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3/6/09

DESCRIBE THE INDICATIONS FOR


AND THE STANDARD TYPES OF
AMPUTATION IN THE LOWER LIMBS
BY
DR. OKPALACHUKWU, I

MODERATOR: DR. G.O. EYICHUKWU,


CHIEF CONSULTANT ORTHOPAEDIC
SURGEON NOHE.
OUTLINE:
-INTRODUCTION
-HISTORY
-EPIDEMIOLOGY
-PROBLEMS IN THE SUB REGION
-INDICATIONS (GENERAL)
-CLASSIFICATION
-ANATOMICAL LEVELS
-ELECTION OF LEVEL OF AMPUTATION
-SPECIFIC INDICATIONS FOR EACH LEVEL
-PRINCIPLES OF AMPUTATION IN LOWER LIMB
-QUALITIES OF A GOOD STUMP E.G. B/K
-COMPLICATION
-CONCLUSION
-REFERENCES
INTRODUCTION:
Amputation is the removal of a part or whole of an
appendage or limb. It may be definitive or
provisional, emergency or elective. It is the oldest
surgical procedure, the meanest, yet the greatest life
saving operation.
The increasing incidence of trauma and peripheral
vascular disease as leading indications for
amputation and activities of traditional bone setters
have made amputation yet more important than ever.
With the invention of modern prosthetic devices, the
level may not be necessarily important in election of
the site of amputation, however, the stump must be
of adequate length to fit into prosthesis.
HISTORY:
1700BC Babylonian code of Hammurabi is the
earliest literature discussing amputation.
460-375BC Hippocrates documented earliest
description of therapeutic amputation.
1588 William Cloves did 1st successful A/K
amputation.
1870 Stokes modified Grittis procedure.
World War II- government funding into research
in amputation.
EPIDEMIOLOGY:
.In USA, about 65000 amputations are
performed yearly.
.>90% due to peripheral vascular dz., DM
accounting for 20%.
.Trauma is commoner in the young.
.Male preponderance.
.In 1965, A/K : B/K =70:30
.In 1980, A/K : B/K =30:70
EPIDEMIOLOGY CONT.D
-In our subregion M:F= 2-5:1
-Trauma is the leading cause
-Age incidence 30-40yrs (trauma)
-Peripheral ischaemic vascular dz (DM) is
becoming very common, age incidence
=50-70yrs.
-More lower extremity amputation
-B/K is commoner
-Mishaps from TBS is an avoidable cause.
PROBLEMS IN THE SUB REGION
-Avoidable indications like bone setters
gangrene.
-Increasing influence of trauma-
commercial motor cyclist.
-Difficulty accepting amputation as a life
saving measure- cultural bias, economic
hardship, scarcity and cost of prosthesis.
-Preference to begging than accepting
prosthesis.
INDICATIONS (GENERAL)
-Colloquially, the 3Ds.
1.Dead/dying limb-gas gangrene
-traumatic gangrene
-peripheral vascular dz -ergotism
-crushed devitalised limb
-TBS gangrene
-lethal sepsis
-burns
-frost bite
INDICATIONS CONTD.
2.Dangerous limb- osteosarcoma
-marjolin ulcer
-malignant melanoma
-crushed limb
3.Damn nuisance- persistent pain
-gross malformation
-recurrent sepsis
-gross severe deformity ( elephantoid limb,
neurofibromatosis, A-V fistulas)
CLASSIFICATIONS
-Emergency or Elective
-Definitive /classical/closed or provisional
guillotine/open (circular open/open
amputation with inverted skin flaps)
-End bearing or Non end bearing
-Weight bearing or Non weight bearing.
ANATOMICAL LEVELS:
-Toe amputation meta tarsophalangeal joint
-Trans metatarsal amputation

-Ray amputation- Tarso metatarsal joint


(single toe)
-Lisfrancs amputation Tarso metatarsal
joint of all five toes
-Choparts amputation-mid tarsal joint
-Pirogoffs amputation sub talar joint
-Symes amputation (end bearing) just above the two
malleoli.
-Wagner amputation two stage symes
-Boyds amputation
ANATOMICAL LEVEL CONT.D
-B/K(Transtibial) amputation, 14cm from
knee joint line
-Knee disarticulation (children)
-Gritti-Stokes amputation
-A/K (Transfemoral) amputation, 12cm
from knee joint line
-Disarticulation of hip
-Hemipelvectomy
ELECTION OF LEVELS OF
AMPUTATION:
-HX (Cause - trauma, DM, peripheral
vascular dz. Congenital, tumours- extent
of metastasis ), pre morbid dz- HBP,
Asthma , epilepsy, occupation
-Clinical examination pallor, jaundice,
cardiac and respiratory impairments,
palpable peripheral pulses, skip lesions-
colour, warmth, extent of functional
disability , patients expectation.
ELECTION OF SITE CONT.D
-INVESTIGATIONS: ( To confirm
diagnosis of tumour, extent of metastasis,
and stage:-
-X-RAY of the limb AP/LATERAL
-CXR-PA
-CTscan
-MRI
-BIOPSY
INVESTIGATIONS- To ascertain whether
the stump will heal:-
-Doppler U/S measurement of segmental
blood pressure
-Xenon-133 clearance test
-Transcutaneous O2 tension measurement
-Fluorescence studies
-Arteriography
-Nutrition & immunocompetence studies
INVESTIGATIONS to optimise the patient
for surgery:-
-FBC+ESR
-SEUC
-FBS
-GRP X-MATCH BLOOD
-Lipid profile
-Urinalysis
-Clinical photography
-Informed consent
SPECIFIC INDICATION FOR EACH LEVEL
-Toe amputation- crush injury to the toe
-Trans metatarsal amputation- crush injury to the
toe.
-Ray amputation subungeal melanoma, toe
deformity, commonly done.
-Lisfranc amputation- forefoot crush injury.
-Chopart amputation- forefoot cush injury
-Pirogoffs amputation- no longer done.
-Symes amputation- uses heel as end bearing.
May have problem of blood supply, forefoot
tumours, fore foot crush injury.
SPECIFIC INDICATIONS CONT.D
-B/K-Amputation , 14cm from knee joint line,
most commonly done, has advantage of knee
joint mechanism, better balance, cheaper and
better fitting prosthesis, psychological
advantage. Done for peripheral vascular dz.,
fore foot gangrene, diabetic foot, crush injury
to the foot.
-A/K-amputation, 12cm from the knee joint line.
Done for indications as in B/K, Preferable
when vascular status is in question, lethal
sepsis in the foot/leg, osteosarcoma of tibia.
SPECIFIC INDICATION CONT.D
-Knee disarticulation preferable in
children.
-Gritti- Stokes amputation end bearing.
-Hip disarticulation- extra compartmental
spread of osteosarcoma of tibia.
-Hemipelvectomy rarely done, extra
compartmental osteosarcoma of tibia or
distal femur.
PRINCIPLES OF AMPUTATION IN THE
LOWER LIMB, E.G. B/K
1.Thorough clinical assessment + indication.
2.Election of site.
-3.Anaesthesia, tourniquet?, exsanguination?
3.Informed consent.
4.Skin incision, anterior + posterior or (medial +
posterior ) skin flaps. May be step lather
particularly peripheral vascular insufficiency.
PRINCIPLES CONT.D
5.Muscles cut distal to bone, nerve proximal to
bone, fibula 3cm proximal to tibia, anterior
border of tibia shelved to make better contour.
6.Major vessels doubly ligated (separate) with
silk.
7.Tourniquet off, haemostasis
8.Myoplasty / myodesis
9.Active drain
10.Firm stump bandaging to mould a conical
stump.
PRINCIPLES CONT.D
11. Adequate analgesia, adequate antibiotic,
adequate fluid and electrolyte therapy, T.T
prophylaxis, DVT prophylaxis.
12. Physiotherapy to prevent joint stiffness
13.Prosthesis
14. Occupational advice?
QUALITIES OF A GOOD STUMP e.g.
A/K
-Good blood supply
-Stable scar, not terminal in end bearing,
but anterior/ posterior
-Adequate soft tissue padding
-Adequate length for prosthesis fitting
-No phantom limb pain
COMPLICATIONS:
.EARLY-Flap necrosis
-Haematoma
-Gas gangrene
.LATE-skin eczema/ ulceration
-Stump ulceration
-Nerve neuroma
-phantom limb
-painful phantom limb
-Insecure fitting prosthesis
-Joint stiffness
-Bone spur /osteoporosis
CONCLUSION
Amputation despite its frightening implication,
continues to be the only life saving option to
some patients.
With the increasing violent world and
modernity, amputation continues to assume
important role in surgical practice.
With new prosthetic designs the level of
amputation is no longer important.
-Adequate stump length for prosthesis fitting is
still very important.
THANK YOU.
REFERENCES:
-1.A.H. CRENSHAW, Campbells
operative orthopaedics vol.1,7th ed.,
pp597-626.
-2.LOUIS SOLOMON et al, Apleys
System of Orthopaedics and fractures, 8th
ed., pp267- 271.
-3.JOHN EBNEZAR, Textbook of
Orthopaedics, 3rd ed., pp593-595.
-4.PART I UPDATE, WACS 2008, P.H.

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