DETAILS REGARDING AMPUTATION FOR MBBS LEVEL

1. AMPUTATION
DR.SUNIL KUMAR
ASST.PROFESSOR
DEPT.OF GEN.SURGERY
MNR MEDICAL COLLEGE ,SANGAREDDY

2. Considered when part of a limb is
• Dead
• Deadly
• Or a dead loss.
• A limb is dead when arterial occlusive disease
is severe enough to cause infarction of
macroscopic portions of tissue, i.e. gangrene.

3. • The occlusion may be in major vessels
1.atherosclerotic
2.or embolic occlusions
or in small peripheral vessels
– Diabetes,
– Buerger’s disease,
– Raynaud’s disease,
– Inadvertent intra-arterial injection.
• If the obstruction cannot be reversed and the
symptoms are severe,amputation is required.

4. • A limb is deadly when the putrefaction and infection of
moist gangrene spreads to surrounding viable tissues.
• Cellulitis and severe toxaemia are the result.
• Amputation is required as a lifesaving operation.
• Antibiotic cover should be broad and massive.
• Other life-threatening situations for which amputation
may be required include
– gas gangrene (as opposed to simple infection),
– neoplasm (such as osteogenic sarcoma)
– and arteriovenous fistula

5. • A limb may be deemed a dead loss in the
following circumstances:
• first, when there is relentless severe rest pain
without gangrene and reconstruction is not
possible – amputation will improve quality of life;
• second, when a contracture or paralysis makes
the limb impossible to use and renders it a
hindrance;
• and third, when there is major unrecoverable
traumatic damage
• (Summary box 56.3).

7. Distal and transmetatarsal
amputation
• In patients with small-vessel disease, typically
caused by diabetes,gangrene of the toes may
occur with relatively good blood supply to the
surrounding tissues.
• Local amputation of the digits can result in
healing.
• If the metatarsophalangeal joint region is
involved, a ray excision is required, taking part
of the metatarsal and cutting tendons back.

8. • Leave the wound open.
• Early mobility aids drainage provided that
cellulitis is not present.
• For less extensive gangrene, if amputation is
taken through a joint, healing is improved by
removing the cartilage from the joint surface.
• A transmetatarsal amputation may be required
when several toes are affected, but the proximal
circulation is adequate.
• The wound may be closed with a viable long
plantar flap (Figure 56.32) or left open.

10. Major amputation
Choice of operation
• The major choice is between an above- or
below-knee operation.
• A below-knee amputation preserves the knee
joint and gives the best chance of walking
again with a prosthesis.
• However, an above-knee amputation is more
likely to heal and may be appropriate if the
patient has no prospect of walking again.

11. • If the femoral pulse is absent, the amputation
should be above the knee.
• Unfortunately, the presence of a femoral pulse
does not guarantee healing of a below-knee
amputation and sometimes a failed below-
knee amputation may require revision to an
above knee procedure.

12. • For above- or below-knee amputations with a
good stump shape, it is possible to hold a
prosthesis in place simply by suction,without
any cumbersome and unsightly straps.
• The stump should be of sufficient length to
give the required leverage, i.e. not less than 8
cm below the knee (preferably 10–12 cm) and
not less than 20 cm above the knee.

13. BELOW-KNEE AMPUTATIONS
Two types of skin flap are commonly used:
– long posterior flap
– and skew flap (described by KP Robinson).
• For both methods, the total length of flap
must be at least one and a half times the
diameter of the leg at the point of bone
section.

14. • The long posterior flap technique is the older
method and remains the more popular probably
because of its relative simplicity (Figure 56.33).
• Anteriorly, the incision is deepened to bone and
the lateral and posterior incisions are fashioned
to leave the bulk of the gastrocnemius muscle
attached to the flap, muscle and skin being
transected together at the same level.

15. • If bleeding is inadequate, the amputation is
refashioned at a higher level.
• Blood vessels are identified and ligated.
• Nerves are not clamped, but pulled down
gently and transected as high as possible.
• Vessels in nerves are ligated.

16. • The fibula is divided 2 cm proximal to the level
of tibial division using bone cutters.
• The tibia is cleared and transected at the
desired level, the anterior aspect of the bone
being sawn obliquely before the cross-cut is
made.
• This, with filing, gives a smooth anterior bevel,
which prevents pressure necrosis of the flap.

17. • The long muscle/skin flap is tapered after
removing the bulk of the soleus muscle (much
of the gastrocnemius may be left, unless it is
very bulky).
• The area is washed with saline to remove
bone fragments and the muscle and fascia are
sutured with an absorbable material to bring
the flap over the bone ends.

18. • A suction drain is placed deep to the muscle
and brought out through a stab incision in the
skin.
• The skin flap should lie in place with all
tension taken by the deep sutures.
• Interrupted skin sutures are inserted. Gauze,
wool and crepe bandages are usually used for
the stump dressing.

19. • The skew flap amputation makes use of
anatomical knowledge of the skin blood
supply.
• Equally long flaps are developed; they join
anteriorly 2.5 cm from the tibial crest,
overlying the anterior tibial compartment, and
posteriorly at the exact opposite point on the
circumference of the leg.

20. • After division of bone and muscle in a fashion
similar to that described above, the
gastrocnemius flap is sutured over the cut
bone end to the anterior tibial periosteum
with absorbable sutures.
• Finally, drainage and skin sutures are inserted
and the limb dressed as for the long posterior
flap operation.

21. ABOVE-KNEE AMPUTATION
• The site is chosen as indicated above, but may
need to be higher if bleeding is poor on
incision of the skin.
• Equal curved anterior and posterior skin flaps
are made of sufficient total length.
• Skin,deep fascia and muscle are transected in
the same line.

22. • Vessels are ligated.
• The sciatic nerve is pulled down and
transected cleanly as high as possible and the
accompanying artery ligated.
• Muscle and skin are retracted and the bone
cleared and sawn at the point chosen.
• Haemostasis is achieved.

23. • The muscle ends are united over the bone by
absorbable sutures incorporating the fascia.
• A suction drain deep to the muscle is brought
out through the skin clear of the wound.
• The fascia and subcutanous tissues are further
brought together so that the skin can be
apposed by interrupted sutures.
• Gauze, wool and crepe bandages form the
stump dressing.

24. POSTOPERATIVE CARE OF AN AMPUTEE
• Opiate pain relief should be given regularly.
• Care of the good limb must not be forgotten
as a pressure ulcer on the remaining foot will
delay mobilisation, despite satisfactory
healing of the stump.
• Exercise and mobilisation are of the greatest
importance.

25. • After surgery, flexion deformity must be
prevented and exercises started to build up
muscle power and coordination.
• Mobility is progressively increased with
walking between bars and the use of an
inflatable artificial limb, which allows weight-
bearing to be started before a pylon or
temporary artificial limb is ready (Figure
56.34).

27. • Early assessment of the home is part of the
programme;it allows time for minor
alterations, such as
– the addition of stair rails,
– movement of furniture to give support near doors
– and provision of clearance in confined passages.

28. COMPLICATIONS
• Early complications include
– haemorrhage (which requires return to the
operating theatre for haemostasis),
– haematoma (which requires evacuation)
– and infection (usually in association with a
haematoma).
• Any abscess must be drained and appropriate
antibiotics given.

29. • Gas gangrene can occur in a mid-thigh stump
from faecal contamination.
• Wound dehiscence and gangrene of the flaps are
caused by ischaemia; a higher amputation may
be necessary.
• Amputees are at risk of
– deep vein thrombosis
– and pulmonary embolism in the early postoperative
period and prophylaxis with subcutaneous heparin is
essential.

30. • Later complications include
– pain resulting from
– unresolved infection
• sinus
• osteitis,
• sequestrum
– , a bone spur,
– a scar adherent to bone
– and an amputation neuroma.

31. • Patients frequently remark that they can feel
the amputated limb (phantom limb) and
sometimes remark that it is painful (phantom
pain).
• The surgeon’s attitude should be one of firm
reassurance that this sensation will almost
certainly disappear with time; amitriptyline or
gabapentin may help.

32. • Other late complications include
– ulceration of the stump because of pressure
effects of the prosthesis or increased ischaemia.

37. THANK YOU