AMPUTATIONS

INTRODUCTION
• Amputation is the loss or removal of a body part such as a
finger, toe, hand, foot, arm or leg.
• It can be a life changing experience affecting ability to move,
work, interact with others and maintain independence.
• Amputation can be traumatic (due to an accident or injury) or
surgical (due to any of multiple causes such as blood vessel
disease, cancer, infection, excessive tissue damage,
dysfunction, pain, etc.)
• A portion of the body could also be missing before birth,
called congenital amputation.
• Healing, recovery and rehabilitation from a major amputation
require a multidisciplinary approach.
• Amputation of lower limb is more commonly performed than
that of upper limb; however, partial amputation of fingers or
hand is common in developing countries, mainly as a
sequelae of farm and machine injuries.
AMPUTATION
• Amputation is a procedure where a part of the limb is
removed through one or more bones.
DIAARTICULATION
• Amputation should be distinguished from disarticulation
where a part is removed through a joint.
INDICATIONS
• Overall, injury is the commonest cause of amputation in
developing countries.
• The injury may be sustained in traffic accidents, in
agriculture fields during harvesting season, in riots etc.
• Upper limb amputations occur commonly by kutti chopper or
thresher machines.
• Train accidents, at a level railway crossing, unaware of a
coming train, is a common cause of lower limb amputation.
• Indications for amputation vary in different age groups.
• In the elderly (50-75 years), peripheral vascular disease with
or without diabetes is the main cause. In younger adults (25-
30 years), amputation is most often secondary to injury or its
sequelae.
• In children, limbs may be deficient since birth. Amongst the
acquired causes, injury and malignancy top the list.
TYPES
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 flaps after a few days.
Plastic repair. Soft tissues are repaired without cutting the
bone and skin flaps are closed.
• Revision of the stump: Terminal granulation tissue and scar
tissue, as well as a moderate amount of bone is removed and
the stump reconstructed.
• Re-amputation: This is amputation at a higher level, as if an
amputation is being performed for the first time.
Closed Amputation
• This is where the skin is closed primarily
SURGICAL PRINCIPLES-FOR CLOSED
TYPE
• 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.
• A device, such as a strip of cloth or a band of rubber, that is
wrapped tightly around a leg or an arm to prevent the flow of
blood to the leg or the arm for a period of time.
• A tourniquet may be used when drawing blood or to stop
bleeding after an injury.
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. One tends to be conservative with dry-
gangrene (vascular) and trauma, but liberal with acute life
threatening infections and malignancies.
• 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. These are contraindicated in
peripheral vascular diseases.
• 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.
• Large nerves such as the sciatic nerve contain relatively large
vessels and should be ligated before they are divided.
• Major blood vessels should be isolated and doubly ligated
using non-absorbable sutures. The tourniquet should be
released before skin closure and meticulous haemostasis
should be secured.
• Bone level Excessive periosteal stripping proximally may
lead to the formation of 'ring sequestrum' from the end of the
bone. Bony prominences which are not well padded by soft
tissues should be resected. Sharp edges of the cut bone
should be made smooth.
• 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.
• The latter has been found to be advantageous for wound
healing and early prosthetic fitting.
• SOFT DRESSING: This is conventional dressing using
gauge, cotton and bandage.
• RIGID DRESSING: In this type of dressing, after a
conventional dressing, a well moulded PoP cast is applied on
to the stump at the conclusion of surgery. This helps in
enhancing wound healing and maturation of the stump. In
addition, the patient can be fitted with a temporary artificial
limb with a prosthetic foot (pilon) for almost immediate
mobilisation.
• 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.
Upper limb
Forequarter amputation
• Scapula+lateral ½ of clavicle whole of the upper limb

Shoulder disarticulation
• Removal through the gleno humeral joint
Above elbow
• Through the arm amputation

Elbow disarticulation
• Through the elbow
Below elbow
• amputation Through the forearm bones Through the radio-
carpal joint

Wrist disarticulation Ray amputation

Hip disarticulation
• Through the hip
Above knee
• Through the femur amputation

Knee disarticulation
• Through the knee
Below knee
• Through the tibia-fibula amputation

Syme's amputation
• Through the ankle joint
Chopart's amputation
• talo-navicular joint

Lisfrane's amputation
• Through inter-tarsal joints
COMPLICATIONS
1. Haematoma:
• Inadequate haemostasis, loosening of the ligature and
inadequate wound drainage are the common causes.
• Haematoma results in delayed wound healing and infection.
It should be aspirated and a pressure bandage given.
2. Infection:
• The cause generally is an underlying peripheral vascular
disease, diabetes or a haematoma.
• Wound breakdown and occasionally spread of infection
proximally may necessitate amputation at a higher level.
• 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.
• Small areas of flap necrosis may heel with dressings but for
larger areas, redesigning of the flaps may be required.
4. Deformities of the joints:
• These results from improper positioning of the amputation
stump, leading to contractures.
• A mild or moderate contracture is treated by appropriate
positioning and gentle passive-stretching exercises.
• Severe deformity may need surgical correction.
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. If it does form, it is to be excised at a more proximal
level.
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.
Phantom pain is the awareness of pain in the amputated limb.
PROSTHESES IN ORTHOPAEDIC
PRACTICE
• Prosthetics is a unit of rehabilitation medicine dealing with
the replacement of whole or a part of a missing extremity
with an artificial device. The device so manufactured is
called a prosthesis.
Uses of prostheses:
• A prosthesis may be used to replace a body part externally
(e.g., an artificial limb) or internally (e.g., an artificial hip
joint).
• A prosthesis can be: (i) cosmetic-to provide normal
appearance or (ii) functional-to provide function of the
missing part.
• The prosthesis does not have sensation, proprioception or
muscle power.
• The power is provided to a prosthesis by forces arising from
movement of the residual or other side limb.
• These are called body powered prostheses; in others an
external source of power, usually rechargeable batteries is
used.
Parts of a prosthesis:
• The prosthesis consists of a socket, designed to be in close
contact with the stump; a suspension to hold the socket to the
stump; a prosthetic extension with substitue joints; and a
terminal device.
• The sockets are shaped according to the shape of the stump.
These could be end bearing sockets-where end of the stump
bears the weight, or total contact socket-where the weight is
distributed evenly throughout the surface of the socket.
• The socket is the fundamental component to which the
remaining components are attached.
• Most sockets are double-walled.
• A plaster cast moulding of the stump is used to fabricate the
socket for optimal fit, function and comfort.
• Traditionally, the terminal device of a lower limb prosthesis
is a prosthetic foot, called SACH foot.
• It is a simple device that has a wooden core surrounded by a
solid rubber foot.
• This permits a combination of stiffness with pliability.
• The cushioned heel absorbs the impact of heel strike.
Commonly used prostheses
Above-knee amputation
• Quadrilateral socket prosthesis
Below-knee amputation
• PTB (Patellar Tendon Bearing) prosthesis
Syme's amputation
• Canadian Syme's prosthesis
Partial foot amputation
• Shoe fillers
ORTHOSES IN ORTHOPAEDIC
PRACTICE
• Orthotics is the unit of rehabilitation which deals with
improving function of the body by the application of a device
which aids the body part The device so manufactured is
called an orthosis.
• Orthoses can be divided into static and dynamic types.
• Static orthoses are used: (i) to support an arthritic joint or a
fractured bone; (ii) to prevent joint contractures in a paralytic
limb; and (iii) for serial splinting of a joint to correct
contracture.
• Dynamic orthoses are used to apply forces to a joint which is
damaged by arthritis or when the muscles that normally
control the joint are weak.
COMMONLY USED ORTHOSIS
• AFO Ankle Foot Orthosis(previously called below-knee
caliper)
• KAFO Knee-Ankle-Foot Orthosis(previously called above-
knee caliper)
• HKAFO Hip-Knee-Ankle-Foot Orthosis(previously called
above-knee caliper with pelvic band)
• KO Knee Orthosis (previously called knee brace)
• CO Cervical Orthosis(previously called cervical collar)
• WHO Wrist Hand Orthosis
• CTLSO(previously called cock up splint)
• Cervico-Thoraco-Lumbo-Sacral Orthosis
• FO Foot Orthosis(previously called body brace)(previously
called surgical shoes)
USES OF ORTHOSES
Orthoses are used for the following functions:
• To immobilize a joint or body part e.g., a painful joint
• To prevent a deformity e.g., in a polio limb
• To correct a deformity e.g., in Volkmann's contracture
• To assist movement e.g.. in a polio limb.
• To relieve weight bearing e.g., in an un-united fracture
• To provide support e.g., to a fractured spine Some common
clinical conditions requiring orthoses are cervical spondylosis
or whiplash injury (common cervical collar or cervical
orthosis) wrist drop (WHO), foot drop (AFO), poliomyelitis
(orthosis depending upon muscle power), rheumatoid
arthritis, and spinal injury.