AMPUTATION

Amputation is a procedure where a part of the limb is removed through one or

more bones. It should be distinguished from disarticulation where a part is
removed through a joint.

INDICATION;

 Injury
 Peripheral vascular disease including diabetes
 Tumors
 Nerve Injury
 Congenital anomalies
 Infection (gangrene)

TYPES;

1. Guillotine or Open Amputation

This is where the skin is not closed over the amputation stump, usually when
the wound is not healthy.

The operation is followed, after some period, by one of the following

procedures for constructing a satisfactory stump:

 Secondary closure: Closure of skin flap after few days

 Plastic repair: Repair of soft tissues without cutting the bone and the
skin flaps are closed
 Revision of the stump: Terminal granulation and scar tissue as well as
a moderate amount of bone is removed and the stump is reconstructed.
 Re-amputation: This is amputation at a higher level, as if an
amputation is being performed for the first time.

2. Closed amputation
This is where the skin is closed primarily (e.g., most elective amputations).

Surgical principles for closed type;

Amputation surgery is a very important step in the rehabilitation of an amputee,
and must be approached as a plastic and reconstructive procedure. Following
are some of the basic principles to be followed meticulously:
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. Principles guiding the level
of amputations are as follows:

• The disease: Extent and nature of the disease or trauma, for which amputation
is being done, is an important consideration.

• Anatomical principles: A joint must be saved as far as possible. These days, it

is possible to fit artificial limbs to stumps shorter than ‘ideal’ length, as long as
the stump is well healed, non-tender and properly constructed.

• Suitability for the efficient functioning of the artificial limb: Sometimes, length
is compromised for efficient functioning of an artificial limb to be fitted on a
stump. For example, a long stump of an above knee amputee may hamper with
optimal prosthetic fitting.

Skin flaps: The skin over the stump should be mobile and normally sensitive,
but atypical skin flaps are preferable to amputation at a more proximal level.

Muscles: Muscles should be cut distal to the level of bone. Following methods
of muscle sutures have been found advantageous:

• Myoplasty i.e., the opposite group of muscles are sutured to each other.

• Myodesis i.e., the muscles are sutured to the end of the stump

Nerves are gently pulled distally into the wound, and divided with a sharp knife
so that the cut end retracts well proximal to the level of bone section.

Major blood vessels should be isolated and doubly ligated using non-
absorbable sutures.

Bone level is decided as discussed earlier. Excessive periosteal stripping

proximally may lead to the formation of 'ring sequestrum' from the end of the
bone.
Drain: A corrugated rubber drain should be used for 48-72 hours post-
operatively.

After treatment: Treatment, from the time amputation is completed till the
definitive prosthesis fitted, is important if a strong and maximally functioning
stump is desired. Following care is needed:

 Dressing: There are two types of dressings used after amputation surgery:
(i) conventional or soft dressing; and (ii) rigid dressing.
 Positioning and elevation of the stump: This is required to prevent
contracture and promote healing.
 Exercises: Stump exercises are necessary for maintaining range of motion
of the joint proximal to the stump and for building up strength of the
muscles controlling the stump.
 Wrapping the stump helps in its healing, shrinkage and maturation. This
can be done with a crepe bandage.
 Prosthetic fitting and gait training: This is started usually 3 months after
the amputation.

COMPLICATIONS

1) Haematoma: Inadequate haemostasis, loosening of the ligature and

inadequate wound drainage are the common causes.
2) Infection: The cause generally is an underlying peripheral vascular
disease, diabetes or a haematoma. A wound should not be closed
whenever the surgeon is in doubt about the vascularity of the muscles or
the skin at the cut end. Any discharge from the wound should be treated
promptly.
3) Skin flap necrosis: A minor or major skin flap necrosis indicates
insufficient circulation of the skin flap. It can be avoided by taking care at
the time of designing skin flaps that as much subcutaneous tissues remain
with the skin flap as possible.
4) Deformities of the joints: These results from improper positioning of the
amputation stump, leading to contractures.
5) Neuroma: A neuroma always forms at the end of a cut nerve. In case a
neuroma is bound down to the scar because of adhesions, it becomes
painful. Painful neuroma can usually be prevented by dividing the nerves
sharply at a proximal level and allowing it to retract well proximal to the
end of the stump, to lie in normal soft tissues.
6) Phantom sensation: All individuals with acquired amputations
experience some form of phantom sensation, a sensation as if the
amputated part is still present. This sensation is most prominent in the
period immediately following amputation, and gradually diminishes with
time.
7) Causalgia: It is due to division of the peripheral nerves. Even local
stimulus stimulates pain.