Principles of amputation

A presentation on the Principles of Amputation

1. PRINCIPLES OF AMPUTATION Dr Umar M Aminu Department of Surgery ATBUTH Bauchi

2. Outline Introduction Definition History Epidemiology Indications Principles Preoperative Intraoperative Postoperative Amputation in Children Complications Prosthesis Conclusion

3. Introduction Definition Removal of part of or an entire limb through one or more bones When it is through a joint= disarticulation

4. Introduction Not a failure of surgery but a reconstructive procedure Goal is surgical reconstruction that maintains most functional limb possible

5. Introduction History Earliest reference in Babylonian code of Hammurabi-1700BC Hippocrates in De Articularis-385BC William Cloves did first successful AKA-1588 Botallus and Fabricus Holdani describe use of torniquet-16 th century Norman Kick used Guillotine amputation during World War-1943

6. Introduction History

7. Introduction Epidemiology 350,000-1 mil amputees 20,000-30,000 new amputees a yr >> age 50-75yrs >> Lower limbs >> Males

8. Introduction Epidemiology The estimated prevalence of extremity amputation in Nigeria is 1.6 per 100,000 The most frequent indications for amputation were trauma (34%); complication of traditional bonesetting (TBS )( 23%); malignant tumours (14.5%); diabetic gangrene (12.3%); infections(5.1 %); peripheral artery disease (2.1%); and burns (2.1%). The average age of the Nigerian amputee is 33 years. Hospital mortality after amputation is 10.9%. Extremity amputation in Nigeria a review of indications and mortality. Thanni LO , Tade AO . Surgeon. 2007 Aug;5(4):213-7.

9. Introduction Epidemiology 320 limb amputations were performed on adults at the Ahmadu Bello University Hospital, Nigeria over a period of 10yrs. Major indication for upper limb amputation was trauma and post-fracture splintage gangrene (57%). In the lower limb the most common indication for amputation was advanced squamous cell carcinoma of the skin involving the bone. No case of peripheral vascular disease in these patients other than diabetic ulcers Major Limb Amputation in Adults,Zaria,Nigeria . Yakubu A , Muhammad I, Mabogunje OA . J R Coll Surg Edinb. 1996 Apr;41(2):102-4 .

10. Introduction Locally (Amputation in ABUTH)- 37 cases Commonest age group-10-19 Commonest indication-Gangrene Commonest procedure- Below Knee Amputation

11. Introduction

12. Introduction

13. Classification Emergency/Traumatic/Elective Provisional/Definitive Open/Closed End bearing/Cone bearing Named/Eponymous amputation Gritti -Stoke Syme Progoff Chopart (@ midtarsal joint) Lisfranc (@ Tarsometatarsal joint) Ray

14. Amputation levels ( upper limbs ) Hand & Partial-Hand Amputations Finger, thumb or portion of the hand below the wrist Wrist Disarticulation Limb is amputated at the level of the wrist Transradial (below elbow amputations) Amputation occurring in the forearm, from the elbow to the wrist   Transhumeral (above elbow amputations) Amputation occurring in the upper arm from the elbow to the shoulder Shoulder Disarticulation Ambutation at the level of the shoulder, with the shoulder blade remaining. Forequarter Amputation Amputation at the level of the shoulder in which both the shoulder blade and collar bone are removed

15. Amputation levels ( lower limbs ) Foot Amputations Amputation of greater toes and other toes Amputation through the metatarsal bones Lisfranc`s operation : at the level of the tarsometatarsal joints Chopart`s operation : through the midtarsal joints Transtibial Amputations (below the knee) Amputation occurs at any level from the knee to the ankle  Knee Disarticulation Amputation occurs at the level of the knee joint Transfemoral Amputations (above knee ) Amputation occurs at any level from the hip to knee joint Hip Disarticulation   Amputation is at the hip joint with the entire thigh and lower portion of the leg being removed.

16. Indications Congenital/ Acquired 3 Ds

17. Indications Congenital Hemimalia Polydactly Congenital pseudoarthrosis PFFD Gross congenital malfiormations Acquired Trauma- Mangled limb, Crush injury Vascular- D M angiopathy , PVD Infectivce -COM, Clostridia Neoplasm- Osteosarcoma, Frost bite Burns

18. Indications 3 Ds Dead/ limb-Gangrene Dying/Deadly/Dangerous limb- Crush injury, Osteosarcoma, Melanoma Damn nuisance-Gross congenital anomalies,

19. Goals of amputation To get rid of all necrotic, infected & painful tissue. To have a wound that heals successfully. To have an appropriate remnant stump that is able to accommodate a prosthetic.

20. Pre-Operative Assessment To: Ascertain indication Site of amputation General medical condition Rehabilitation potential Counselling Consent Optimisation

21. 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.

22. Pre-operative Evaluation History Aetiology Comorbidities Physical examination MSS-MESS ≥ 7 Removes subjectivity from decision making in trauma cases. No scoring system can replace experience & good clinical judgment. CVS, Renal & Nervous system

23. Pre-operative Evaluation Investigation To confirm Diagnosis Doppler X-Ray FBS Technitium 99 Pyrophosphate bone scan Capability of Wound Healing Transcutaneous Oxygen Hemoglobin Serum Albumin Absolute lymphocyte count

24. 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.

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

26. Pre-operative Evaluation… Counseling & consent Procedure, anaesthesia, complications, prosthesis & limitations. Involvement of support groups

27. Intra-operative Principles Determine outcome of function and rehabilitation Meticulous attention to detail and careful soft tissue handling Effort to be directed at achieving ideal stump

28. Ideal stump It should be of optimum length The end of stump should be smooth & rounded It should be firm The opposing group of muscles should be sutured together over the end of the bone. The muscles are sutured in such a way that they will be converted into fibrous tissue & serve as an effective cushion.

29. Ideal stump Vascularity of the flaps should be normal There should be no projecting spur of bone. The stump shouldn't ’ t be under tension. The position of the scar should be avoided of pressure n should be transverse to avoid pulling up between 2 bones in ap scar. In case of U.L the scar can be terminal, but in L.L a posterior scar is desirable to avoid pressure of weight of artificial limb.

30. Traditional Sites of Election Upperlimb A/E – 20cm from Acromion B/E – 18cm from Olecranon Lowerlimb A/ K – 12cm from Joint line B/ K – 14cm from Joint line

31. Site of Selection Examination Skin color Hair growth Lowest palpable pulse Skin temperature Investigation Doppler USS

32. INTRA - OPERATIVE Anaesthesia : GA or Regional Position: Supine Tourniquet +/_ Exsanguination

33. Intra-Operative Principles

34. Intra-Operative Principles Skin Incisions Fish mouth Vs Racquet

35. Intra-Operative Principles Controlling Bleeding Isolate and ligate Pinch ends of muscle Identify and cut btw sutures

36. Intra-Operative Principles Controlling Bleeding Isolate and ligate Pinch ends of muscle Identify and cut btw sutures

37. Intra-Operative Principles Cutting Muscle Transverse 5cm distal to site of bone section With amputation knife

38. Intra-Operative Principles Nerves Isolated, gently pulled distally into wound and divided sharply Large nerves should be ligated Prevent painful neuroma

39. Sawing Bone Reflect periosteorum 1-2cm distally Protect soft tissue with amputation shield Smoothen edges Wash bone dust with saline

40. Intra-Operative Principles

41. Intra-Operative Principles Closing the Wound H emostasis is secured Opposing group of muscles are sutured across both the ends with interrupted stitches. Fascia & skin are sutured over the muscle without tension. Preferably a suction drain is placed. Wound is covered with gauze & roller bandages tightly from below upwards.

42. Intra-Operative Principles Open Amputation Indications- infected limb Battle injuries Soft tissue injury/contamination Uncertain blood ss Types- Inverted edges Circular

43. Intra-Operative Principles Wound Dressing Soft vs Rigid Rigid dressing : decreses edema, decreases post operative pain, protect limb from trauma, early mobilsation . Good bandaging to mold the stump into Conical shape to accept the prosthesis Soft dressing concept: The stump is dressed with the sterile dressing & crepe bandage applied over it.

44. Post-operative Care General- Analgesia Antibiotics DVT prophylaxis Specific- Joint Positioning+excercise Drain removal Mobilisation Rehabilitation-prosthetic fittiing , home, occupation & hobby

45. Complications General vs Specific Early vs Late

46. Complications General Haemorrhage- Reactionary/ 2 o Infection Specific Flap breakdown Flexion contracture Residual pain Stump ulceration Phantom sensation Phantom limb pain Dermatologic complications

47. Smith and Burgess method: the central one third of the wound is closed, and the remainder of the wound is packed open.

48. Phantom sensation The phantom is the sensation of the limb that is no longer there. The phantom, which usually occurs initially immediately after surgery, is often described as a tingling, burning, itching or pressure, sensation, sometimes a numbness. Phantom sensation may be painless although, most people find it uncomfortable & often report it as pain; it usually does not interfere with prosthetic rehabilitation. (Physical rehabilitation;Susan B O’ Sullivan; 5th )

49. Phantom Limb Pain Phantom pain and sensations are defined as perceptions ranging from slight tingling to sharp, throbbing pain or aching that patients perceive relating to an extremity or an organ that is physically no longer a part of the body. It has been reported in various trials that the estimated prevalence of phantom pain varies from 49% to 83%.

50. Rehabilitation Residual Limb Shrinkage and Shaping Limb Desensitization Maintain joint range of motion Strengthen residual limb Maximize Self reliance Patient education: Future goals and prosthetic options

51. Psychological stress Up to 2/3 of amputees will manifest postoperative psychiatric symptoms Depression Anxiety Crying spells Insomnia Loss of appetite Suicidal ideation

52. AMPUTATIONS IN CHILDREN

53. Amputations in children is divided into two general categories—congenital (60%) and acquired (40%) Amputations In Children

54. Amputations In Children Congenital Congenital deficiencies of the long bones Amniotic band syndrome Exposure to teratogens ( thalidomide ) Polydactyly Macrodactyly Congenital pseudoarthrosis of the tibia and fibula, radius and ulna Acquired Secondary to trauma Neoplasm Infection. Vascular disease

55. 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

56. 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

57. Prosthetics It is a replacement of substitution of a missing or a diseased part

58. Types of Prosthesis

59. Ideal prosthesis Fits comfortably Function well Looks presentable Fit as soon after the operation

60. TYPES Temporary – Used following amputation till paient is fitted with permanent prosthesis eg;pylon Permanent prosthesis

61. Conclusion Goal is to achieve useful residual limb in an individual who is active with a positive attitude an continues to be a productive member of society

62. Reference Current Diagnosis & Treatment in Orthopedics 3rd edition : by Harry Skinner (Editor) Publisher: Appleton & Lange (June 20, 2003) Campbel Operative Orthopedics , 11 th Edition

63. Thank you for Listening