Amputation

Amputation is the complete removal of an injured or deformed body part

A.Indications for Amputation

1. Peripheral vascular disease 2. Peripheral Arterial occlusive disease3. Acute occlusion due to embolism4. Aneurysm5. Diabetic limb disease6. Necrotising fasciitis 7. Trauma (severe tissue damage) - traumatic amputation8. Infection (chronic disabling infection, Gas Gangrene)9. Tumours (Malignant)10. Nerve injury (trophic ulceration – insensitive limb) 11. Congenital anomalies (eg. extra digits/ Gross deformity dysmelia) 12. Diabetes

o Damage to micro-vesselso Peripheral neuropathy, no sensationo Ulcers develop due to trauma, infection often ensueso Arterial blood supply is reducedo Ulcer becomes chronic with bouts of acute infection leading to loss of digits/foot/limb

13. Other Factorso Malignancy: squamous cell carcinomao Cardiac disease: AF, CCF, MI, o Trauma: RTA, crushing injury, gunshot, bomb blast, industrial machinery and burns.

B.Aims

1. Return Patient to maximum level of independent function 2. Ablation of diseased tissue (tumor or infection)3. Reduce morbidity & mortality (tumor or infection)4. Considered first part of a Reconstruction to produce a physiological end organ .

C.Determination of level

1. Zone of Injury (trauma)2. Adequate margins (tumor)3. Adequate circulation (vascular disease)4. Soft tissue envelope5. Bone and joint condition6. Control of infection7. Nutritional status

D.Techniques

1. Debridement of all Nonviable tissue and foreign material2. Several debridements may be required3. Primary wound closure often contraindicated4. High voltage, electrical burn injuries require careful evaluation because necrosis of deep muscle

may be present while superficial muscles can remain viable5. Nerve

Prevent neuroma formation Draw nerve distally, section it, allow it to retract proximally

6. Skin Opportunistic flaps Rotation flaps Tension free Skin grafts

7. Bone: Choose appropriate level Smooth edges of bone Narrow metaphyseal flare for some disarticulations

8. Goals of Postoperative Management Prompt, uncomplicated wound healing Control of edema Control of Postoperative pain Prevention of joint contractures Rapid rehabilitation

9. Post operative:

a. Rigid dressing : decreses edema, decreases post operative pain, protect limb from trauma, early mobilsation. Good bandaging to mold the stump into Conical shape to accept the prosthesis.

b. In postoperative prosthesis : early training with an IPOP is believed to increase the long term acceptance and use of prosthesis

c. Epidural analgesia

d. Cast to be appied at the end of the procedure, changed on the post op day 5 + IPOP

e. Cast changed weekly

f. Early prosthetic fitting . New prosthesis around 18 months

g. Avoid proximal compression of the limb.h. Prevent contracture (by splinting and / or muscle exercises)

E.Complication

1. Failure of wound to heal : gap if wider than 1cm needs revision

2. Infection : open – flaps retract / edematous

results in shortening the bone

3. Phantom sensation : diminishes over time, telescoping

4. Pain and phantom pain : massage , cold packs, exercise and neuromuscular stimulation

TENS ( trans cutaneous electric nerve stimulation) : incorporated in a prosthesis

-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine

-Preioperative analgesia can prevent or decrease the later incidence of phantom pain .(Epidural\perineural)

5. Edema- mistakes :- 1) Too tightly applied cast 2) Soft spica cast 6. Haematoma 10. Infection 11. Necrosis of stump end.12. Contractures (due to muscle imbalance)13. Neuroma at the cut nerve ending14. Phantom pain 15. Terminal overgrowth (children)

Pain

in the postoperative period- 3 sources, wound pain, back pain and phantom pain. Wound pain can be controlled with opiates in the immediate phase and, if needed, NSAID’s used.

between normal postoperative (ie, surgical) pain and phantom limb pain.

Surgical pain usually responds well to opioids.

Phantom limb pain usually is like a burning, stinging, electric pain, and it can be increased with anxiety and stress.

phantom pain is quite common initially,

if it is still present at 6 months postsurgery, the prognosis is unfavorable.

Phantom limb sensation also must be differentiated from phantom limb pain.

Phantom limb sensation is the sensation that the amputated limb is still present.

Patients usually report that the absent hand/arm/limb is itching, tickling, or moving through space.

Phantom sensation is perceived as a "funny" or "different" feeling but usually is not perceived as painful.

Phantom limb pain theories

Three theories as to why patients experience phantom limb pain and sensation exist.

One theory is that the remaining nerves continue to generate impulses.

A second theory is that the spinal cord nerves begin excessive spontaneous firing in the absence of expected sensory input from the limb.

The third theory is that there is altered signal transmission and modulation within the somatosensory cortex.

Telescoping

Another common phenomenon is telescoping.

Telescoping is the sensation that the distal part of the amputated extremity has moved proximally up the arm.

A patient might report that it feels like the entire extremity has shrunk so that the hand is now up at the elbow.

This is a normal part of the nerve healing process and usually fades with time.

F. What do the following terms mean?

Residual limb - The preferred term for the remaining portion of the amputated limb (Stump, while still used, is politically incorrect.)

Terminal device - Most distal part of the prosthesis used to do work (eg, hand)

Myodesis - Direct suturing of muscle or tendon to bone

Myoplasty - Suturing muscles to periosteum

Prehensile - Grasp

Forequarter Amputation

is the removal of the upper limb with the scapula

Mainly for malignancy

Krukenberg procedure

Separate radial and ulna rays distally

forming radial and ulna pincers capable of strong prehension and excellent manipulative ability

SYME'S AMPUTATION: The Syme's amputation provides an end-bearing stump that in many circumstances allows ambulation without a prosthesis over short distances. It is an excellent amputation for children, in whom it preserves the physes at the distal end of the tibia and fibula (26).

BOYD AMPUTATION

The Boyd procedure provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus

Compared to a Syme's amputation, it provides more length and better preserves the weight-bearing function of the heel pad. Its increased complexity and morbidity have made it less used now than the Syme's amputation.

Chopart's amputation amputation of the foot by a midtarsal disarticulation.

closed amputation one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone.

amputation in contiguity amputation at a joint.

amputation in continuity amputation of a limb elsewhere than at a joint.

double-flap amputation one in which two flaps are formed.

Dupuytren's amputation amputation of the arm at the shoulder joint.

elliptic amputation one in which the cut has an elliptical outline.

Gritti-Stokes amputation amputation of the leg through the knee, using an oval anterior flap.

guillotine amputation one performed rapidly by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing.

Hey's amputation amputation of the foot between the tarsus and metatarsus.

interpelviabdominal amputation amputation of the thigh with excision of the lateral half of the pelvis.

interscapulothoracic amputation amputation of the arm with excision of the lateral portion of the shoulder girdle.

Larrey's amputation amputation at the shoulder joint.

Lisfranc's amputation

1. Dupuytren's a.

2. amputation of the foot between the metatarsus and tarsus.

oval amputation one in which the incision consists of two reversed spirals.

Pirogoff's amputation amputation of the foot at the ankle, part of the calcaneus being left in the stump.

racket amputation one in which there is a single longitudinal incision continuous below with a spiral incision on either side of the limb.

root amputation removal of one or more roots from a multirooted tooth, leaving at least one root to support the crown; when only the apex of a root is involved, it is called apicoectomy.

spontaneous amputation loss of a part without surgical intervention, as in diabetes mellitus.

subperiosteal amputation one in which the cut end of the bone is covered by periosteal flaps.

Syme's amputation disarticulation of the foot with removal of both malleoli.

Teale's amputation amputation with short and long rectangular flaps.