Lower limb amputation

different type of lower limb amputation with indication, peri-operative care, surgical steps, post op care complication and different type of prosthesis

1. LOWER LIMB AMPUTATION DR. pratik agarwal

2. DEFINITION Amputation - SURGICAL ABLATION OF BODY PART THROUGH ONE OR TWO BONE. Disarticulation - surgical ablation of body part through joint.

3. Indication of amputation: Peripheral vascular disease Trauma Burns Frostbite Infection Tumors Neuropathy Congenital limb deficiency

4. SALVAGIBILITY OF A LIMB VARIOUS SCORING SYSTEM- PREDICTIVE SALVAGE INDEX LIMB SALVAGE INDEX LIMB INJURY SCORE MANGLED EXTREMITY SEVERITY SCORE

5. SCORE<6- SALVAGEABLE; SCORE>7- HIGHLY PREDICTIVE OF AMPUTATION

6. BASIC PRINCLIPLES OF AMPUTATION TOURNIQUET USE : EXCEPT FOR IN ISCHEMIC LIMB, USE OF TOURNIQUET IS DESIRABLE AND MAKES AMPUTATION EASIER.

7. MYOPLASTY TRANSECTED MUSCLE IS SUTURED TO SOFT TISSUE SUCH ASOPPOSING MUSCLE GROUP OR FASCIA. PREFERRED IN YOUNG AND ISCHEMIC LIMB WHERE MYODESIS IS CONTRAINDICATED.

8. MYODESIS TRANSECTED MUSCLE GROUPS ARE SUTURED TO BONE UNDER PHYSIOLOGIC TENSION. MYODESIS SHOULD BE PERFORMED TO PROVIDE STRONGER INSERTION, MAXIMIZE STRENGTH AND MINIMIZE ATROPHY.

9. NERVES TO PREVENT FORMATION OF NEUROMA NERVE IS CUT BY KNIFE AFTER PULLING IT GENTLY DISTALLY, AND ALLOWING AT TO RETRACT ABOVE THE SAW LINE.

10. PRE-OP CARE: Nutritional status of the patient Limb perfusion Serum albumin OF ATLEST 3.5 G/DL Total lymphocyte count >1500/ML HEMOGLOBIN >10 GM/DL Diabetes control PRE OPERATIVE COUNSELLING REHABILITATION ASSESSMENT PROXIMAL JOINT FUNCTION SHOULD BE NORMAL.

11. INTRA-OP CARE: AVOID EXCESSIVE PRESSURE ON SKIN EDGES. Thick skin flap. BONY PROMINENCES SHOULD BE REMOVED. Controlling hemostasis. CLOSURE SHOULD BE DONE WITHOUT TENSION AT MARGIN. PRESERVE AS MUCH LENGTH IS POSSIBLE.

12. POST-OP CARE: DRESSING LIKE HYDROCOLLOID, HYDROGEL, ALGINATE ETC. BIOLOGICAL DRESSING LIKE ALLOMATRIX AND GRAFTJACKET REGENERATIVE TISSUE MATRIX. VACCUM ASSISTED CLOSURE IS ALSO BENEFICIAL IN LARGER WOUND MEASURES TO PREVENT CONTRACTURES TO MAXIMIZE FUNCTION AND MINIMIZE COMPLICATION OF THE AMPUTED LIMB PEDORTHIST, ORTHOTIST AND PROSTHETIST MUST BE INVOLVED.

13. GOALS OF AMPUTATION: ABLATION OF DISEASE TISSUE RECONSTRUCTION PROVIDE PHYSIOLOGICAL END ORGAN OPTIMIZE PATIENT FUNCTION AND REDUCE MORBIDITY.

14. COMPLICATIONS HEMATOMA SKIN COMPLICATION BONY COMPLICATION WOUND NECROSIS STUMP OEDEMA CONTRACTURES NEUROMA PHANTOM LIMB PHANTOM PAIN MUSCLE WASTING PSYCHOLOGICAL PAIN

15. PHANTOM PAIN SENSATION OF PRESENCE OF AMPUTATED PART. CAUSES : UNABLATION OF CORTICAL REPRESENTATION. TENDS TO DISAPPEAR WITH TIME. WALK ON MISSING LEG

16. PHANTOM PAIN PAINFUL, DISAGREEABLE SENSATION WITH STRONG PARESTHESIA IN ABSENT LIMB. CONSTANT OR INTERMITTENT. DESTRUCTION OF SENSORY FIBRES RESULTING IN DECREASE INHIBITORY CONTROL BY RETICULAR ACTIVATING SYSTEM. SOMATOSENSORY PROJECTION AREA DEVELOP SELF SUSTAINING NEURAL ACTIVITY THUS CAUSING PAIN. TREATMENT- EARLY USE OF PROSTHESIS DRUGS LIKE CARBAMAZEPINE, BETA BLOCKERS, MORPHINE, ANTIDEPRESSANT, PHENYTOIN, AMITRIPTYLINE. SYMPATHECTOMY SUBCORTICAL NEURECTOMY, ANTEROLATERAL CORDOTOMY; ELECTRICAL STIMULATION OF DORSAL COLUMN

17. Types of lower limb amputation: HEMIPELVICTOMY HIP DISARTICULATION TRANSFEMORAL AMPUTATION KNEE DISARTICULATION TRANSTIBIAL AMPUTATION FOOT AMPUTATION

18. Amputation of foot: Toe amputation or disarticulation Metatarsal phalangeal disarticulation Transmetatarsal amputation Lisfranc amputation Chopart amputation Syme amputation Boyd’s amputation

19. Toe amputation: AMPUTATION OF GRAET TOE : WHILE STANDING OR WALKING NORMALLY- FUNCTIONALLY NO EFFECT. WHILE RUNNING- LIMP APPEARS. AMPUTATION OF 2 ND TOE : CAUSES SEVERE HALLUX VALGUS. TO PREVENT SCREW FIXATION IS USED. AMPUTATION OF ALL TOE : WHILE SLOW WALKING- LITTLE DISTURBANCE. WHILE RAPID GAIT- DISABLING. INTERFERES IN SQUATING AND TIPTOEING. NO PROSTHESIS IS REQUIRED OTHER THAN SHOE FILLER.

20. TERMINAL SYME AMPUTATION: INDICATION : HALLUX TERMINAL ULCERATION, CHRONIC INGROWN NAILS WITH PARONYCHIA, HALLUX TUFT OSTEOMYELITIS OR TRAUMATIC INJURY TO TIP OF HALLUX. REMOVING DISTAL ASPECT OF DISTAL PHALYNX OF HALLUX RETAINING EXTENSOR HALLUCIS LONGUS AND FLEXOR HALLUCIS LONGUS INSERTION.

21. AMPUTATION AT BASE OF PROXIMAL PHALYNX

22. Metatarsal phalangeal disarticulation: Long plantar and short dorsal skin flap. For 1 st metatarsal incision starting medially and curve it distally over the lateral and posterior aspect. For 5 th metatarsal incision starting laterally and curve it distally over medial and posterior aspect.

23. Transmetatarsal amputation: Ray amputation- toe amputation with head of metatarsal. Gillies’ amputation- t RANSMETATARSAL with PROXIMAL TO NECK OF METATARSAL, DISTAL TO BASE of metatarsal.

24. Prosthesis for toe amputation

25. MIDFOOT AMPUTATION AMPUTATION THROUGH MIDFOOT INCLUDE LISFRANC AMPUTATION AT TARSOMETATARSAL JOINTS AND CHOPART AMPUTATION AT TRANSVERSE TARSAL JOINT. MIDFOOT AMPUTATION LEAD TO SEVERE EQUINOVARUS DEFORMITY.

26. Lisfranc amputation Tarsometatarsal disarticulation. LEAD TO SEVERE EQUINOVARUS DEFORMITY. TO PREVENT EQUINOVARUS DEFORMITY- PRESERVE INSERTION OF TIBIALIS ANTERIOR AND PERONEUS LONGUS AT MEDIAL CUNEIFORM AND PERONEUS BREVIS AT THE BASE OF 5 TH METATARSAL. BASE OF 2 ND METATARSAL SHOULD BE SPARED TO PRESERVE PROXIMAL TRANSVERSE ARCH.

27. Chopart amputation: DISARTICULATION OF TALO-NAVICULAR & CALCANEO-CUBOID JOINTS. To prevent equinovarus deformity- One or more dorsiflexors must be transferred. Decrease strength of achilles tendon. Position the stump in slight dorsiflexion and rigid dressing for 6 weeks. Alternatively, ankle arthrodesis may be done immediately.

28. CHOPART FRACTURE Transfer TIBIALIS ANTERIOR tendon to lateral aspect of neck of talus, using bone tunnel with biotenodesis screw and using a suture anchor or staple to secure fixation. Transfer extensor hallucis longus to anterior process of calcaneus.

29. Prosthesis for chopart amputation

30. Hindfoot and ankle amputation Goal is to produce end bearing stump and enough space between end of stump and ground for construction of some type of ankle joint mechanism for artificial foot. Types- Syme amputation Boyd amputation Pirogoff amputation

31. Syme amputation Bone transection at distal tibia and fibula 0.6 cm proximal to periphery of ankle joint and passing through the dome of the ankle centrally. The tough durable skin of heel flap provides normal weight bearing skin. Sarmiento modified syme procedure by transecting tibia and fibula 1.3 cm proximal to ankle joint and excision of medial and lateral malleolus to produce less bulbous stump and allow use of more cosmetic prosthesis.

32. Syme’s amputation Can be done in- One stage - original / classic Syme's amputation. Two stage- in case of gross infection of forefoot. Modified amputation- modified to get a less bulbous and more cosmetic stump by removing metaphyseal flare of tibia and beveling distal end of fibula.

33. Syme’s amputation

34. SYME’S AMPUTATION

35. SYME’S AMPUTATION

36. Syme’s prosthesis PROSTHESIS CONSIST OF MOLDED PLASTIC SOCKET WITH REMOVABLE MEDIAL WINDOW TO ALLOW PASSAGE OF BULBOUS END OF STUMP THROUGH ITS NARROW SHANK.

37. BOYD’S AMPUTAION To produce excellent end bearing stump and eliminates the problem of posterior migration of the heel pad that occurs after Syme amputation. It involves talectomy, Excision of anterior part of calcaneus, distal to peroneal tubercle. forward shift of calcaneus and calcaneo -tibial arthrodesis by using Steinmann pin or cannulated screw.

38. PiRiGOFF AMPUTATION Involves arthrodesis between tibia and part of calcaneus. Calcaneus is sectioned vertically, removing anterior part and rotating posterior portion with heel pad forward and upward 90* to meet denuded distal end of tibia.

39. TRANSTIBIAL AMPUTATION Most common lower limb amutation . Energy expenditure is an important consideration in choosing the level of amputation. Depending on ischemic or non-ischemic limb, level of amputation, choice of skin flap, stabilization techniques like myodesis or myoplasty and post operative care varies. In case of combat injuries standard FLAP MAY BE IMPOSSIBLE. SKIN GRAFT MAY BE USED TO COVER SOFT TISSUE DEFECT, BUT SKIN GRAFT ARE NOT IDEAL FOR STUMP PROSTHESIS INTERFACE.

40. VARIOUS DESIGN OF SKIN FLAP: EQUAL ANTERIOR AND POSTERIOR FLAP EQUAL MEDIAL AND LATERAL FLAP (SCANDINAVIAN FLAP). LONG POSTERIOR FLAP (SKEWED FLAP).

41. IDEAL LENGTH OF STUMP: IN BELOW KNEE AMPUTATION- IDEAL LENGTH 12.5 TO 17.5 CM DISTAL TO MEDIAL TIBIAL ARTICULAR SURFACE. MINIMUM WORKING LENGTH -9 CM <12 CM LESS EFFICIENT <6 CM DO NOT FUNCTION RULE OF THUMB FOR SELECTING LEVEL OF BONE SECTION IS TO ALLOW 2.5 CM OF BONE LENGTH FOR EACH 30 CM OF BODY HEIGHT.

42. INTRA-OPERATIVE PRECAUTION WHILE TAILORING AN IDEAL STUMP SKIN FLAP AS PER CAUSE. MUSCLE ARE DIVIDED 0.6 CM DISTAL TO LEVEL OF BONE SECTION. NERVES ARE DIVIDED CLEAN WITH KNIFE AFTER GENTLE TRACTION AND ALLOW TO RETRACT PROXIMAL TO END OF STUMP. VESSELS ARE DOUBLY LIGATED JUST PROXIMAL TO THE LEVEL OF BONE SECTION. BEVELLING OF TIBIA TO PREVENT SHARP END WHICH MIGHT IMPINGE OR COME IN DIRECT CONTACT WITH SKIN FLAP.

43. INTRA-OPERATIVE PRECAUTION WHILE TAILORING AN IDEAL STUMP FIBULA SHOULD BE SECTIONED 1.2 CM PROXIMALLY. RELEASING THE TOURNIQUET AND ACHIEVING HEMOSTASIS BEFORE CLOSURE. DRAIN TO KEPT IN-SITU. CLOSURE WITH NO TENSION AT MARGIN. IMMEDIATE POST OPERATIVE RIGID DRESSING SHOULD BE DONE.

44. TRANSTIBIAL AMPUTATION NON-ISCHEMIC LIMB USE OF TOURNIQUET ADVOCATED. EQUAL ANTERIOR AND POSTERIOR FLAP PREFFERED. LEVEL OF AMPUTATION- 12.5 TO 17.5 CM. MYOPLASTY IS COMMONLY DONE, BUT IN YOUNG AGE GROUP MYODESIS IS ADVOCATED. ISCHEMIC LIMB REFRAINING FROM USE OF TOURNIQUET. LONG POSTERIOR FLAP AND SHORT ANTERIOR ONE IS PREFFERED. LEVEL OF AMPUTATION- 8.8 TO 12.5 CM. TENSION MYODESIS IS CONTRAINDICATING BECAUSE IT CAUSES FURTHER COMPROMISE IN MARGINAL BLOOD SUPPLY.

45. NON-ISCHEMIC LIMB

46. ISCHEMIC LIMB

47. POST OPERATIVE CARE: IMMEDIATE POST OPERATIVE RIGID DRESSING. CHANGE OF RIGID DRESSING EVERY 5-7 DAYS. WEIGHT BEARING IS LIMITED INITIALLY WITH SUPPORT. AFTER 3-4 WEEKS, RIGID DRESSING CAN BE CHANGED TO REMOVABLE TEMPORARY PROSTHESIS IF NO SKIN COMPLICATION. PROSTHESIS TO BE GIVEN AFTER 2-3 MONTHS.

48. PROSTHESIS FOR TRANSTIBIAL AMPUTATION

49. PROSTHESIS FOR TRANSTIBIAL AMPUTATION

50. KNEE DISARTICULATION ADVANTAGE - RESULT IN EXCELLENT END BEARING STUMP. CREATION OF LONG LEVER ARM CONTROLLED BY STRONG MUSCLES. STABILITY OF THE PROSTHESIS. KNEE FLEXION CONTRACTURES AND ASSOCIATED DISTAL ULCER WITH TRANSTIBIAL AMPUTATION ARE ALSO AVOIDED. IN NON-AMBULATORY PATIENT ADDITIONAL EXTREMITY LENGTH PROVIDE ADEQUATE SUPPORT AND BALANCE. BENEFIT IN CHILDREN AND YOUNG ADULTS, BUT NOT AS SUCCESSFUL IN POSTTRAUMATIC AMPUTAION.

51. KNEE DISARTICULATION BATCH, SPITTLER, AND MCFADDIN TECHNIQUE

52. BATCH, SPITTLER, AND MCFADDIN TECHNIQUE

53. MAZET AND HENNESSY DISARTICULATION OF KNEE DEBULKING STUMP BY RESECTING PROTRUDING MEDIAL, LATERAL AND POSTERIOR SURFACES OF FEMORAL CONDYLES FOR WHICH IS MORE COSMETICALLY ACCEPTABLE PROSTHESIS CAN BE CONSTRUCTED. REQUIRES SMALLER SKIN FLAP, WHICH MAY BE BENEFICIALFOR WOUND HEALING IN ISCHEMIC LIMB. MAY USE SUCTION TYPE PROSTHESIS.

54. KJOBLE DISARTICULATION OF KNEE Medial and lateral skin flap. Better technique for healing in ischemic limb.

55. PROSTHESIS FOR KNEE DISARTICULATION

56. TRANSFEMORAL AMPUTATION: Can BE CLASSIFIED AS SHORT TRANSFEMORAL MEDIAL TRANSFEMORAL LONG TRANSFEMORAL SUPRACONDYLAR AMPUTATION EXTREMELY IMPORTANT FOR THE STUMP TO BE AS LONG AS POSSIBLE TO PROVIDE A STRONG LEVER ARM FOR CONTROL OF THE PROSTHESIS.

57. TRANSFEMORAL AMPUTATION NON-ISCHEMIC LIMB USE OF TOURNIQUET ADVOCATED. EQUAL ANTERIOR AND POSTERIOR FLAP PREFFERED. LEVEL OF AMPUTATION- 12 CM FROM MEDIAL JOINT LINE or 18 cm from greater trochanter tip. MYOPLASTY IS COMMONLY DONE, BUT IN YOUNG AGE GROUP MYODESIS IS ADVOCATED. ISCHEMIC LIMB REFRAINING FROM USE OF TOURNIQUET. EQUAL ANTERIOR AND POSTERIOR FLAP PREFFERED. LEVEL OF AMPUTATION- 12 CM FROM MEDIAL JOINT LINE or 18 cm from greater trochanter tip. TENSION MYODESIS IS CONTRAINDICATING BECAUSE IT CAUSES FURTHER COMPROMISE IN MARGINAL BLOOD SUPPLY.

58. TRANSFEMORAL AMPUTATION

59. TRANSFEMORAL AMPUTATION

60. GOTTSCHALK TECHNIQUE: DIVIDE ADDUCTOR MAGNUS FROM ADDUCTOR TUBERCLE AND ATTACH ATTACH IT TO LATERAL ASPECT OF DISTAL ASPECT OF FEMUR USING DRILLED HOLES KEEPING FEMUR IN MAXIMUM ADDUCTION.

61. PROSTHESIS FOR TRANSFEMORAL AMPUTATION

62. PROSTHESIS FOR TRANSFEMORAL AMPUTATION

63. Hip disarticulation Dfferent techinues - Anatomic method of boyd hip disarticulation. Posterior flap method of slocum . Inguinal or iliac lymph node are not routinely removed.

64. HEMIPELVECTOMY IN CONTRAST TO HIP DISARTICULATION, HEMIPELVECTOMY REMOVE INGUINAL AND ILIAC LYMPH NODE. DIFFERENT TECHNIQUES: STANDARD HEMIPELVECTOMY EXTENDED HEMIPELVECTOMY CONSERVATIVE HEMIPELVECTOMY GORDON-TAYLOR CALLED HINDQUATER AMPUTATION “ ONE OF THE MOST COLLOSAL MUTILATIONS PRACTICED ON HUMAN FRAME.”

65. HEMIPELVECTOMY STANDARD HEMIPELVECTOMY EMPLOYS A POSTERIOR OR GLUTEAL FLAP AN DISARTICULATES THE SYMPHYSIS PUBIS AND SACROILIAC JOINT AND THE IPSILATERAL LIMB. CONSERVATIVE HEMIPELVECTOMY RESECTION OF ADJACENT MUSCULOSKELETAL STRUCTURES, SUCH AS SACRUM OR PART OF LUMBAR SPINE. EXTENDED HEMIPELVECTOMY BONY SECTION DIVIDE ILIUM ABOVE THE ACETABULUM, PRESERVING THE CREST OF THE ILIUM.

66. PROSTHESIS FOR HEMIPELVECTOMY

67. AMPUTATION IN CHILDREN Categories- Congenital (60%)- phacomelia , hemimelia. Acquired (40%)- secondary to trauma, neoplasm and infection. Dysvascular amputation is rare in children.

68. General principles of childhood amputation by krajbich

69. COMPLICATION IN CHILDHOOD AMPUTATION TERMINAL OVERGROWTH- MORE COMMON AFTER TRAUMATIC AMPUTATION. TREATMENT - CAPPING THE BONE WITH EPIPHYSEAL GRAFT HARVESTED FROM AMPUTED LIMB OR TRICORTICAL ILIAC CREST GRAFT.

70. ADVANTAGE IN CHILDHOOD AMPUTATION LESS INCIDENCE OF PHANTOM LIMB. EXTENSIVE SCARS ARE TOLERATED WELL. PSYCHOLOGICAL PROBLEMS ARE RARE. FUNCTIONS WELL WITH SIMPLE PROSTHESIS. SPUR MAY DEVELOP BUT ALMOST NEVER REQUIRE RESECTION.

71. THANK YOU AMPUTATION SHOULD BE CONSIDERED AS A RECONSTRUCTIVE PROCEDURE NOT AS FAILURE OF TREATMENT