AMPUTATIONSAMPUTATIONS

INDICATIONSINDICATIONS

DEAD

DEADLY

DEAD LOSS

DEADDEAD

Gangrene

large vessel – Atherosclerosis– embolus

small vessel – Diabetes– Buerger,s disease– Raynaud,s disease

DEADLYDEADLY

moist gangrene with surrounding putrefaction and infection

spreading cellulitis

neoplasm (osteogenic sarcoma)

AV fistula

DEAD LOSSDEAD LOSS

severe trauma

severe contracture or paralysis

severe rest pain

TYPES OF AMPUTATIONSTYPES OF AMPUTATIONS

MINOR– Ray– Trans-metatarsal

MAJOR

CONE BEARING END BEARING

Below knee

Above knee

Gritti-Stokes

Through knee

Syme,s

MINOR AMPUTATIONMINOR AMPUTATION

RAY AMPUTATION– excision of phalanges with head of

metatarsal– tendons are cut back– wound left open– Commonly done for diabetic foot

MAJOR AMPUTATIONMAJOR AMPUTATIONPreoperative preparationPreoperative preparation

Informed consent Improvement of general condition of the

patient Physiotherapy Antibiotics Analgesia Assessment of joints

Choice of operationChoice of operation

Cone bearing– Stump should be of sufficient length

• ( below knee 10-12cm)• (above knee > 20 cm)

– Stump must not be too long• Below knee7.5 cm above the ankle joint• Above knee 12.5 cm above the knee joint

– Stump with gentle rounded contour– Adequate muscle padding over the bone

Below Knee AmputationBelow Knee Amputation

2 types:– Long posterior flap– Skew flap

RULE:

length of flap must be at least one and a half times the diameter of the leg at the point of bone section.

Below Knee AmputationBelow Knee Amputation

LONG POSTERIOR FLAP: Incision deepened to bone anteriorly Bulk of gastrocnemiuas left with flap

laterally and posteriorly Blood vessels identified and ligated Nerves transected as high as possible. Vessels in nerves ligated Fibula divided 2 cm proximal to tibia

Below Knee AmputationBelow Knee Amputation

Tibia divided at desired levelWound washed with N/SBoner covered with muscles of

posterior flapSuction drain placedInterrupted skin sutures appliedPressure dressing done

Above Knee AmputationAbove Knee Amputation

Curved equal ant. and post. flaps made

Skin and muscles are divided in same line

Vessels are ligatedSciatic nerve ligated and cut high Bone is divided

Above Knee AmputationAbove Knee Amputation

Hemostasis securedBone covered with musclesSuction drain placedWound closed with interrupted

stitchesPressure dressing done

End Bearing AmputationsEnd Bearing Amputations

Rarely performed now Gritti-Stokes amputation: trans-condylar Through knee amputation: less complex Syme’s amputation:

– Preserves blood supply of heel flap– Dissection of calcaneum done– Tibia and fibula divided as low as possible

Syme’s AmputationSyme’s Amputation

POST OPERATIVE CAREPOST OPERATIVE CARE

pain relief with opiates

care of good limb

exercises and mobilization

Use of artificial limb

COMPLICATIONSCOMPLICATIONS

EARLY– Reactionary haemorrhage– Hematoma formation– Abscess formation– Gas gangrene– Wound dehiscense– Gangrene of flaps– DVT and pulmonary embolism

COMPLICATIONSCOMPLICATIONS

LATE– unresolved infection (sinus, osteitis,

sequestrum)– bone spur– amputation neuroma– phantom limb– Phantom pain– ulceration of stump