Amputation

AMPUTATIONS
DR THIT LWIN
FACULTY OF MEDICINE &
HEALTH SCIENCE
UCSI
Definition:
amputation is removal of part or

all of a body part enclosed by skin
Removal of an appendix would not be termed
amputation..
Amputation" is derived from the Latin word
"amputare" (to excise, to cut out).
. A person
who has undergone an amputation is called an
amputee.
INDICATIONS
Three
Ds: Dead, Dangerous, Danm nuisance.

Dead: peripheral vascular disease,(90%)
severe trauma
burns or frostbite.
The only absolute indication for amputation is
irreversible ischemia in a diseased or traumatized
limb.
Dangerous:
malignant tumour
potentially lethal sepsis (gas gangrene)
crushed injury (release of compression may
cause renal failure)
Danm nuisance: gross malformations
severe loss of functions

VARIETIES
1.
provisional amputations
2. definitive end-bearing amputations
e.g. through-knee and Symes
3. definitive non-end-bearing amputations
-scar can be terminal
Usual
site of election in lower limb

amputation.
Through-knee
and Symes amputation are
end-bearing:
the scars are not terminal:
Usual
site of election in upper limb

amputation.
Preoperative preparation
Control
diabetes, infection, dehydration,

anemia, shock, & cardiac insufficiency.
Prepared to withstand & survive surgical
trauma.
Preoperative clinical assessment of skin color,
hair growth, & skin temperature
Preoperative preparation
Skin flap perfusion- thermography, laser Doppler

flowmetry,
Transcutaneous oxygen measurements-2040mm Hg
Simple screening tests for nutritional status &

immunocompetence.
Serum albumin level >3.5g/dL
Total lymphocyte count 1500cells/mL
1) GUILLOTINE AMPUTATION
Emergency amputation done as a life saving

measure.
Done in cases of gross crush injuries of the limb.
Also indicated in cases of gas gangrene, as a life
saving procedure.
Incision is circular around the limb at the site of
bone section and all the tissues are cut at the same
level and the wound is left open to provide free
drainage
When infection controlled & patient stabilizedRevision amputation done
Two
types
a) Open amputation with inverted skin
flaps
b) Circular open amputation
a) Open amputation with

inverted skin flaps
Wound
allowed to drain fully

Interrupted suture through edges to create rolled
flaps
If no infection & sufficient granulation tissue
stump closed in 2 weeks.
Sutures removed & edges unrolled
ADV: No revision surgery
DISADV: Maceration
Difficult to maintain skin traction
guillotine amputation
Non-ischaemic limb
amputation
Ischaemic limb
amputation
General complications
chest infections,
angina, heart attacks and
strokes.
Because your mobility is restricted
after an amputation, pressure sores
can also develop
Local Complications:
- wound Infection
-Tissue necrosis
-Pain(phantom limb pain, neuroma pain)
-Dehiscence/wound breakdown
-Problems associated with the surrounding
skin(contracture)
-Bone erosion/osteomyelitis
-Haematoma
-Stump edema
-dermatological problems: contact dermatitis,
bacterial folliculitis, epidermoid cyst, verrucous
hyperplasia.
Three distinct gas-forming infections

Anaerobic
cellulitis
Closridial
myonecrosis
Streptococcal
myonecrosis
Tissue necrosis
COMMON LEVEL OF
AMPUTATIONS
A dehisced above knee amputation with exposed

femur bone
Above knee amputation
Below knee amputation
Through
knee amputations
Rays amputations
Amputated
blister
stump showing
Toe
amputation
Transmetartarsal amputation
Sims amputation
Rays amputation
Lisfranc amputation
Stump sinus masking underlying osteomyelitis
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 / flabbiness
Basic principlesSKIN 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 principles5) 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 principles5) 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 principles6) 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 principles7) 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.
WOUND DRESSING
SOFT DRESSING
Snugly
applied, with elastic

bandage.
Stump elevated with foot end
elevation
Muscle setting exercises &
mobilization of joints
Wound Dressing
Hard dressing
Postoperative POP casts applied with appropriate
padding
Advantages
Prevent
edema
Promote wound healing
Early maturation of stump
Decrease postoperative pain
Allows early mobilization
Prevent contractures
Decreased stay
Physiological benefits
psychological benefits
Basic principles8) Drain

Drains
Cast
removed after 48 hours
loosening, excessive drainage, or

systemic symptoms, wound infection are
indications for early cast removal
Jigli saw
Amputation
saw
Amputations in Children
general principles of childhood amputation:
(1) preserve length,
(2) preserve important growth plates,
(3) perform disarticulation rather than transosseous
amputation whenever possible,
(4) preserve the knee joint whenever possible,
(5) stabilize and normalize the proximal portion of the
limb, and
(6) be prepared to deal with issues in addition to limb
deficiency in children with other clinically important
conditions.
A.Terminal overgrowth of a trans-humeral

amputation in a pediatric patient.
B, Stump capping procedure. The bone end has
been split longitudinally and capped with an
osteochondral graft.

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AMPUTATIONS

amputation is removal of part or

Ds: Dead, Dangerous, Danm nuisance.

site of election in lower limb

and Symes amputation are

site of election in upper limb

diabetes, infection, dehydration,

Skin flap perfusion- thermography, laser Doppler

Simple screening tests for nutritional status &

Emergency amputation done as a life saving

a) Open amputation with

allowed to drain fully

Three distinct gas-forming infections

A dehisced above knee amputation with exposed

Above knee amputation

Below knee amputation

Stump sinus masking underlying osteomyelitis

Stump- Firm & smooth, tapering segment ,

Basic principlesSKIN FLAP

Flaps should be kept thick.

Skin at ends should be mobile & normally

Unnecessary dissection should be avoided to

Basic principles MUSCLE FLAP

Muscles usually are divided distally (at least 5 cm

Myodesis --suturing muscle or tendon to bone.

Myoplasty --suturing muscle to periosteum or to

Basic principles5) Nerves

Nerves should be isolated, gently pulled distally

Large nerves such as the sciatic often contain

Basic principles5) Nerves

Strong tension on the nerve should

Crushing also should be avoided.

Basic principles6) BLOOD VESSELS

Basic principles7) BONE:

applied, with elastic

Basic principles8) Drain

removed after 48 hours

loosening, excessive drainage, or

A.Terminal overgrowth of a trans-humeral

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