Amputation and disarticulation

Amputation, Disarticulation, Definition, stump, idea stump, types, methods,complication

1. Amputation and Disarticulation Indications, methods and complications Dr Yash Oza

2. "Amputation is one of the meanest yet one of the greatest operations in surgery, i.e. mean-when resorted to where better may be done. Great-as the only step to give comfort and prolong life .“ - Sir William Ferguson

3. Definition Amputation : Removal of a part of limb completely or partially proximal to the lesion is called amputation. D isarticulation   It is the separation of two bones at their joint, either traumatically by way of injury or by a surgeon during arthroplasty or amputation.

4. Indications DEAD, DYING, DEVITALISED TISSUE Peripheral vascular disease (with or without diabetes) is the commonest indication for amputation . Gangrene due to atherosclerosis, embolism, TAO, etc. Trauma is leading indication in young patients. To save life in crush injuries Burns : thermal, chemical or electric may necessitate amputation. Frostbite

5. Infections . acute/chronic infection which are unresponsive to antibiotics and surgical debridement. Most worrisome of these are infections causes by gas forming organ isms which typically result from battle field injuries; farm injuries, severe motor vehicle accidents and gunshot wounds. Neoplasm : Osteosarcoma, Marjoilin’s ulcer, melanomas Severe deformity : congenital or acquired

6. Types of Amputation Weight is taken up by the joint Weight is taken up by the body

7. Types of Amputation

8. Types of flaps

9. Ideal Stump Should heal adequately by 1 st intention. Should have rounded, gentle contour, with adequate muscle padding . 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.

10. Should have thin scar which does not interfere with prosthetic function. Should have adequate adjacent joint movement . Should have adequate blood supply . Scar should be in a place where it is not exposed to pressure . Scar should be freely mobile over underlying tissues, Skin and scar should be freely mobile over the underlying bone. It is achieved only if deep fascia is closed properly. Scar and skin should be free to achieve free movement of the prosthesis. Socket of prosthesis with mobile skin creates a piston to bone to move like a joint. Skin should not be unfolded. Redundant soft tissue should not be there. Stump should be free from tenderness and conical.

11. Principles in Amputation Adequate blood supply of the flap should be maintained. Tourniquet should not be used if amputation is done for vascular diseases. Proximal part of the flap contains muscle component but distal part should contain only skin and deep fascia. Nerve should be pulled down and cut using a sharp knife and allowed to retract into the soft tissue otherwise neuromas may develop. In crush injury/entrapment injury/sepsis guillotine amputation is done. Later skin is pulled down by using skin traction, eventually to have better skin coverage. Bone should be cut with beveling and all sharp margins should be rounded. Post-operatively active exercise should be given to the proximal joint so that the prosthesis can be fitted properly.

12. Myodesis : muscle sutured to the bone via drill holes establish resting tension provides better limb control, avoid contracture Myoplasty : muscle of opposing compartment sutured to each other under tension can achieve function as similar to myodesis

13. Different Amputation

14. Amputation of Foot & Ankle

15. 1.Toe amputation : disarticulation of toes from Interphalangeal joint Single or multiple toes 2. Metatarsophalangeal disarticulation 3. Transmetatarsal amputation

16. 4. Lisfrank : at level of tarso -metatarsal joint 5. Chopart’s : at level of midtarsal joint

17. 6. Syme amputation : through ankle at the level just proxy mal to malleoli - disadvantages include: poor cosmesis (bulbous stump) and migration of heel pad posteriorly).

18. 7. Boyd amputation is a modification of Syme amputation. It involves talectomy followed by calcaneo -tibial arthrodesis sis. This preserves the heel pad for weight bearing. 8. Pirogoff amputation involves sectioning of calcaneus vertically. The remaining posterior part of calcaneus is ro tated to produce tibia calcaneal arthodesis .

19. 9. Ray amputation ( lateral ray, middle rays and medial ray)

20. Amputation of lower limb

21. Trans-tibial (below knee) amputation is the commonest level. The ideal stump length in a below knee amputation is 12.5-17.5 cm depending on the patient's height. (2.5 cm bone length for each 30 cm of body height). Stump lacking quadriceps insertion are not useful. A tibio -fibular synostosis ( Ertl Procedure) creates wider stump and removes fibular instability.

22. 2. Disarticulation of knee : is an excellent end bearing stump

23. 3. Gritty-Stokes amputation : the level is at the distal most part of femoral condyles. The advantage is good fixation of muscle and skin to the cancellous bone of distal femoral condyles. 4. Trans-femoral (above knee) amputation: The stump length should allow adequate room for fitting of prosthesis with knee joint at same level with the normal knee. The longer stump results in a distally placed prosthetic knee which is undesirable.

24. 5. Disarticulation of hip : most common indication are bone & soft tissue sarcoma of femur or thigh 6. Hemipelvectomy : Sarcoma, life threatening infection, arterial insufficiency are common indication. hemipelvectomy disarticulates the symphysis pubis, sacroiliac joint and ipsilateral limb

25. Amputation of hand 1. Finger tip amputation: a split thickness graft is sufficient if the bone is only slightly exposed/ not exposed. Flaps/ full thickness grafts are desirable for better sensation and durability. Flaps available for finger tip cover include: a. V-Y advancement flaps ( Kutler / Atasoy ) b. Cross finger flap c. Thenar flap d. Island pedicle flap e. Ulnar hypothenar flap

26. 2. Index/2nd ray amputation ideal level is through second metacarpal if amputation is anticipated proximal to PIP. 3. Amputation of hand at wrist: grasp may be obtained by Krukenberg reconstruction which converts forearm into a forceps where radial ray acts against the ulnar ray.

27. 4. Thumb amputation reconstruction of thumb can be done by pollicisation of 2nd digit (Buck- Gramcko ). 2nd toe may be used with micro-vascular technique to replace for thumb.

28. Amputation of Upper limb 1. Wrist Amputation : transcarpal amputation ( in between distal & proximal row ) and disarticulation of hand are preferred to amputation through distal forearm, because this preserves the supination and pronation at forearm.

29. 2. Forearm amputation ( Transradial ) 3. Elbow Disarticulation

30. 4. Transhumeral amputation 5. Disarticulation of shoulder

31. 6. Fore-quarter amputation: removes the entire upper extremity in the interval between scapula & chest wall ( Tickhoff Limberg procedure)

32. Complication Early Hemorrhage Hematoma Infection Late Pain Ulceration of the stump Ring sequestrum formation Flap Necrosis Painful ulcer Phantom Limb

33. Early complication Haematoma It is identified by pain, swelling over the stump underneath the flap. It is aspirated using a wide bore needle. Haematoma may delay healing; may precipitate infection or flap necrosis due to pressure. After aspiration, pressure dressing is needed. If haematoma reforms after 2-3 aspirations, it should be drained by opening the wound on one corner and inserting haemostat into the wound.

34. Early complication Infection of the Stump It may cause abscess formation, delay in wound healing, flap necrosis, giving way of the wound. Removing few or all sutures to relieve pressure and draining the pus underneath is needed. Infection may also lead to poor scar, adherent scar which causes difficulty in placing the prosthesis.

35. Late complication Flap Necrosis It is a common complication. Main causes for flap necrosis are poor blood supply, infection, haematoma underneath, inadequate length of the flap causing stretching of flap. Small area of necrosis can be excised. Wider area needs laying opening of the wound or revision of the stump or higher level amputation. Anaemia, poor nutrition, nutritional deficiencies, diabetes mellitus, immunosuppression, smoking, old age are other factors causing flap necrosis.

36. Late complication Stump Neuroma It can occur due to proliferation of the nerve fibrils beyond the point of nerve division and is usually due to failure of cutting of the nerve more proximal to the level of division of the bone. It causes pain and tenderness over the stump. It is usually relieved by analgesics, re-assurance and prosthesis. Occasionally, it may require re-exploration of the wound, excision of end neuroma and also cutting nerve more proximally.

37. Late complication Stump Pain after Amputation It is a common problem. Causes are-infection, poor blood supply, causalgia, stump neuroma, phantom pain/limb, deep vein thrombosis, adherent scar, formation of spurs and osteophytes at amputated bone end. Scar adhesion to bone is prevented by keeping adequate length of deep fascia underneath intact. Spurs and osteophytes are confirmed by X-ray and needs removal using bone nibbler after appropriate skin incision.

38. Late complication Phantom Limb It is typical awareness of sensation that as if amputated part is still present partly or in toto ; often such part may be painful or disturbing or hyperaesthetic . Exact cause is not known, but it is probably due to presence of severe pain at the amputated part just prior to amputation making brain area for that part in alert situation causing phantom limb. Reassurance, prosthesis, analgesics help to control the condition. It is said that it can be prevented by proper pain control for 24 hours prior to amputation; but it is often difficult. It is common in upper limb.

39. Late complication Ulceration over the stump It is not uncommon. It is due to necrosis, infection, lengthy bone stump pressing on the summit of the flap, prosthesis, nutritional deficiencies, diabetes mellitus, ischemic. Ulcer may be small/large; superficial/deep Callous chronic ulcer at the end of the stump is called as Douglas ulcer. Small ulcer is later treated by regular dressings and suturing. Large ulcer needs flap to cover the defect. Osteomyelitis of the stump should be ruled out in chronic stump ulcer. Ring sequestrum may be typical in such situation. Revision amputation is needed for the stump.

40. Late complication Contracture of the Joint Contracture of the joint proximal to the amputated stump is common. It is mainly due improper positioning after amputation due to pain, poor exercise and occasionally due to inflammation of surrounding soft tissues. Contracture interferes with proper fitting and functioning of the prosthesis and delays rehabilitation. Proper positioning, passive stretching and exercises, strengthening exercises with help to correct it. Rarely needs surgical release of the contracture.

41. Other Complications Scar hypertrophy, skin thickening, hyperkeratosis, papilloma, Eczema, Lymphoedema , boils, bursae over bony point Spur, osteophyte formation, causalgia , jactitation of the stump, stump aneurysm, stump fracture

42. Thank you