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.

 Dying (ischaemic).INDICATIONS  Amputation should only if limb is  Dead be considered (gangrenous).  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.

 It is indicated in   Infections and  Severe traumatic wounds with extensive distruction of tissue and gross contamination by foreign material. .  The purpose is to prevent or eliminate infection.Open or Guillotine amputation It is an emergency amputation done as a life saving measure.

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

Two types  Open amputation with inverted skin flaps Circular open amputation  .

 Convoluted scar that results. 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.  Often it is treated by reamputation at a more proximal level. .Circular open amputation   Healing is prolonged. is difficult to manage prosthetically.

 Tissue status evaluation by   Transcutaneous oxygen tension  PO2 >35 mm Hg  Ankle/ brachial pressure index > 0.PREOPERATIVE PREPARATION Patient should be brought to best possible condition to withstand and survive surgical trauma.5 gm/dl and .45  Arteriogram  Immune competence  Serum albumin level should be >3.

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

.  Usually the limb should be exsanguinated except in cases of infection and malignant growths.BASIC PRINCIPLES OF AMPUTATION Tourniquet  Except in ischaemic limbs. the use of tourniquet is highly desirable and makes the amputation easier.

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

healthy and with good circulation. No dog ears.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. folds or puckers No redundant flaps Linear and mobile operative scar .

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    .Skin Flaps  Skin at the end should be mobile and normally sensate.

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

Nerves Nerves are isolated.  .  Strong tension should be avoided. 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.

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

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   .Bone  Excessive periosteal stripping is contraindicated and may result in formation of ring sequestrum.

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Dressings Soft dressings  These are applied snugly and elastic bandage applied over it. Pillows should not be used as this may cause flexion contractures of  .  The stump is elevated by raising the foot end of bed. with care to avoid constriction of stump proximally.

A metal Pylon with prosthetic foot is attached to the stump and properly  .Rigid dressings  This method employs use of POP cast. applied to the stump in the OT at the end of surgery. a true prosthetic cast should be applied.  If weight bearing ambulation is anticipated in the early post operative period.

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. 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.  Promptly. ambulation on attached pylon and prosthetic foot may be initiated  Immediately after surgery. strength and agility of patient and his ability to protect stump from injury .  The choice of optimal time to begin prosthetic ambulation depends on factors including age.

It also improves his muscle strength and mobility of his joints thus preparing him for the more compact permanent prosthesis of future. 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.   .

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 . Acquired : 40% secondary to trauma followed by neoplasm and infection.AMPUTATION IN CHILDREN  Congenital : 60% secondary to congenital limb deficiencies.

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. Additionally prosthetic suspension is improved with a disarticulation secondary to preservation of the metaphyseal flares. Length and physis are preserved without the risk of terminal overgrowth. .

and . The bones most likely to exhibit overgrowth are the humerus.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. fibula. Overgrowth is not seen after about 12 years of age. and several revisions (three or more) may be required during the growing years.

   It may cause swelling. 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 . Terminal overgrowth is treated with surgical resection of the excess bone and its bursa. pain and bursa formation and in severe cases may penetrate the skin.edema.

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

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.Infection  Treated by hot packs. and the .

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

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

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

Neuroma  Forms on the cut end of the nerve.  Treated by  Alterations in prosthetic socket &  Excision of neuroma with division at a more proximal level. Jactitation  Painful contraction of the amputated .  Pain results due to traction on a nerve when neuroma is bound down by scar tissue.

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

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

Final closure of stump. . 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.

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

All types of hemipelvectomy remove the inguinal and iliac lymph nodes.   .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.

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

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

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

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

The larger posterior defect is covered by a quadriceps myocutaneous flap maintained by the superficial femoral artery.  .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.

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

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

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  .

Carry the incision posteriorly across the medial thigh to join the first incision . Start the incision 1 to 2 cm above the anterior superior iliac spine.  . and continue it to just above and parallel to the inguinal ligament to the pubic tubercle. 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 posteriorly and laterally across the greater trochanter to the gluteal crease.

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

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

 In myoplasty. muscle is sutured to soft tissue. 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   . tension myodesis is contraindicated because it may compromise further an already marginal blood supply. Also. such as opposing muscle groups or fascia. In ischemic limbs.

g.   . clean end margins for tumor. level of trauma. A longer residual limb would have a more normal gait appearance. The amputation level also is governed by the cause (e.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. and congenital abnormalities). but stumps extending to the distal third of the leg have been considered suboptimal because there is less soft tissue available for weight bearing..

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. the ideal bone length for a below-knee amputation stump is 12. depending on body height.5 to 17.5 cm. Usually the most satisfactory level is about 15 cm distal to   . The distal third of the leg also has been considered relatively avascular and slower to heal than more proximal levels. In adults.

that retention of the fibular head is desirable because the modern total-contact socket    .5 cm long is less efficient. however.8 cm or less. Stumps lacking quadriceps function are not useful. 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. In a short stump of 8. A stump less than 12. Many prosthetists find.

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

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

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

 C. . Fashioning of posterior myofascial flap.

Suture of myofascial flap to periosteum anteriorly. . D.

 E. . Closure of skin flaps.

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

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    . Within 3 to 4 weeks. The cast can be changed every 5 to 7 days for skin care. 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 rigid dressing can be changed to a removable temporary prosthesis if there are no skin complications.

Transtibial amputation techniques for the ischemic limb are characterized by skin flaps that favor   .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.

 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 . .

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  . 10 to 12.g.. . Also. amputations performed in ischemic limbs are customarily at a higher level (e.

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

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

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

Initial postoperative efforts are centered on skin healing.  If immediate or prompt prosthetic ambulation is not to be pursued. well-padded cast that extends proximally to midthigh and is applied in such a manner as to avoid proximal constriction of the limb. the stump can be dressed in a simple. Good suspension of the cast is essential to  .AFTERTREATMENT  Rehabilitation in patients with ischemic limbs must proceed cautiously because of potential skin healing compromise and accompanying medical conditions.

 The cast should be removed in 5 to 7 days. including cognitive status. a new rigid dressing or prosthetic cast is applied. and coexisting medical .  Success of rehabilitation depends on multiple variables. and if wound healing is satisfactory. condition of the upper extremities and contralateral lower limb. premorbid functional level.

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,

A

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.

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

Femoral condyles are remodelled. Suture the patellar tendon to the     . 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. Smoothly rounded all bony prominences with rasp.Mazet and Hennessy  fish-mouth skin incision.5 cm distal to the same level Patella is desected from its tendon and discard .

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

Approximate the skin edges with interrupted nonabsorbable sutures Kjøble     . With the patient prone on the operating table. Identify and sharply transect the peroneal and tibial nerves so that their cut ends retract well proximal to the end of the stump. Kjøble described modified skin incision that allows greater use of this amputation level in patients with ischemia. 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 . Suture the patellar tendon and the hamstring tendons to each other and to the cruciate ligaments in the intercondylar notch. and divide the popliteal vessels. Doubly ligate.

 Kjøble disarticulation of knee with medial and lateral skin flaps. .

and the bone must be amputated this far proximal to the knee to allow room for the joint. medial transfemoral. long transfemoral. 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. and supracondylar . constant friction knee joint used in most above-knee prostheses extends 9 to 10 cm distal to the end of the prosthetic socket.   . the patient's knee joint is lost. The conventional.TRANSFEMORAL (ABOVE-KNEE) AMPUTATIONS  Amputation levels above the knee can be classified as short transfemoral. In this procedure.

 When the level of amputation is more distal than this. Amputation stumps in which the level of bone section is less than 5 cm distal to the lesser trochanter function as and are prosthetically  . 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.

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

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

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

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

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

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

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  .the patella is sutured in place under the distal end of femur .GRITTI STROKE AMPUTATIONadductor tubercle .   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 .closure done with anterior flap.after removal Femur section at the level of  of the patellar articular surface .

Levels of partial foot amputation .

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 .HINDFOOT AND ANKLE AMPUTATIONS  Amputations around the ankle joint not only must fulfill the requirements of an end-bearing stump.

Syme Amputation  The Syme amputation consists of a bone section at the distal tibia and fibula 0. durable skin of the heel flap provides normal weight bearing skin.6 cm proximal to the periphery of the ankle joint and passing through the dome of the ankle centrally. The tough.  .

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.

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

Division of tibia and fibula just through dome of ankle joint centrally. . G. 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.

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

 A and B. Frontal view of Syme amputation with prosthesis .

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

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 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.

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

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  .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 . that both stages can be safely combined when infection is not adjacent to the heel pad. However.

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 .

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

  .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. 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.

the calcaneus is sectioned vertically. 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. The Pirogoff amputation involves arthrodesis between the tibia and part of the calcaneus. This amputation has no advantage   . Its anterior part is removed.

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

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

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

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

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

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

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

 Second ray amputation with screw fixation to narrow the foot. .

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. Dissect the skin flaps proximally to the    . Fashion a similar plantar flap. but make it slightly longer than the dorsoplantar diameter of the toe at the level of bone section. Amputation of a Toe Fashion a long plantar and a short dorsal skin flap.

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

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

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

This allows for retention of some weight bearing properties. where 1 cm of proximal phalanx allows for some contribution by the flexor hallucis brevis and the plantar fascia.Amputation at the Base of the Proximal Phalanx  Maintaining the base of the proximal phalanx often is preferable to metatarsophalangeal joint disarticulations. especially in the hallux. 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.

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

Disarticulation at metatarsophalangeal joint of great toe . A.

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

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

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

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

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

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SHOULDER DISARTICULATION (DUPUYTREN’S)  This procedure is for nonsalvageable proximal arm injuries or for severe brachial plexopathies and malignant tumours. .

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Transhumeral amputation .

such as fascia and tendons. an amputation at the junction of the middle and . The underlying soft tissues distally consist primarily of relatively avascular structures. In these exceptional circumstances.FOREARM AMPUTATIONS    When circulation in the upper extremity is severely impaired. and the subcutaneous tissue is scant. 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.

 In amputations through the proximal third of the forearm.  From a functional standpoint. even a short belowelbow stump is preferable to an amputation through or above the elbow. preserving the patient's own elbow joint is crucial. .

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

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. 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. This index ray amputation is especially desirable in women for cosmetic reasons.Index Ray Amputation    When the index finger is amputated at its PIP joint or at a more proximal level. any secondary amputation should be through the base of second Metacarpal.

 .  At 24 hrs the drain is removed. Digital motion initiated at 5 to 7 days post operatively.After treatment  The hand is elevated immediately after surgery for 48hours.

 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 proximal phalanx of the middle finger is important functionally.  The 3rd and 4th metacarpal heads are .MIDDLE / RING RAY AMPUTATION  In contrast to the proximal phalanx of the index finger.

 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.

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

 After 2 to 3 weeks rehabilitation is begun to develop abduction and adduction of the rays.After Treatment  The limb is constatntly elevated for 3 to 4 days. .

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.  .

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

GOALS OF PREPROSTHETIC CARE .

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

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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.  Treatment consists of improved hygiene and socket modifications. oily skin. Epidermoid cysts  may develop at the socket brim.

 This problem is preventable through good prosthetic fitting that achieves total contact in the socket.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. Psychosocial maladjustment .

Thank….u .

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