Amputations

INTRODUCTION: 

Amputation is defined as removal of the limb through a part of the bone.

INCIDENCES:

Age     common in 50 to 70 years age group.

Sex      70% men, 25 % women

Limbs 85% is through the lower limbs, 15 % is through the upper limbs

PRINCIPLES OF AMPUTATIONS:

Closed Amputations: In this the skin is closed primarily after amputation.

Tourniquets: These are desirable except in ischemic limbs.

Level of amputation: As in the past the level of amputation is no longer important, thanks to the modern and sophisticated present day prosthesis.

Skin flaps: Good skin coverage for the amputation site is of vital importance. The skin should be mobile and sensitive. Location of the scar is not important

Muscles: The muscle is divided at least 5 cm distal to the level of intended bone section and sutured.

Open Amputations(Guillotine operation):In this type of amputation the skin is not closed primarily and later it is followed by any one of the closure methods like secondary closure,  reamputation, revision amputation or plastic repair.

INDICATIONS:

Common causes:

In patients less than 50 yrs of age: Trauma due to RTA, industrial accidents, etc. are common in young people. Crush injuries devoid of blood and nerve supply warrant amputations.

More Than 50 years: Diseases like Buerger’s disease, diabetes, atherosclerosis, etc. are common after 50 years .These disease usually lead to gangrene which warrant amputations.

Less common causes:

Infections: Severe infections like gas gangrene, Hansen’s disease, severe osteomyelitis, etc. rarely require amputation and are indicated when all other measures fail.

Malignancy Advanced stages of malignant bone tumors need amputations.

Nerve injuries: A severe anesthetic limb due to extensive nerve injuries requires amputation.

Severe congenital anomalies; Rudimentary limbs, accessory thumb, congenital absence of bones, etc. need amputations

Severe cold or heat: Severe burns or extreme cold, like frostbite, electrical burns, etc. require amputation of the limbs in rare instances.

TYPES OF AMPUTATIONS:

Closed Amputations: This is done most of the times as an elective procedure and may be above knee or below knee, above elbow and below elbow, etc. Here after the amputations, the soft tissues are closed primarily over the bony stump.

Open Amputation: In open amputation, the wound is left open over the amputation stump and is not closed. This is done as an emergency procedure in the face of life-threatening infections. There are two types in this depending upon the skin flaps.

Open amputations with inverted skin flap.

Circular open amputation

In this type of amputation skin is closed at a later date.

AMPUTATION LEVELS:

Aims: The amputation should be carried out at a level which will give a stump of optimum length to facilitate prosthetic fitting at later stages.

Upper limbs:

Shoulder disarticulation

Short above elbow

Standard above elbow

Elbow disarticulation

Very short below elbow

Medium below elbow

Long below elbow

Lower limbs:

Hip disarticulation

Very short above knee

Short above knee

Medium above knee

Long above knee

Very long above knee

Knee disarticulation

Very short below knee

Short below knee.

Ankle Amputation:

Syme’s amputation: Here the level of bone section is 0.6 cm proximal to the ankle joint.

Sarmiento’s amputation: Here the level is 1.3 cm proximal to the joint.

Wagner’s is two-stage Syme’s amputation.

Boyd’s: This consists of talectomy and calcaneotibial arthrodesis.

Pirogoff’s amputation: In this only anterior part of the calcaneum is removed

Foot Amputation:

Amputation of great toes and other toes

Amputation through the metatarsal bones

Lisfranc’s operation: amputation is at the level of the tarsometatarsal joints(lisfranc joint)

Chopart’s operation: Amputation is through the midtarsal joints

COMPLICATIONS :

Haematomas

Infections

Necrosis of the skin flaps

Contractures

Neuromas

Phantom limb sensation

Phantom pain

Causalgia

Jacitations

BELOW KNEE AMPUTATION

This is the most common amputation performed techniques vary in non ischaemic and ischaemic

NON ISCHEMIC LIMBS:

Here the ideal level of amputation is at the musculotendenious junction of the gastronemius because distal to this level the tissue are relatively Avascular and soft tissue padding is scanty. Though soft tissue may heal early, it usually breaks down later due to the prosthetic use and advancing physiologic age.

ISCHEMIC LIMBS:

Here the skins blood supply is better to the posterior than the anterior. Hence a long posterior flap is preferred in ischemic limbs. To preserve vascular connections, unnecessary dissections are avoided. Unlike in non ischemic limbs, amputation is performed at a higher level tension myodesis and myoplasty are contraindicated for fear of damaging the already precarious blood supply.

PHYSIOLINE’S SPECIALIZED PHYSIOTHERAPY HAS VITAL ROLE TO PLAY

At Physioline, all the members of the rehabilitation team work together so as to provide proper care and the therapy in order to:

Relief pain

Restore strength

Muscle reeducation

Restore sensation

Prescription of orthoses  and prostheses

Gait Training

Management of stump: Stump cleanliness

Stump conditioning

 

Kindly contact PHYSIOLINE for further consultation and rehabilitation