jameel amputation

Dr. Yasir Jameel

Clinical Fellow

Orthopedic dept.

Bone and joint Centre

HMC

• Derived from the Latin amputare.

• "to cut away", from ambi- ("about", "around") and putare ("to prune").

• Amputation is the complete removal of an injured or deformed body part.

• The English word "amputation" was first applied to surgery in the 17th century.

Amputation

Nomenclature.

History• Most ancient of surgical procedure.

• Historically were stimulated by the aftermath of war.

• It was a crude procedure by which limb was rapidly severed from unanesthetized 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.

• Morels – 1674 : introduced Tourniquet.

• Lord Listers – 1867 : introduced Antiseptic technique

Amputation

Incidence and Indications of amputation

• >90% amputations are due to PVD in aged

population.

• Trauma > Malignancy is more common in

younger pts.

• The only Absolute indication for

amputation is irreversible ischemia.

Incidence and Indications of amputation

Peripheral Vascular Disease

Trauma

Burns

Malignant Tumors

Neurologic Conditions

Infections

Congenital Deformities

Amputation

Amputation

Trauma

Amputation

Malignant Tumor

Amputation

Gangrene

Crush

Amputation

Amputation

Peripheral Vascular Disease

Polydactyly

Congenial Anomaly

Amputation

• the most common indication for amputation. with or without diabetes. Most frequently occurs in individuals age 50 to 75 years.

• If vascular disease has progressed to the point of requiring amputation, it is not limited to the involved extremity.

• Most patients also have concomitant disease processes in the cerebral vasculature, coronary arteries, and kidneys.

• Approximately half of amputations for peripheral vascular disease are performed on patients with diabetes.

• The most significant predictor of amputation in diabetics is peripheral neuropathy. (insensitive to Weinstein 5.07 monofilament)

1. Peripheral Vascular Disease

Amputation

Other documented risk factors include

I. Prior stroke

II. Prior major amputation

III. Decreased transcutaneous oxygen levels

IV. Decreased ankle-brachial blood pressure

index

Peripheral Vascular Disease

Amputation

• Before performing an amputation for

peripheral vascular disease, a vascular

surgery consultation is almost always

indicated as improved techniques currently

allow for revascularization of limbs that

previously would have been unsalvageable.

Peripheral Vascular Disease

Amputation

If amputation becomes necessary,

• Optimize the pt. for surgery

• Controlle the infection

• Nutrition and Immune status should be

evaluated. ( Risk for wound complications

greatly increases in patients whose serum

albumin is less than 3.5 g/dL or whose total

lymphocyte count is less than 1500 cells/mL).

Peripheral Vascular Disease

Amputation

• Trauma is the leading indication for

amputations in younger patients

• More common in men because of

vocational and avocational hazards.

• The only absolute indication for primary

amputation is an irreversible ischemia.

2. Trauma

Amputation

To predict which limbs will be salvageable,

available scoring systems include :-

The predictive salvage index

The limb injury score

The limb salvage index

The mangled extremity syndrome index

The mangled extremity severity score.

Trauma

Amputation

• Most useful score as it is easy to apply, grades the injury on the basis of the energy that caused the injury, limb ischemia, shock and the patient's age.

• Score of 6 or less = salvageable limb

• Score of 7 or greater = amputation

• Ischemia points × 2 if ischemic time exceeds 6 hours.

Trauma Mangled Extremity Severity Score

Amputation

Trauma Mangled Extremity Severity Score

• Amputation of an injured extremity is

necessary to preserve life as attempts to

salvage a severely injured limb may lead to

metabolic overload and secondary organ

failure which is more common in patients

with multiple injuries and in the elderly.

Trauma

Amputation

• Thermal or electrical injury to an extremity

may necessitate amputation.

• The full extent of tissue damage may not be

apparent at initial presentation, especially with

electrical injury.

• Treatment involves early débridement of

devitalized tissue, fasciotomies when

indicated, and aggressive wound care, might

need 2nd look procedure in OR.

3. Burns

Amputation

• Compared with early amputation, delayed

amputation of an unsalvageable limb has

been associated with increased risk of local

infection, systemic infection, myoglobin-

induced renal failure, and death.

Burns

Amputation

• Frostbite denotes the actual freezing of tissue in the extremities, with or without central hypothermia.

• This is a common problem for high-altitude climbers, skiers, and hunters.

• Also at risk are homeless, alcoholic, and schizophrenic individuals.

• When heat loss exceeds the body's ability to maintain homeostasis, blood flow to the extremities is decreased to maintain central body temperature.

4. Frostbite

Amputation

• Actual tissue injury occurs through two

mechanisms:

1. Direct tissue injury through the formation of

ice crystals in the extracellular fluid

2. Ischemic injury resulting from damage to

vascular endothelium, clot formation, and

increased sympathetic tone

Frostbite

Amputation

• Amputation for frostbite routinely should be delayed 2 to 6 months.

• Clear demarcation of viable tissue may take this long.

• Even after demarcation appears to be complete on the surface, deep tissues still may be recovering.

• Despite the presence of mummified tissue, infection is rare if local wound management is maintained.

Frostbite

Amputation

• Triple-Phase Technetium Bone Scan has

helped to delineate deep tissue viability.

• Performing surgery prematurely often

results in greater tissue loss and increased

risk of infection.

Frostbite

Amputation

• Amputation may be necessary for acute or chronic infection that is unresponsive to antibiotics and surgical débridement.

• Open amputation is indicated - two methods.

1. A guillotine amputation may be performed with later revision to a more proximal level after the infection is under control.

2. Amputation may be performed at the definitive level by initially inverting the flaps and packing the wound open with secondary closure at 10 to 14 days.

5. Infections

Amputation

• Kritter’s method for partial foot amputation

with primary closure in patients with active

infection.

• By this method, the wound is closed loosely

over a catheter through which an antibiotic

irrigant is infused.

• The constant infusion is continued for 5 days.

Infections

Amputation

• The wound must be closed loosely enough to

allow the fluid to escape into the dressings.

• The dressings must be changed frequently until

the catheter is removed on postoperative day 5.

• This method may allow for primary wound

healing, while avoiding a protracted course of

wound healing by secondary intention.

Infections Kritter’s method

Amputation

Kritter’s Method

Amputation

In the acute setting, the most worrisome

infections are those produced by gas-forming

organisms.Typically associated with:

• Battlefield injuries

• Farm injuries

• Motor vehicle accidents

• Civilian gunshot wounds.

Infections

Amputation

Infections

Clostridial myonecrosis: • Develop with in 24 hour,

• Acute onset of pain, swelling, Toxemia

• Wound bronze colour, serosanguineous exudate

with musty odor.

• Gram stain: gram +ive Rods

• Treatment: high dose of iv penicillin / clindamycin,

hyperbaric Oxygen, Amputation one joint above

the involed compartment as life saving.

Amputation

Infections

Streptococcal Myonecrosis• Develops over 3 to 4 days

• Swelling usually sever but pain not sever

• Wound with seropurulent discharge, small amount of gas,

• Treatment: involved muscle compartment debribment

Penicillin iv

Amputation

Infections

Anaerobic cellulitis• Develops after several days of wound closure

• Subcutaneous Emphysema may spread rapidly

• Pain, swelling and toxemia usually minimal

• Abundent gas with foul smell

• Treatment: debribment, broad-spectrum ABX, rarely

amputation

Amputation

• Four issues that must be considered when contemplating limb salvage instead of amputation, as follows:

1. Would survival be affected by the treatment choice?

2. How do short-term and long-term morbidity compare?

3. How would the function of a salvaged limb compare with that of a prosthesis?

4. Are there any psychosocial consequences?

6. Tumors

Amputation

1. Would survival be affected by the

treatment choice?

• Long-term survival for Osteosarcoma pts

improved from approximately 20% to

approximately 70% With the use of

multimodal treatment, including surgery and

chemotherapy

• Osteosarcoma: rate of local recurrence after

wide resection and limb salvage is 5% to 10%,

equivalent to the local recurrence rate after a

transfemoral amputation

Amputation

2. How do short-term and long-term

morbidity compare?

• Amputation in malignancy is often technically

demanding, requiring nonstandard flaps, bone

graft, or prosthetic augmentation to obtain a

more functional residual limb.

• Limb salvage is associated with greater

perioperative morbidity compared with

amputation.

Amputation

• Limb salvage requires a extensive surgical procedure with greater risk of infection, wound dehiscence, flap necrosis, blood loss, and deep venous thrombosis.

• Long-term complications vary depending on the type of reconstruction which include periprosthetic fractures, prosthetic loosening or dislocation, nonunion of the graft-host junction, allograft fracture, leg-length discrepancy, and late infection.

• A patient with a salvaged limb is more likely to need multiple subsequent operations for treatment of complications.

• After initial successful limb salvage surgery, one third of long-term survivors ultimately may require an amputation.

Tumors

Amputation

3. How would the function of a salvaged limb compare with that of a prosthesis?

• The location of the tumor is the most important factorwith regard to function.

• Resection of an upper extremity lesion with limb salvage, even with sacrifice of a major nerve, generally provides better function than amputation and subsequent prosthetic fitting.

• Resection of a proximal femoral or pelvic lesion with local reconstruction generally provides better function than hip disarticulation or hemipelvectomy.

• Sarcomas around the ankle and foot frequently are treated with amputation followed by prosthetic fitting

• Sarcomas around knee should be individualized.

Amputation

• Patients who had undergone Resection and Prosthetic Knee Replacement showed higher self-selected walking velocities and a more efficient gait with regard to oxygen consumption than patients with Transfemoral Amputations.

• Individuals with a Transfemoral Amputation functioned at more than 50% of their maximum aerobic capacity at free walking speeds, requiring anaerobic mechanisms to sustain muscle metabolism, which results in decreased endurance.

Tumors

Amputation

• Patients with an amputation had difficulty walking on steep, rough, or slippery surfaces, but were very active and were the least worried about damaging the affected limb.

• Patients with an arthrodesis performed the most demanding physical work and recreational activities, but they had difficulty with sitting, especially in the back seat of cars, theaters, or sports arenas.

Tumors

Amputation

Determination of Amputation level

• Understand tradeoff between increased

function with more distal amputation and

decreased complications with more

proximal amputation.

• The energy required for walking is

inversely proportionate to the length of the

remaining limb.

• Patients with amputations at the transfemoral, transtibial, and Syme levels secondary to trauma or chronic limb ischemia were evaluated.

• Compared with controls without amputations, the self-selected walking velocity for vascular amputees was 66% at the Syme level, 59% at the transtibial level, and 44% at the transfemorallevel.

• For traumatic amputees, generally younger patients, the rates were 87% at the transtibial level and 63% at the transfemoral level.

• At self-selected walking velocities, the slower rates for amputees seem to be a compensatory mechanism to conserve energy per unit time.

Determination of Amputation level

• Patients tended to decrease their velocities to keep their relative energy costs per minute within normal limits.

• When energy expenditure per minute is not compensated, anaerobic mechanisms are summoned to sustain muscle function, and endurance is greatly compromised.

• Thus it becomes apparent that amputation should be performed at the most distal level possible if ambulation is the chief concern.

• If a patient has no ambulatory potential, wound healing with decreased perioperative morbidity should be the chief concern.

Determination of Amputation level

Determination of Amputation level

Amputation

• Zone of Injury (trauma)

• Adequate margins (tumor)

• Adequate circulation (vascular disease)

• Soft tissue envelope

• Bone and joint condition

• Control of infection

• Nutritional status

Level of Amputation

• 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

Amputation

Skin and Muscle Flaps

• Flaps should be kept thick.

• Avoid unnecessary dissection to prevent further devascularization of already compromised tissues.

• Scar should not be adherent to the bone as an adherent scar makes prosthetic fitting extremely difficult, and often breaks down after prolonged prosthetic use.

• Avoid redundant soft tissues or large “dog ears” to avoid problems with prosthesis

Techniques

• Muscles are usually divided at least 5 cm distal to

the intended bone resection.

• 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).

• Myodesis should be performed to provide a

stronger insertion, help maximize strength, and

minimize atrophy

Techniques

Myodesis

• Myodesed muscles continue to

counterbalance their antagonists, preventing

contractures and maximizing residual limb

function.

• Contraindicated in severe ischemia because

of the increased risk of wound breakdown.

Techniques

Hemostasis

• Use the tourniquet as it makes the amputation easier.(except for severely ischemic limb)

• Use Esmarch bandage (except infection and neoplasm)

• Major blood vessels should be isolated and individually ligated.( vein and artery separately)

• Doubly ligate larger vessels.

• Deflate tourniquet before closure, and do meticulous hemostasis.

• Use drain in most cases for 48 to 72 hours.

Techniques

Nerves

• Avoid formation of neuroma

• Neuroma becomes painful if it forms in a position where it would be subjected to repeated trauma.

• Isolate the nerve, gently pull distally and divide cleanly with a sharp knife so that the cut end retracts well proximal.

• Avoid crushing the nerve

• Ligate large nerves (sciatic nerve) to ligate accompanying vessels.

• Avoid strong tension on nerve, otherwise wound will be painfull.

Techniques

Bone

• Avoid excessive periosteal stripping as it 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.

Techniques

• Skin is not closed over the end of the stump.

• Indicated in infections and in severe traumatic wounds with extensive destruction of tissue and gross contamination.

• May require multipule surgeries

• Must be followed by secondary closure, reamputation, revision, or plastic repair.

• Vacuum-assisted closure ( VAC ) is applied to the open stump immediately after the initial débridement.

• Subsequent débridements are scheduled at 48-hour intervals.

• Reaply VAC after each debridement until the wound is ready for closure

Open Amputations

• Goals

• Prompt, uncomplicated wound healing

• Control of edema

• Control of Postoperative pain

• Prevention of joint contractures

• Rapid rehabilitation

Postoperative Care

Amputation

• Requires multidisciplinary team approach

• Perioperative antibiotics, DVT prophylaxis, and pulmonary hygiene.

• Pain management

• If weight bearing ambulation is not planned in the immediate postoperative period, the rigid dressing ( POP ) may be applied

• If weight bearing ambulation in the immediate postoperative period is anticipated, a true prosthetic cast should be applied.

Postoperative Care

• Dressing• Soft dressing (elastocreap)

• Rigid dressing (pop cast)

• Advantages of rigid dressing- Prevent edema at the surgical site

- Protect the wound from bed trauma

- Enhance wound healing and early maturation of the stump

- Decrease postoperative pain

- Allow earlier mobilization from bed to chair and ambulation with support

- For transtibial amputations- prevent the formation of knee flexion contractures

Postoperative Care

• Drains usually are removed at 48 hours.

• The stump is elevated by raising the foot of the bed, which helps manage edema and postoperative pain.

• The patient is cautioned against leaving the stump in a dependent position.

• Early unprotected weight bearing can result in sloughing of the skin or delayed wound healing.

• If the wound is progressing well, weight bearing can progress in 25-lb increments each week.

• Supervision is important in patients with peripheral neuropathy who may have difficulty judging how much weight they are placing on their stumps.

Postoperative Care

• Regardless of when prosthetic ambulation is begun, the rigid dressing should be removed and the wound inspected in 7 to 10 days.

• Cast loosening, fever, excessive drainage, or systemic symptoms of wound infection are indications for earlier cast removal.

• If the wound is healing well, a new rigid dressing is applied, and ambulation with or without prosthetic is continued.

Postoperative Care

• After the wound is well healed, the rigid

dressing can be removed for bathing and

stump hygiene

• Use rigid dressing until the stump volume

appears unchanged from the previous week.

• Then prosthetist may apply the first prosthesis.

• One or more socket changes frequently over

the first 18 months

Postoperative Care

1. Hematoma

2. Infection

3. Wound necrosis

4. Contractures

5. Pain

6. Dermatological problems

COMPLICATIONS

• Hemostasis before closure, use of drain, and a

rigid dressing should minimize hematoma

formation.

• Can delay wound healing and source of

bacterial infection.

• If formed, Should be treated with a

compressive dressing, evacuation.

1. Hematoma

• More common in amputations for PVD especially in diabetic patients.

• Any deep wound infection should be treated with immediate debridement and irrigation and open wound management.

• Delayed closure may be difficult because of edema and retraction of the flaps.

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

This allows for continued open wound management, while maintaining adequate flaps for distal bone coverage.

2. Infection

• skin edge necrosis less than 1 cm can be

treated conservatively

• Severe necrosis with poor coverage of the

bone end, wedge resection can be done.

• The basic principle of wedge resection is to regard

the end of the amputation stump as a hemisphere.

• Resection of a wedge incorporating the full

diameter of the stump would allow for reformation

of the hemisphere, while minimizing local

pressures

3. Wound Necrosis

• Mild or moderate contractures of the joints can be prevented by

• proper positioning of the stump,

• gentle passive stretching,

• engage in exercises to strengthen the muscles controlling the joint.

• Severe fixed contractures may require

• wedging casts

• surgical release of the contracted structures.

4. Contractures

1. Mechanical low back pain

2. Residual limb pain is caused by

Poor fitting prosthesis-

abnormal pressure, especially over bony prominences.

Distal stump edema “choking”

Treatment with socket modifications.

Painful neuroma

• due to pressure or repeated irritation of nerve end.

• usually palpable and positive Tinel sign.

Treatment initially socket modification

If not resolved then neuroma excision.

5. Pain

• Contact Dermatitis

• Bacterial Folliculitis

• Epidermoid cyst

• Verrucous hyperplaysia

To avoid such conditions • Wash the stump at least once a day.

• Stump should be thoroughly rinsed and dried before fitting prosthesis.

• keep the prosthesis clean and should be thoroughly dried before fitting.

• Treat infection and modify prosthesis as required

6. Dermatological problems

Techniques… Few examples

Amputation

Techniques… Few examples

Amputation

After 12 months

Techniques… Few examples

Amputation

Amputation

Rehabilitation and Prosthetics

Rehabilitations.

Amputation

• 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

Psychological stress.

Amputation

• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms

• Depression

• Anxiety

• Crying spells

• Insomnia

• Loss of appetite

• Suicidal ideation

AMPUTATIONS IN

CHILDREN

• Amputations in children is divided into two general categories—congenital (60%) and acquired (40%)

• Causes of Acquired amputations:-

• Secondary to trauma

• Neoplasm

• Infection.

• Motor vehicle accidents, gunshot wounds, and

power tool injuries are the most common causes

of limb loss from injury in older children; in

young children, accidents with power tools, such

as lawnmowers, and other household accidents

are the most common causes.

• Dysvascular amputations in children are rare, but

when they do occur, they usually are secondary to

thrombotic or embolic events caused by another

underlying problem.

• Causes of congenital amputations

Amniotic band syndrome

Exposure to teratogens ( thalidomide )

Polydactyly

Syndactyly

Macrodactyly

Congenital pseudoarthrosis of the tibia and fibula, radius and ulna

Constrictions of the leg

Congenital deficiencies of the long bones

1. Preserve length

2. Preserve important growth plates

3. Perform disarticulation rather than transosseousamputation whenever possible

4. Preserve the knee joint whenever possible

5. Stabilize and normalize the proximal portion of the limb

6. Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions.

Principles Of Childhood Amputation

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

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.

Children use prostheses extremely well, and their proficiency increases as they age and mature.

• A progressive prosthetic program should be designed that parallels normal motor development.

• 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.

Techniques… Few examples

Amputation

Techniques… Few examples

Amputation

After 12 months

Techniques… Few examples

Amputation

Amputation

Rehabilitation and Prosthetics

Rehabilitations.

Amputation

• 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

Psychological stress.

Amputation

• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms

• Depression

• Anxiety

• Crying spells

• Insomnia

• Loss of appetite

• Suicidal ideation

Management of Amputee

Amputation

• Preparation

• Good Surgical Technique

• Rehabilitation

• Early Prosthetic Fitting

• Team Approach

• Vocational and Activity Rehabilitation