amputation from orthopaedic point of view

must read topic

1. Amputation Presented by Roll no: 48, 49, 50 MBBS, 2 nd Batch Morderator: Dr. Manoj Rajbanshi

2. Introduction with a brief history Indications Preoperative consideration & level ​ Surgical anatomy & its principles Complications associated with amputation surgery Postoperative care , Rehabilitation and recent advances Outline of Presentation

3. Introduction Surgical removal of limb or part of limb through one or more bones Performed for removed diseased or injured tissue, ischemia, malignancy, congenital deformity or improve the function Main goal: preserve functional length while ensuring optimal prosthetic uses and rehabilitation

4. Historical Evolution of Amputation Ancient era: ​ Derived from the Latin amputare . – " to cut away ", from ambi - ("about", "around") and putare ("to prune").. • The English word "amputation" was first applied to surgery in the 17th century Evidence from Neolithic period ( crude stone tools ) ​ Hippocrates- describe ligature for haemorrhagic control .

5. Continue… Middle ages : ​ Ambroise pare(1529)- introduced arterial ligatures and improved prosthetic ​ Morels- introduced tourniquet in 1674 .

6. Continue… 18th- 19th century: ​ Lister- development of antiseptic techniques ​ Introduction of anaesthesia – reduced surgical mortality.

7. Continue… Modern advances: ​ Myodesis and advanced prosthetic .

8. Incidence More than 2 million people with amputation live in U.S. More than 90% people with amputation is due to peripheral vascular disesases . In Nepal : leading cause of amputation is trauma(48.6%) and diabetes(33.6%) Lower limb more common than upper limb

9. Indications Absolute indications: Irreversible limb ischemia Overwhelming life threatening infection High energy trauma with non salvageable injury

10. Continue… Relative indications Non reconstructible peripheral vascular diseases Severe diabetic complications Malignant tumours or aggressive neoplasms of bone/soft tissue Congenital deformities or chronic pain

11. MESS SCORE

12. Level of Amputation Major amputation : resection proximal to the ankle , resulting in significant gait alteration and prosthetic dependence Major amputation in lower limb ​​ Transtibial ​ Knee disarticulation ​ Trans femoral ​ Hip disarticulation

13. Continue… Major amputation – upper limb ​ Trans radial ​ Trans humeral ​ Shoulder disarticulation

14. Continue… Minor amputation of lower limb ​ Toe/ray(1 st ray most critical for push off) ​ Trans metatarsal ​ Lis franc( tarso -metatarsal) ​ Chopart (midtarsal)

15. Continue… Minor amputation of upper limb ​ Digital / ray ​ Metacarpal

16. Pre Operative Consideration for Amputation Patient assessment ​ Level selection ​ Medical optimization ​ Surgical planning ​ Psychological preparation

17. Vascular and Nerve Supply Consideration Lower limb: Transtibial anatomy ​ Arteries : posterior tibial artery ​ Nerve : tibial nerve ​ Transfemoral anatomy ​ Arteries : superficial/deep femoral artery ​ Nerve : sciatic nerve transection

18. Continue… Upper limb: Transradial anatomy ​ Arteries : radial/ulnar arteries(double ligation) ​ Nerve : median/ulnar(proximal traction neurectomy) ​ Transhumeral anatomy ​ Artery : brachial artery ligation proximal to bifurcation ​ Nerve : radial/median/ulnar nerve individually addressed

19. 1. Principles of Amputation Surgery 2. Types of Amputation by Level 3. Guillotine vs Formal Amputation 4. Complications of Amputation Surgery Contents

20. Preserving life Preservation of function Early return to function Minimize energy expenditure Goals of amputation surgery

21. 1. Determination of Amputation Level 2. Atraumatic tissue handling 3. Hemostasis 4. Appropriate flap design 5. Myodesis and Myoplasty 6. Bone beveling and nerve management Principles of Amputation Surgery

22. 1.Determination of Amputation Level Clinical condition Anatomy of affected area Vascular supply Functional considerations Patient preferences

23. 2. Atraumatic tissue handling Gentle handling of tissues Preservation of vascular supply Sharp and precise incisions Minimize electrocautery use

24. 3. Hemostasis Correction of coagulopathies Use of tourniquet Ligation of major vessels Electrocautery Packing and pressure Use of drains

25. 4. Appropriate flap design Adequate length and coverage Good vascular supply Avoidance of tension Avoiding scar over pressure points Tailor flap type to amputation level

26. 5. Myodesis and Myoplasty

27. 6. Bone beveling and nerve management

28. Guillotine Amputation Indications: a. Life threatening limb sepsis b. Wet gangrene c. Gas gangrene d. Necrotizing fasciitis e. Severe infected diabetic foot f. Crushed/ infected traumatic limbs

29. Formal Amputation Indications: a. Non-viable limb b. Failed limb salvage c. Diabetic foot d. Post- gulliotine amputation e. Congenital limb deformities f. Bone/ soft tissue tumors

30. Features Guillotine Formal Timing Emergency/ lifesaving Planned/ definitive Purpose To control infection rapidly To create a functional stump suitable for prosthesis Skin closure Left open for drainage Primary closure with flaps Nerve management Not done/ Minimal Proper nerve traction, cutting and retraction Bone beveling Usually not done Done Myoplasty / Myodesis Not performed Performed for stump stability Prosthetic Readiness Not suitable Designed for prosthetic fitting Further steps Followed by formal No further surgery

31. compliacations Ajibade et al PMID:  24669024 Kunwar et al , BPKIHS

32. 1. Infection Complications of Amputation Surgery

33. 2. Wound Dehiscence

34. 3. Hematoma

35. 4. Neuroma

36. 5. Phantom limb sensation

37. Content Postoperative care Rehabilitation Advances

38. Post operative care Immediate care: Pain management Monitoring of stump healing Stump bandaging and shaping

39. 1)Pain management 2) Monitoring of stump healing and stump bandaging

40. Long term rehabilitation Goals of long-term rehabilitation 1)To achieve mobility and function 2) To promote wound healing and prevent complications 3) To facilitate prosthesis use and training. 4) To manage phantom limb pain and residual limb care. 5) To support mental health and psychological adjustment

41. Components of long term rehabilitation Physiotherapy Strengthening exercises( especially for remaining limbs) ROM to prevent joint contractures Balance and coordination training Gait training Occupational therapy 1)Training in activities of daily living( e.g dressing ,bathing) 2)use of assistive devices and modification at home or work

42. Emotional and psychological support 1)Psychological counselling coping with body images, depression, or anxiety 2)Peer support groups sharing experiences with other amputees for motivation and guidances . 3)Social and vocational rehabilitation

43. Advances in amputation care Surgical advances 1)Osseointegration Titanium implant is inserted into the bone directly, allowing direct attachment of the prosthesis. advantages : better proprioception, comfort, motility and eliminates sockets related issues. Common sites : femur , humerus . 2) Targeted muscles reinnervation (TMR) nerves stumps from the amputed limbs are surgically rerouted to the remaining muscles. Allows the better control of the myoelectric prosthesis and reduces neuroma pain or phantom pain.

44. Rehabilitation Innovations A. Virtual Reality (VR) and Augmented Reality (AR) • Used for gait training, phantom pain therapy, and mental engagement. • Increases patient motivation and neuroplasticity. B. Mirror Therapy & Phantom Limb Pain Management • Advanced forms include VR-based mirror therapy and neuromodulator. • Help reduce phantom limb sensations and improve brain adaptation.

45. Prosthesis Timing of fitting begins after adequate wound healing (typically 4-8 weeks post operative) Assessment factors for prosthesis selection 1) level of amputation (above knee, below knee, limb) 2) condition of residual limb 3) patient’s age, motivation and activity level 4) comorbidities

46. Types of prosthesis

47. Prosthetic technology Myoelectric prostheses uses electric signals from the residual limb muscles to control the prosthetic. Provides the fine motor control of the upper limb. 2) Bionic and robotic prostheses integrated with sensors and microprocessors for real time movement adjustments. Provide the adaptive gait ,climbing stairs.

48. Outcomes and quality of life Physical Outcomes A)Functional Independence • Better outcomes in lower limb below-knee amputations than above-knee due to preserved knee joint. • Many patients regain the ability to walk with or without a prosthesis. B) Prosthetic Use and Mobility • mobility and independence.

49. 76.74% of participants scored high in mental health and 81.40% in physical health

50. Psychological outcomes A)Mental Health • depression, anxiety, grief, and body image issues B)Adaptation and Acceptance • Younger, motivated patients and those with social/family support adapt better. • faster emotional recovery.

51. Social and Vocational Outcomes • Work, education, or household responsibilities • Participation in sports or recreational activities • Social stigma and environmental barriers may limit community reintegration in some regions .

52. References Canale ST, Beaty JH, editors. Campbell's operative orthopaedics . 13th ed. Philadelphia: Elsevier Mosby; 2017. Solomon L, Warwick D, Nayagam S. Apley's system of orthopaedics and fractures . 10th ed. Boca Raton: CRC Press; 2017. Williams NS, O'Connell PR, McCaskie AW, editors. Bailey & Love's short practice of surgery . 28th ed. Boca Raton: CRC Press; 2022. Choo YJ, Kim DH, Chang MC. Amputation stump management: A narrative review. World J Clin Cases. 2022 May 6;10(13):3981-3988. doi : 10.12998/wjcc.v10.i13.3981. PMID: 35665133; PMCID: PMC9131228.

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