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Amputation

AMPUTATION:- Removal of limb, partly or totally from the body, is termed as amputation.

DIS-ARTICULATING :- Dis-articulating is removing the limb through a joint.

Amputation of lower limb is more commonly performed.

Indication-

  1. Trauma-RTAs
  2. Malignant tumours
  3. Nerve injuries and infection:-Anesthetic limb often develops ulceration, infection and severe tissue damage when ulceration and infection persist and fail to respond to the medical treatment amputation performed.
  4. Extreme heat or cold:-

  • Electrical burns
  • Accidental burns
  • Prolonged exposure of the limb to extreme cold condition (blockage of blood circulation)

  1. Peripheral vascular disease or insufficiency :-

  • Diabetes
  • Berger’s disease
  • Atherosclerosis
  • Embolism
  • Arterial thrombosis

  1. Congenital absence of limbs or malformation:- When rudimentary portion (undeveloped) of limb interfere with fitting of prosthesis, amputation become necessary.
  2. Severe infection:-

  • Gas gangrene
  • Chronic intractable infection
  • Osteomyelitis
  • Unstable diabetes mellitus

Level of Amputation:-

An amputation is carried out at a level which will given the stump an optimum length to facilitate subsequent prosthetic fitting.

A) Upper Extremity:-

1) Fore-Quarter Amputation-

  • It is carried out proximal to the shoulder joint for malignant bone tumors of the upper end of the humerus.
  • Part of the scapula and clavicle are removed along with the shoulder girdle muscles.

2) Dis-Articulation-

  • Shoulder joint(glenohumeral joint)

3) Above-Elbow Amputation-

  • (Amputation through the arm)
  • A 20 cm long stump as measured from the tip of the acromion is ideal.

4) Below-Elbow Amputation-

  • (Amputation through the forearm bones).
  • Optimum length of a below-elbow stamp is 20cm as measured from the tip of olecranon.

5) Krukenberg Amputation-

  • With bilateral below-elbow amputation
  • After it below-elbow prosthesis or a hook-prosthesis use.

6) Amputation Through the Hand-

  • Ray amputation
  • Removal of finger with respective metacarpal from carpo-metacarpal joint.

B) Lower Extremity:-

1) Hind Quarter Amputation:-

  • Indicated for malignant tumor at the upper end of femur.
  • Part of the pelvis ilium is removed along with the lower extremity.

2) Above Knee Amputation:-

  • ( Amputation through the thigh)
  • The optimum length of the above knee stump is about 25-30cm as measured from the tip of the greater trochanter.

3) Dis-articulation:-

  • Knee dis-articulation cosmetically unacceptable.

4) Below Knee Amputations:-

  • Most commonly performed.
  • This amputation is performed through the leg bone.
  • The optimum length of the below-knee stump is 14cm from the tibial tubercle.
  • A patellar tendon bearing(PTB) prosthesis can be fitted over a stump of adequate length.

5) Syme’s Amputations:-

  • In this amputation tibia and fibula are divided just above the ankle joint.
  • The intact skin over the heel is attached back to the end of the stump with or without a part of the calcaneum.
  • Because of the intact heel, it becomes an end bearing stump and the patient’s generally manage very well walking even bare foot after this type of amputation.

C) Foot Amputation:

  • Toes:- Amputation of great toe and other toes.
  • Metatasal:-Amputation through metatarsal bones.
  • Lisfranc amputation:- Amputation at the level of tarsometatarsal joints.
  • Midtarsal joint amputation or chopart’s Amputation:- Amputation is performed at the level of midtarsal joint.

Types of Amputation:-

Two types of Amputation-

  1. Closed Amputation
  2. Open Amputation or guillotine Amputation

1) Closed Amputation:–

  • In this type of Amputation the stump is closed primarily over the bony stump by retaining skin and muscles at least 5c.m. distal to the bone end to facilitate closing of the stump.
  • All elective Amputation are closed Amputations.

2) Open Amputation or Guillotine Amputation:-

  • It is an emergency procedure.
  • In this type of Amputation ,the skin is not closed over the Amputation stump.
  • After Amputation ,the stump is left open and dressed regularly till the Infection subsides And stump wound becomes healthy

The stump is then coverd by following procedurs.

  • Secondary dosure:- closure of skin flaps after a few days.
  • Plastic repair:- soft tissue are repaired without cutting the bone and skin flaps are closed.
  • Revision of the stump:- terminal granulation tissue and scar tissue, as well as a moderate amount of bone is removed and the stump reconstructed.
  • Re-Amputation

SURGICAL PRINCIPLES-FOR CLOSED TYPE

  1. CARE DURING THE PROCESS OF AMPUTATION-
  2. TOURNIQUET:-

  • Use of a tourniquet is highly desirable except in case of an ischaemic limb. Commonly apply during Amputation.
  • It is a constricting or compressing device, specifically a bandage, used to control venous and arterial circulation to an extremity for a period of time.

  1. EX-SANGUINATION:-

  • Usually a limb should be squeezed (ex-sanguination)by wrapping it with a stretchable bandage (Esmarch bandage) before a tourniquet is inflated.
  • It is contraindicated in case of infection and malignancy for fear of spread of the same proximally.

  1. SKIN FLAPS AND SCAR:-

  • Stump must always be covered with a healthy skin flap.
  • Care should be taken not to allow the scar to be adherent to the bone.

  1. BLOOD VESSELS:-

  • Should be isolated and doubly ligated (double binding) using non-absorbable sutures.
  • The tourniquet should be released before skin closure and meticulous haemostasis should be secured.

  1. NERVES:-

Muscle suture

Myodesis-here muscle is sutured to the bone

Myoplasty –here muscle is sutured to the opposite muscle group.

  1. MUSCLES:-

  • They should be divided distal to the level of the bone cut.
  • Opposite group of muscles are sutured together distal to the bone(myoplasty).
  • When the muscle are sutured to the end of the bone is called as myodesis.

  1. BONE:-

  1. DRAIN:-

  • To prevent haematoma formation suction drain is applied.
  • A drain should be used for 48-72 hour post operatively for prevent post-operative complication.

B.AFTER TREATMENT:-

  1. Conventional or soft dressing –using gauge cotton and bandage.
  2. Rigid dressing- after a conventional dressing a moulded POP cast is applied on to the stump at the conclusion of surgery.

This help  to enhancing wound healing and maturation of the stump.

In addition, the patient can be fitted with a temporary artificial  limb with a prosthetic foot (pilon) for almost immediate mobilization.

ELASTROCREPE BANDAGE:-

In case where a temporary prosthesis is not fitted immediately after surgery, a elastrocrepe bandage is used after applying sterile dressing.

The stitches are removed after 2 week.

The use of crepe bandage, however, is continued for another 3 weeks.

It helps in shaping the stump well into a conical shape which is considered idea for the subsequent prosthetic fitted.

POSITIONING AND ELEVATION OF STUMP:-

This is required to prevent contracture and promote healing.

Exercise:- stump exwrcise necessary for

  • Maintaining range of motion of the joint proximal to the stump.
  • For building up strength of the muscle controlling the stump.

PROTHETIC FITTING AND GAIT TRAINING:-

this is started usually 3 months after the amputation.

Complication:-

  1. Haematoma:- A swelling of blood usually clotted, which forms as a result of a brokeh blood vessel.
  2. Infection :- peripheral vascular disease-
    1. Diabetes
    2. Haematoma

  1. Skin flap necrosis:- due to insufficient circulation of the skin flap.
  2. Deformities of the joints:- due to improper positioning of stump.
  3. Neuroma:- it form at the end of a cut nerve
  4. Phantom sensation:- a sensation as if the amputation part is still present.

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