Dr.guruprasad amputation

overview of amputations and its various types n its complications n how it is different in children, for medicos ,postgraduates n physiotherapy

1. Amputations Dr. Guru prasad DNB orthopaedics

2. OUTLINE Introduction Indications Types Preoperative evaluation Operative techniques Postoperative care Levels of amputations Complications Amputation in children

3. Amputation “Surgical removal of limb or part of the limb through a bone or multiple bones” Disarticulation;- “ Surgical removal of whole limb or part of the limb through a joint”

4. Introduction …

5. Most ancient of surgical procedure. Historically were stimulated by the aftermath of war. It was a crude procedure - limb was rapidly severed from unaesthetized patient. The open stump was then crushed or dipped in boiling oil to obtain hemostasis. Hippocrates was the first to use ligature. Ambroise Pare ( a France military surgeon) introduced artery forceps. He also designed prosthesis. Amputation of a leg without anaesthetic History

6. Introduction As a punishment in Islam According to Islamic Sharia Law, the punishment for stealing is the amputation of the hand & after repeated offense, the foot (Quran 5:38 ) This controversial practice is still in practice today in countries like Iran, Saudi Arabia & Northern Nigeria.

7. Introduction Other Sometimes professional athletes may choose to have digit amputated to relieve chronic pain & impaired performance. Australian footballer Daniel Chick elected to have his left ring finger amputated as chronic pain & injury was limiting his performance. Rugby player Jone Tawake also had a finger removed. 10-Apr-15 7

8. Common causes . Injury peripheral vascular disease Less common . Infection(fulminating gas gangrene) . Malignancy . Nerve injury . Congenital anomalies . miscellaneous Indications

9. Indications: ‘ DDD’ Dead Dangerous Damned Nuisance

10. Indication Dead limb: Severe trauma Peripheral vascular disease Burns Frostbite.

11. Indication… Dangerous limb: Crush injury Malignancy Lethal sepsis Forgotten tourniquet >6hrs.

12. Indication… Damned nuisance: Gross deformity Recurrent sepsis Loss of function. The only absolute indication for amputation is irreversible ischaemia .

13. “The energy required for walking is inversely proportionate to the length of the remaining limb” Amputation of the lower extremity is often the treatment of choice for an unreconstructable or a functionally unsatisfactory limb The higher the level of a lower-limb amputation, the greater the energy expenditure that is required for walking As the level of the amputation moves proximally, the walking speed of the individual decreases, and the oxygen consumption increases Pathophysiology

14. In transtibial amputations, the energy cost for walking is not much greater than that required for persons who have not undergone amputations. For those who have undergone transfemoral amputations, the energy required is 50-65% greater than that required for those who have not undergone amputations .

15. Open Guillotine modified guillotine Closed amputation revised planned Types of amputation

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

17. Determination of level Zone of Injury (trauma) Adequate margins (tumor) Adequate circulation (vascular disease) Soft tissue envelope Bone and joint condition Control of infection Nutritional status

18. Pre Operative period Assessment Physical Social Psychological Training Re-assurance

19. Pre Operative Assessment Assessment of – The affected limb The unaffected limb & The patient as a whole is conducted thoroughly. Assessment of physical, social & psychological status of the patient should be made.

20. Physical Assessment Muscle strength of UL, trunk & LL apart from the affected limb before level of amputation. Joint mobility , particularly proximal to the amputation level. Respiratory function Balance reaction in sitting & standing Functional ability Vision & hearing s tatus

21. Social assessment includes Family & friends supports Living accommodation – Stairs, ramps, rails, width of door, wheelchair accessibility Proximity of shops

22. Pre-operative Evaluation History Aetiology Comorbidities Physical examination CVS, Renal & Nervous system Investigation Doppler indices Transcutaneous O 2 tension

23. Pre-operative Evaluation… Optimization: Anaemia, hypotension, infection, nutrition Consultations: Nephrologist, Cardiologist, Neurologist If vascular dx has progress to the point of amputation, most patients also have concomitant dx process in the cerebral, renal & coronary vasculatures.

24. Pre-operative Evaluation… Counseling & consent Procedure, anaesthesia, complications, prosthesis & limitations. MESS ≥ 7 Removes subjectivity from decision making in trauma cases. No scoring system can replace experience & good clinical judgment.

25. Principles of operative techniques Anaesthesia Regional, G.A Antibiotics Broad-spectrum, IV Tourniquet Except in arterial insufficiency

26. Principles of operative techniques..

27. Principles of operative techniques..

28. Debridement of all Nonviable tissue and foreign material Several debridements may be required Primary wound closure often contraindicated High voltage, electrical burn injuries require careful evaluation because necrosis of deep muscle may be present while superficial muscles can remain viable Techniques

29. Skin and Muscle Flaps Flaps should be kept thick. Unnecessary dissection should be avoided to prevent further devascularization of already compromised tissues. Technical Aspects

30. The scar should not be adherent to the underlying bone as an adherent scar makes prosthetic fitting extremely difficult, and this type of scar often breaks down after prolonged prosthetic use. Redundant soft tissues or large “dog ears” create problems in prosthetic fitting and may prevent maximal function of an otherwise well-constructed stump.

31. Muscles usually are divided at least 5 cm distal to the intended bone resection. They may be stabilized by Myodesis (suturing muscle or tendon to bone) or by Myoplasty (suturing muscle to periosteum or to fascia of opposing musculature). ( transected muscles atrophy 40% to 60% in 2 years if they are not securely fixed). If possible, myodesis should be performed to provide a stronger insertion, help maximize strength, and minimize atrophy   

32. Myodesis

33. Myodesed muscles continue to counterbalance their antagonists, preventing contractures and maximizing residual limb function. Myodesis may be contraindicated, however, in severe ischemia because of the increased risk of wound breakdown.

34. Hemostasis Except in severely ischemic limbs, the use of a tourniquet is highly desirable and makes the amputation easier. Major blood vessels should be isolated and individually ligated . Larger vessels should be doubly ligated . The tourniquet should be deflated before closure, and meticulous hemostasis should be obtained.

35. Nerves A neuroma always forms after a nerve has been divided. A neuroma becomes painful if it forms in a position where it would be subjected to repeated trauma. 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.

36. Strong tension on the nerve should be avoided during this maneuver ; otherwise, the amputation stump may be painful even after the wound has healed. Large nerves, such as the sciatic nerve, often contain relatively large arteries and should be ligated .

37. Bone Excessive periosteal stripping is contraindicated and may result in the formation of ring sequestra or bony overgrowth. Bony prominences that would not be well padded by soft tissue always should be resected , and the remaining bone should be rasped to form a smooth contour.

38. Principles of operative techniques.. Closure Drain is placed Skin closed without tension. With modern total-contact prosthetic sockets, the location of the scar rarely is important, but the scar should not be adherent to the underlying bone

39. Principles of operative techniques.. Conical Dressing Soft dressing with crepe bandage Rigid dressing with POP Rigid dressings prevent edema at the surgical site Enhance wound healing & early maturation of stump Decrease postoperative pain Allow earlier mobilization & ambulation Prevent knee flexion contractures in B/K amputation

40. Principles of operative techniques.. Ideal stump Conical Heal adequately Adequate stump Adequate muscle padding Thin scar not interfering with prosthesis Adjacent joint movements Adequate blood supply

41. Post-operative management Analgesics Antibiotics DVT prophylaxis Stump elevation (foot of the bed) Avoid flexion contracture at knee & hip

42. Post-operative management… Educate patient how to position the stump Mobilize out of bed in 1DPO Remove drain in 48hrs Remove stitches after wound evaluation

43. Post-operative management… Early physiotherapy Muscle setting exercises 1st Joint movement exercises Ambulation with parallel bars, then crutches Prosthetic ambulation time depends on: Age of the patient Strength & agility of the patient Patient's ability to protect the stump

44. Post-operative management…

45. Surgical Principles Level – sites of Election versus sites of Emergency Amputation Levels Optimum     Shortest    Longest Transradial ( forearm )    junction prox 2/3 & distal 1/3    3cm below biceps insertion     5cm above wrist joint Transhumeral ( arm )   middle third    4cm below axillary fold    10cm above olecranon Transfemoral  ( thigh )  middle third    8cm below pubic ramus    15cm above knee joint Transtibial  ( leg )  8cm for every metre of height  (12cm)  7.5cm below knee joint

46. Amputation Level Nomenclature Old Terminology Current Terminology Partial hand Partial hand Wrist disarticulation Wrist disarticulation Below elbow Transradial Elbow disarticulation Elbow disarticulation Above elbow Transhumeral Shoulder disarticulation Shoulder disarticulation Forequarter Forequarter Partial foot Partial foot Syme’s Ankle disarticulation Below knee Transtibial Knee disarticulation Knee disarticulation Above knee Transfemoral Hip disarticulation Hip disarticualation Hemipelvectomy Transpelvic

47. Levels of Amputation Partial toe Excision of any part of one or more toes Toe disarticulation Disarticulation at the MTP joint Partial foot/ ray resection Resection of 3 rd -5 th metatarsal & digit Transmetatarsal Amputation through the midsection of all metatarsals Syme’s Ankle disarticulation with attachment of heel pad to distal of tibia Long transtibial (Below knee) More than 50% tibial length Short transtibial (Below Knee) Between 20% and 50% of tibial length Knee disarticulation Through knee joint Long transfemoral ( Above knee) More than 60% femoral length Transfemoral (above knee) Between 35 % and 60% femoral length Short transfemoral (Above Knee ) Less than 35% femoral length Hip disarticulation Amputation through hip joint, pelvis intact Hemipelvectomy Resection of lower half of the pelvis Hemicorporectomy / Translumbar Amputation both lower limb & pelvis below L4-L5 level

48. Forearm amputation

49. Level of Amputation

50. Transtibial amputations are the most common amputations performed for peripheral vascular disease. All technical procedures may be divided into those used for Non-ischemic limbs Ischemic limbs Below Knee Amputations

51. Non ischemic limb Ischemic limb Muscle flaps - both Myoplasty and Myodesis can be done Myodesis is contra-indicated as it may further compromise an already marginal blood supply Skin flaps - both anterior and posterior skin flaps can be equal Long posterior flap and short/absent anterior flap is recommended as anteriorly the blood supply is less abundant than elsewhere in the leg

52. Transtibial amputations can be divided into three levels

53. Syme’s Amputation- amputation at the distal tibia and fibula 0.6 cm proximal to the periphery of the ankle joint and passing through the dome of the ankle centrally. Modified Syme’s Amputation ( Sarmiento) - transection of the tibia and fibula approximately 1.3 cm proximal to the ankle joint and excision of the medial and lateral malleoli . Hindfoot and Ankle Amputations

54. 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). The Syme's amputation works well for tumors and trauma, assuming that the heel flap has been spared from the trauma. In the past, it has had a high failure rate in ischemic limbs because of failure of wound healing. Today, the success of amputation at this level has increased because local tissue perfusion is preoperatively determined with Doppler ultrasound measurement of blood pressures, with radioactive 133 Xe clearance tests, and with measurement of oxygenation.

55. Lisfranc’s Amputation - amputation at the level of tarsometatarsal joint. Chopart’s Amputation - amputation at the level of calcaneocuboid and talonavicular joint Boyd Amputation- talectomy , forward shift of the calcaneus, and calcaneotibial arthrodesis . Midfoot Amputations

56. 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. The Pirogoff amputation removes the anterior two thirds of the calcaneus but has no advantage over the Boyd amputation,

57. 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 after talectomy Compared to a Syme’s amputation, it provides more length and better preserves the weight-bearing function of the heel pad. BOYD’s AMPUTATION

58. amputation of the foot by a midtarsal disarticulation. Chopart amputation

59. Chopart’s amputation

60. amputation of the foot between the metatarsus and tarsus. Lisfranc amputation

61. More than 80 years ago, Krukenberg described a technique that converts a forearm stump into a pincer that is motorized by the pronator teres muscle. Indications for this procedure have been debated; however, they generally include bilateral upper-extremity amputations, in those who are also blind. not recommended as a primary procedure at the time of an amputation, To consider this surgical option, the ulna and radius must extend distal to the majority of the pronator teres (the motor for pinching) and an elbow flexion contracture of less than 70°. Krukenberg procedure ;-

62. Krukenberg procedure Separate radial and ulna rays distally forming radial and ulna pincers capable of strong prehension and excellent manipulative ability

63. Complications Haematoma Infection Necrosis of stump end. Contractures (due to muscle imbalance) Neuroma at the cut nerve ending Phantom pain Terminal overgrowth (children)

64. Complication of amputation Haematomas Infections Necrosis Contractures Neuromas Stump pain Phantom sensation Hyperesthesia of stump Stump edema Bone overgrowth Causalgia

65. Amputation - Complications Phantom Limbs – Some amputees experience the phenomenon of Phantom Limbs ; they feel body parts that are no longer there. Limbs can itch, ache, & feel as if they are moving. Scientists believe it has to do with neural map that sends information to the brain about limbs regardless of their existence.

66. Amputation – Complications cont… In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb.

67. 1. Because of growth issues and increased body metabolism, children often can tolerate procedures on amputation stumps that are not tolerated by adults , which includes More forceful skin traction Application of extensive skin grafts Closure of skin flaps under moderate tension. Advantages Of Amputation In Children In Comparison To Adults

68. 2. Complications after surgery tend to be less severe in children , which includes Painful phantom sensations do not develop Neuromas rarely are troublesome enough to require surgery. Extensive scars usually are tolerated well.

69. One or more spurs usually develop on the end of the bone, but, in contrast to terminal overgrowth, almost never require resection. Psychological problems after amputation are rare in children

70. 3. Children use prostheses extremely well, and their proficiency increases as they age and mature. In general, a progressive prosthetic program should be designed that parallels normal motor development. At a young age, children function well with simple prostheses. As they grow, modifications may be made, such as the addition of a knee joint, a mobile elbow joint, or a mechanical hand.

71. Preserve the physis . Amputations through the metaphysis (such as above-knee or distal forearm level) or diaphysis are not recommended in children because of the progressive relative shortening of the residual limb. This is most critical in the femur, but it is applicable to other long bones as well. Disarticulate when possible. Disarticulation completely eliminates the problem of terminal overgrowth and subsequent revision surgery. Standard surgical principles for amputation in the child

72. Preserve stump shape. The pediatric amputation stump becomes conical with growth, so preservation of bony architecture such as a short segment of proximal fibula or the distal condyles of the humerus will assist in subsequent rotational control of the prosthesis. The split-thickness skin graft can hypertrophy and become sufficiently strong to withstand the shear forces of prosthesis use.

73. Preserve length Preserve important growth plates Perform disarticulation rather than transosseous amputation whenever possible Preserve the knee joint whenever possible Stabilize and normalize the proximal portion of the limb Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions . Principles Of Childhood Amputation

74. After 12 months

75. Thank you