LIMB AMPUTATION

Preentation by Dr. Gaurav Mendon, Final year Post Graduate

Moderator – Dr. Shridhar Shetty, HOD Orthopaedics and
Trauma
Introduction

■ Amputation – surgical removal of all or part of limb through one or more bone
■ Disarticulation – surgical ablation through joint
Introduction

■ Amputation surgery is the most ancient of surgical procedures dating back to

prehistoric times
■ Neolithic(New stone Age; 10,200 BC to 4500-2000 BC) humans are known to have
survived traumatic, ritualistic, and punitive rather than therapeutic amputations.
■ Unearthed mummies have been found buried with cosmetic replacements for
amputated extremities
■ In 385 BC, Plato's Symposium mentions therapeutic amputation of the hand and
the foot
■ Hippocrates provided the earliest description of therapeutic amputation in De
Articularis for vascular gangrene
■ The main risks described in the early history of amputation surgery were
hemorrhage, shock, and sepsis
■ Before the discovery of anesthesia, the procedure itself was quite difficult/crude.
– Patient would be held down by a number of assistants and be given alcohol
(usually rum)
– Patient would essentially be awake and aware during the procedure
– Open stump was crushed or dipped in boiling oil to obtain hemostasis
– Associated with high mortality rate and poorly suited stump for prosthesis in
survivors
■ Due to a lack of analgesics and narcotics the operation had to take only a few minutes.
– Therefore the amputation was completed in one cut (i.e., detachment of the skin,
muscles, and bone at the same level).
– This technique, known as "classic circular cut”

■ Petit recommended that we transect the skin first and the muscles and bone more
proximally ("two-stage circular cut," 1718), and

■ Bromfield approved that the skin be cut first, the muscles more proximally and the bone
most proximal ("three-stage circular cut," 1773).

■ Lowdham (1679), Verduyn (1696), and Langenbeck (1810) changed the operative technique
in that they used a soft-tissue flap to cover the bone without tension ("flap amputation").
■ 1588-William Cloves - 1st successful above-knee amputation
■ 1679- Youngen and Lowdham -introduction of local flaps for wound closure without tension –
flap amputation
■ 1781-John Warren-first successful shoulder amputation
■ 1802-Dominique Jean-Larrey-removal of 200 limbs in a 24-hour period at the Battle of
Beresina
■ 1806-Walter Brashear -first successful hip joint amputation
■ 1843-Sir James Syme –symes amputation
■ 1857-gritti-patella placed over the end of the transected femoral condyles.
■ 1890-Jaboulay and Girard -first successful hindquarter amputation
■ 1943-Major General Norman T. Kirk -indicated guillotine amputations in war setting should
be completed as distal as possible and completed later under calmer conditions
Robert Liston(1794-1847)
■ Pioneering Scottish surgeon.

■ Famous for his skill in an era prior to anesthetics, when speed made a difference in terms of
pain and survival.

■ able to perform the removal of a limb in an amputation in 28 seconds

Classification

■ In Utero Amputation
■ Acquired amputation
In utero amputation

■ Constriction of fetal limbs by fibrous bands of amnion

leading to strangulation of limb
– Due to amniotic band syndrome i.e. rupture of inner
amnion without rupture of outer chorion
– ETIOLOGY: teratogenic drugs, ionizing radiation, trauma
 Acquired Amputation
ACCORDING TO ETIOLOGY

– Therapeutic/prophylactic
– Ritual
– Traumatic(war, RTA) (direct result of accident)
– Self-amputation
– Auto-amputation(cryoglobulinemia, TAO)
– Criminal(e.g. Hand amputation of theft in
Saudi/Iran/Yemen/Nigeria/Sudan)
 ACCORDING TO SITE

– Lower limb
– Upper limb
– Genital (penis)
– Hemicorporectomy (amputation at waist)
– Decapitation (amputation at neck)
Indications

■ PERIPHERAL VASCULAR DISEASE

■ TRAUMA
■ BURNS
■ FROSTBITE
■ INFECTION
■ TUMORS
■ NEUROPATHY
■ CONGENITAL LIMB DEFICIENCY
Trauma

■ Lower Extremities ≈20-30% of all amputations

Upper Extremities - 77%
■ Trauma is the leading indication for amputation in younger
age group.
■ Men > Women.
■ The only absolute indication for primary amputation is an
irreparable vascular injury in an ischemic limb
Peripheral Vascular Disease
Lower Extremities 60-70% of amputations
upper Extremities 6%
Arteriosclerosis
Thromboembolism
– diabetics
– Most significant predictor of amputation in diabetes:-
peripheral neuropathy
– Infection increases in : -
S. alb <3.5gm/dl
WBC < 1500cells/ml
– Prior stroke
– decrease ankle-brachial blood pressure index
Infections
Gas gangrene.
■ Clostridial myonecrosis- within 24 hr.
bronze discoloration
serosanguineous exudates, musty odor
immediate radical debridement
I/V penicillin or clindamycin

■ Streptococcal myonecrosis- 3-4 days

■ Anaerobic cellulitis or necrotizing fasciitis
■ Acute or chronic infection that is unresponsive to
antibiotics and surgical debridement.
- open amputation done
Congenital Limb Deformities
■ L/E <3% of all amputations
U/E 9%
■ Occurs in ≈1/2000 births
■ failure of partial or complete formation of a portion of
the limb.
■ Congenital extremity deficiencies have been classified
as longitudinal, transverse, or intercalary.
■ Radial or tibial deficiencies are referred to as
preaxial, and
■ ulnar and fibular deficiencies are referred to as
postaxial
Tumours

❑ L/E≈5% of all amputations

U/E 8%

❑ Amputation is performed less frequently

with the advent of advanced limb-
salvage techniques.
Burns and Frostbite

Burns : -
– delayed amputation – local infection
– - systemic infection
– - myoglobin induced renal failure
– - death

Frostbite :-

Typically occurs when one is trapped in extreme cold conditions for extended periods
– direct tissue injury- ice crystals in ECF
– Ischaemic injury- vascular endothelium
Pathophysiology
“The energy required for walking is inversely proportionate to the length of the
remaining limb”

– Amputation of the lower extremity is often the treatment of choice

for an unreconstructable or a functionally unsatisfactory limb

– The higher the level of a lower-limb amputation, the greater the

energy expenditure that is required for walking

– As the level of the amputation moves proximally, the walking

speed of the individual decreases, and the oxygen consumption
increases
– In transtibial amputations, the energy cost for
walking is not much greater than that required for
persons who have not undergone amputations.

– For those who have undergone transfemoral

amputations, the energy required is 50-65% greater
than that required for those who have not undergone
amputations .
Pre-Operative Evaluation

■ Haematocrit, control of anaemia by transfusing blood/packed

cells.
■ Control of infection using antibiotics.
■ Decision of level of amputation by skin temperature,
arteriography, arterial Doppler, transcutaneous Po2, laser
evaluation.
■ Informed consent.
■ Plan for prosthesis and rehabilitation by physiotherapist and
rehabilitation team.
SALVAGIBILITY OF A LIMB
VARIOUS SCORING SYSTEM

• PREDICTIVE SALVAGE INDEX

• LIMB SALVAGE INDEX
• LIMB INJURY SCORE
• MANGLED EXTREMITY SEVERITY SCORE
Blood Investigation
– Haematocrit

– Creatinine levels should be monitored. In individuals with muscle injury and

necrosis, myoglobin enters the systemic circulation and can lead to renal
insufficiency and failure. especially in individuals with thermal and electrical
burns.

– Potassium and calcium levels should be monitored. Elevated levels of these

electrolytes may lead to cardiac arrhythmias and seizures.

– White blood cell count, C-reactive protein , and ESR Expect the C-reactive
protein to be the first laboratory value to respond to treatment,

– Platelets
Radiological Investigation

– X-ray AP & Lat view

– Computed tomography (CT) scanning and magnetic resonance

imaging (MRI) are performed for the patient tumour workup or for
osteomyelitis to ensure that the surgical margins are appropriate.

– Technetium-99m (99mTc) pyrophosphate bone scanning has

been used to predict the need for amputation in persons with
electrical burns and frostbite.
A 94% sensitivity rate and a 100% specificity rate has been
reported in demarcating viable tissues from nonviable tissues.
Doppler ultrasonography - measure arterial pressure;
– In approximately 15% of patients with PVD, the results are falsely elevated
because of the non compressibility of the calcified extremity arteries.
– Doppler ultrasonography has been used in the past to predict wound
healing.
A minimum measurement of 70 mm Hg is believed to be necessary for
wound healing.
Ischemic index (II): -
This index is the ratio of the Doppler ultrasonography pressure at the level
being tested to the brachial systolic pressure. An II of 0.5 or greater at the
surgical level is necessary to support wound healing.
Ankle-brachial index: -
At the ankle level is believed to be the best indicator for assessing adequate
inflow to the ischemic limb. An index less than 0.45 indicates incisions
distal to the ankle will not heal.
SURGICAL PRINCIPLES OF AMPUTATION
Flap
■ Adequate blood supply of the flap should be maintained.
■ Proper marking of the skin incision is essential.
■ Skin should not be crushed or traumatised. Clean cut on the flap is essential
■ Opposing two equal flaps or long single flap is used or combined length of
two equal flaps should be 1½ times the circumference of the limb at the
level of bone section.
■ Tension free flap suturing should be achieved
■ When unequal flaps are used, shorter flap should be broader than longer
flap so that skin edges sutured as equal length
■ Flap length should be adequate; not short. It should be ideally semi-circular
not rectangular to get a conical stump.
Muscle

■ In conventional amputations, muscles are cut at the level of transection of

bone
■ But now myodesis or myoplasties are routinely done
■ In myodesis, opposing muscle groups are sutured/anchored to bone end
using drill holes.(Myodesis is contraindicated in peripheral vascular disease.)
■ In myoplasty, opposing muscles which are divided 5 cm distal to bone
transection are sutured to one another adjacent to bone end. (It is preferred
in peripheral vascular disease)
■ transected muscles atrophy 40% to 60% in 2 years if they are not
securely fixed
 myodesis myoplasty

Myodesis
Neuro-vascular structures

■ Nerve should be pulled down and cut using a sharp knife

and allowed to retract into the soft tissue otherwise
neuromas may develop.

■ Major vessels should be individually isolated and ligated.

Mass ligature should be avoided.
Bone

■ Bone should be cut with bevelling and all sharp

margins should be rounded using rasp
■ Osteoplasty can be done by raising a sleeve of
periosteum over the bone; after cutting the bone
periosteum is closed over the bone end
■ Usually drain is placed (tube drain) through the wound which is removed in 48-72
hours
■ Postoperatively patient is mobilised using axillary crutches.
■ After 3 months, once scar has matured and stump has become supple, proper
prosthesis is fit.
■ Stump should be elevated by raising the foot end of the bed.
■ In above knee amputation avoid placing pillow below or on inner aspect of the
stump so as to prevent fixed flexion or abduction contracture.
Principles Of Childhood Amputation

1. Preserve length
2. Preserve important growth plates
3. Perform disarticulation rather than trans osseous amputation whenever possible
4. Preserve the knee joint whenever possible
5. Stabilize and normalize the proximal portion of the limb
6. Be prepared to deal with issues in addition to limb deficiency in children with
other clinically important conditions.
Advantages Of Amputation In Children
In Comparison To Adults
1. Because of growth issues and increased body metabolism, children often can
tolerate procedures on amputation stumps that are not tolerated by adults, which
includes

• More forceful skin traction

• Application of extensive skin grafts

• Closure of skin flaps under moderate tension.

2. Complications after surgery tend to be less severe in children, which
includes

■ Painful phantom sensations do not develop

■ Neuromas rarely are troublesome enough to require surgery.
■ Extensive scars usually are tolerated well.
■ One or more spurs usually develop on the end of the bone, but, in
contrast to terminal overgrowth, almost never require resection.
■ Psychological problems after amputation are rare in children

3. Children use prostheses extremely well, and their proficiency increases

as they age and mature.
GOALS OF AMPUTATION

• ABLATION OF DISEASE TISSUE

• RECONSTRUCTION
• PROVIDE PHYSIOLOGICAL END ORGAN
• OPTIMIZE PATIENT FUNCTION AND REDUCE MORBIDITY
Ideal Stump
■ It should have adequate blood supply. It should heal adequately by first intention
■ It should have rounded gentle contour; with adequate muscle padding, conical
shape with distal tapering is better. Stump should be free from tenderness and
conical.
■ opposing groups of muscles should be fixed together over the end of the bone to
attain optimum power and control of the muscles at the stump
■ Joint proximal to the amputation stump should show full range of movements
without any contracture
■ Freely mobile skin over the bone and soft tissues should be achieved to get free
movement of the prosthesis to be placed later.
■ Should have sufficient length to bear prosthesis
– For B-K 7.5 (minimum) to 12.5 cm from tibial tuberosity
– For above and below elbow 20 cm stump.
– For A-K 23 cm from greater trochanter.

■ It should have thin scar which does not interfere with prosthetic function. Scar
should be in a place where it is not exposed to pressure
Complications

Early
Haemorrhage, haematoma, infection.

Late
■ Flap necrosis
■ Stump neuroma
■ Stump pain
■ Phantom limb
■ Ulceration
– due to necrosis, infection, lengthy bone stump pressing on the summit of the
flap, prosthesis, deficiencies, diabetes mellitus, ischaemia
– Callous chronic ulcer at the end of the stump is called as Douglas ulcer
– Osteomyelitis of the stump should be ruled out in chronic stump ulcer. Ring
sequestrum may be typical in such situation

■ Contracture of the joint proximal to the amputated stump

 TYPES OF
AMPUTATIONS
Foot And Ankle Amputations
Toe Amputations

■ Amputation of the great toe does not functionally affect standing or walking at a
normal pace.
■ If the patient walks rapidly or runs, however, a limp appears because of the loss of
push-off normally provided by the great toe.
■ Amputation of the second toe frequently is followed by severe hallux valgus because
the great toe tends to drift toward the third toe to fill the gap left by amputation.
■ Amputation of all toes causes little disturbance in ordinary slow walking, but is
disabling during a more rapid gait and when spring and resilience of the foot are
required.

■ It interferes with squatting and tiptoeing.

■ Usually, amputation of all toes requires no prosthesis, other than a shoe filler
Metatarsophalangeal Joint
Disarticulation
■ The skin incision varies with the toe involved.

■ A long posteromedial flap is desired for great toe.

■ Begin the incision at the base of the toe in the midline anteriorly, and
curve it distally over the medial and posteromedial aspects for a
distance slightly greater than the anteroposterior diameter of the digit;
extend it proximally across the plantar surface of the toe to the web.
■ In the second, third, and fourth toes, amputation is performed through a short
dorsal racquet-shaped incision.
■ Begin the incision 1 cm proximal to the metatarsophalangeal joint, and pass it
distally to the base of the proximal phalanx, dividing it to pass around the toe and
across the plantar surface at the level of the flexor crease.
■ In the fifth toe, fashion a lateral flap long enough to cover the defect
left by the amputation.

■ Raise the flaps to the level of the MTP joint.

■ Identify the capsule of the MTP joint and, with the toe in acute flexion,
incise its dorsal side first; straighten the toe, and expose and incise the
remainder of the capsule after dividing the flexor tendons and
neurovascular bundles.
■ Removing the sesamoids in the insensate foot is recommended.

■ Draw the tendons distally, divide them, and allow them to retract.

■ Identify the digital nerves, and divide them proximal to the end of the
bone, and divide and ligate the digital vessels.

■ Close the skin edges with interrupted nonabsorbable sutures.

Transmetatarsal Amputations

■ Amputation through the metatarsals causes loss of push-off in the absence of a

positive fulcrum in the ball of the foot which is chiefly responsible for impairment of
gait.

■ No prosthesis is required other than a shoe filler.

Transmetatarsal Amputations
Midfoot Amputations

■ Lisfranc’s Amputation- amputation at the level of tarsometatarsal joint.

■ Chopart’s Amputation- amputation at the level of calcaneocuboid and talonavicular

joint

■ Pirogoff’s Amputation- calcaneus is rotated forward to be fused to the tibia after

vertical section through its middle
Chopart’s amputation
■ Lisfranc or Chopart amputations often results in an equinus deformity
because of loss of the foot dorsiflexor attachments.

■ Dorsiflexors of the foot and their insertion-

▪ Tibialis anterior- medial cuneiform and base of 1st metatarsal bone

▪ EDL- extensor expansion of lateral four toes
▪ Peroneus tertius- base of 5th metatarsal bone
▪ EHL- base of the distal phalanx of great toe
Severe equinus deformity after
Lisfranc's amputation
Hindfoot and Ankle Amputations

■ Syme’s Amputation- amputation at the distal tibia and fibula 0.6 cm proximal to the
periphery of the ankle joint and passing through the dome of the ankle centrally.

■ Modified Syme’s Amputation ( Sarmiento)- transection of the tibia and fibula

approximately 1.3 cm proximal to the ankle joint and excision of the medial and
lateral malleoli.
■ Boyd Amputation- talectomy, forward shift of the calcaneus, and calcaneotibial
arthrodesis.
Syme’s Amputation

■ Amputation at the distal tibia and fibula 0.6 cm proximal to the periphery of the
ankle joint and passing through the dome of the ankle centrally.

■ The tough, durable skin of the heel flap provides normal weight bearing skin.
■ Disadvantages :
i. Posterior migration of heel pad

ii. Skin slough resulting from overly vigorous trimming of “Dog ears”.

iii. Cosmesis- the stump is large and bulky (bulbous) because of the flair of the distal
tibial metaphysis which is covered with heavy plantar skin. ( not recommended for
women)
 Technique
■ Begin the incision at the distal tip of the
lateral malleolus, and pass it across the
anterior aspect of the ankle joint at the level
of the distal end of the tibia to a point one
fingerbreadth inferior to the tip of the medial
malleolus; extend it directly plantar ward and
across the sole of the foot to the lateral
aspect, and end it at the starting point
■ Place the foot in marked equinus, and divide
the anterior capsule of the ankle joint + insert
knife b/w medial malleolus and the talus and
lateral malleolus and the talus to section the
deltoid and calcaneofibular ligament
■ Bone hook pulling talus distally, exposing
distal articular surface of tibia and fibula
■ Dissection of soft tissues from calcaneus
(tendoachilles)
Subperiosteal removal of calcaneus,
leaving heel pad intact
■ Division of tibia and fibula just through
dome of ankle joint centrally 0.6 cm
proximal to the ankle joint.

■ The plane of the transection should be

such that the cut surfaces of the tibia and
fibula are parallel to the ground when the
patient is standing

■ Holes drilled in anterior edge of tibia and

fibula to anchor heel pad
■ Edge of deep fascia lining heel pad is
anchored to tibia and fibula
■ Skin closure over drain, and application of
above-knee cast.

■ “Dog ears,” are found at each end of the

suture line; these should never be
removed because they carry a large share
of the blood supply to the heel flap and
disappear later under bandaging.
Two-Stage Syme Amputation

■ Wagner et al. popularized the technique and was used in diabetic patients with
gross infection or gangrene of the forefoot who did not respond to conservative
treatment.

■ Had 95% success rate.

■ Many authors believe that both stages can be safely combined when infection is not
adjacent to the heel pad.
■ 1 st stage- ankle disarticulation, preserving the tibial articular cartilage
and the malleoli, and performing a Syme-type closure over a suction-
irrigation system that allows installation of an antibiotic solution into
the wound. Irrigation is continued until local and systemic signs of
infection have resolved.

■ 2 nd stage-After 6 weeks, if the stump is healed, a second procedure is

performed to remove the malleoli and narrow the stump for good
prosthetic fitting.
Below Knee Amputations

■ Transtibial amputations are the most common amputations performed for

peripheral vascular disease.

■ All technical procedures may be divided into those used for

-Non-ischemic limbs
-Ischemic limbs
 Non ischemic limb Ischemic limb

Muscle flaps- both Myoplasty Myodesis is contra-indicated

and Myodesis can be done as it may further compromise
an already marginal blood
supply

Skin flaps- both anterior and Long posterior flap and

posterior skin flaps can be short/absent anterior flap is
equal recommended as anteriorly
the blood supply is less
abundant than elsewhere in
the leg
Transtibial amputations can be divided
into three levels
Non-ischemic Limbs

■ The optimal level of amputation has been chosen to provide :-

-A stump length that allows a controlling lever arm for the prosthesis
-Sufficient “circulation” for healing
-Sufficient “soft tissue” for protective end weight bearing.

■ The amputation level also is governed by the cause (e.g., clean end
margins for tumour, level of trauma, and congenital abnormalities)
■ A longer residual limb would have a more normal gait appearance, but
it is not true for stumps extending to the distal third of the leg, as there
is less soft tissue available for weight bearing.

■ The distal third of the leg is relatively avascular and slower to heal than
more proximal levels.
Ideal bone length
■ In adults, the ideal bone length for a below-knee amputation stump is
to allow 2.5 cm of bone length for each 30 cm of body height.

■ Stumps lacking quadriceps function are not useful.

■ In a short stump whether fibula should be removed or preserved is

controversial as fitting of the prosthesis depends on it.

■ Transecting the hamstring tendons to allow a short stump to fall deeper

into the socket also may be considered
Procedure
A. Fashioning of equal anterior
and posterior skin flaps, each
one half anteroposterior
diameter of leg at level of bone
section.
B. Division and ligation of anterior
tibial vessels and division of
deep peroneal nerve
C. Fashioning of posterior myofascial
flap.
Suture of myofascial flap to periosteum
anteriorly.
E. Closure of skin flaps.
Procedure for ischemic limb

A. Fashioning of short anterior and

long posterior skin flaps
B. Separation and removal of distal
leg
C. Tailoring of posterior muscle mass
to form flaps
D. Suture of flap to deep fascia and
periosteum anteriorly.
E. Closure of skin flaps.
Above knee amputation

■ Lower third and middle third level amputations are done. Ideally the required length
of the femur as stump is 25cm from the greater trochanter.
■ Femoral vessels individually ligated two times.
■ Femur is cut with anterolateral bevel.
■ Sciatic nerve is pulled and cut.
■ Quadriceps sutured to hamstrings .myodesis can be done.
■ Advantages its easy, healing chances is better and faster.
■ Disadvantages is cosmetically poor, rehabilitation is difficult needs a third support
for walking.
■ Trans carpal amputation ;-

– It is disarticulation between proximal and distal rows of the carpal bone

complex
– At this level, supination and pronation of the forearm, as well as flexion
and extension of the wrist,
– Ideally, a long full-thickness palmar and shorter dorsal flap should be
created in a ratio of 2:1.
– Finger flexor and extensor tendons should be drawn, divided, and allowed
to retract deep into the proximal wound. Conversely, wrist flexor and
extensor tendons are identified and released from their distal insertions
and reflected proximally out of the way.
– The wrist flexors and extensors should be anchored to the
remaining carpus in line with their insertions to preserve
active wrist motion
■ Long palmar and short dorsal skin flap incision
which is 1.3cm distally curved from radial and
ulnar styloid processes on the palmar aspect
with a connecting straight incision on the dorsal
aspect. Radial ulnar arteries ligated. Styloid
process of radius and ulna removed
.median,radial,ulnar nerves cut. Tendons
divided. Long palmar flap sutured back on the
posterior aspect after placing a suction drain.
■ As much as possible should be preserved

■ Distal amputation is done at the junction of distal

1/3 and proximal 2/3 of forearm.

■ In proximal amputation as proximal as 3.8cm

stump is retained.

■ Both are done with equal flaps.

– More than 80 years ago, Krukenberg
described a technique that converts a
forearm stump into a pincer that is
motorized by the pronator teres muscle.
Indications for this procedure have been
debated; however, they generally include
bilateral upper-extremity amputations,
in those who are also blind.

– not recommended as a primary

procedure at the time of an amputation

– To consider this surgical option, the ulna

and radius must extend distal to the
majority of the pronator teres (the motor
for pinching) and an elbow flexion
contracture of less than 70°.
Prosthesis or Artificial limbs
■ A prosthesis a is an artificial device
that replaces a missing body part or a
limb( or its part ) lost due to trauma,
disease, or congenital conditions.
■ These are devices to make shape and
function of the residual limb and help
patient readapt to his job and life
style
Prosthesis or Artificial limbs
■ In Lower Limb-
1 Syme’s amputation-Elephant boot, Canadian Syme’s prosthesis

2. Below Knee amputation- Patellar tendon bearing (PTB) prosthesis and

solid ankle cushion heel (SACH)

3.Above Knee amputation- Suction type prosthesis, it is placed above the

stump. It is better and well tolerated

4.Nonsuction type prosthesis- It is placed at the end. It requires additional

support
Lower limb prosthesis
■ Jaipur foot- It is Indian modification for bare foot walking made of
vulcanized rubber and shaped like normal foot. It is flexible and is
helpful in walking on uneven surfaces

■ SACH foot( Solid Ankle Cushioned Heel)- It is most commonly used foot.
It has no mechanical ankle joint .The cushioned heel stimulates the
plantar flexion motion.

■ Endoskeleton prosthesis- It uses aluminum, titanium, graphite and

tubular material to form central supporting structure and have modular
or interchange able connectors and components like knee and feet.
The structural strength is derived from central Skelton like components.
It is covered by foam material like skin.

■ Exoskeletal prosthesis- there is outer plastic laminated skin or shell with

wood or poly urethane foam interiors. Here strength is provided by outer
lamination and shape is an integral part of prosthesis
 Types of Prosthesis
PROSTHETICS
LOWER EXTREMITY

KNEE HIP
BELOW KNEE DISARTICULATION ABOVE KNEE DISARTICULATION
 Prosthesis
Upper Extremity prosthesis-
a.Partial hand amputation- Cosmetic glove
b.Wrist disarticulation- Plastic laminate socket with triceps cuff and wrist unit
with terminal device
c.Below elbow amputation- Same as wrist disarticulation but with different
socket confg.
d.Elbow disarticulation- cosmetically undesirable as outside locking elbow
hinge is bulky
e.Above elbow amputation- The unit has internal locking system and turn
table which permits passive control of rotation. Elbow joint lock is controlled
by shoulder depression and terminal device is operated by scapular
abduction or shoulder flexion
■ Advantages of Prosthesis-
- Cosmetic
- Function of the part is gained to some extent
- Ambulation in lower limb prosthesis

■ Disadvantages-
-
-Infection
- Pressure ulcers
- Joint disability
There are 5 Stages of Rehabilitation:

1. Healing and Starting Physiotherapy

2. Visiting the Prosthetist

3. Choosing an Artificial Limb

4. Learning to Use your Artificial Limb

5. Life as a New Amputee

THANK YOU