massage – repeated tapping can help restore the tone of muscles
bed mobility ✓ Massage the entire residual limb with 1 or 2 hands by doing soft
4. Management of stump gentle kneading. Be cautious over the sutured area
▪ Improper management of stump is one of the major causes of ✓ Once the sutures or clips are removed you can increase the
delayed rehabilitation pressure on the deeper muscle and soft tissue
▪ Stump edema delays prosthetic fitting and ambulation ✓ 5 minutes: 3-4x a day or as needed to reduce phantom limb
▪ Causes of stump edema: pain
(1) Surgical trauma itself ✓ Gently massage the proximal residual limb, to include pressure
(2) Incorrect bandaging of stump point in the inguinal region
(3) Incorrect stump positioning 8. Stimulation – ES with the stump in elevation can improve the muscle
(4) Uncontrolled diabetes tone and reduce edema
(5) Atherosclerotic disease 9. Pressure – exposing the stump to pressure by gradual training of bearing
▪ Measure to control stump edema: weight on the terminal weight bearing area of the stump
✓ Limb in elevation with bandage ▪ Crawling or knee walking on a mattress placed over a bed with
✓ Resistive exercises to the stump and other joints hard top is ideal as a pressure bearing technique for above knee
✓ Stump bandaging: it plays an important role in or through knee amputation
conditioning and shaping the stump by reducing
edema
- An elastrocrepe bandage of 4 to 6 inches is PROSTHESIS – a replacement of / substitution of a missing or a diseased part
necessary
- Bandage should be taken out during CLASSIFICATION:
exercise
▪ Endoprosthesis
5. Stump hygiene – regular washing of stump with warm disinfected soap
- implants used in orthopaedic surgery
water and thorough dying
- Eg. Austin moore prosthesis
6. Exercise
▪ Exoprosthesis
✓ After 3-4 days of surgery active assisted exercises should be
- external replacement for a lost part of the limb
started in a small ROM
✓ Assisted hip flexion, abduction, and adduction movements can
be performed in back rest sitting
EARLY PROSTHETIC FITMENT • Below-knee amputation – knee extensors and flexors, hip
abductors and extensors
• Golden period of 30 days • Syme’s amputation – same as in below-knee amputation
• Reduces edema ▪ ROM exercises – full ROM exercises are regularly given to the joint
• Facilitated fast healing proximal to the stump and other joints susceptible for contracture
• Reduces pain ▪ Gait training – it should be carried out in patient with lower limb
• Enhances prosthetic use amputations
• Early return to activities esp. two-handed grasping patterns ▪ Desensitization
• This helps to make the residual limb less sensitive to touch and
will improve the tolerance to touch
MOBILITY STAGE • 2-3 times a day when the soft dressing is off (this could be done
during or after bathing
▪ This is stage of mobilization and restoration of functional independence
• Start by using soft material, like a cotton ball or towel, to gently
▪ It starts with crutch walking as early as possible
rub the skin in circular motions
- The normal alignment of pelvis and the reciprocal movement of
• Progress by using a rougher material, like a paper towel, and
the stump should be maintained during walking
then progress to a towel or cloth until you can tolerate these
- It has bee observed that usually patients tend to walk on
materials
crutches holding the stump in flexion which needs immediate
▪ Scar mobilization
attention
• This will keep the scar from adhering to the underlying tissue as
▪ Elderly patients may need initial ambulation practice in parallel bars
it could be the cause of pain and blisters when the patient start
▪ Functional training with crutches should be given to all hemipelvectomy,
wearing a prosthesis
hip disarticulation, and above knee amputees
• Performed when the soft dressing or compression is off
▪ Resistive mat activities using proprioceptive neuromuscular facilitation
• The patient can do this daily when taking a bath
(PNF) techniques offer easy and stable mobility
• Place two fingers over a bony portion and by keeping the fingers
▪ Two weeks after surgery, muscle-contraction exercises and progressive
on the same spot, make a circular motion for 1 minute
desensitization of the residual extremity are initiated
• Repeat this over and around bone on the residual limb
▪ Mobilization and strengthening exercises – concentrate on:
• After wound healing, this could be done over the incision line to
• Disarticulation of the arm – shoulder elevators, depressors,
mobilize the scar tissue
protractors, and retractors. Mobility exercise to the neck and
trunk
• Above-elbow amputation – flexors, abductors, and extensors of
the shoulder. Scapular elevators and retractors on the normal
side
• Below-elbow amputation – elbow flexors, extensors, pronators,
and supinators of the forearm with mobilization of the trunk
• Above-knee amputation – hip extensors, abductors, flexors, and
shoulder girdle muscles