The document discusses amputations, including definitions, indications, types, techniques, and rehabilitation. Amputation is the surgical removal of a limb or part of a limb. It may be necessary for conditions like peripheral vascular disease, trauma, burns, or malignant tumors. The main types are provisional, definitive end-bearing, and definitive non-end-bearing amputations. Proper pre-surgical evaluation, anesthesia use, soft tissue and bone cutting techniques, and post-operative care including physiotherapy and prosthetics are essential to optimize outcomes. Complications can include flap breakdown, gas gangrene, skin issues, ulceration, nerve damage, and phantom limb sensation.

1. AMPUTATIONS Lando Elvis {moi}
Amputation is defined as surgical removal or loss of body part such as arms or limbs in part
or full.
While disarticulation is defined as removal of the limb or part of the limb through the joint.

2. INDICATIONS
The ‘three Ds’: (1) Dead, (2) Dangerous
and
(3) Damned nuisance:
 Dead (or dying) Peripheral vascular
disease accounts for almost 90 per cent
of all amputations.
 Other causes of limb death are severe
trauma, burns and frostbite.
 Dangerous ‘Dangerous’ disorders are
malignant tumours, potentially lethal
sepsis and crush injury.
 In crush injury, releasing the
compression may result in renal failure
(the crush syndrome).
 Damned nuisance Retaining the limb
may be worse than having no limb at
all. This may be because of: (1)pain;
(2) gross malformation;
(3) recurrent sepsis or
(4) severe loss of function.
The combination ofdeformity and loss of
sensation is particularly trying,and in
the lower limb is likely to result in
pressure ulceration.

3. TYPES/VARIETIES
 A provisional amputation: May be necessary
because primary healing is unlikely.
 The limb is amputated as distal as the causal
conditions will allow.
 Skin flaps sufficient to cover the deep tissues
are cut and sutured loosely over a pack.
 Re-amputation is performed when the stump
condition is favourable.
 A definitive end-bearing amputation:
Performed when pressure or weight is to be
borne through the end of a stump.
 Therefore the scar must not be terminal, and
the bone end must be solid, not hollow, which
means it must be cut through or near a joint.
 Examples are through-knee and Syme’s
amputations.
 A definitive non-end-bearing amputation: Is
the commonest variety.
 All upper limb and most lower limb
amputations come into this category. Because
weight is not to be taken at the end of the
stump, the scar can be terminal.

4. AMPUTATIONS OTHER THAN AT
SITES OF ELECTION….Upper limb
 Interscapulo-thoracic (forequarter) amputation): This
mutilating operation should be done only for traumatic
avulsion of the upper limb (a rare event), when it offers the
hope of eradicating a malignant tumour, or as palliation for
otherwise intractable sepsis or pain.
 Disarticulation at the shoulder: This is rarely indicated, and
if the head of the humerus can be left, the appearance is
much better. If 2.5 cm of humerus can be left below the
anterior axillary fold, it is possible to hold the stump in a
prosthesis.
 Amputation in the forearm: The shortest forearm stump
that will stay in a prosthesis is 2.5 cm, measured from the
front of the flexed elbow. However, an even shorter stump
may be useful as a hook to hang things from.
 Amputations in the hand.
 Shoulder Disarticulation.
 Fore-Quadrant Amputation.
 Trans-Humeral Amputation.
 Through Elbow Amputation.
 Elbow Dislocation.
 Proximal & Distal Forearm
Amputations.
 Wrist Disarticulation.
 Hand Amputations.
 Trans-Carpal Amputation.
 Trans-Metacarpal Amputation.
 Phalanx Amputation.
 Digital Amputation.

5. AMPUTATIONS OTHER THAN AT
SITES OF ELECTION….Lower limb
 Hemipelvectomy (hindquarter amputation): This operation
is performed only for malignant disease.
 Disarticulation through the hip: This is rarely indicated and
prosthetic fitting is difficult. If the femoral head, neck and
trochanters can be left, it is possible to fit a tilting-table
prosthesis in which the upper femur sits flexed; if,
 Transfemoral amputations: A longer stump offers the
patient better control of the prosthesis and it is usual to
leave at least 12 cm below the stump for the knee
mechanism.
 Around the knee: The Stokes–Gritti operation (in which the
trimmed patella is apposed to the trimmed femoral
condyle) is rarely performed. The main indication for this
procedure is in children because the lower femoral physis is
preserved, effectively permitting a stump length equivalent
to an above-knee amputation to be reached when the child
is mature.
 Hip Dis-articulation.
 Hind Quadrant Amputation.
 Sub Trochanteric Amputation.
 Above Knee Amputation.
 Knee Disarticulation.
 Through Knee Amputation.
 Below Knee Amputation.
 Through Ankle Amputation
(Syme)
 Ankle Disarticulation.
 Trans-Tarsal Amputation
(Lisfranc).
 Trans meta-tarsal Amputation.
 Toe Amputation (Ray).

6. AMPUTATIONS OTHER THAN AT
SITES OF ELECTION…lower limb 2
 Transtibial (below-knee) amputations:
Healthy below knee-stumps can be fitted
with excellent prostheses allowing good
function and nearly normal gait, but there
is no advantage in prolonging the stump
beyond the conventional 14 cm.
 Above the ankle Syme’s amputation: This
is sometimes very satisfactory, provided
the circulation of the limb is good. It gives
excellent function in children, and shares
the same advantage as a through-knee
amputation in that the distal physis is
preserved. The flap must contain not only
the skin of the heel but the fibro-fatty heel
pad so as to provide a good surface for
weight bearing. The bones are divided just
above the malleoli to provide a broad area
of cancellous bone, to which the flap
should stick firmly; otherwise the soft
tissues tend to wobble about.
 Pirogoff’s amputation: Similar in
principle to Syme’s but this is rarely
performed. It is amputation of the foot
through the articulation of the ankle
with retention of part of the calcaneus.
The back of the of calcaneus is fixed
onto the cut end of the tibia and fibula.
 Partial foot amputation: The problem
here is that the tendo-Achillis tends to
pull the foot into equinus; this can be
prevented by splintage, tenotomy or
tendon transfers. The foot may be
amputated at any convenient level. The
only prosthesis needed is a specially
moulded slipper worn inside a normal
shoe.
 In the foot : Where feasible, it is better
to amputate through the base of the
proximal phalanx rather than through
the metatarsophalangeal joint. With
diabetic gangrene, septic arthritis of
the joint is not uncommon; the entire
ray (toe plus metatarsal bone) should
be amputated.

7. AMPUTATIONS SITES SECTION
 Most lower limb amputations are for ischaemic
disease and are performed through the site of
election below the most distal palpable pulse.
 The selection of amputation level can be aided by:
CT-angiogram, Doppler indices; if the ankle/
brachial index is greater than 0.5, or if the
occlusion pressure at the calf and thigh are greater
than 65 mmHg and 50 mmHg respectively.).
 An alternative means is by using transcutaneous
oxygen tension as a guide, but the level that
assures wound healing and avoids unnecessary
above-knee amputations has not been confidently
determined.
 The knee joint should be preserved if clinical
examination and investigations suggest this is at
all feasible – energy expenditure for a trans-tibial
amputee is 10–30 per cent greater as compared to a
40–67 percent increase in trans-femoral cases
(Czerniecki, 1996;Esquenazi and Meier, 1996;
Mattes et al., 2000).
 The sites of election are determined also by the
demands of prosthetic design and local
function.
 Too short a stump may tend to slip out of the
prosthesis.
 Too long a stump may have inadequate
circulation and can become painful, or
ulcerate; moreover, it complicates the
incorporation of a joint in the prosthesis.

8. Amputation Level Prevalence.

9. Pre-Surgical Evaluation
 General system review- Cardiovascular
& Respiratory Nutritional status
 Diabetes Control if appropriate
 Bowel & Bladder Function
 Past medical history
 Social history
 Pre-morbid mobility
 Consent.
 Psychological assessment to access
emotion impact of amputation
 Strength & Condition of Healthy
limb
 Assessment of Level of
Amputation.
 Marking of site & Tagging of side.
 Arrangement of Cross Matched
Blood.
 Prosthesis planning.
 Rehabilitation Planning.
 Medico-legal issues.
 Employment Consideration.
 Explanation of post-operative
regimen.

10. PRINCIPLES OF TECHNIQUE
 A tourniquet is used unless there is arterial insufficiency.
 Skin flaps are cut so that their combined length equals 1.5 times the width of the limb at
the site of amputation.
 As a rule anterior and posterior flaps of equal length are used for the upper limb and for
transfemoral (above-knee) amputations; below the knee a long posterior flap is usual.
 Muscles are divided distal to the proposed site of bone section; subsequently, opposing
groups are sutured over the bone end to each other and to the periosteum, thus
providing better muscle control as well as better circulation.
 It is also helpful to pass the sutures that anchor the opposing muscle groups through
drill-holes in the bone end, creating an osteomyodesis.
 Nerves are divided proximal to the bone cut to ensure a cut nerve end will not bear
weight.

11. PRINCIPLES OF TECHNIQUE…cont
 The bone is sawn across at the proposed level.
 In trans-tibial amputations the front of the tibia is usually bevelled and filed to
create a smoothly rounded contour; the fibula is cut 3 cm shorter.
 The main vessels are tied, the tourniquet is removed and every bleeding point
meticulously ligated.
 The skin is sutured carefully without tension.
 Suction drainage is advised and the stump covered without constricting passes
of bandage; figure-ofeight passes are better suited and prevent the creation of a
venous tourniquet proximal to the stump.

12. Anesthesia
 Depends on level of Amputation & cause of amputation.
 General Anesthesia for major limb amputation.
 Regional Anesthesia for mid-limb amputation.
 Augmented local anesthesia for minor digital amputations.
 For Diabetic Distal amputation may be some time without anesthesia if no pain.

13. Steps of Limb Amputations.
 I. Incision Through soft tissue
 II. Cutting of periosteal and bone tissue.
 III. Making an adequate stump.

14. Types of Amputations
(according to soft tissues cutting)
 1. Flap amputations:
- single-flap amputation
- double-flap amputation
 2. Circular amputations:
- one-step (guillotine) amputation
- two-step amputation (variety – “cuff”method of forearm amputation)
- three-step (conical-circular)amputation

15. Stages of Below knee amputation

16. Marking out Incision for BKA.

17. Cutting of bone

18. Exposure and Ligation of Main Vessels

19. Stump Formation & Myoplasty

20. Stump care
 For hygiene and skin care
 A hip flexion contracture may
develop because of elevation to
reduce swelling
 Stump bandaging is done to ‘cone’
the stump, thereby preventing
oedema, which occurs because there
is no muscle pump and the stump
hangs
 Swelling must be prevented to
allow proper attachment of
the prosthesis, and the prevention
of pressure sores
 The stump sock is put on first,
then the prosthesis
 The prosthesis must be cleaned
and maintained (children who are
still growing, grow out of their
prostheses)

21. AFTERCARE
 If a haematoma forms, it is evacuated as
soon as possible.
 After satisfactory wound healing, gradual
compression stump socks are used to help
shrink the stump and produce a conical
limb-end.
 The muscles must be exercised, the joints
kept mobile and the patient taught to use
his prosthesis.
Post Surgical Evaluation
 General system review- Cardiovascular &
Respiratory
 Nutritional status
 Diabetes Control if appropriate
 Bowel & Bladder Function
 Strength & Condition of Healthy limb
 Psychological assessment to access
emotion impact of amputation
 Signs of Infection
 Type of pain(Incisional, phantom, other)
 Level of Pain(VAS 1 - 10)
 Functional status (Bed mobility,
transfers, sitting, standing, walking,
balance)
 Strength and/or pain of the un-
amputated limb

22. Rehabilitation
There are 5 Stages of Rehabilitation:
 Healing and Starting Physiotherapy
 Visiting the Prosthetist
 Choosing an Artificial Limb
 Learning to Use your Artificial Limb
 Life as a New Amputee

23. Goals of Post-operative Physiotherapy
Management
 Patient education on amputation and
rehabilitation post amputation.
 Maintenance of respiratory &
cardiovascular status both pre- & post-
surgery
 Proper positioning of amputated limb to
maintain the limb in right anatomical
position.
 Maintaining/improving strength of
unamputated limb
 Residual Limb care
 Balance training
 Transfer Training
 Mobility Training
 Prosthetic training

24. PROSTHESES
 All prostheses must fit comfortably,
should function well and look
presentable.
 The patient accepts and uses a
prosthesis much better if it is fitted
soon after operation; delay is
unjustifiable now that modular
components are available and only the
socket need be made individually.
 In the upper limb, the distal
portion of the prosthesis is
detachable and can be replaced by
a ‘dress hand’ or by a variety of
useful terminal devices.
Electrically powered limbs are
available for both children and
adults.
 In the lower limb, weight can be
transmitted through the ischial
tuberosity, patellar tendon, upper
tibia or soft tissues. Combinations
are permissible; recent
developments in silicon and gel
materials provide improved
comfort in total-contact self-
suspending sockets.

25. COMPLICATIONS OF AMPUTATION
STUMPS
EARLY COMPLICATIONS
 In addition to the complications of
any operation (especially
secondary haemorrhage), there are
two special hazards: breakdown of
skin flaps and gas gangrene:
 Breakdown of skin flaps; This may
be due to ischaemia, suturing
under excess tension or (in below-
knee amputations) an unduly long
tibia pressing against the flap.
 Gas gangrene; Clostridia and
spores from the perineum may
infect a high above-knee
amputation (or reamputation),
especially if performed through
ischaemic tissue.

26. LATE COMPLICATIONS
 Skin Eczema is common, and tender purulent
lumps may develop in the groin. A rest from the
prosthesis is indicated.
 Ulceration is usually due to poor circulation,
and re-amputation at a higher level is then
necessary. If, however, the circulation is
satisfactory and the skin around an ulcer is
healthy, it may be sufficient to excise 2.5 cm of
bone and resuture.
 Muscle If too much muscle is left at the end of
the stump, the resulting unstable ‘cushion’
induces a feeling of insecurity that may prevent
proper use of a prosthesis; if so, the excess soft
tissue must be excised.
 Blood supply Poor circulation gives a cold, blue
stump that is liable to ulcerate. This problem
chiefly arises with below-knee amputations and
often re-amputation is necessary.
 Nerve A cut nerve always forms a neuroma and
occasionally this is painful and tender.
 Phantom limb’ This term is used to
describe the feeling that the
amputated limb is still present. In
contrast, residual limb pain exists in
the area of the stump.
 Both features are prevalent in
amputees to a varying extent, and
appear to have greater significance
in those who also have features of
depressive symptoms.
 The patient should be warned of the
possibility; eventually the feeling
recedes or disappears but, in some,
long-term medication may be
needed.

27. LATE COMPLICATIONS…cont
 Joint The joint above an amputation may be stiff or deformed. A common
deformity is fixed flexion and fixed abduction at the hip in above-knee
stumps (because the adductors and hamstring muscles havebeen divided). It
should be prevented by exercises.
 Bone; A spur often forms at the end of the bone, but is usually painless.
 If the bone is transmitting little weight, it becomes osteoporotic and liable to
fracture.

28. References
 Apley and Solomon's system of orthopaedics and trauma 10th edition
 NHS choices. NHS on Amputation. 2019 August 12 Available from:
https://www.nhs.uk/conditions/amputation/
 Dunkin MA. Limb Amputation overview: Reasons, procedure, recovery. WebMD;
2020 February 05 Available from: https://www.webmd.com/a-to-z-
guides/definition-amputation