Amputation

RS2480 CSMC

October 2, 2018
Amanda Weeks
Clinical Associate
With information contributed by Dr. Sam Chan

Textbook
Solomon, L., Warwick, D.J., & Nayagam,
S. (2001). Apley’s System Of
Orthopaedics And Fracture (8th ed.).
London: Arnold.
Chapters 19, 20, 21, 29, 30, 31
Pre-lecture Activities
 View Videoclip and answer following questions
 https://www.youtube.com/watch?v=XFb2fXPZi8A

1. What factors determine the level of amputation?

2. What bodily tissues are involved during an
amputation operation?
3. What kinds of post-op medical interventions are
needed?
Pre-lecture Activities
1. The level of amputation would be above the injured
or necrotic tissues
2. Bodily tissues
 Skin, fascia, muscles (Note: skin flap)
 Nerves, blood vessels
 Bones
3. Post-op interventions
1. Blood drainage
2. Edema control
3. Wound dressing
4. Pain control
Amputations

 Indicated if the presence of the limb is a

threat to life
OR
 If replacement by a substitute offers the
best prospect of functional and
sometimes cosmetic improvement
Amputations
Indications
 Trauma
 Damaged part cannot be repaired
most common types that lead to
 Vascular insufficiency amputation--> e.g. DM II and PAD

 Severe peripheral vascular disease

 To save life, to relieve pain and to enable patient to
lead a more normal life
 Malignant new growths
 neoplastic conditions (tumors, cancers, etc)
 Others
 Infection, gross congenital deformities
Major Causes

 Vascular diseases including DM II

and Peripheral Artery Diseases (PAD)
leading cause of amputation
worldwide
 Increasing prevalence in HK (projected
to 11.9% of population by 2030)
 Aging population
 Increasing westernized diet

 Sedentary lifestyle Diabetes Atlas, 5 th Edition. Brussels:

International Diabetes Federation; 2011 .
Diabetic Foot Ulcers
 Hyperglycemia (high blood
sugar) leads to narrowing of
blood vessels
 Vasoconstriction →ischemia
→neuropathy→impaired peripheral
sensation
 Minor wounds are not noticed and
significantly worsen
 Damage to autonomic nerves
impairs sweat gland function →
decreased ability to moisturize →
cracks and skin breakdown
 Poor circulation inhibits healing
 the location of the ulcers depend on the

Diabetic Foot Ulcers way of weight bearing

Meggitt-Wagner Grading System
Treatment
Recommendations
Grade 0: Represents at high risk
for breakdown due to no
sensation. Education.

Grade 1: Use of proper footwear

with custom inserts

Grade 2: Non-Weight bearing or

healing cast

Grade 3-5: Surgical Management

(amputation) likely, treatment for
bone infection (osteomyelitis)
Ulcer Evaluation and Risk

 Neurological Status
 Presence of “protective sensation” (Sensate to10-g
monofilament)
 Vascular Status
-dorsalis pedis
 Checking pedal pulses -posterior tibial

 Capillary filling time to the digits

 Wound evaluation
 Location, size, shape, depth, border, signs of
infection
Diabetic Foot
 Conservative
Management:
 Patient Education
and Prevention
 Foot hygiene
 Foot self-examination
 Proper footwear
 Shoe orthotics (e.g.
insoles) to distribute
weight over the foot
Charcot Degeneration
 Charcot degeneration (Neuropathic Arthropathy)
 Progressive degeneration of a weight bearing joint, a process marked
by bony destruction, bone resorption, and eventual deformity.
 Onset is usually insidious
 Symptoms: Inflammation, erythema, pain and increased skin
temperature
 Treatment: Offloading (non-weight bearing, total contact casting)
Peripheral Vascular Disease
 Narrowing of peripheral arteries due
to plaque
 Symptoms
 Pain when walking
 Skin Ulcers/Discoloration (slow to heal)
 Cold skin
 Poor nail/hair growth
 Can lead to gangrene

https://www.heart.org/idc/groups/heart-
public/@wcm/@hcm/documents/downloadable/ucm
_300323.pdf
Gangrene

 Tissue death due to insufficient blood

supply

Video (graphic):
https://www.youtube.com/watch?v=rcgtaLVWpEY
www.ampsurg.org
Stages

 Pre-Operative Phase
 Intra-Operative Phase
 Post-Operative Phase
 Pre-Prosthetic Phase
 Post-Prosthetic Phase (if appropriate)
Goals of Pre-Operative Stage

 Considerations of level of amputation

 Salvage of knee joint=better outcomes
 General medical management
 Comorbid conditions such as heart failure,
diabetes, hypertension and UTI require
adequate treatment to reduce surgical risk
 Physical preparation may need to reduce weight before surgery

 Upper limb strength, weight management

 Mental preparation
Lower Extremity Amputations

 Below Knee Amp (“BKA”)

 Above Knee Amp (“AKA”)
 Levels of amputations
 Through bone
 Through joint (disarticulation)
AKA-->poorer prognosis and outcome compared
with BKA
Lower Extremity
(BKA)
Types of BKA Surgical Procedure

 Long Posterior Flap

 Burgess Technique***
 Bruckner Technique

 Sagittal Flap***
 Skewed Flap
 Modified sagittal flap
 Anterior/Posterior Technique
 Commonly applied on AKA

*** more commonly applied clinically

Long Posterior Flap of BKA:
Burgess Technique
 Tibia cut 10-12 cm below
tibial tuberosity (15cm below
knee joint line)
 Fibula cut 1-1.5 cm shorter
than tibia
 Long flap with length
5 cm longer than the
diameter of the calf diameter
 Long flap consists of lateral
and medial gastrocnemius
and some soleus
Burgess Technique

Video (graphic): https://www.youtube.com/watch?v=9ssU4xxUouU

Bruckner Technique
 Fibular disarticulation
and resected
 Complete resection of
anterior and lateral
compartment and soleus Burgess
 Flap consists mainly of
medial gastrocnemius
and some lateral
gastrocnemius
Bruckner
Sagittal Flap
 Tibia cut 13-15 cm
below knee joint line (A)
 Anterior apex of skin flap
1cm lateral to tibial crest
(1)
 Semi-circular flaps run
laterally and medially
 Inferior margin of flap =
13-15cm + ¼ calf
circumference at cut end
of tibia
Sagittal Flap

 Lateral flap
 Anterior and lateral
muscles (what are
they?)
 Medial flap
 Mainly medial
gastrocnemius and
skin
 Suture runs anteriorly
and posteriorly
Skewed Flap
 Posterior junction 180
from anterior junction
 Posterior muscle flap of
gastrocnemius is
trimmed to cover distal
end of tibia and fibula
 Scar line runs
anterolaterally and
posteromedially
Anterior/Posterior Technique

“Fish Mouth” Flap

http://www.indiasurgerytour.com/india-general-surgery/india-
surgery-amputation-below-knee.html
Upper Extremity
Causes:
• Trauma
• Tumors
• Infection
• Congenital Defects

Over 70% are distal to the elbow

http://biomed.brown.edu/Courses/BI108/BI10
8_2003_Groups/Hand_Prosthetics/stats.html
Wrist Amputation

 Wrist Disarticulation
 Pronation/Supination Preserved
 Functional movement for prosthetic use
 Transcarpal Amputation
 Preserved
 Pronation/Supination
 Wrist flexion/extension

Cambell’s Operative Orthopedics. 13th Ed.

Frederick M Azar, MD, S. Terry Canale, MD and
James H. Beaty, MD (2016)
Forearm Amputation

 Transradial Amputation
 Elbow
Flexion/Extension
preserved
 Longer length= more
functional
 Some
pronation/supination
preserved Cambell’s Operative Orthopedics.
13th Ed. Frederick M Azar, MD, S.
Terry Canale, MD and James H.
Beaty, MD (2016)
 What are the level of
amputation and the related
surgical procedure?

BKA: Burgess Technique

AKA: Antero-posterior
Technique

BEA:
Anteroposterior
Technique
Surgical Principles of Amputation
 Level of amputation
 through tissue that will
be healed satisfactorily
 at a level that will
remove the diseased or
15cm below knee
otherwise abnormal part joint line
 Preserve all possible
length consistent with
good surgical judgment
 Longer limb would
facilitate better
prosthesis fitting at later
stage
Surgical Principles of Amputation
 Skin Flaps
 Greatest skin length
possible should be
maintined for muscle
coverage and tension-free
closure
 Skin at the end of the stump
should be mobile and
normally sensitive “dog ears”
 Scar should not be adherent
to the underlying bone
 It makes prosthetic fitting
extremely difficult and
because this type of scar
often breaks down after
prolonged prosthetic use What is the surgical procedure?
 Redundant soft tissues also Burgess Procedure
create problems in
prosthetic fitting and may
prevent maximum function
Surgical Principles of Amputation
 Muscle  Bone
 Divided either just distal or 5cm  Bony prominence not to be well
padded by soft tissue should always
distal to the level of intended
be resected and the remaining bone
bone section should be rasped to form a smooth
 Sutured to the bone or to contour
apposing muscle groups under
appropriate tension
 Longer muscles suture is
believed to improve the function
of the muscles and circulation in
the stump and help prevent
phantom pain
Surgical Principles of Amputation
 Nerve
 Nerves are best treated
when isolated, gently pulled
and divided and litigated so
it can retract into the
underlying muscle, thus
preventing the migration of
axons
 Strong tension on the nerve
should be avoided during
this procedure; otherwise
the stump may be painful
even after the wound has
healed
Post-operative Management
 Pain management
 Prevention of edema
 Prevention of infection
 Prevention of DVT
 Care of concurrent medical
problems
 Reduce risk for contracture
Complications of Amputation
 Hematoma
 Delay wound healing
 Should be drained or
aspirated followed by
applying firm
compression
 Infection
 Necrosis
 Contracture
 Prevented by properly
positioning of the stump
and by exercises to
strengthen the muscles
and mobilize the joints
 Passive stretching and
splinting are helpful
Complications of Amputation
 Neuromas
 Tumor-like tissue formed at  When conservative treatment
the end of a cut nerve fails, the neuroma should be
 Pain from a neuroma is excised and the nerve should
usually caused by traction be divided at a more proximal
on a nerve when a neuroma level
is bound down by scar
tissue
 Pain can usually be
managed by appropriate
alternations in the prosthetic
socket to avoid pressure or
traction on the lesion
Complications of Amputation

 Phantom Sensation  Treatment

 After almost every  Drug therapy,
amputation the patient
is aware of sensation
that the amputated
part is still present
 This sensation is
disturbing but it is
rarely painful

 Sensory Re-education
 Psychotherapy
 Transcutaneous or
direct electrical
stimulation of nerves,
or a combination
Complications of Amputation
 Phantom Pain
 Perceived pain in the body
part that have been
amputated
 It may be due to disinhibited
motor cortical activity without
afferent sensory feedback
(MacIver et al., 2008)
 Treatments
 Pharmacological techniques
(e.g. Tricyclic
antidepressants, sodium
channel blockers)
 Mirror therapy
 Deep-brain stimulation
Phantom Limb Pain
Phantom Limb Pain
Stump Shaping

 Aims to reduce
edema and form to
conical shape for
better subsequent Stump sock
prosthesis fitting

Stump
Bandaging
http://physiotherapyguide.blogspot.com/2012/01/stump-bandaging-for-
above-and-below.html
Amputee Mobility Predictor

 Designed to measure an amputee

patient’s functional capabilities without a
prosthesis
 Predict his/ her ability to ambulate with a
prosthesis
 https://www.youtube.com/watch?v=Y7V8
nJraUYc&t=124s
Psychological Issues

 Phantom sensation / pain

 Body image
 Depression
 Stigmatization