AMPUTATIONS Flashcards
WHAT IS AMPUTATION?
Removal of a limb or other appendage of the body
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”
WHAT ARE THE INDICATIONS FOR AMPUTATIONS IN ACCORDANCE TO AGE?
Indications vary with age.
1. In elderly (50-75yrs) - peripheral vascular disease with or without diabetes is the main cause.
2. In younger adults (25-30 yrs) - often secondary to injury or its sequelae.
3. In children, limbs may be congenital deformities.
Amongst acquired causes, injury and malignancy top the list
Indication are classified as congenital/ acquired
EXPLAIN THE Ds OF AMPUTATION
4 Ds mnemonic for indications of amputation
Indicated when part of the limbs is Dead, Deadly or Dangerous, Dead loss or Damn nuisance
i) Dead (Vitality of limb part is destroyed)
The limb may be dead when arterial occlusion or stenosis causes tissue infarction with putrefaction of macroscopic portion of tissue (gangrene)
Dry gangrene due to arterial occlusion or stenosis
Arterial occlusion
a) Major (large) vessels – atherosclerotic/embolic occlusions
b) Small vessel - DM, Buegers disease, Raynaud‘s disease, egotism
ii) Deadly/ Dangerous (life Saving)
Limb may be deadly or dangerous and jeorpadise the life of the patient if amputation is not done or delayed
a) When wet gangrene occurs with its accompanying putrefaction infection
b) If infection spreads to surround viable tissue e.g. necrotizing fasciitis
c) When spreading cellulitis e.g. severe toxemia overwhelming systemic infection can occur Gas gangrene due to C. perfringes
d) Neoplasm like osteogenic sarcoma, extensive melanoma
e) Arteriovenous fistula
Life of the Pt. is threatened by spread of a local condition
iii) Dead loss
a) Severe laceration, #, partial amputation due to trauma or burns
b) Severe contracture or paralysis e.g. poliomyelitis
c) Severe rest pain without gangrene in patient with an Ischemia
iv) Damn nuisance (deformed/ neuropathy)
a) Polydactyl
b) Severely impaired gait
WHAT ARE THE TYPES OF AMPUTATION?
- Open amputation
a) Guillotine or Open Amputation- skin is not closed over amputation stump, usually wound is not healthy.
b) modified guillotine - Closed amputation- skin is closed primarily (e.g., most elective amputations).
a) Revised
b) Planned
LIST THE TYPES OF AMPUTATIONS OF THE LOWER LIMB
Types of amputations - Lower limbs
1. Ray amputation- Amputation of toe with head of metatarsal or metacarpals.
2. Transmetatarsal amputation (Gillies’) - Here
amputation is done proximal to the neck of the
metatarsals, distal to the base.
3. Lisfranc‘s amputation (Tarsometatarsal
amputation)- Here tarsometatarsal joint is
disarticulated with a long volar flap
4. Chopart‘s amputation (Midtarsal amputation)-
Here talonavicular joint and calcaneocuboid joints
are disarticulated
5. Syme’s amputation-It is removal of the foot with
calcaneum and cutting of tibia and fibula just
above the ankle joint with retaining heel flap
(dividing both malleoli).
6. Pirogoff‘s amputation-It is like Syme’s amputation except posterior part of the calcaneum is retained along
with heel flap.
7. Below-knee amputation
8. Above knee amputation
9. Transcondylar-Gritti-Stokes amputation with long posterior flap. Femur is divided just above the articular
surface and patella is anchored to the divided femur.
10. Hip disarticulation
11. Hind quarter amputation-Inter innominate abdominal
amputation (Sir Gordon Taylor’s amputation): Removal of one
side pelvis with innominate bone, pubis, muscles and vessels.
WHAT FACTORS DO YOU NEED TO EVALUATE A PT WHO NEEDS AMPUTATION?
a) Hematocrit
b) Creatinine level- muscle injury and necrosis, release myoglobin which enters the systemic circulation and can lead to renal insufficiency and failure. especially in individuals with thermal and electrical burns
c) K+ and Ca2+
levels- Elevated levels of these electrolytes may lead to cardiac arrhythmias and seizures
d) WBC, C-reactive protein , and ESR, but C-RP is the first laboratory value to respond to treatment,
e) Platelets
WHAT IMAGING TECHNIQUES ARE UNDERTAKEN FOR AMPUTATION?
Imaging
a) X-ray AP & Lat view
b) CT scanning and MRI- Performed in pt for tumour workup or for osteomyelitis to ensure that the surgical margins are appropriate.
c) Technetium-99m (99mTc) pyrophosphate bone scanning- to predict need for amputation in persons with electrical burns and frostbite. A 94% sensitivity rate and a 100% specificity rate has been reported in demarcating viable tissues from nonviable tissues.
d) Doppler ultrasonography - measure arterial pressure; and predict wound healing. A minimum measurement of 70 mm Hg is believed to be necessary for wound healing.
e) Ischemic index (II): - Ratio of Doppler ultrasonography pressure at the level being tested to the brachial systolic pressure. An II of 0.5 or greater at the surgical level is necessary to support wound healing.
f) Ankle-brachial index: - The II at the ankle level is believed to be the best indicator for assessing adequate inflow to the ischemic limb. An index less than 0.45 indicates incisions distal to the ankle will not heaL
OUTLINE THE PRINCIPLES OF AMPUTATION
General principles for amputation surgery involve appropriate management of skin, bone, nerves & vessels
Adequate blood supply of the flap should be maintained.
Proper marking of the skin incision is essential. Greatest skin length possible should be maintained for muscle coverage and a tension-free closure
Tourniquet should not be used if amputation is done for vascular diseases.
Proximal part of flap contains muscle component but distal part should contain only skin and deep fascia.
Flap length should be adequate; not short: ideally semicircular not rectangular to get a conical stump.
Pull down the nerve and cut it using a sharp knife, so that it retract into soft tissue to avoid neuromas to develop.
In crush injury/entrapment injury/sepsis—guillotine amputation is done. Later skin is pulled down by using skin traction, eventually to have better skin coverage.
Bone should be cut with beveling and around all sharp margins. Bony prominences around disarticulations are removed with a saw and filed smooth. Diaphyseal transections can be covered with a local flexible osteoperiosteal graft. Maintaining the maximal extremity length possible is desirable. But, below-knee amputations are best performed 12.5-17.5 cm below the joint line for non-ischemic limbs
Postoperatively regular dressings are done. Mobilise pt. using axillary crutches. After 3 months, once scar has matured and stump has become supple, proper prosthesis is fit.
Stumps can be side bearing (sutures are on the side); end bearing/conical (sutures are on the end) or cylindrical. Muscle is placed over the cut end of bones via a myodesis (ie, muscle sutured through drill holes in bone), a long posterior flap sutured anteriorly, or a well-balanced myoplasty
Give postoperatively active exercise to the proximal joint so that prosthesis can be fit to it properly.
Relieve flaps open or loosely sutured, in sepsis especially in gangrene limb, otherwise flap necrosis occurs.
Know proper anatomy of muscles and neurovascular bundle around in all amputations
WHAT ARE THE STANDARD SURGICAL PRINCIPLES IN CHILDREN?
Standard surgical principles for amputation in children
a) Preserve the physis.
b) 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.
c) Disarticulate when possible. Disarticulation completely eliminates the problem of terminal overgrowth and subsequent revision surgery.
d) 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
OUTLINE THE SURGICAL PRINCIPLES FOR A CLOSED TYPE AMPUTATION
a) Tourniquet: Use of a tourniquet is highly desirable except in case of an ischaemic limb.
b) Ex-sanguination: Usually a limb should be squeezed (ex-sanguinated) by wrapping it with a stretchable bandage (Esmarch bandage) before a tourniquet is inflated. It is contraindicated in cases of infection and malignancy for fear of spread of the same proximally
c) Level of amputation: With modern techniques of fitting artificial limbs, strict levels adhered to in the past are no longer tenable
OUTLINE THE PRINCIPLES GUIDING THE LEVEL OF AMPUTATION
Principles guiding the level of amputations are as follows:
i. Disease: Extent and nature of disease or trauma, for which amputation is being done. One tends to be conservative with dry-gangrene (vascular) and trauma, but liberal with acute life threatening infections and malignancies.
ii. Anatomical principles: A joint must be saved as far as possible.
iii. Suitability for the efficient functioning of the artificial limb:
WHAT ARE THE EARLY COMPLICATIONS OF AMPUTATIONS?
Immediate / early complications
(a) Associated with spinal anesthesia
- Hypotension
- Failure to breathe because it can affects phrenic nerve
- Compression of nerve- paralysis
(b) Surgical complications
- Reactionary hemorrhage
- Hematoma
WHAT ARE THE INTERMEDIATE COMPLICATIONS OF AMPUTATIONS?
Intermediate complication
-Wound infection usually associated with hematoma
-Abscess formation
-Wound dehiscence-Gangrene of the flaps due to ischemia
-Higher amputation leading to Gas gangrene in mid-thigh stump due to fecal contamination
-Deep vein thrombosis (DVT)
-Pulmonary embolism
-Psychological effect – depression
