Principles of amputation

Principles of
AMPUTATION
Dr Arojuraye S.A
National Orthopaedic Hospital
Dala-Kano

OUTLINE
 Introduction
 Indications
 Types
 Preoperative evaluation
 Operative techniques
 Postoperative care
 Complications
 Conclusion
 References

Introduction
 Definition
Trans-osseous removal of a limb or part of it.
 Most ancient surgical procedure
 Multidisciplinary: Surgeon, Nurses,
Prosthetist, Physiotherapist, Occupational
therapists, Social worker & Psychologist.

Introduction…
 Amputation: not a failure of Rx, but the 1st
step toward a patient's return to a more
comfortable & reproductive life.
 The procedure should be planned &
performed with the same care & skill used in
any other reconstructive surgery.

Introduction…
 Early surgical amputations ► limb was
severed from an unanesthetized patient.
 Stump was dipped in boiling oil (hemostasis)
 Stump was poorly suited for prostheses.
 High mortality rate.

Introduction…
 Hippocrates: first to use ligatures
 1529: Popularized by Ambroise Paré
 Paré also introduced the “artery forceps
 He also designed sophisticated prostheses
 1674: Morel's introduce tourniquet
 1867: Lord Lister's introduce asepsis

Indication
 Dead limb:
o Severe trauma
o Peripheral
vascular disease
o Burns
o Frostbite.

Indication…
 Dangerous limb:
o Crush injury
o Malignancy
o Lethal sepsis
o Forgotten
tourniquet >6hrs.

Indication…
 Damned nuisance:
o Gross deformity
o Recurrent sepsis
o Loss of function.
 The only absolute
indication for
amputation is
irreversible ischaemia .

Types
 Provisional amputation
o Circular or with flaps
o When primary healing is unlikely or
o Amputate as distal as aetiology will allow
o Skin flap is sutured loosely over a pack
o Re-amputation perform when stump is ok

Types…
 Definitive end-bearing amputation
o Weight is taken through the end of the stump
o The scar should not be terminal
o Bone end must be solid (cut near the joint)
 Definitive non-end-bearing amputation
o Commonest variety
o All upper limb & most lower limb amputations
o The scar can be terminal

Pre-operative Evaluation
 History
o Aetiology
o Comorbidities
 Physical examination
o CVS, Renal &
o Nervous system
 Investigation
o Doppler indices
o Transcutaneous O2 tension

Pre-operative Evaluation…
 Optimization:
Anaemia, hypotension, infection, nutrition
 Consultations:
Nephrologist, Cardiologist, Neurologist
If vascular dx has progress to the point of amputation, most
patients also have concomitant dx process in the cerebral, renal &
coronary vasculatures.

Pre-operative Evaluation…
 Counseling & consent
Procedure, anaesthesia, complications,
prosthesis & limitations.
 MESS ≥ 7
Removes subjectivity from decision making
in trauma cases.
No scoring system can replace experience & good clinical judgment.

Principles of operative
techniques
 Anaesthesia
Regional, G.A
 Antibiotics
Broad-spectrum, IV
 Tourniquet
Except in arterial insufficiency

techniques..

techniques..  Skin flaps
o The combined length equals 1.5 times the
width of the limb at the site of amputation.
o Ant. & post. Flaps of equal length for UL &
A/K amputations. Long posterior flap for BK
amputation.

techniques..  Muscles
o Divided distal to bone
o Myoplasty or Myodesis
 Blood vessels
o Main vessels are doubly ligated individually
o Tourniquet is removed before closure
o Haemostasis is meticulously secured

techniques..
 Nerves
o Sharply cut & allow to retract
o Large nerves are ligated

techniques..
 Bone (site of election)
o A/K : 12cm above the joint
o B/K : 14cm below the joint
o B/E : 18cm from the olecranon
o A/E : 20cm from acromion
o sawn across @ proposed level
o Front of tibia is beveled
o Fibula is cut 2-3cm proximal to tibia

techniques..  Other than site of election
o Gritti-Stokes
o Symes
o Pirogoff’s
o Chopart
o Lisfranc
o Krukenberg
 the skill of the modern prosthetist has made it
possible to amputate at almost any site.

techniques..
 Closure
o Drain is placed
o Skin closed
without tension.
With modern total-contact
prosthetic sockets, the
location of the scar rarely is
important, but the scar
should not be adherent to
the underlying bone

techniques..
 Conical Dressing
o Soft dressing with crepe bandage
o Rigid dressing with POP
• Rigid dressings prevent edema at the surgical site
• Enhance wound healing & early maturation of the stump
• Decrease postoperative pain
• Allow earlier mobilization & ambulation
• Prevent knee flexion contractures in B/K amputation

techniques..
 Ideal stump
o Conical
o Heal adequately
o Adequate stump
o Adequate muscle padding
o Thin scar not interfering with prosthesis
o Adjacent joint movements
o Adequate blood supply

Post-operative management
 Analgesics
 Antibiotics
 DVT prophylaxis
 Stump elevation (foot of the bed)
 Avoid flexion contracture at knee & hip

Post-operative management…
 Educate patient how to position the stump
 Mobilize out of bed in 1DPO
 Remove drain in 48hrs
 Remove stitches in 2/52

Post-operative management…
 Early physiotherapy
o Muscle setting exercises 1st
o Joint movement exercises
o Ambulation with parallel bars, then crutches
 Prosthetic ambulation time depends on:
o Age of the patient
o Strength & agility of the patient
o Patient's ability to protect the stump

Complications
 Early
o Bleeding & haematoma
o Flap necrosis
o Surgical wound infection
o Gas gangrene

Complications …
 Late
o Phantom pain
o Phantom limb
o Joint deformity

Conclusion
 Amputation is the most ancient surgical
procedure
 It should not be seen as a failure of Rx, but
rather as the first step towards a patient’s
return to a more comfortable & productive life
 It does not end in the operating room; post op
care is equally important.

References
 Selvadurai Nayagam, David Warwick. Orthopaedic
operations; Apley’s system of orhtopaedics &
fractures, 9th Ed; 12:325-328.
 Canale & Beaty: General principles of amputations:
Campbell's Operative Orthopaedics, 11th edition.
 John Ebenezer: Amputations; Textbook of
Orthopaedics, 4th Edition; 60:787-791.
 Tintle SM et. Al: Traumatic & trauma-related
amputations: Bone Joint Surg Am. 2010 Dec
15;92(18):2934-45.

Principles of amputation

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