Tbilisi State Medical University

Amputation

Dr. Levan Labauri M.D., Ph.D.

Assistant Professor of Surgery

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 This dramatic picture is a
tribute to St. Damian and
St. Cosmos, the patron
saints of surgeons.

There is a lot happening in this

picture, with the obvious amputation
of the leg
2
The history of human amputation is ancient. Initially
the many thousands of years, limb loss was the result
of trauma or 'nonsurgical' removal.
This was followed by the hesitant beginnings of
surgical intervention, mainly on gangrenous limbs or
those already terribly damaged, which developed
through to surgical amputations around the 15th
century, and the aim of saving a life and achieving a
healed stump.
Improvements in surgical techniques were married
with better haemorrhage control in and with
anaesthesia and efficient infection control.
The 20th century noted marked improvements in
surgical techniques and also a move to increasingly
sophisticated prosthetic limbs. 3
Amputation is derived from the Latin
amputare, to cut away, from amb
(about) and putare (to prune). The
Latin word has never been recorded
in a surgical context, being reserved
to indicate punishment for criminals.
The English word amputation was
first applied to surgery in the 17th
century, possibly first in Peter Lowe's
A discourse of the Whole Art of
Chirurgerie (1597 or 1612), his work
was derived from 16th century
French texts and early English writers
also used the words "extirpation”,
"disarticulation," and
"dismemberment”, or simply "cutting."
but by the end of the 17th century
amputation had come to dominate as
the accepted medical term.
4
Amputation is the removal of a body extremity by trauma or
surgery. As a surgical measure, it is used to control pain or a
disease process in the affected limb, such as malignancy or
gangrene. In some cases, it is carried out on individuals as a
preventative surgery for such problems.

Amputation: Removal of part or all of a body part enclosed by skin.

Amputation:
Amputation removal of the peripherial part of the limb or any other
organ.

Amputation refers to the surgical or traumatic removal of the

terminal portion of the upper or lower extremity.

Hemicorporectomy (translumbar amputation or "halfectomy") is a

radical surgery in which the body caudal to the waist is amputated,
transecting the lumbar spine
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Amputation often saves the life of the patient,
but mutilates him/her. By this reason, surgeon
should do his/her best not only save the life of
the patient, but also create all the possible
conditions for the proper functioning of the
limb.
The indications for the amputation have
markedly restricted recent times. Mentioned
trend is predicted one the one hand by the
advanced development of the battle against the
infection and on the other hand because of the
achievements of reconstructive surgery (tissue
replacement, neurovascular technique etc.).
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 Indications
Severe Mechanical Injury (the tissues
are damaged and major vessels and
nerves are disconnected, when the limb
is avulsed or hanged on the flip);
Limb gangrene (anaerobic infection,
obliterating endarteritis, injuries of the
major vessels, embolism, malignancies,
etc.
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 Contraindications
Shock

The patient should be relieved from the

shock but no more than 2-4 hours
should be spent.

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 According to the terms of
Intervention

Early (Primary & Secondary)

Delayed

Repeated

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 Primary Amputation
During the first 24 h of trauma
acquisition, before the development of
inflamative changes in the site
The wound can be closed by the
primary sutures, primary delayed
closure or secondary sutures.

10
 Secondary Amputation
More delayed terms (after 24 h)
It is applied when in the beginning of the
trauma there is no absolute need for limb
amputation; despite, the applied
treatment is not effective and the life-
threating conditions (such a post-ligation
necrosis, anaerobic infection etc.) may
set on;
Can be done in cases of deep (IV D)
burns and freeze
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 Delayed Amputation
Can be done in cases of prolonged
heeling, when the body is exhausted
and there is the risk of mortality
because of the parenchymal organ
dystrophy

12
Early (primary & secondary)
Can be planned as a preliminary as well
as definite intervention.
The preliminary amputation can be
done simply: with no wound closure
(anaerobic infection); in this case, later
the limb can be amputated (re-
amputation)
Re-amputation can be done in the case
of fallacious stump formation,
(incompatible for prosthesis).
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Prosthesis compatible stump:
Should not be painful;
The sewed bone should be covered by
soft tissues;
The skin and scar should be mobile;
It is preferable the working surface of
the stump be the scar free

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The working surface of the stump
Upper Limb – lateral surface and palm

Lower Limb – anterior surface and

dorsal surface of the foot

The stump surface should be free for the

risk of the development of trophycal
disturbances and ulcers (the adequate
processing of the stump elements –
skin, muscles, bone, nerve)
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The length of the stump is much depend
on the localization of injury;
The damaged limb should be amputated
on the level that will prevent the
spreading of the process over;
The principle of the “tissue economy”
should be considered in any case; in this
respect the exclusion is the anaerobic
infection or obliterating endarteritis (in
such cases the limb should be cur
upper).
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 Fallacious Stump:
No adequate length and shape for
prosthesis;
The muscular strength and movement
diapason is dramatically decreased;
The skin is damaged;
The sensitivity is disturbed
(hyperesthesia, pain);
Crutch ability is important for lower limb
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 Patients’ Position
On back;
The limb is extended;
The target limb is on the right side of
surgeon;
The assisting surgeon is standing
opposite to the operating surgeon.

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 Anaesthesia
General (narcosis)

Local (infiltrative)

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 Tourniquet
Before the amputation and exarticulation
as usual tourniquet should be applied on
the limb;
The limb should be hold up (blood flows
down);
The ends of the tourniquet should be tied
simply;
Tourniquet application is contra-indicates
in cases of anaerobic infection and
obliterating endarteritis. 20
 Amputation
Set

Linteum fissum et bifissum

21
 Incision DIrection
Circular

Oval

Scarp shaped

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According to the stages of the
tissue incision/excision

One moment (guillotine)

Two moment
Three moment (conoid-circular)
Scarp rule
Oval (ellipsoid)

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Upper Extremity Amputation

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 Amputation: Etiology
Trauma
Burns
Peripheral Vascular Disease
Malignant Tumors
Neurologic Conditions
Infections
Congenital Deformities
 Etiology: Trauma
90 % of Upper Extremity Amputation
Male:Female = 4:1
Most Amputations at level of Digit
Major Limb Amputations less common
Revascularization possible for
incomplete amputation
Replantation possible for complete
amputation
Etiology: Trauma
Etiology: Tumor
Etiology: Gangrene
Etiology: Gangrene (cont.)

Radiograph:
Subcutaneous air throughout arm
 Etiology:Failed Forearm
Vascular Repair after trauma
Etiology: Vascular Disease

Ischemia after AV Fistula Procedure

Etiology: Crush
Etiology: Congenital

polydactyly
Etiology: Infarction associated
with IV Drug Abuse
Etiology: Scleroderma
 Amputation: Trauma and
Replantation
Candidates for Replantation after Trauma
 1. Thumb
 2. Multiple Digits
 3. Partial Hand
 4. Wrist or Forearm
 5. Above Elbow
 6. Isolated Digit Distal to FDS insertion
 7. Almost any part in child
Replantation: Multiple Digits
 Surgical Technique: Digit
Replantation
1. Identify Vessels and Nerves
2. Debride
3. Shorten and fix bone
4. Repair Extensor Tendon
5. Repair Flexor Tendon
6. Repair Arteries
7. Repair Nerves
8. Repair Veins
9. Skin Closure (skin graft if necessary)
 Amputation: Replantation
Poor Candidates for Replantation
 1. Severely crushed or mangled parts
 2. Multiple levels
 3. Other serious injuries or diseases
 4. Atherosclerotic vessels
 5. Mentally unstable
 6. > 6 hours ischemic time
 7. Severe contamination
Amputation: Replantation

Mangled and Crushed – Poor Candidate

 Surgical Technique: Major
Limb Replantation
Myonecrosis is greater concern than in digit replant
Immediate shunting to obtain arterial inflow may be
necessary
High Potassium levels (>6.5 mmol/l ) in venous
outflow from amputated part negative prognostic
factor
Sequence of repair similar to digit
 Identify structures, Debride, Rapid bone stabilization,
Vascular repair (artery then veins), Tendons and Nerves
 Upper vs Lower Limb
Upper extremity nonweightbearing
 Less durable skin acceptable
 Decreased sensation better tolerated

 Joint deformity better tolerated

 Late amputations rare

 Transplants now being performed

 Major Limb Replantation

Include Surgical Prep of Legs Rapid Bone Stabilization

for vascular and nerve grafts Ready for Anastomosis
 Amputation: Major Limb
Replantation Outcomes
>2/3 survival rate
Can be a life threatening undertaking
Multiple Surgeries often required
 Late Nerve, Bone, Tendon Surgeries
Function of major upper extremity
replantations superior to prosthetic
function
 Outcomes: Major Limb
Replantation
Comparison of functional results of replantation
versus prosthesis in a patient with bilateral arm
amputation
Peacock, Tsai, CORR, 1987
Major amputation of the UE: Functional Results after
replantation/revascularization in 47 cases
Daoutix et al, Acta Orthop Scand, 1995
Major Replantation versus revision amputation and
prosthetic fitting in the upper extremity: a late
functional outcome study
Graham et al, J Hand Surg, 1998
 Amputation: Technique

Preservation of functional residual limb

length

balanced with

Soft tissue reconstruction to provide a well-

healed, nontender, physiologic residual limb
Technique: Determination of
Level
Zone of Injury (trauma)
Adequate margins (tumor)
Adequate circulation (vascular disease)
Soft tissue envelope
Bone and joint condition
Control of infection
Nutritional status
 Tumor

Forequarter Amputation
Gangrene

Emergent Open Shoulder Disarticulation

 Trauma

High Transhumeral
Nerves Avulsed
from High in Plexus
 Failed Vascular Repair

Transradial
 Levels of Amputation
Wrist Disarticulation vs. Transradial
 Disarticulation offers potential of better active
pronation and suppination of forearm
 Transradial often difficult to transmit rotation
through prosthesis
 Disarticulation poor aesthetically
 Disarticulation more difficult to fit prosthetic
 Transradial needs to be done 2 cm or more
proximal to joint to allow prosthetic fitting
 Transradial usually favored
 Levels of Amputation
Transhumeral vs. Elbow Disarticulation
 Adults: Elbow disarticulation allows
enhanced suspension and rotation control of
prosthesis however retention of full length
precludes use of prosthetic elbow. Long
transhumeral favored
 Pediatrics: Transhumeral amputation
results in high incidence of bony overgrowth.
Elbow disarticulation is level of choice.
Humeral growth slowed after trauma.
 Levels of Amputation
Preservation of Elbow function is a
priority
 Consider replantation/salvage of parts to
maintain elbow function
 4-5 cm of proximal ulna necessary for
elbow function
 For very proximal amputations, it may be
necessary to attach bicep tendon to ulna
 Techniques
Debridement of all Nonviable tissue and
foreign material
Several debridements may be required
Primary wound closure often contraindicated
High voltage, electrical burn injuries require
careful evaluation because necrosis of deep
muscle may be present while superficial
muscles can remain viable
 Techniques
Nerve: Prevent neuroma formation
 Draw nerve distally, section it, allow it to
retract proximally
Skin:
 Opportunistic flaps
 Rotation flaps
 Tension free
 Skin grafts
 Techniques
Bone:
 Choose appropriate level
 Smooth edges of bone
 Narrow metaphyseal flare for some
disarticulations
Postoperative Dressing:
 Soft
 Rigid
 Techniques
Goals of Postoperative Management
 Prompt, uncomplicated wound healing
 Control of edema

 Control of Postoperative pain

 Prevention of joint contractures

 Rapid rehabilitation
Technique: Example

30 yo male, assault
Technique: Example

ray amputation

Be sure to identify all injuries and treat

 Technique: Example

1 year postop
 Technique: Example

debridement and preservation of viable structure

Technique:Example

Late reconstruction after

initial amputation surgery
Rehabilitation and Prosthetics
 Rehabilitation
1. Residual Limb Shrinkage and Shaping
2. Limb Desensitization
3. Maintain joint range of motion
4. Strengthen residual limb
5. Maximize Self reliance
6. Patient education: Future goals and
prosthetic options
 Psychological Adaptation
Amputation represents loss of function,
sensation and body image
Psychological response is determined by
many variables
 Psychosocial/Age
 Personality
 Coping Strategies
 Economic/Vocational
 Health
 Reason for amputation
 Psychological Adaptation
Up to 2/3 of amputees will manifest
postoperative psychiatric symptoms
 Depression
 Anxiety
 Crying spells
 Insomnia
 Loss of appetite
 Suicidal ideation
 Psychological Adaptation:
Stages
1. Preoperative
 Tumor, Vascular Disease, Chronic Infection
 Support Groups

2. Immediate Postoperative
 Hours to days
 Safety, Pain, Disfigurement

3. In-Hospital Rehabilitation
4. At-Home Rehabilitation
 In-Hospital Rehabilitation
Initial: concerns about safety, pain, disfigurement
Later: emphasis shifts to social reintegration and
vocational adjustments

Grief Response:
 1. “numbness” or denial
 2. yearning for what is lost
 3. Disorganization: all hope is lost for recovery of lost
part
 4. Reorganization
 Management of Amputee
Preparation
Good Surgical Technique
Rehabilitation
Early Prosthetic Fitting
Team Approach
Vocational and Activity Rehabilitation
 Prosthetics
Passive
 Cosmetic
Body Powered
 Harnesses and cables
Myoelectric
 Surface EMG
 Activation delay
Neuroprosthetics
 Investigational
 Rehabilitation
Suggested timeline for transradial amputation
1-14 days: immediate postop prosthesis
2-4 weeks: training body powered prosthesis
6-12 weeks: definitive body powered
prosthesis
6-12 weeks: training electronic prosthesis
4-6 months: definitive electronic prosthesis
Merci bien de
votre attention!

74
 Hans Von Gersdorff's
Feldtbuch der Wundtarzney
Strassburg, J. Schott, 1517

A reproduction is reputed to be the first known picture of

an amputation. The four figures are the patient, the
operator and his assistant, and probably a priest.