orthopedocts.amputation of extremities.(dr.omer barawe)

Amputation of Amputation of extremitiesextremities

DefinitionDefinition Cutting of the extremity or part of the Cutting of the extremity or part of the

extremity through the boneextremity through the boneWhile ………..While ………..Cutting of the extremity extremity or part of Cutting of the extremity extremity or part of

the extremity through the joint is the extremity through the joint is disarticulationdisarticulation

indicationsindications Amputation can be regarded as a Amputation can be regarded as a

treatment and not tragedytreatment and not tragedy indications :-indications :-1.1. Dead ( or dying ) limbDead ( or dying ) limb2.2. Dangerous limbDangerous limb3.3. Damn nuisance limb Damn nuisance limb

Dead or dying limbDead or dying limb

1.1. Peripheral vascular disease ( 90% )Peripheral vascular disease ( 90% )2.2. Sever traumatized limb Sever traumatized limb 3.3. Burns Burns 4.4. Frostbite Frostbite

Dangerous limbDangerous limb

1.1. Malignant tumors Malignant tumors 2.2. Lethal sepsisLethal sepsis3.3. Crush injury leading to crush syndrome Crush injury leading to crush syndrome

Damn nuisanceDamn nuisance

Remaining the limb is more worse than Remaining the limb is more worse than having no limb at all …. Because ofhaving no limb at all …. Because of :- :-

1.1. Pain Pain 2.2. Gross malformation Gross malformation 3.3. Recurrent sepsisRecurrent sepsis4.4. Sever loss of function Sever loss of function

Varieties of amputationsVarieties of amputations

ProvisionalProvisional amputationamputation When primary healing is unlikely When primary healing is unlikely The limb amputate as distal as the causal The limb amputate as distal as the causal

factor will allow factor will allow Skin flap suture loosely over a pack Skin flap suture loosely over a pack Re-amputation perform when stump Re-amputation perform when stump

condition is favorable condition is favorable

Definitive end-bearingDefinitive end-bearing When weight is taken through the end of When weight is taken through the end of

the stumpthe stumpThe scar must not be terminal The scar must not be terminal Bone end must be solid (cut near the joint)Bone end must be solid (cut near the joint)Example through knee , syme’sExample through knee , syme’s

Definitive non-end-bearingDefinitive non-end-bearingCommonest variety Commonest variety All upper limb & most lower limb All upper limb & most lower limb

amputations are come under this typeamputations are come under this typeThe scar can be terminalThe scar can be terminal

Amputations Amputations at the sites of at the sites of election election

The The “ sites of election ”“ sites of election ” are are determined by :-determined by :-

1.1. the demand of the prosthetic design the demand of the prosthetic design 2.2. local function e.g bellow the most distal local function e.g bellow the most distal

palpable arterial pulsation palpable arterial pulsation

Too short a stumpToo short a stump slips out slips out from the prosthesis from the prosthesis

Too long a stumpToo long a stump painful , painful , ulcerate , complicates the incorporation of ulcerate , complicates the incorporation of the joint in the prosthesis the joint in the prosthesis

Now a day the skill of orthotiest make Now a day the skill of orthotiest make amputation possible at any level amputation possible at any level

Principles Principles of of technique technique

Tourniquet is used unless there is Tourniquet is used unless there is vascular insufficiency vascular insufficiency

Skin flaps are cut so that there combined Skin flaps are cut so that there combined length equals one & half the width of the length equals one & half the width of the limb at the site of the amputationlimb at the site of the amputation

Equal flaps are for upper limb & trans-Equal flaps are for upper limb & trans-femoral amputations , long posterior femoral amputations , long posterior flap for bellow – knee flap for bellow – knee

Muscle cut at distal level from the level of Muscle cut at distal level from the level of the bone proposed the bone proposed

MyoplastyMyoplasty …. When the muscles …. When the muscles sutured together over the bone sutured together over the bone

A raw nerve end should not bear weight A raw nerve end should not bear weight

Divide the nerve Divide the nerve proximal to the bone cutproximal to the bone cut

Saw is used to make the bone ends Saw is used to make the bone ends smooth , and for beveling the tibia smooth , and for beveling the tibia interiorly interiorly

Fibula is cut 3 cm shorter Fibula is cut 3 cm shorter

Remove the tourniquet and stop bleeding Remove the tourniquet and stop bleeding

Suture the skin without tensionSuture the skin without tension

Apply suction drain Apply suction drain

Bandage the stump tightly Bandage the stump tightly

AftercareAftercare Evacuate the hematoma as soon Evacuate the hematoma as soon Elastic bandaging the stump for shrinkage Elastic bandaging the stump for shrinkage Exercise the musclesExercise the musclesKeep joints mobileKeep joints mobileAdvice using the prosthesis Advice using the prosthesis

Amputations Amputations other than the other than the sites of electionsites of election

upper limb amputationsupper limb amputations

Interscapulo - thoracic amputation Interscapulo - thoracic amputation which is known as fore-quarter which is known as fore-quarter amputation amputation

Disarticulation of the shoulder Disarticulation of the shoulder Transradial amputation Transradial amputation Amputations in the hand Amputations in the hand

Lower limb amputationsLower limb amputations Hemipelvectomy Hemipelvectomy Disarticulation through the hip joint Disarticulation through the hip joint Transfemoral ( at least 12 cm )Transfemoral ( at least 12 cm ) Around the knee ( Stokes – Gritti )Around the knee ( Stokes – Gritti ) Through knee Through knee Transtibial ( 14 cm )Transtibial ( 14 cm ) Above the ankle ( Syme’s ) Above the ankle ( Syme’s ) Boyd’s amputation in which there is calcaneo tibial fusion .Boyd’s amputation in which there is calcaneo tibial fusion . Mid-tarsal joint ( chopart )Mid-tarsal joint ( chopart ) Tarsometatarsal joint ( lisfranc ) Tarsometatarsal joint ( lisfranc ) Ray excision of entire toe.Ray excision of entire toe.

Complications Complications of the of the

amputation amputation stump stump

Stump is the terminal Stump is the terminal segment of the limb segment of the limb remaining after the remaining after the amputation amputation

Early complicationsEarly complications

1.1. Secondary hemorrhage Secondary hemorrhage 2.2. Breakdown of the skin flaps Breakdown of the skin flaps

(may be due to ischemia or (may be due to ischemia or excessive suture tension )excessive suture tension )

3.3. Gas gangrene Gas gangrene

Late complicationsLate complications

Skin Skin eczema eczema purulent lumps purulent lumps fissuring & ulceration fissuring & ulceration infected epidermoid cyst infected epidermoid cyst Squamouse cell carcinoma Squamouse cell carcinoma Verrucous hyperplasiaVerrucous hyperplasia

MMuscleuscle .. If excessive muscle left , it will .. If excessive muscle left , it will produce unstable , loose cushionproduce unstable , loose cushion

ArteryArtery… poor vascularity gives … poor vascularity gives cold cold blue color stump blue color stump liable to ulcerateliable to ulcerate

Nerve Nerve ..Painful neuromas attached to the scar Painful neuromas attached to the scar

Phantom limbPhantom limb

A feeling that the amputated A feeling that the amputated limb still present limb still present

It is difficult to be treatedIt is difficult to be treated

..

Joint Joint the joint above the site of amputation the joint above the site of amputation

may become stiff or deformed may become stiff or deformed Deformities are fixed flexion & fixed Deformities are fixed flexion & fixed

abduction in above knee ….. Fixed flexion abduction in above knee ….. Fixed flexion in bellow knee amputations . in bellow knee amputations .

Fore-foot amputation maybe cpmplicated Fore-foot amputation maybe cpmplicated by equineus deformity.by equineus deformity.

Bones Bones terminal bone spur may cause pain & terminal bone spur may cause pain &

infection infection Stump bone fracture may result from sever Stump bone fracture may result from sever

osteoporosis osteoporosis

prosthesisprosthesis

Ideal prosthesisIdeal prosthesis

1.1. Fits comfortably Fits comfortably 2.2. Function well Function well 3.3. Looks presentableLooks presentable4.4. Fit as soon after the operation Fit as soon after the operation

In the upper limb the distal portion is In the upper limb the distal portion is detachable & can be replaced detachable & can be replaced

In lower limb weight can be transmitted In lower limb weight can be transmitted through the greater trochanter , tibial through the greater trochanter , tibial tuberocity , patellar tendon , upper tibia or tuberocity , patellar tendon , upper tibia or soft tissues soft tissues

Electrically powered limb is present now Electrically powered limb is present now

Some real photos Some real photos of amputationof amputation

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