PRINCIPLES of AMPUTATION

Indications for Amputation
‡ Peripheral vascular disease ‡ Trauma (severe tissue damage) - traumatic amputation ‡ Infection (chronic disabling infection, Gas Gangrene) ‡ Tumours (Malignant) ‡ Nerve injury (trophic ulceration ± insensitive limb) ‡ Congenital anomalies ± (eg. extra digits) ± Gross deformity (dysmelia)

Aims
‡ Return Patient to maximum level of independent function ‡ Ablation of diseased tissue (tumor or infection) ‡ Reduce morbidity & mortality (tumor or infection) ‡ Considered first part of a Reconstruction to produce a physiological end organ .

5cm below knee metre of joint height (12cm) .Surgical Principles ‡ Level ± sites of Election versus sites of Emergency Amputation Levels Transradial (forearm) Optimum Shortest Longest 5cm above junction prox 2/3 & 3cm below biceps distal 1/3 insertion wrist joint 4cm below axillary 10cm above fold olecranon 8cm below pubic 15cm above ramus knee joint Transhumeral middle third (arm) Transfemoral ( middle third thigh) Transtibial (leg) 8cm for every 7.

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‡ Avoid proximal compression of the limb.‡ Aftercare ‡ Good bandaging to mold the stump into Conical shape to accept the prosthesis. ‡ Prevent contracture (by splinting and / or muscle exercises) ‡ Early prosthetic fitting .

‡ Children ‡ ‡ ‡ ‡ Usually for congenital limb deficiencies Try to retain limb if possible Preserve length Disarticulate if possible to preserve growth potential rather than trans-diaphyseal amputation ( bony overgrowth) .

‡ Complications ‡ ‡ ‡ ‡ ‡ ‡ ‡ Haematoma Infection Necrosis of stump end. Contractures (due to muscle imbalance) Neuroma at the cut nerve ending Phantom pain Terminal overgrowth (children) .

the prognosis is unfavorable. .Pain ‡ in the postoperative period must distinguish between normal postoperative (ie. ‡ Surgical pain usually responds well to opioids. and it can be increased with anxiety and stress. electric pain. surgical) pain and phantom limb pain. ‡ phantom pain is quite common initially. ‡ if it is still present at 6 months postsurgery. stinging. ‡ Phantom limb pain usually is like a burning.

‡ Patients usually report that the absent hand/arm/limb is itching. ‡ Phantom sensation is perceived as a "funny" or "different" feeling but usually is not perceived as painful. tickling. ‡ Phantom limb sensation is the sensation that the amputated limb is still present present.‡ Phantom limb sensation also must be differentiated from phantom limb pain. or moving through space. .

‡ The third theory is that there is altered signal transmission and modulation within the somatosensory cortex. . ‡ A second theory is that the spinal cord nerves begin excessive spontaneous firing in the absence of expected sensory input from the limb.Phantom limb pain theories ‡ Three theories as to why patients experience phantom limb pain and sensation exist. ‡ One theory is that the remaining nerves continue to generate impulses.

Telescoping ‡ Another common phenomenon is telescoping. . ‡ A patient might report that it feels like the entire extremity has shrunk so that the hand is now up at the elbow. ‡ This is a normal part of the nerve healing process and usually fades with time. ‡ Telescoping is the sensation that the distal part of the amputated extremity has moved proximally up the arm.

Grasp .) Stump.Most distal part of the prosthesis used to do work (eg.Direct suturing of muscle or tendon to bone ‡ Myoplasty .Suturing muscles to periosteum ‡ Prehensile .The preferred term for the remaining portion of the amputated limb (Stump while still used. hand) ‡ Myodesis . ‡ Terminal device .What do the following terms mean? ‡ Residual limb . is politically incorrect.

‡ Forequarter Amputation ‡ is the removal of the upper limb with the scapula ‡ Mainly for malignancy .

‡ Shoulder ‡ Disarticulation ± divide capsule and muscles ± then reflect the cut ends of all the muscles over the glenoid and suture them there ‡ Proximal amputation ± Resect bone at desired level ± then suture the muscles over the end of the humerus ± Proximal humeral amputations behave like a shoulder disarticulation. but better cosmesis and suspension ± Prostheses provide a function and cosmesis .

‡ Divide the muscles 5 cm below the bony resection.‡ Above Elbow Amputations ‡ Use equal anterior and posterior flaps. ‡ Close flaps over drains . ‡ Suture triceps to anterior muscles ‡ Elbow disarticulation ‡ Leave the articular surface intact and suture tendons of flexors to extensors.

‡ Elbow disarticulation versus Humeral Amputation ± Better suspension with elbow disarticulation but poor cosmesis ± Better function with distal humeral amputation (3.5 cm proximal to elbow) .

‡ Below Elbow Amputations ‡ Try to Preserve Length ‡ Myoplastic closure or suturing flexors to the extensor group .

‡ Krukenberg procedure ‡ Separate radial and ulna rays distally ‡ forming radial and ulna pincers capable of strong prehension and excellent manipulative ability .

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‡ Wrist disarticulation ‡ Preserves forearm rotation ‡ The Flare of distal radius improves prosthetic suspension ‡ Difficult prosthetic fitting due to length ‡ Resect radial and ulna styloids' without damage to distal radio-ulna joint .

.‡ Transcarpal ‡ Use a long palmar and short dorsal fish mouth flap (2:1) ‡ Suture tendons over the ends of the carpus ‡ Hand Amputations ‡ Preserve length. function. sensation ‡ For irreversible Ischemia and tumours.

‡ Finger Amputation ‡ From Distal to PIPJ (terminal phalanx) ‡ To Proximal to base Mc (Whole ray) ‡ Thumb Amputation ‡ Preserve: ± Length as much as possible ± Stability as good as possible ± Sensation ± Mobility ± Cosmesis .

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the function or appearance of a missing limb or body part.PROSTHETICS OF THE UPPER LIMB ‡ What is the difference between a prosthesis and an orthosis? ‡ A prosthesis is a device designed to replace. as much as possible. ‡ An orthosis is a device designed to supplement or augment the function of an existing limb or body part. .

Reasons to apply a prosthesis ‡ traumatic amputation ‡ tumors (osteosarcoma .esp. humerus) amputation ‡ deformity of limb (dysmelia) ‡ shortened upper-limb (phocomelia) ‡ absence of upper-limb (amelia) .

Classification of prosthetics ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ finger partial hand (trans-metacarpal) hand wrist disarticulation (transcarpal) below-elbow (Trans-radial) through elbow above-elbow amputation (Trans-humeral) shoulder disarticulation & forequarter .

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Requirements of a prosthesis ‡ function of ± manipulation ± prehension (grip) ‡ cosmesis ‡ sensory feedback .

‡ Sensory Feedback (Pedretti page 213)
‡ Sensory information perceived is used to manage motor activities and correct errors in movement through Feedback mechanism. ‡ eg. If a wrong word is written visual and proprioceptive feedback signals that an incorrect motor response was made correct it. ‡ Holding objects (errors corrected by feedback)

‡ This is done through :
± Exteroception(external senses- sight, hearing etc.) ± Proprioception (internal sense)
‡ Joint Position Sense (JPS) ‡ Tendon force & Muscle length

characteristics of a successful prosthesis? ‡ A prosthesis must be comfortable to wear, ‡ easy to put on and take off, ‡ light weight and durable (strong), and ‡ cosmetically pleasing. ‡ Furthermore, a prosthesis must function well mechanically and ‡ have reasonable maintenance. ‡ Finally, compliance with a prosthesis largely depends on the motivation of the individual, as ‡ none of the above characteristics matter if the patient will not wear the prosthesis.

What should be considered when choosing a prosthesis?

‡ What is the amputation level? ‡ What is the expected function of the prosthesis? Cosmosis vs Function. ‡ What is the cognitive function of the patient? ‡ What is the patient's vocation (desk job or manual laborer)? ‡ What are the patient's avocational interests (ie, hobbies)? ‡ What is the cosmetic importance of the prosthesis? ‡ What are the patient's financial resources?

deformed.» Continued ‡ Past medical history ‡ Muscle testing ± Good power better function ‡ Sensory testing ‡ Condition of other limb ± Amputated. normal ‡ Skin condition of the amputated limb .

‡ Anatomy ‡ Most important muscles for hand operation located in forearm ± Flexor/Extensor Digitorum (finger muscles) ± Flexor/Extensor Policis (thumb muscles) ± Flexor/Extensor Carpi radialis/ulnaris (wrist muscles) ‡ Intrinsics ± Finger abductors & adductors ± Lumbricals (involved in flexing fingers) .

fine) grip ± tip (pinch) ± Lateral (key holding) ± Pronation/supination ("wrist motion") from rotation of radius about ulna (limited in short stumps) .‡ Movements ± Grips ‡ power grip ± hook ± span ‡ precision (delicate.

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Socket is the part of prosthesis that articulates with the residual limb Materials ‡ thermoplastics preferable for comfort ‡ Low density polyethylene ‡ carbon-fiber for heavy-users Function ‡ transmits forces between the stump & the prosthesis in all planes ‡ may be proximal. distal or total weight-bearing .ELEMENTS OF A PROSTHESIS ‡ 1.

Means of Suspension ‡ suction socket (-ve press.) ‡ suspension belts .‡ 2.

bend) ‡ Hydraulic cylinder ‡ Intelligent prosthesis . Joint mechanism (knee .‡ 3.computer adjusts rate of swing to cadence (steps/min) .

Terminal device (hand / foot) ‡ The continuum of prostheses ranges from being mostly cosmetic on one end to being mostly functional on the other end. but they are often more difficult to keep clean.4. and usually sacrifice some function for increased cosmetic appearance. ‡ Cosmetic prostheses can look extremely natural. ‡ The purpose of most prostheses falls somewhere in the middle. . can be expensive. ‡ Terminal devices generally are broken down into 2 categories: passive and active.

‡ With newer advances in materials and design. . ‡ However.Passive terminal devices ‡ The main advantage of a passive terminal device is its cosmetic appearance. passive terminal devices usually are less functional and more expensive than active terminal devices. a device that is virtually indistinguishable from the native hand can be manufactured.

Active terminal devices ‡ Active terminal devices usually are more functional than cosmetic. ‡ however. active devices that are equally cosmetic and functional should be available. . ‡ Active devices can be broken down into 2 main categories: ± (1) hooks (Captain Hook) ± (2) prosthetic hands which is powered by: » cable or » myoelectric-based devices. in the near future.

cosmetically pleasing. . ‡ The Functional hand prostheses generally can be divided into 2 categories: ± (1) body-powered protheses (cables) and ± (2) myoelectric protheses.prosthetic hands ‡ A prosthetic hand usually is bulkier and heavier than a hook but it is more hook.

Body-powered prostheses (Cables) ‡ Body-powered prostheses (cables) usually are of moderate cost and weight. body-powered prostheses are less cosmetically pleasing than a myoelectric unit. ‡ and they require more gross limb movement. . ‡ However.1. ‡ They are the most durable (strong) prostheses and have higher sensory feedback.

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the patient can initiate palmar tip grasp by contracting residual forearm flexors and ‡ can release by contracting residual extensors.Myoelectric protheses ‡ Prostheses operated by myoelectricity may give more proximal function and increased cosmesis.2. . ‡ With the myoelectric device. but they can be heavy and expensive. ‡ They function by transmitting electrical activity that the surface electrodes on the residual limb muscles detect to the electric motor.

. ± For example.‡ Two types of myoelectric units exist. a strong contraction opens the device. ± The patient uses muscle contractions of different strengths to differentiate between flexion and extension. ‡ The 1-site/2-function device has one electrode for both flexion and extension. and a weak contraction closes it. ‡ The 2-site/2-function device has separate electrodes for flexion and extension.

carrying a briefcase by the handle). 3-jaw chuck pinch): The pad of the thumb is against pads of index and middle finger. ‡ Tripod grip (ie.‡ The major function of the hand that a prosthesis tries grip. grain of rice). palmar grip. ‡ Spherical grip: Tips of fingers and thumb are flexed (eg. screwing in a light bulb or opening a doorknob). turning a key in a lock). ‡ Hook power grip: The distal interphalangeal (DIP) joint and proximal interphalangeal (PIP) joint are flexed with the thumb extended (eg. . ‡ Lateral grip: The pad of the thumb is in apposition to the lateral aspect of the index finger to manipulate a small object (eg. small bead. to replicate is grip The 5 different types of grips are as follows: ‡ Precision grip (ie. pincher grip): The pad of the thumb and index finger are in apposition to pick up or pinch a small object (eg.

The wrist unit can be: ‡ 1.Locking wrist unit ‡ Wrist units with a locking capacity prevent rotation during grasping and lifting.Wrist units ‡ The wrist unit functions as an attachment for the terminal device and can be positioned manually or myoelectrically. ‡ 2.Wrist flexion unit ‡ In a patient with bilateral amputations a wrist flexion amputations. unit can be placed on the longer residual limb to allow midline activities such as shaving or manipulating buttons. ‡ 3. .Quick disconnect wrist unit ‡ This style is configured to allow easy exchange of many terminal devices with specialized functions.

Flexible elbow unit (allow forearm rotation) ‡ When the patient has sufficient voluntary pronation and supination as well as elbow flexion and extension. a rigid elbow hinge provides additional stability. ‡ 1. .Rigid elbow unit ‡ When a patient can achieve little or inadequate pronation and supination but does have adequate native elbow flexion. such as in a wrist disarticulation or a long transradial amputation. such as in a short transradial amputation. a flexible elbow hinge usually works well. ‡ 2.Elbow units ‡ Elbow units are chosen based on the level of the amputation and the amount of residual function.

‡ This is due to a combination of the weight of the prosthetic components. ‡ For this reason. as well as the increased energy expenditure necessary to operate the prosthesis. . function is very difficult to restore.‡ Shoulder and forequarter units ‡ When an amputation is required at the shoulder or forequarter level. some individuals with this level of amputation choose a purely cosmetic prosthesis to improve body image and the fit of their clothes.

‡ However. a patient who needs an upper extremity prosthesis should be seen by the rehabilitation team prior to the surgery prepare him for the matter. . this may not always be possible. and training in activities of daily living (ADL).‡ Preamputation ‡ Ideally. since most upper extremity amputations are traumatic in nature. strengthening. ‡ This allows a chance to evaluate postoperative needs and desires and to begin range of motion (ROM) exercises.

‡ Systemic ± control diabetes ± evaluate cardiac. ‡ Psychological ± early plan for return to function ± preoperative counseling ± amputee support groups ‡ Preoperative Pain Control ± Pain clinic review ± Spinal anaesthesia . renal + cerebral circulation ± Preoperative calorie¶s control in malnourished patient.

‡ Early postsurgery ‡ During this phase. ‡ (2) massage to prevent excessive scar formation. ‡ A skin desensitization program consists of ‡ (1) gentle tapping on the distal portion of the residual limb to mature the site. a program to prepare the residual limb for the prosthesis should be initiated. .

‡ Alternatively. ‡ The prosthesis must be individually fitted to the patient. young patients with traumatic amputations. so when the patient awakes he or she can visualize a limb in place. ‡ Temporary prostheses usually are fitted this early in healthy. One size does not fit all. in which case rehabilitation physicians work integrally with orthopedic specialists and prosthetists (team work) work). .‡ Prosthesis fitting and testing ‡ A temporary prosthesis can be fit in surgery. a prosthesis is not fit until the suture line has completely healed healed. in older patients or in those with vascular disease.

limb is still maturing ‡ A preparatory prosthesis allows the patient to train with the prothesis several months earlier in the process. . the patient ³test drives´ the prosthesis and learns what it can and cannot do. ‡ The advantage to using a preparatory prosthesis is that it is fitted while the residual maturing. ‡ During this period.‡ Prostheses are either preparatory or definitive. ‡ A preparatory prosthesis often allows a better fit in the final prosthesis as the preparatory socket can be used to mold the residual limb into the desired shape.

‡ If a patient is being fitted for a final prosthesis without ever having a preparatory prosthesis. delay fitting for the socket until the residual limb is fully mature (usually 3-4 months).‡ Sometimes a preparatory prosthesis is not feasible because of financial considerations. ‡ In this case. a patient can only be fitted for the definitive (final) prosthesis. .

e. poliomyelitis patients. and Polio.Knee Ankle Foot Orthosis (KAFO) and Ankle Foot Orthosis (AFO) ‡ These splints are used to avoid flexion contractions in the joints of the body. with ‡ A hinge applied on the KAFO (with or without a lock system) is to give a knee the required stability during walking.and foot. Osteo Imperfecta. DropFoot.g. ‡ The KAFO is used for patients who have a weak or very poor knee function. . ‡ There are many diagnosis to prescribe an AFO such as: Clubfoot. in this case the knee.

KAFO -SPLINT KAFO with a Swiss-Lock system AFO (Ankle Foot Orthosis) .

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skin temperature. inaccurate with calcified blood vessels ± Arteriogram . level of dependent redness ± Doppler (U/S)± check limb circulation.Pre-operative Evaluation ‡ Tissue ± Clinical .feel pulses.

‡ Systemic ± control diabetes ± evaluate cardiac. renal + cerebral circulation ± Preoperative calorie¶s control in malnourished patient. ‡ Psychological ± early plan for return to function ± preoperative counseling ± amputee support groups ‡ Preoperative Pain Control ± Pain clinic review ± Spinal anaesthesia .

‡ Skin flaps ± Use defined flaps. with the apex of the fish mouth at the level of the bony resection ± Use any available flaps in trauma to preserve length ± Tailor flaps at least as long as the diameter of the stump .

AE and disarticulations .‡ Muscles ± ± ± ± ± ± Divide ~5 cm distal to level of bone resection Stabilisation of muscle mass by good suturing. Adequate stump padding prevents atrophy (Muscle exercises) improves function Myoplasty = involves suture of flexors to the extensors over bony stump ± Myodesis = direct suture of muscle to bone .most useful in AK.

allow to retract ± Large nerves eg sciatic.‡ Nerves ± Divide cleanly under gentle tension proximal to bone ends . median .ligate due to large contained vessels ‡ Blood vessels ± Large arteries & veins should be doubly ligated and haemostasis achieved prior to closure ‡ Bone ± Avoid excessive periosteal stripping (prevent spur formation) ± Bevel & smooth the bone end .

‡ Closure ± Do not close under tension ± Interrupted sutures preferably ‡ Drains ± are necessary .

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