Dr. Ammar Talib Al-Yassiri College of medicine/Baghdad University AMPUTATIONS Dr. Ammar Talib Al-Yassiri College of medicine/Baghdad University

Learning outcomes Define amputation Realize the epidemiology of amputation Describe the indications of amputation Describe the varieties of amputation Explain the principles of techniques Describe the characteristics of the prosthesis Recognize the complications of amputation stumps

definition Amputations is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is the most ancient of surgical procedures. Early surgical amputation was a crude procedure by which a limb was rapidly severed from an unanesthetized patient. The open stump was crushed or dipped in boiling oil to obtain hemostasis.

epidemiology It has been estimated that more than 300,000 patients with amputations live in the United States. Greater than 90% of amputations performed in the Western world are secondary to peripheral vascular disease. In younger patients, trauma is the leading cause, followed by malignancy.

Indications the indications are summarized by 3D.s: Dead, Dangerous and Damned nuisance:

Dead (or dying) Peripheral vascular disease accounts for almost 90 % of all amputations. severe trauma, Burns, and frostbite.

Dangerous 'Dangerous' disorders are malignant tumors, potentially lethal sepsis, crush injury: In crush injury, releasing the compression may result in renal failure (the crush syndrome).

Damned nuisance: Retaining the limb may be worse than having no limb at all. pain; gross malformation; recurrent sepsis or severe loss of function. The combination of deformity and loss of sensation is particularly trying, and in the lower limb is likely to result in pressure ulceration.

Varieties A provisional amputation: necessary because primary healing is unlikely. The limb is amputated as distal as the causal conditions will allow. Skin flaps sufficient to cover the deep tissues are cut and sutured loosely over a pack. Re-amputation is performed when the stump condition is favorable.

A definitive end-bearing amputation performed when pressure or weight is to be borne through the end of a stump. the scar must not be terminal, the bone end must be solid, not hollow, which means it must be cut through or near a joint. Examples are through-knee and Syme's amputations.

A definitive non-end-bearing amputation the commonest variety. All upper limb and most lower limb amputations come into this category. Because weight is not to be taken at the end of the stump, the scar can be terminal.

AMPUTATIONS AT SITES OF ELECTION Most lower limb amputations are for ischaemic disease and are performed through the site of election below the most distal palpable pulse. The selection of amputation level can be aided by Doppler indices; if the ankle/brachial index is greater than 0.5, or if the occlusion pressure at the calf and thigh are greater than 65 mmHg and 50 mmHg respectively, then there is a greater likelihood the below-knee amputation will succeed An alternative means is by using transcutaneous oxygen tension as a guide, The knee joint should be preserved if feasible .the energy expenditure for a trans-tibial amputee is 10-30 % greater as compared to a 40-67 % increase in trans-femoral cases.

demands of prosthetic design and local function. Too short a stump may tend to slip out of the prosthesis Too long a stump may have inadequate circulation and can become painful, or ulcerate; moreover, it complicates the incorporation of a joint in the prosthesis. For all that, the skill of the modern prosthetist has made it possible to amputate at almost any site.

Principles of technique A tourniquet is used unless there is arterial insufficiency. Skin flaps are cut so that their combined length = 1.5 times the width of the limb at the site of amputation. Muscles are divided distal to the proposed site The bone is sawn across at the proposed level. Nerves are divided proximal to the bone cut The main vessels are tied. opposing muscle groups are sutured over the bone end to each other and to the periosteum. The skin is sutured carefully without tension Suction drainage is advised.

AMPUTATIONS OTHER THAN AT SITES OF ELECTION interscapulo-thoracic (forequarter) amputation: mutilating operation traumatic avulsion of the upper limb eradicating a malignant tumour, or as palliation. disarticulation at the shoulder: This is rarely indicated . amputation in the forearm: The shortest forearm stump will stay in a prosthesis is 2.5 cm, measured from the front of the flexed elbow. Amputations in the hand

Hemipelvectomy (hindquarter amputation): for malignant disease. disarticulation through the hip: rarely indicated. transfemoral amputations : it is usual to leave at least 12 cm below the stump for the knee mechanism. around the knee (The Stokes-Gritti operation) the trimmed patella is apposed to the trimmed femoral condyle.

Above the ankle Syme's amputation . Pirogoff's amputation Transtibial (below-knee) amputations: the conventional stump length 14 cm. Above the ankle Syme's amputation . Pirogoff's amputation Partial foot amputation: through the mid-tarsal joints (Chopart), through the tarsometatarsal joints (Lisfranc), through the metatarsal bones or through the metatarsophalangeal joints. In the foot: diabetic gangrene

PROSTHESES must fit comfortably. should function well and look presentable. Should be fitted soon after operation. In the upper limb, the distal portion of the prosthesis is detachable and it can be changed. Electrically powered limbs are available for both children and adults.

COMPLICATIONS OF AMPUTATION STUMPS Early complications the complications of any operation (especially secondary haemorrhage). Breakdown of skin flaps: may be due to ischaemia, or suturing under excess tension Gas gangrene: Clostridia and spores from the perineum may infect a high above-knee amputation, especially if performed through ischaemic tissue

Late complications Skin Eczema is common, and tender purulent lumps may develop in the groin. A rest from the prosthesis is indicated. Ulceration is usually due to poor circulation, and re-amputation at a higher level is then necessary. Muscle If too much muscle is left at the end of the stump, the resulting unstable 'cushion' induces a feeling of insecurity that may prevent proper use of a prosthesis; if so, the excess soft tissue must be excised. Blood supply Poor circulation gives a cold, blue stump that is liable to ulcerate. often re-amputation is necessary

Nerve: painful neuroma: occurs when the nerve end is subjected to pressure or repeated irritation Prevention: by gentle traction on the nerve followed by sharp proximal division, allowing the nerve end to retract deep into the soft tissue. Treatment: initially socket modification. If this fails, simple neuroma excision or a more proximal neurectomy. Phantom limb sensations: are so common that they should be considered normal. management is simply to educate the patient regarding these sensations so that they are not surprised by their presence.

Phantom limb pain: far less common. More often present with proximal amputations, such as forequarter and hindquarter amputations. some patients may benefit from massage, ice, heat, increased prosthetic use, relaxation training, sympathetic blockade, local nerve blocks, epidural blocks, ultrasound, transcutaneous electrical nerve stimulation.

Joint: the joint above an amputation may be stiff or deformed Above knee amputation: fixed flexion and fixed abduction .prevented by exercises, treated by subtrochantric osteotomy Below knee amputation: fixed flexion Bone: a spure Osteoperosis fracture

To take home message >90% of amputations performed in the Western world are secondary to peripheral vascular disease. the indications are summarized by 3D.s Varieties of amputation Provisional Definitive End bearing Definitive Non end bearing It is possible to amputate at almost any site. Gas gangrene may complicate a high above-knee amputation, especially if performed through ischaemic tissue