INTRODUCTION

Amputation is the most ancient of surgical procedure. Amputation is no longer a crude ablational surgery but a refined reconstructive procedure to prepare the stump for its motor functions ,sensory feed back and cosmesis. Early surgical amputation was a crude procedure by which a limb was rapidly severed from an unanesthetized patient. The open stump was crushed or dipped in boiling oil to obtain hemostasis.

In 1674 Morels introduced use of tourniquet. In 1867 Lister's introduced the antiseptic technique. With the use of chloroform and ether general anesthesia in the late 19th century, surgeons for the first time could fashion reasonable sturdy and functional stumps. In the past 3 decades there has been increased interest in improving

DEFINITION
Amputation is defined as surgical ablation of a part or whole of limb through one or more bones. DISARTICULATION is removal of a part through a joint INCIDENCE Age: Common in 50 to 75 years age group Sex: 75% men and 25% women Limbs: 85% is through the lower limbs,

INDICATIONS

Amputation should only if limb is

Dead

be

considered

(gangrenous), Dying (ischaemic), Dangerous (malignancy) or Dud (useless)

The only ABSOLUTE indication is Irreversible ischaemia of a diseased or injured limb

Vascular TAO Atherosclerosi s Arteriosclerosi s Gangrene Traumatic Crush injuries

Infective Gas gangrene Leprosy Actinomycosis Filariasis Neoplastic Congenital anomalies

TYPES OF AMPUTATION
1) 2)

Open or Guillotine amputation Closed Closed Amputations are classical planned amputations where regular skin and muscle flaps are raised and wound is closed to get an ideal stump.

Open or Guillotine amputation

It is an emergency amputation done as a life saving measure. The purpose is to prevent or eliminate infection. It is indicated in

Infections

and Severe traumatic wounds with extensive distruction of tissue and gross contamination by foreign material.

Incision is circular around limb and all tissues including bone are cut at same level. The wound is left open for free drainage. When all infection is controlled and patient condition is stabilized, a revision amputation is done.

Two types

Open amputation with inverted skin flaps Circular open amputation

Circular open amputation

Healing is prolonged, bone ends become covered with granulation tissues and skin margins become closed by scar contracture. Disadvantages
It

needs constant skin traction that helps to pull all of the soft tissue over the end of the stump. Convoluted scar that results, is difficult to manage prosthetically. Often it is treated by reamputation at a more proximal level.

PREOPERATIVE PREPARATION
Patient should be brought to best possible condition to withstand and survive surgical trauma. Tissue status evaluation by

Transcutaneous

oxygen tension PO2 >35 mm

Hg Ankle/ brachial pressure index > 0.45 Arteriogram

Immune competence
Serum

albumin level should be >3.5 gm/dl

and

Systemic - To control diabetes, infection, dehydration, anemia, shock and cardiac insufficiency. Psychological support by preoperative counseling and through amputee support group. Pre-operative pain control

BASIC PRINCIPLES OF AMPUTATION

Tourniquet Except in ischaemic limbs, the use of tourniquet is highly desirable and makes the amputation easier.

Usually the limb should be exsanguinated except in cases of infection and malignant growths.

Level of amputation

Any well healed, non tender and properly constructed amputation stump can now be satisfactorily fitted with a prosthesis. CARDINAL RULE To preserve all possible length consistent with good surgical judgement

Ideal Stump

Firm and Smooth somewhat tapering segment with full range of movement and whose muscles are well developed Rounded or conical in shape Skin is free of scars, healthy and with good circulation. No dog ears, folds or puckers No redundant flaps Linear and mobile operative scar

Skin Flaps

Skin at the end should be mobile and normally sensate. Scar should not be adherent to underlying bone. The location of scar should be either anteriorly or posteriorly Redundant soft tissue or large dog ear

Muscles

Myodesis is contraindicated in peripheral vascular disease. Advantages of Myoplasty Improves the functions of muscles Increases the circulation of the stump

Nerves
Nerves are isolated, pulled down gently and divided with a sharp knife and allowed to retract above the saw line. Large nerves such as sciatic nerve contains arteries and should be ligated before division. Strong tension should be avoided.

Blood vessels

Major blood vessels should be doubly ligated with absorbable or nonabsorbable suture before division. Before the skin is closed tourniquet is released and all bleeding points should be clamped and ligated.

Bone

Excessive periosteal stripping is contraindicated and may result in formation of ring sequestrum. Bone ends are rasped to form a smooth contour. Some surgeons have advised closing the medullary canal at the end of the bone by osteoperiosteal flap to

Dressings
Soft dressings These are applied snugly and elastic bandage applied over it, with care to avoid constriction of stump proximally.

The stump is elevated by raising the foot end of bed. Pillows should not be used as this may cause flexion contractures of

Rigid dressings This method employs use of POP cast, applied to the stump in the OT at the end of surgery.

If weight bearing ambulation is anticipated in the early post operative period, a true prosthetic cast should be applied. A metal Pylon with prosthetic foot is attached to the stump and properly

Advantages Prevents edema at surgical site Decreases post operative pain Physiological benefits of erect posture Psychological benefits Shorter stay in hospital and earlier fitting of definitive prosthesis Disadvantages Excessive pressure and constriction proximally can cause necrosis of the stump end Early detection of infection is not possible

Immediate postsurgical prosthetic fittings

Following application of rigid dressing, ambulation on attached pylon and prosthetic foot may be initiated
Immediately

after surgery. Promptly, when good stump healing is evidenced (7-10 days) Early after stump has healed (2-3 weeks) or Later after stump is mature and there is no chance of stump break down.

The choice of optimal time to begin prosthetic ambulation depends on factors including age, strength and agility of patient and his ability to protect stump from injury

The use of pylon in the immediate postoperative period is of valuable psychological importance. It makes the patient ambulant at an early stage which is good for his morale. It also improves his muscle strength and mobility of his joints thus preparing him for the more compact permanent prosthesis of future.

AMPUTATION IN CHILDREN

Congenital : 60% secondary to congenital limb deficiencies. Acquired : 40% secondary to trauma followed by neoplasm and infection.

General principles KRAJBICH

Preserve length Preserve important growth plates Perform disarticulation rather than amputation Preserve the knee joint whenever possible Preserve stump shape Be creative with soft-tissue coverage Stabilize and normalize the proximal portion of limb

Disarticulation can provide children with a well balanced sturdy stump capable of end weight bearing. Length and physis are preserved without the risk of terminal overgrowth. Additionally prosthetic suspension is improved with a disarticulation secondary to preservation of the metaphyseal flares.

Terminal overgrowth

The over growth is results from distal apposition of bone by the active periosteum and is unrelated to the growth of the physis. Most severe before 6 years of age, and several revisions (three or more) may be required during the growing years. Overgrowth is not seen after about 12 years of age. The bones most likely to exhibit overgrowth are the humerus, fibula, and

It may cause swelling,edema, pain and bursa formation and in severe cases may penetrate the skin. Terminal overgrowth is treated with surgical resection of the excess bone and its bursa. Improved results have been obtained by CAPPING the bone with an epiphyseal graft harvested from the amputated limb at the index procedure or by capping with cortical iliac crest graft at a revision

COMPLICATIONS
Immediate postoperative bleeding Gradual oozing or massive haemorrhage due to loosening of ligature may cause collection of blood within the wound. If minimal, aspiration and application of compression bandage helps. If it is massive, the wound is to be opened and bleeders ligated. Accumulation of blood leads to infection and scaring which results in a poor

Infection Treated by hot packs, elevation of stump and antibiotics. Any deep wound infection should be treated with immediate debridement and irrigation For this the central one third of the wound is closed, and the

Ulceration Due to improper skin approximation, infection or haemorrhage. Necrosis of skin flaps - Due to insufficient circulation. If <1 cm - treated conservatively with open wound management. In cases of severe necrosis with poor coverage of the bone end, wedge resection may be indicated. Basic principle of wedge resection is to regard the end of the amputation stump as a hemisphere. Hyperbaric oxygen therapy and

Stump oedema Due to inadequate elastic bandaging in the postoperative period. Bandage should be applied with even pressure throughout and care should be taken to avoid excessive pressure and constricting turns. Stump contractures Particularly in flexion is due to abnormal position and lack of physiotherapy

Phantom limb Shortly after amputation most patients perceive a sensation as the lost portion of limb is still present. Sometimes the sensation becomes painful and annoying. Use of morphine, sympathectomy, procaine block, psychotherapy and early use of prosthesis may help.

Neuroma Forms on the cut end of the nerve. Pain results due to traction on a nerve when neuroma is bound down by scar tissue. Treated by
Alterations

in prosthetic socket & Excision of neuroma with division at a more proximal level.

Jactitation Painful contraction of the amputated

DISARTICULATION OF THE HIP

Hip disarticulation is indicated After massive trauma, for arterial insufficiency, Infection (e.g., infected subtrochanteric nonunion), or for certain congenital limb deficiencies. For treatment of bone or soft-tissue sarcomas of the femur or thigh that cannot be resected adequately by limb-sparing methods. The inguinal or iliac lymph nodes are not routinely removed with hip disarticulation.

Boyd disarticulation of hip

Femoral vessels and nerve have been ligated, and sartorius, rectus femoris, pectineus, and iliopsoas muscles have been detached. Inset, Line of skin incision.

Gluteal muscles have been separated from insertions, sciatic nerve and short external rotators have been divided, and hamstring muscles have been detached from ischial tuberosity. Inset, Final closure of stump.

Posterior Flap Slocum

The incision at the level of the inguinal ligament, carry it distally over the femoral artery for 10 cm, curve it along the medial aspect of the thigh, continue it laterally and proximally over the greater trochanter, and swing it anteriorly to the starting point. A posteromedial flap long enough to cover the end of the stump is formed. long posteriomedial flap containing gluteus maximus swing anteriorly and sutured to anterior margins of incision .

HEMIPELVECTOMY (hind quarter amputation)

Hemipelvectomy most often is performed for tumors that cannot be adequately by limb-sparing techniques or hip disarticulation. Other indications for hemipelvectomy include life-threatening infection and arterial insufficiency. All types of hemipelvectomy remove the inguinal and iliac lymph nodes.

standard hemipelvectomy employs a posterior or gluteal flap and disarticulates the symphysis pubis and sacroiliac joint. extended hemipelvectomy involves the posterior bony section passing through the sacrum. conservative hemipelvectomy, the bony section divides the ilium above the acetabulum, preserving the crest of the ilium. Internal hemipelvectomy is a limbsparing resection, often achieving

All types of hemipelvectomy are extremely invasive and mutilating procedures. They require optimizing the patient's nutritional status, preparing for blood replacement, and adequate monitoring during surgery. Flap necrosis and wound sloughs are common complications. Appropriate emotional and

Standard hemipelvectomy. A, Incision. B and C, Transection of iliac arteries and division of internal iliac vessels. D, Release of iliac crest and gluteus maximus.

E, Division of symphysis pubis. F, Division of muscles from pelvis.

Anterior Flap Hemipelvectomy

Anterior flap hemipelvectomy is indicated for lesions of the buttock or posterior proximal thigh that cannot be adequately treated by limb-sparing methods. The larger posterior defect is covered by a quadriceps myocutaneous flap maintained by the superficial femoral artery.

ANTERIOR FLAP HEMIPELVECTOMY. A, Anterior and posterior incision. B, Detachment of gluteus maximus origins from coccyx and sacrotuberous ligament. C, Severing vastus lateralis from femur and separating tensor fascia femoris from

D, Separation of myocutaneo us flap. E, Transection of internal iliac vessels and branches.

Conservative Hemipelvectomy

Conservative hemipelvectomy is indicated for tumors around the proximal thigh and hip that cannot be resected adequately by limb-sparing techniques and do not require sacroiliac disarticulation for satisfactory proximal margins. The operation is a supraacetabular amputation that divides the ilium through the greater sciatic notch

Start the incision 1 to 2 cm above the anterior superior iliac spine, and continue it posteriorly and laterally across the greater trochanter to the gluteal crease. Follow the crease to the medial thigh posteriorly. Begin a second incision from the first incision 5 cm below its starting point, and continue it to just above and parallel to the inguinal ligament to the pubic tubercle. Carry the incision posteriorly across the medial thigh to join the first incision .

Conservative hemipelvecto my, A, Racquet type of incision. B, Separation of muscles from ilium. C, Division of ilium by Gigli saw.

TRANSTIBIAL (BELOW-KNEE) AMPUTATIONS

Although many variations in technique exist, basically all procedures may be divided into those for nonischemic limbs and those for ischemic limbs. In nonischemic limbs, skin flaps of various design and muscle stabilization techniques, such as tension myodesis and myoplasty, are frequently used. In tension myodesis, transected muscle groups are sutured to bone under

In myoplasty, muscle is sutured to soft tissue, such as opposing muscle groups or fascia. In ischemic limbs, tension myodesis is contraindicated because it may compromise further an already marginal blood supply. Also, a long posterior myocutaneous flap and a short or even absent anterior flap are recommended for ischemic limbs because anteriorly the blood supply is less abundant

Nonischemic Limbs

The optimal level of amputation in this population traditionally has been chosen to provide a stump length that allows a controlling lever arm for the prosthesis with sufficient circulation for healing and soft tissue for protective end weight bearing. The amputation level also is governed by the cause (e.g., clean end margins for tumor, level of trauma, and congenital abnormalities). A longer residual limb would have a more normal gait appearance, but stumps extending to the distal third of the leg have been considered suboptimal because there is less soft tissue available for weight bearing.

The distal third of the leg also has been considered relatively avascular and slower to heal than more proximal levels. In adults, the ideal bone length for a below-knee amputation stump is 12.5 to 17.5 cm, depending on body height. A reasonably satisfactory rule of thumb for selecting the level of bone section is to allow 2.5 cm of bone length for each 30 cm of body height. Usually the most satisfactory level is about 15 cm distal to

A stump less than 12.5 cm long is less efficient. Stumps lacking quadriceps function are not useful. In a short stump of 8.8 cm or less, it has been recommended that the entire fibula together with some of the muscle bulk be removed so that the stump may fit more easily into the prosthetic socket. Many prosthetists find, however, that retention of the fibular head is desirable because the modern total-contact socket

Transecting the hamstring tendons to allow a short stump to fall deeper into the socket also may be considered. Although the procedure has the disadvantage of weakening flexion of the knee. Amputations in nonischemic limbs result from tumor, trauma, infection, or congenital anomaly. In each, the underlying lesion dictates the level of

Amputation through middle third of leg for nonischemic limbs. A, Fashioning of equal anterior and posterior skin flaps, each one half anteroposterior diameter of leg at level of bone section.

B, Division and ligation of anterior tibial vessels and division of deep peroneal nerve.

C, Fashioning of posterior myofascial flap.

D, Suture of myofascial flap to periosteum anteriorly.

E, Closure of skin flaps.

AFTERTREATMENT

Rehabilitation after transtibial amputation in a nonischemic limb is fairly aggressive, unless the patient is immunocompromised, there are skin graft issues . An immediate postoperative rigid dressing helps control edema, limits knee flexion contracture, and protects the limb from external trauma. A prosthetist can be helpful with such casting and can apply a jig that allows attachment and alignment for early pylon use. Weight bearing is limited initially, with bilateral upper extremity support from parallel bars, a walker, or crutches

The cast can be changed every 5 to 7 days for skin care. Within 3 to 4 weeks, the rigid dressing can be changed to a removable temporary prosthesis if there are no skin complications. The patient is shown the proper use of elastic wrapping to control edema and help contour the residual limb when not wearing the prosthesis. The physiatrist and therapist can assist in monitoring progress through the various transitions of temporary prosthetics to the permanent design . The endoskeletal designs have been

Ischemic Limbs

The frequent comorbidities in patients with ischemic limbs demand precautionary measures Because the skin's blood supply is much better on the posterior and medial aspects of the leg than on the anterior or anterolateral sides, Transtibial amputation techniques for the ischemic limb are characterized by skin flaps that favor

The long posterior flap technique popularized by Burgess is most commonly used, but medial and lateral flaps of equal length as described by Persson, .

All techniques stress the need for preserving intact the vascular connections between skin and muscle by avoiding dissection along tissue planes and by constructing

. Also, amputations performed in ischemic limbs are customarily at a higher level (e.g., 10 to 12.5 cm distal to the joint line) than are amputations in nonischemic Tension myodesis and the osteomyoplasty procedure are contraindicated in patients with ischemic limbs because the procedures tend to compromise an already precarious blood

Transtibial amputation in ischemic limbs. A, Fashioning of short anterior and long posterior skin flaps.

B, Separation and removal of distal leg. C, Tailoring of posterior muscle mass to form flaps.

D, Suture of flap to deep fascia and periosteum anteriorly. E, Closure of skin flaps.

AFTERTREATMENT

Rehabilitation in patients with ischemic limbs must proceed cautiously because of potential skin healing compromise and accompanying medical conditions. Initial postoperative efforts are centered on skin healing.

If immediate or prompt prosthetic ambulation is not to be pursued, the stump can be dressed in a simple, well-padded cast that extends proximally to midthigh and is applied in such a manner as to avoid proximal constriction of the limb. Good suspension of the cast is essential to

The cast should be removed in 5 to 7 days, and if wound healing is satisfactory, a new rigid dressing or prosthetic cast is applied.

Success of rehabilitation depends on multiple variables, including cognitive status, premorbid functional level, condition of the upper extremities and contralateral lower limb, and coexisting medical

DISARTICULATION OF THE KNEE

Disarticulation of the knee results in an excellent end-bearing stump. Newer socket designs and prosthetic knee mechanisms that provide swing phase control have eliminated many of the former complaints concerning this level of amputation.

Advantages The large end-bearing surfaces of the distal femur covered by skin and other soft tissues that are naturally suited for weight bearing are preserved,

long lever arm controlled by strong muscles is created, and

The

prosthesis used on the stump is stable.

Knee

flexion contractures and associated distal ulcers common with transtibial

Disarticulation of knee joint. ( Batch, Spittler, and McFaddin ) A, Skin incision. B, Anterior flap elevated, including insertion of patellar tendon . C, Cruciate ligaments and posterior capsule divided. D, Tibial nerve divided high.

E, Patellar tendon sutured to cruciate ligaments. F, Wound closed over drain

Mazet and Hennessy

fish-mouth skin incision, making the anterior flap longer and extending 10 cm distal to the level of the knee joint, and making the posterior flap shorter and extending only about 2.5 cm distal to the same level Patella is desected from its tendon and discard . Femoral condyles are remodelled. Smoothly rounded all bony prominences with rasp. Suture the patellar tendon to the

Mazet and Hennessy disarticulation of knee. A, Anterior view. B, Lateral

Kjble described modified skin incision that allows greater use of this amputation level in patients with ischemia. With the patient prone on the operating table, outline a lateral flap that is one half the anteroposterior diameter of the knee in length and a medial flap that is 2 to 3 cm longer to allow adequate coverage of the large medial femoral condyle . Doubly ligate, and divide the popliteal vessels. Identify and sharply transect the peroneal and tibial nerves so that their cut ends retract well proximal to the end of the stump. Suture the patellar tendon and the hamstring tendons to each other and to the cruciate ligaments in the intercondylar notch. Approximate the skin edges with interrupted nonabsorbable sutures

Kjble

Kjble disarticulation of knee with medial and lateral skin flaps.

TRANSFEMORAL (ABOVE-KNEE) AMPUTATIONS

Amputation levels above the knee can be classified as short transfemoral, medial transfemoral, long transfemoral, and supracondylar . In this procedure, the patient's knee joint is lost, so it is extremely important for the stump to be as long as possible to provide a strong lever arm for control of the prosthesis. The conventional, constant friction knee joint used in most above-knee prostheses extends 9 to 10 cm distal to the end of the prosthetic socket, and the bone must be amputated this far proximal to the knee to allow room for the joint.

When the level of amputation is more distal than this, the knee joint of the prosthesis is more distal than the knee of the opposite limb, which is cosmetically undesirable and is especially noticeable when the patient is seated. Amputation stumps in which the level of bone section is less than 5 cm distal to the lesser trochanter function as and are prosthetically

Position the patient supine on the operating table, and perform the surgery under tourniquet . Equal anterior and posterior skin flaps are outlined. The length of each flap should be at least one half the anteroposterior diameter of the thigh at this level. Fashion the anterior flap with an incision that starts at the midpoint on the medial aspect of the thigh at the level of anticipated bone section. Divide the quadriceps muscle and its overlying fascia along the line of the anterior incision, and reflect it proximally to the level of intended bone section as a myofascial flap. Identify, individually ligate, and transect the femoral artery and vein in the femoral canal on the medial side of the thigh at the level of bone section.

Incise the periosteum of the femur circumferentially, and divide the bone with a saw immediately distal to the periosteal incision With a sharp rasp, smooth the edges of the bone, and flatten the anterolateral aspect of the femur to decrease the unit pressures between the bone and the overlying soft tissues. Identify the sciatic nerve just beneath the hamstring muscle,ligate it well proximally to the end of the bone and divide it just distal to the ligature.

Through several small holes drilled just proximal to the end of the femur, attach the adductor and hamstring muscles to the bone with nonabsorbable or absorbable sutures. The muscles should be attached under slight tension. Bring the quadriceps apron over the end of the bone, and suture its fascial layer to the posterior fascia of the thigh, trimming any excess muscle or fascia to permit a neat, snug approximation. Approximate the skin edges with interrupted sutures of nonabsorbable material .

Amputation through middle third of thigh. A, Incision and bone level. B, Myofascial flap fashioned from quadriceps muscle and fascia. C, Adductor and hamstring muscles attached to end of femur through

Gottschalk

Develop skin flaps using a long medial flap in the sagittal plane when possible Divide the femur 12 cm above the knee joint. Drill holes in the lateral, anterior, and posterior aspects of the femur, 1.5 cm from its end. Hold the femur in maximal adduction, and suture the adductor magnus to its lateral aspect using previously drilled holes . Also, place anterior and posterior sutures to prevent its sliding backward or forward.

Suture the quadriceps to the posterior femur by drawing it over the adductor magnus, while holding the hip in extension. Suture the remaining posterior muscles to the posterior aspect of the adductor magnus. Close the investing fascia and skin, and apply a soft dressing.

GRITTI STROKE AMPUTATIONadductor tubercle ,after removal Femur section at the level of

of the patellar articular surface ,the patella is sutured in place under the distal end of femur ,closure done with anterior flap.

Advantages

Long lever arm is easy for control of prosthesis Balance is easy when contralateral limb is amputated.

Disadvantages

Limb tolerance of skin at end of stump(if the end of the femur is reduced to the size of the patella ,the pressure per unit area of the skin is greatly increased and limits tolerance of the skin at the end of the stump ) Patellar union is fibrous

Levels of partial foot amputation

HINDFOOT AND ANKLE AMPUTATIONS

Amputations around the ankle joint not only must fulfill the requirements of an end-bearing stump, but also must leave enough space between the end of the stump and the ground for the construction of some type of ankle joint mechanism for the artificial foot

Syme Amputation

The Syme amputation consists of a bone section at the distal tibia and fibula 0.6 cm proximal to the periphery of the ankle joint and passing through the dome of the ankle centrally. The tough, durable skin of the heel flap provides normal weight bearing skin.

A single long posterior heel flap is used. Begin the incision at the distal tip of the lateral malleolus, and pass it across the anterior aspect of the ankle joint at the level of the distal end of the tibia to a point one fingerbreadth inferior to the tip of the medial malleolus; extend it directly plantarward and across the sole of the foot to the lateral aspect, and end it at the starting point

Syme amputation. A, Incision and bone level. B, Exposure of ankle and division of ligaments.

C, Bone hook pulling talus distally, exposing distal articular surface of tibia and fibula. D, Dissection of soft tissues from calcaneus.

E and F, Subperiosteal removal of calcaneus, leaving heel pad intact.

G, Division of tibia and fibula just through dome of ankle joint centrally. H, Holes drilled in anterior edge of tibia and fibula to anchor heel pad.

I, Edge of deep fascia lining heel pad is anchored to tibia and fibula.

J and K, Skin closure over drain, and applicatio n of aboveknee cast.

A and B, Frontal view of Syme amputation with prosthesis

C and D, Anteroposterior and lateral radiographs of Syme amputation.

The two most common causes of an unsatisfactory Syme stump are posterior migration of the heel pad and skin slough resulting from overly vigorous trimming of dog ears. Both can be prevented by attention to surgical technique The chief objection to this amputation is cosmetic. The prosthesis used must accommodate the flair of the distal tibial metaphysis that is covered with heavy plantar skin and is large and bulky. For this reason, the

The prosthesis used for a classic Syme amputation consists of a molded plastic socket, with a removable medial window to allow passage of the bulbous end of the stump through its narrow shank, and a solid-ankle, cushioned-heel foot prosthesis

Two-Stage Syme Amputation

Wagner popularized a two-stage technique of the Syme amputation for use in diabetic patients with an infected or gangrenous foot lesion and have achieved marked success with this technique , However, that both stages can be safely combined when infection is not adjacent to the heel pad. The procedure consists of performing an ankle disarticulation as the first stage, preserving the tibial articular cartilage and the malleoli, and performing a Syme-type closure over a suctionirrigation system that allows installation

Irrigation is continued until local and systemic signs of infection have resolved.

After 6 weeks, if the stump is healed, a second procedure is performed to remove the malleoli and narrow the stump for good prosthetic fitting

Second stage of Wagner-Syme amputation. A and B, Removal of dog ears over each malleolus. C and D, Resection of metaphyseal flare parallel with shaft of fibula; same procedure is carried out at distal tibia.

Boyd Amputation

The Boyd amputation also produces an excellent end-bearing stump around the ankle and eliminates the problem of posterior migration of the heel pad that sometimes occurs after a Syme amputation. It involves talectomy, forward shift of the calcaneus, and calcaneotibial arthrodesis. The arthrodesis makes the procedure technically more difficult than the Syme amputation .

Boyd amputation with calcaneotibial fusion. A, Fullthickness flaps with longer plantar extension in midtarsal amputation. These flaps extend distal to the MTP joints so that wound can be closed without skin tension. B, Midtarsal joint disarticulation, talectomy, and partial fibulectomy. C, Talus has been excised. Calcaneus and tibial platform prepared for arthrodesis. D, Single-layer closure with 2-0 monofilament

Sarmiento described a modification of the Syme technique that produces a less bulbous stump and allows the use of a more cosmetic prosthesis. He advised transection of the tibia and fibula approximately 1.3 cm proximal to the ankle joint and excision of the medial and lateral malleoli. This produces a stump that is only slightly larger in circumference than the diaphyseal portion of the leg and allows fitting with a prosthesis that incorporates an expandable socket,

The Pirogoff amputation involves arthrodesis between the tibia and part of the calcaneus; the calcaneus is sectioned vertically, Its anterior part is removed, and its remaining posterior part and the heel flap are rotated forward and upward 90 degrees until the raw surface of the calcaneus meets the denuded distal end of the tibia. This amputation has no advantage

MIDFOOT AMPUTATIONS

Amputations through the middle of the foot include Lisfranc amputation at the tarsometatarsal joints, which seldom has been performed because of the equinus deformity that usually develops and is frequently followed by severe equinovarus deformity Pirogoff amputation, in which the calcaneus is rotated forward to be fused to the tibia after vertical

To prevent equinus deformity after midfoot amputations, one or more dorsiflexors of the ankle must be transferred. Lessening the plantar flexion strength of the Achilles tendon also is necessary. Tenectomy of the Achilles tendon (removing 2 to 3 cm of the tendon) is recommended, rather than a simple lengthening

Chopart Amputation

Amputation through the midtarsal joint Mark the skin incision preoperatively, creating a fish-mouth flap that is slightly longer on the plantar surface. Begin the incision at the transtarsal joints medially and laterally. Extend the flaps in a dorsal and plantar direction, creating adequate skin flaps for coverage . Carry the incision through the skin and subcutaneous tissue

Tenotomy of the Achilles tendon. Excise 2 cm of tendon, and attempt to preserve the sheath of the tendon. Transfer the anterior tibial tendon to the neck of the talus, using a drill hole or by creating a trough in the talus and using suture or a staple to secure fixation . AFTERTREATMENT The dorsiflexion rigid dressing is changed intermittently to check the wound. Sutures are kept in place for 4 to 6 weeks to allow for adequate healing. The splint must be worn for 6 to 8 weeks to prevent equinus

Chopart amputation. A, Incisionslateral view of dorsal and plantar flaps. B, Dorsal view of incision. C and D, Flaps retracted after resection of distal foot. E, Transfer of anterior tibial tendon through tunnel in neck of talus. F, After closure of incisions.

TOE AMPUTATIONS

Amputation of a single toe, with few exceptions, causes little disturbance in stance or gait. Amputation of the great toe does not functionally affect standing or walking at a normal pace. If the patient walks rapidly or runs, however, a limp appears because of the loss of push-off normally provided by the great toe. Amputation of the second toe frequently is followed by severe hallux valgus because the great toe tends to drift toward the third

Smith recommended a second ray amputation and narrowing the foot. Screw fixation is used in this technique to prevent a severe valgus deformity from occurring. Amputation of any of the other toes causes little disturbance. Of these, the fifth is most commonly amputated, the usual indication being overriding on the fourth toe. Usually, amputation of all toes

Second ray amputation with screw fixation to narrow the foot.

Amputation of a Toe Fashion a long plantar and a short dorsal skin flap. Begin the incision at the level of intended bone section at the midpoint on the medial side of the toe, and curve it over the dorsal aspect to end at a similar point on the lateral side. Fashion a similar plantar flap, but make it slightly longer than the dorsoplantar diameter of the toe at the level of bone section. Dissect the skin flaps proximally to the

Divide the flexor and extensor tendons, and let them retract just proximal to the end of the bone. Isolate and divide the digital nerves, and ligate and divide the digital vessels. Section the bone at the selected level, and smooth its end with a rasp. Close the flaps with interrupted nonabsorbable sutures .

B and C, Severe ischemia of hallux to level of metatarsophalangeal joint.

D, Sesamoids removed in diabetic patient. E, Closure. Note longer plantar flap.

Amputation at the Base of the Proximal Phalanx

Maintaining the base of the proximal phalanx often is preferable to metatarsophalangeal joint disarticulations. This allows for retention of some weight bearing properties, especially in the hallux, where 1 cm of proximal phalanx allows for some contribution by the flexor hallucis brevis and the plantar fascia. It also may slow the deviation of adjacent toes when one of the lesser digits is

Preservation of at least 1 cm of base of proximal phalanx in amputation of hallux is desirable to maximize weight bearing function of first metatarsal.

Metatarsophalangeal Joint Disarticulation

In the diabetic foot, ischemia or osteomyelitis or both are the most compelling indications for amputation at the metatarsophalangeal joint. Toe in flexion incise dorsal side first; straighten the toe, and expose and incise the remainder of the capsule after dividing the flexor tendons and neurovascular bundles, cauterizing

A, Disarticulation at metatarsophalangeal joint of great toe

A and B, Metatarsophalangeal joint disarticulation. Single-layer closure using 3-0 or 4-0 monofilament nylon.

Transmetatarsal Amputation

To fashion long plantar and short dorsal fullthickness flaps , begin the dorsal incision at the level of intended bone section on the anteromedial aspect of the foot, and curve it slightly distal to the level of bone section to reach the midpoint of the lateral side of the foot. Begin the plantar incision at the same point as the dorsal, carry it distally beyond the metatarsal heads, and curve it proximally to end at the midpoint of the lateral side of the

The metatarsals should be removed in a cascading fashion with each successive cut 2 to 3 mm shorter than the previous medial metatarsal. The fifth metatarsal should be even shorter (4 to 5 mm shorter than the fourth). Divide the tendons under tension so that they retract into the foot. A drain may be used as necessary.

A, Dorsal and plantar incisions for transmetatarsal amputation (left) and disarticulation at the metatarsophalan geal joints (right). B, Level of bone transection in transmetatarsal amputation. Osteotomy locations are gently curved. C, One-layer closure using

Custom shoe insert for transmetatarsal amputation

Fifth ray amputation for fifth metatarsal head ulcer

FOREQUARTER AMPUTATION

Forequarter amputation removes the entire upper extremity in the interval between the scapula and the chest wall. Usually it is indicated for malignant tumors that cannot be adequately removed by limb-sparing resections. Extension of the operation to include resection of the chest wall occasionally is required. Two approaches for amputation :
Anterior

approach of Berger

SHOULDER DISARTICULATION (DUPUYTRENS)

This procedure is for nonsalvageable proximal arm injuries or for severe brachial plexopathies and malignant tumours.

Transhumeral amputation

FOREARM AMPUTATIONS

When circulation in the upper extremity is severely impaired, amputations through the distal third of the forearm are less likely to heal satisfactorily than those at a more proximal level because distally the skin is often thin, and the subcutaneous tissue is scant. The underlying soft tissues distally consist primarily of relatively avascular structures, such as fascia and tendons. In these exceptional circumstances, an amputation at the junction of the middle and

In amputations through the proximal third of the forearm, even a short belowelbow stump is preferable to an amputation through or above the elbow.

From a functional standpoint, preserving the patient's own elbow joint is crucial.

WRIST AMPUTATIONS

Transcarpal amputation or disarticulation of the wrist is definitely preferable to amputation through the forearm because, provided that the distal radioulnar joint remains normal, pronation and supination are preserved.

Index Ray Amputation

When the index finger is amputated at its PIP joint or at a more proximal level, the remaining stump is useless and can hinder pinch between the thumb and middle finger. When a primary amputation must be at such a proximal level, any secondary amputation should be through the base of second Metacarpal. This index ray amputation is especially desirable in women for cosmetic reasons.

After treatment The hand is elevated immediately after surgery for 48hours.

At 24 hrs the drain is removed. Digital motion initiated at 5 to 7 days post operatively.

MIDDLE / RING RAY AMPUTATION

In contrast to the proximal phalanx of the index finger, the proximal phalanx of the middle finger is important functionally.

Its absence in either finger makes a hole through which small objects can pass when the hand is used as cup or in a scooping maneuver.

The 3rd and 4th metacarpal heads are

When the middle finger has been amputated proximal to the PIP joint or metacarpal head transposing the fifth ray radialward to replace the fourth rarely is indicated. This operation is more favourable in children and women. But contraindicated in heavy manual labourers.

Krukenberg & Swanson

Amputation of both hands is extremely disabling. It converts the forearm to forceps in which the radial ray act against the ulnar ray. Swanson compares function of the reconstructed limb as chop sticks.

After Treatment The limb is constatntly elevated for 3 to 4 days.

After 2 to 3 weeks rehabilitation is begun to develop abduction and adduction of the rays.

REHABILITATION AND TRAINING

Institute occupational therapy as soon as possible To maintain body symmetry Prevent flexion contractures Reduce surgical edema Prepare the residual limb for the prosthesis Early fitting of a prosthesis and promotion of two-handed function reduce the rejection rate.

Strengthening exercises help to counteract the pendulum effect of the terminal device. Computer programs are used to aid in training patients. Activities of daily living must be taught early.

GOALS OF PREPROSTHETIC CARE

Length, condition, strength, and range of motion of the residual limb are the determining factors in the choice of a prosthetic system. Types
Passive

in which the position of the terminal device or more proximal components is changed with a contralateral hand Body-powered in which gross body movements activate cables for function Myoelectric which is battery-powered and computer-driven

COMPLICATIONS DUE TO PROSTHESIS

Contact dermatitis Failure to rinse detergents from stump socks thoroughly Treatment - removal of the irritant & steroid cream Bacterial folliculitis Occur in areas of hairy, oily skin. Treatment consists of improved hygiene and socket modifications. Epidermoid cysts may develop at the socket brim.

Choke syndrome Proximal restriction in the socket with lack of total contact can lead to edema in the stump Can lead to hemosiderin deposition and the eventual development of verrucous hyperplasia. This problem is preventable through good prosthetic fitting that achieves total contact in the socket. Psychosocial maladjustment

Thank.u