AMPUTATIONMARYUNI OMAR1001335821

CONTENTS•Preoperative preparation for amputation•Ideal stump•Complications of amputation &

prevention

PREOPERATIVE PREPARATIONSelection of amputation site

• Amputation below most distal palpable pulse

• Decision is aided by Doppler index

• ABI >0.5, occlusion pressure at calf and thigh > 65mmHg and >50mmHg respectively, better outcome of BKA

• Depends on demands of prosthetic design and local function ▫ Too short stump, prosthesis may slip out▫ Too long, inadequate circulation & causing pain, ulcerates.

PREOPERATIVE PREPARATION•Patient is given sufficient time to come to

terms with the inevitability of his/her amputation

•Proper and detailed explanation •Counseling if necessary•Optimization of nutritional status,

correction of anemia •Antibiotic to prevent clostridium infection

Principles of technique• Tourniquet is used unless there is already arterial insufficiency

• Muscles are divided distal to proposed site of bone section. Opposing muscles groups are sutured to each other and to periosteum better muscle control and better circulation (osteomyodesis)

• Nerves are divided proximal to cut bone ends nerve end will not bear any weight

• Blood vessels are tied, tourniquet are removed and every bleeding point is ligated

• Skin is sutured without tension

• Suction drainage is advised, stump is not covered with tight bandage.

Post-operative management• Opiate pain relief

• If hematoma forms, evacuation ASAP

• Gradual compression stump sock helps to shrink stump into conical shape

• Joint and muscles must be exercised to prevent fixed flexion deformity

• Refer to physiotherapy and occupational therapy to regain daily functional ability

IDEAL STUMP Stump- Firm & smooth, tapering segment , with full range

of movements whose muscles can activate stump in all directions.

Skin- healthy free of scars with good circulation with no in drawn scars or folds or puckers

Scar- should be linear, fully mobile, preff posterior in lower limb

Flaps- no undue tension / flabbines

Basic principles SKIN FLAP

Flaps should be kept thick. Skin at ends should be mobile & normally

sensate Unnecessary dissection should be avoided

to prevent further revascularization of already compromised tissues.

Basic principles MUSCLE FLAP Muscles usually are divided distally (at least 5 cm distal to the

intended bone resection) Muscle flaps have to be stabilized.

Myodesis --suturing muscle or tendon to bone. (contraindicated in PVD / severe ischemia)

Myoplasty --suturing muscle to periosteum or to fascia of opposing musculature.

Advantages of myoplasty ↑Muscle function ↑ Stump circulation ↓ Phantom pain Counterbalance antagonists Prevent contracture

Basic principles Nerves

Nerves should be isolated, gently pulled distally into the wound, and divided cleanly with a sharp knife so that the cut end retracts well proximal to the level of bone resection. If not neuroma forms at the level of stump.

Large nerves such as the sciatic often contain relatively large arteries and therefore should be ligated

Basic principles Nerves

Strong tension on the nerve should be avoided during this maneuver; otherwise the amputation stump may be painful even after the wound has healed.

Crushing also should be avoided.

Basic principles BLOOD VESSELS

• Major blood vessels should be isolated and individually ligated.

• Larger vessels should be doubly ligated.

• Tourniquet should be deflated before closure, and meticulous hemostasis should be obtained.

Basic principles BONE

•Excessive periosteal stripping is contraindicated and may result in the formation of ring sequestra or bony overgrowth.

•Bony prominences that will not be well padded by soft tissue should always be resected.

•Remaining bone should be rasped to form a smooth contour.

Early complications

Breakdown of skin flaps•Ischemia•Suturing under excess tension •Unduly long tibia pressing against the flap

Gas gangrene

•Clostridia and bacteria from perineum may infect a high above-knee amputation •Anaerobes prefer dead tissue

Late complications •Eczema, tender purulent lumps may develop in groin •Skin ulcer due to poor circulationSkin •Too much muscle is left unstable ‘cushion’ insecure feeling prevent use of prosthesisMuscle

•Poor circulation cold, blue stump; liable to ulcerate•Common in BKA, often re-amputation is needed

Blood supply

Nerve

• Cut nerve form neuroma which is painful

Joint

• Joint above amputation may be stiff or deformed• FFD, fixed abduction at hip (AKA)• Prevented by exercise

‘Phantom limb’

• Feeling that the amputated limb is still present• In contrast, residual limb pain exists in the area of the stump• Greater significance in those who have features of depressive symptoms

Bone

• Bone spur forms at bone end but usually painless• If infected, spur becomes large and painful excision of bone end with spur• Bone is osteoporotic and liable to fracture. It can be prevented by IF

AMPUTATION (10/4/2016)No Contents Marks 1. Introduction 12. Content :

1. Applied anatomy2. Epidemiology3. Pathophysiology4. Clinical features5. Specific clinical tests6. Ddx7. Investigations8. Principle of

management9. Rehabilitation10.Complications

3.5

3. Arrangemnet of presentation

1

4. Literature review 15. Presentation skill 1

Total 7.5/10DR. THIT LWIN