Tbilisi State Medical University

Amputation
Dr. Levan Labauri M.D., Ph.D. Assistant Professor of Surgery

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This dramatic picture is a tribute to St. Damian and St. Cosmos, the patron saints of surgeons.

There is a lot happening in this picture, with the obvious amputation of the leg
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The history of human amputation is ancient. Initially the many thousands of years, limb loss was the result of trauma or 'nonsurgical' removal. This was followed by the hesitant beginnings of surgical intervention, mainly on gangrenous limbs or those already terribly damaged, which developed through to surgical amputations around the 15th century, and the aim of saving a life and achieving a healed stump. Improvements in surgical techniques were married with better haemorrhage control in and with anaesthesia and efficient infection control. The 20th century noted marked improvements in surgical techniques and also a move to increasingly sophisticated prosthetic limbs. 3

4 . to cut away." and "dismemberment´.Amputation is derived from the Latin amputare. being reserved to indicate punishment for criminals. possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (1597 or 1612). his work was derived from 16th century French texts and early English writers also used the words "extirpation´. or simply "cutting. The Latin word has never been recorded in a surgical context. "disarticulation. from amb (about) and putare (to prune). The English word amputation was first applied to surgery in the 17th century." but by the end of the 17th century amputation had come to dominate as the accepted medical term.

Amputation is the removal of a body extremity by trauma or surgery. transecting the lumbar spine 5 . As a surgical measure. Hemicorporectomy (translumbar amputation or "halfectomy") is a radical surgery in which the body caudal to the waist is amputated. it is carried out on individuals as a preventative surgery for such problems. such as malignancy or gangrene. Amputation refers to the surgical or traumatic removal of the terminal portion of the upper or lower extremity. In some cases. Amputation: Removal of part or all of a body part enclosed by skin. it is used to control pain or a disease process in the affected limb. Amputation: Amputation removal of the peripherial part of the limb or any other organ.

but mutilates him/her. Mentioned trend is predicted one the one hand by the advanced development of the battle against the infection and on the other hand because of the achievements of reconstructive surgery (tissue replacement.Amputation often saves the life of the patient. By this reason.). surgeon should do his/her best not only save the life of the patient. The indications for the amputation have markedly restricted recent times. but also create all the possible conditions for the proper functioning of the limb. neurovascular technique 6 etc. .

7 . embolism. injuries of the major vessels. Limb gangrene (anaerobic infection.Indications Severe Mechanical Injury (the tissues are damaged and major vessels and nerves are disconnected. when the limb is avulsed or hanged on the flip). obliterating endarteritis. malignancies. etc.

8 .Contraindications Shock The patient should be relieved from the shock but no more than 2-4 hours should be spent.

According to the terms of Intervention Early (Primary & Secondary) Delayed Repeated 9 .

primary delayed closure or secondary sutures. before the development of inflamative changes in the site The wound can be closed by the primary sutures. 10 .Primary Amputation During the first 24 h of trauma acquisition.

the applied treatment is not effective and the lifethreating conditions (such a postligation necrosis. anaerobic infection etc.Secondary Amputation More delayed terms (after 24 h) It is applied when in the beginning of the trauma there is no absolute need for limb amputation. despite.) may set on. Can be done in cases of deep (IV D) burns and freeze 11 .

when the body is exhausted and there is the risk of mortality because of the parenchymal organ dystrophy 12 .Delayed Amputation Can be done in cases of prolonged heeling.

Early (primary & secondary) Can be planned as a preliminary as well as definite intervention. in this case. (incompatible for prosthesis). The preliminary amputation can be done simply: with no wound closure (anaerobic infection). 13 . later the limb can be amputated (reamputation) Re-amputation can be done in the case of fallacious stump formation.

The skin and scar should be mobile.Prosthesis compatible stump: Should not be painful. It is preferable the working surface of the stump be the scar free 14 . The sewed bone should be covered by soft tissues.

muscles. nerve) 15 .The working surface of the stump Upper Limb ± lateral surface and palm Lower Limb ± anterior surface and dorsal surface of the foot The stump surface should be free for the risk of the development of trophycal disturbances and ulcers (the adequate processing of the stump elements ± skin. bone.

16 . in this respect the exclusion is the anaerobic infection or obliterating endarteritis (in such cases the limb should be cur upper). The damaged limb should be amputated on the level that will prevent the spreading of the process over.The length of the stump is much depend on the localization of injury. The principle of the ³tissue economy´ should be considered in any case.

The sensitivity is disturbed (hyperesthesia. The skin is damaged.Fallacious Stump: No adequate length and shape for prosthesis. pain). The muscular strength and movement diapason is dramatically decreased. Crutch ability is important for lower limb 17 .

The assisting surgeon is standing opposite to the operating surgeon. 18 . The limb is extended.Patients¶ Position On back. The target limb is on the right side of surgeon.

Anaesthesia General (narcosis) Local (infiltrative) 19 .

Tourniquet application is contra-indicates in cases of anaerobic infection and obliterating endarteritis. 20 . The limb should be hold up (blood flows down). The ends of the tourniquet should be tied simply.Tourniquet Before the amputation and exarticulation as usual tourniquet should be applied on the limb.

Amputation Set Linteum fissum et bifissum 21 .

Incision DIrection Circular Oval Scarp shaped 22 .

According to the stages of the tissue incision/excision
One moment (guillotine) Two moment Three moment (conoid-circular) Scarp rule Oval (ellipsoid)
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Upper Extremity Amputation

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Amputation: Etiology
Trauma Burns Peripheral Vascular Disease Malignant Tumors Neurologic Conditions Infections Congenital Deformities

Etiology: Trauma 90 % of Upper Extremity Amputation Male:Female = 4:1 Most Amputations at level of Digit Major Limb Amputations less common Revascularization possible for incomplete amputation Replantation possible for complete amputation .

Etiology: Trauma .

Etiology: Tumor .

Etiology: Gangrene .

Etiology: Gangrene (cont.) Radiograph: Subcutaneous air throughout arm .

Etiology:Failed Forearm Vascular Repair after trauma .

Etiology: Vascular Disease Ischemia after AV Fistula Procedure .

Etiology: Crush .

Etiology: Congenital polydactyly .

Etiology: Infarction associated with IV Drug Abuse .

Etiology: Scleroderma .

Partial Hand  4. Above Elbow  6. Wrist or Forearm  5.Amputation: Trauma and Replantation Candidates for Replantation after Trauma 1. Multiple Digits  3. Isolated Digit Distal to FDS insertion  7. Almost any part in child  . Thumb  2.

Replantation: Multiple Digits .

Repair Extensor Tendon 5.Surgical Technique: Digit Replantation 1. Shorten and fix bone 4. Repair Nerves 8. Debride 3. Repair Arteries 7. Repair Veins 9. Repair Flexor Tendon 6. Identify Vessels and Nerves 2. Skin Closure (skin graft if necessary) .

Atherosclerotic vessels  5. Severely crushed or mangled parts  2. > 6 hours ischemic time  7. Other serious injuries or diseases  4. Severe contamination  . Multiple levels  3. Mentally unstable  6.Amputation: Replantation Poor Candidates for Replantation 1.

Amputation: Replantation Mangled and Crushed ± Poor Candidate .

Vascular repair (artery then veins). Debride. Rapid bone stabilization.Surgical Technique: Major Limb Replantation Myonecrosis is greater concern than in digit replant Immediate shunting to obtain arterial inflow may be necessary High Potassium levels (>6. Tendons and Nerves .5 mmol/l ) in venous outflow from amputated part negative prognostic factor Sequence of repair similar to digit  Identify structures.

Upper vs Lower Limb Upper extremity nonweightbearing Less durable skin acceptable  Decreased sensation better tolerated  Joint deformity better tolerated  Late amputations rare  Transplants now being performed  .

Major Limb Replantation Include Surgical Prep of Legs for vascular and nerve grafts Rapid Bone Stabilization Ready for Anastomosis .

Bone. Tendon Surgeries Function of major upper extremity replantations superior to prosthetic function .Amputation: Major Limb Replantation Outcomes >2/3 survival rate Can be a life threatening undertaking Multiple Surgeries often required  Late Nerve.

1998 .Outcomes: Major Limb Replantation Comparison of functional results of replantation versus prosthesis in a patient with bilateral arm amputation Peacock. Tsai. 1987 Major amputation of the UE: Functional Results after replantation/revascularization in 47 cases Daoutix et al. J Hand Surg. Acta Orthop Scand. CORR. 1995 Major Replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcome study Graham et al.

nontender. physiologic residual limb .Amputation: Technique Preservation of functional residual limb length balanced with Soft tissue reconstruction to provide a well-healed.

Technique: Determination of Level Zone of Injury (trauma) Adequate margins (tumor) Adequate circulation (vascular disease) Soft tissue envelope Bone and joint condition Control of infection Nutritional status .

Tumor Forequarter Amputation .

Gangrene Emergent Open Shoulder Disarticulation .

Trauma High Transhumeral Nerves Avulsed from High in Plexus .

Failed Vascular Repair Transradial .

Levels of Amputation Wrist Disarticulation vs. Transradial       Disarticulation offers potential of better active pronation and suppination of forearm Transradial often difficult to transmit rotation through prosthesis Disarticulation poor aesthetically Disarticulation more difficult to fit prosthetic Transradial needs to be done 2 cm or more proximal to joint to allow prosthetic fitting Transradial usually favored .

 .Levels of Amputation Transhumeral vs. Elbow Disarticulation Adults: Elbow disarticulation allows enhanced suspension and rotation control of prosthesis however retention of full length precludes use of prosthetic elbow. Humeral growth slowed after trauma. Long transhumeral favored  Pediatrics: Transhumeral amputation results in high incidence of bony overgrowth. Elbow disarticulation is level of choice.

Levels of Amputation Preservation of Elbow function is a priority Consider replantation/salvage of parts to maintain elbow function  4-5 cm of proximal ulna necessary for elbow function  For very proximal amputations. it may be necessary to attach bicep tendon to ulna  .

electrical burn injuries require careful evaluation because necrosis of deep muscle may be present while superficial muscles can remain viable .Techniques Debridement of all Nonviable tissue and foreign material Several debridements may be required Primary wound closure often contraindicated High voltage.

allow it to retract proximally Skin: Opportunistic flaps  Rotation flaps  Tension free  Skin grafts  . section it.Techniques Nerve: Prevent neuroma formation  Draw nerve distally.

Techniques Bone: Choose appropriate level  Smooth edges of bone  Narrow metaphyseal flare for some disarticulations  Postoperative Dressing: Soft  Rigid  .

Techniques Goals of Postoperative Management Prompt. uncomplicated wound healing  Control of edema  Control of Postoperative pain  Prevention of joint contractures  Rapid rehabilitation  .

Technique: Example 30 yo male. assault .

Technique: Example ray amputation Be sure to identify all injuries and treat .

Technique: Example 1 year postop .

Technique: Example debridement and preservation of viable structure .

Technique:Example Late reconstruction after initial amputation surgery .

Rehabilitation and Prosthetics .

Maximize Self reliance 6. Maintain joint range of motion 4. Patient education: Future goals and prosthetic options . Residual Limb Shrinkage and Shaping 2.Rehabilitation 1. Limb Desensitization 3. Strengthen residual limb 5.

Psychological Adaptation Amputation represents loss of function. sensation and body image Psychological response is determined by many variables       Psychosocial/Age Personality Coping Strategies Economic/Vocational Health Reason for amputation .

Psychological Adaptation Up to 2/3 of amputees will manifest postoperative psychiatric symptoms Depression  Anxiety  Crying spells  Insomnia  Loss of appetite  Suicidal ideation  .

Immediate Postoperative Hours to days  Safety. Pain. Disfigurement  3. Chronic Infection  Support Groups  2. In-Hospital Rehabilitation 4. Vascular Disease. Preoperative Tumor.Psychological Adaptation: Stages 1. At-Home Rehabilitation .

³numbness´ or denial 2. Disorganization: all hope is lost for recovery of lost part 4.In-Hospital Rehabilitation Initial: concerns about safety. yearning for what is lost 3. Reorganization . pain. disfigurement Later: emphasis shifts to social reintegration and vocational adjustments Grief Response:     1.

Management of Amputee Preparation Good Surgical Technique Rehabilitation Early Prosthetic Fitting Team Approach Vocational and Activity Rehabilitation .

Prosthetics Passive  Cosmetic Harnesses and cables Surface EMG Activation delay Investigational Body Powered  Myoelectric   Neuroprosthetics  .

Rehabilitation Suggested timeline for transradial amputation 1-14 days: immediate postop prosthesis 2-4 weeks: training body powered prosthesis 6-12 weeks: definitive body powered prosthesis 6-12 weeks: training electronic prosthesis 4-6 months: definitive electronic prosthesis .

Merci bien de votre attention! 74 .

the amputation. operator and his assistant. Schott. The four figures are the patient. 1517 A reproduction is reputed to be the first known picture of an amputation. . and probably a priest. priest. J.Hans Von Gersdorff's Feldtbuch der Wundtarzney Strassburg.

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