AMPUTATION
DEFINITION
· It is the surgical cutting of a limb or outgrowth of the body. The word amputation is reserved for surgical, traumatic and disease-created limb losses.
TWO MAJOR CATEGORIES OF AMPUTATION:
1. Congenital Amputation
Ø Loss of a limb in utero and are believed to result form such stimuli as drug toxicity. There is failure of formation or strangulation of limb buds by the umbilical cord.
2. Acquired Amputation
Ø Loss of a limb as a direct result of trauma or ischemia. It is also
done to revise a congenital limb amputation or alter a deformity secondary to burns or trauma.
AGE BRACKETS:
1. Birth-16 years old = high incidence is possibly related to congenital amputation.
2. 17-55 years old = most common cause is trauma due to injury obtained in work situations and highway traffic.
3. 60-65 years old = highest incidence of amputation due to PVD often associated with diabetes mellitus (60%)
EPIDEMIOLOGY
· 5:1 ratio of lower limb to upper limb amputees, majority are men than women
90% lower extremity
5% - partial foot ankle
50% - below knee
35% - above knee
7-10% - at the hip
· Peripheral Vascular Disease (PVD)
Ø most common cause of LE amputation, especially when associated with smoking and diabetes
Ø 10% upper extremity: less frequent due to a better blood supply
· Trauma
Ø most common cause of upper limb amputation
GENERAL INDICATIONS FOR AMPUTATION:
· Irreparable loss of blood supply in a disease or injured limb
· Injury that is so severe that function would be better after amputation
· To save life when infection is uncontrollable
· To remove part or all of a congenital abnormal limb for cosmesis or improving functions
ETIOLOGY
1. Congenital Anomaly
-refers to the absence or abnormality of a limb evident at birth often of no etiology.
-ex. Polydactyly, congenital absence of a distal part
2. Peripheral Vascular Disease
-buerger’s or arteriosclerosis
-emboli or thrombus may cause a loss of blood supply to extremity resulting to ischemia, ulceration or gangrene requiring amputation
-mostly involve lower limbs and the level of amputation depend on the adequacy of remaining circulation
3. Trauma
-amputation is done where blood supply or tissues are destroyed, gangrene is inevitable or reconstruction is impossible.
-ex. Blast injuries
4. Infection
-in acute or chronic infections that can’t be controlled by medical or ordinary surgical treatment and has local or systemic sequelae
-ex. chronic osteomyelitis, gas gangrene of high virulence
5. Tumor
-for primary malignant tumors not possible to resect or irradiate without heavy risks or recurrence or dysfunction
-w/o metastasis – amputation is curative
-w/ metastasis – it is palliative (relieves pain; prevents hemorrhage & pathological fracture; enhance chemotherapy; improve systemic status)
6. Thermal, Chemical, Electrical Injuries
-excess of these creates severe tissue damage resorting to amputation
CLASSIFICATION OF AMPUTATION LEVELS
UPPER EXTREMITIES LEVELS OF AMPUTATION:
Below – Elbow Amputation (BEA)
| Percentage of Normal | Classification |
| 0-35% | Very short below elbow |
| 35-55% | Short below elbow |
| 55-90% | Long below elbow |
| 90-100% | Wrist disarticulation |
Above – Elbow Amputation (AEA)
|
LOWER EXTREMITIES LEVELS OF AMPUTATION:
Above – Knee Amputation (AKA) & Below – Knee Amputation (BKA)
| Percentage of Normal | Classification |
| <33% | Short AK & BK stump |
| 33-66% | Medium length BK &AK stump |
| >66% | Long AK &BK stump |
PATHOPHYSIOLOGY
ž A severe blow causes destruction of blood vessels and other soft tissues of the limb, amputation is done when useful reconstruction is impossible.
ž PVD, compression of vessels deficiency or decrease of Blood supply, necrosis of tissue
ž Osteosarcoma metastasize is proximal part of the limb causing greater damage, amputation relieve pain, hemorrhage and some pathologic Fx and stops the spreading of the metastasized tumors.
ž Electrical burn (fourth degree) coagulation necrosis resulting to progressive thrombosis w/in blood vessels. necrosis below apparent skin. necrosis of soft tissue and bones.
ž Acute infection –gangrene – loss of blood supply – anoxia – necrosis of tissue
ž Chronic infection (osteomyelitis) – inflammatory pressure inc. w/in the rigidly confined focus of infection- vascular supply compromised – ischemic necrosis, glomerular nephritis and bacterial endocarditis (systemic effects)
CLINICAL MANIFESTATIONS
Ø Skin problems- major percentage of complication.
- Maceration
- Skin ulceration
- Dark pigmentation of the stump
- Stump infection
- Folliculitis
ž Skin hypersensitivity
ž Neuroma
ž Phantom sensation
ž Phantom pain
ž Psychological problems
ž Edema
ž Bone problem
PROGNOSIS:
ž 5 year survival rate – tumor resection followed by limb reconstruction.
ž Poor incident of healing of both the transphalangeal and transmetatarsal level ranging from 40% to 60%
ž Operative mortality for isolated tumor , trauma and infection is < 30%
ž Mortality rates doubles sin pt’s who exhibit sign of arterosclerotic disease and is inc. in two-fold by postoperative complications.
ž Diabetes does not sig. influence mortality rate
ž The higher the amputation the greater the mortality rate.
ž Result of recent series : mortality rate of 3% and failure rate of 49 %
TYPES OF SURGICAL AMPUTATION
1. Open Amputation (Guillotine Amputation)
-often indicated for infection. The fact that the stump is not closed over with a skin flap allows the free drainage of purulent or infectious material. Patient undergoing an open amputation require antibiotic therapy and the use of strict aseptic technique whenever the incision is cleansed and the dressing is changed.
2. Closed Amputation (Flap Amputation)
-amputation in which the stump is closed or covered by a flap of skin sutured over the bone end of the stump. This type of amputation is preferred when there is no evidence of infection and consequently no need for extensive open drainage.
Ø Long Posterior Flap (Burgess Technique) – good for dysvascular BK amputation because posterior tissues have good blood supply.
Ø Equal Anterior and Posterior Flaps (Fishmouth) – placing the scar distal end of the bone.
Ø Skew Flaps – for several compromised distal articulation; is an angular medial-lateral incision that places the scar away the bony prominences.
3. Minor Amputation
-amputation is done through or distal to the metacarpus or the metatarsus.
4. Major Amputation
-amputation is done proximal to the metatarsal or metacarpal bones and they are designed to produce a stump suitable for an artificial limb.
5. Joint Disarticulation
-amputation done at the joint.
ENERGY EXPENDITURES FOR DIFFERENT LEVELS OF AMPUTATION:
| BKA | 10-40% |
| AKA | 65% |
| BKA & AKA | 75% |
| Bilateral BKA | 41% |
| Crutch w/o prosthesis | 60% |
| Wheelchair | 9% |
| Bilateral AKA | 110% |
COMPLICATIONS AFTER AMPUTATION:
1. Skin problems – painful bursae
2. Choke syndrome – distal strangulated limb becomes darken with hemosiderin (necrosis)
3. Skin infections
4. Dermatitis
5. Bone problems
6. Neuromas – end of cut nerve
7. Phantom sensation – sensation of the presence of the amputated part
8. Phantom pain – sensation of the absent limb is painful and disagreeable with strong paresthesia with crumping and squeezing sensation.
PRESSURE SENSITIVE AREA:
1. Fibular head; hamstrings
2. Anterodistal end of the stump
3. Tibial tubercle, crest and distal tibia
PRESSURE TOLERANT AREA:
1. Patellar tendon; pretibial muscles
2. Popliteal area; gastros-soleus; medial tibial flare
LEVELS OF AMPUTATION:
ž Above-elbow stumps – tip of the acromion to the bone ends.
ž Below- elbow stumps – from the medial epicondyle to the end of the ulna or radius.
CLASSIFICATION OF AMPUTATION OF UPPER EXTREMITY:
1. Partial hand amputation
2. Amputation through the wrist
3. Wrist disarticulation
4. Forearm disarticulation
5. Short below elbow amputation
6. Long below elbow amputation
7. Elbow disarticulation
8. Supracondylar amputation
9. Short arm stump
10. Forequarter or interscapulothoracic amputation
11. Cineplastic amputation
AMPUTATION OF LOWER EXTREMITIES:
I. FOOT AND ANKLE
1. Lisfranc’s amputation/disarticulation
-amputation through the tarsometatarsal joint
2. Chopart’s amputation
-through the talonavicular and calcaneocuboid joints
3. Symes amputation
-involves disarticulation of the ankle joints and may include removal of the medial and lateral malleoli and distal tibial/fibular flares
4. Boyd amputation and pirogoff amptutation
-amputation done which include tibio-calcaneal fusion
5. Partial toe
-excision of any part of one or more toes
6. Toe disarticulation
-through the metatarsophalangeal joint
7. Partial foot/Ray resection
-resection of 3rd, 4th and 5th metatarsal and digits
8. Transmetatarsal
-through the midsection of all metatarsals
II. BELOW KNEE AMPUTATION (BKA)
-transtibial amputation
a. short below knee – less than 20% of tibial length
b. long below knee – more than 50% of tibial length
III. AMPUTATION THROUGH OR JUST ABOVE THE KNEE JOINTS
1. Gritti-Stokes
-a supracondylar amputation
2. Kirk’s amputation
-a supracondylar tendoplastic amputation
3. Callander amputation
-suprcondylar amputation with minimum tissue dissection
4. Roger’s amputation
-knee joint disartiulation with arthrodesis
5. Knee disarticulation
-through the knee joint
6. Long above knee
-amputation of more than 60%femoral length
IV. ABOVE KNEE AMPUTATION
- transfemoral amputation most commonly seen in the elderly
- ideal length is 10-12 inches below the greater trochanter
IV. HIP DISARTICULATION
- amputation through the hip joint, pelvis intact
V. HEMIPELVECTOMY(HIND QUARTER ABLATION)
- Resection of lower half of the pelvis and bears weight on soft tissues and chest cage
-
VI. HEMICORPORECTOMY(HUMPY-DUMPY)
- Amputation of both lower limbs and of pelvis below L4/L5 level
INDICATIONS:
ž Improve pt. welfare by removal of a damage, deformed ,dangerous, painful or useless body part.
ž When blood supply of the limb is lost and cannot be restored.
ž Permanent irreparable loss of nerve supply.
MEDICAL MANAGEMENT
ž Skin problems : antiperspirant , iontophoresis w/ copper sulfate or formalin, cornstarch or unscented tale, exposure to air to control sweating
ž Stump infection: antibiotic treatment
ž Phantom pain: mm relaxant or heat, therapeutic modalities, amitryptyline , opioids (morphine, codeine)
ž Psychological problems: limb provision (orthosis), encouragement, education.
SURGICAL MANAGEMENT:
ž Cardinal rules must be “to save all possible bone length, soft tissue and skin. The lower the amputation the better is the function w/ prosthesis.
ž Definitive non-end bearing : done when wt. will not be borne through the end of the stump.
ž Provisional : performed when re-amputation may be necessary when it is anticipated that primarily healing will be unlikely or delayed . Usually infections, amputation is performed as far distally as possible. Leaving skin and mm flaps open.
ž Traumatic amputation – in potentially “dirty” amputations ,incision may be left open with the proximal joint immobilized in a functional position for 5 – 9 days prevent invasive procedure.
ž Vascular disease amputation – is generally considered an electric procedure. The surgeon determine the level of amputation by evaluating tissue viability through a variety of measures.
REHABILITATIVE MANAGEMENT:
ž Good and ideal stump
1. It must be cone and round in shape
2. Not too long ,not too short
3. Sensation is intact, it must be firm
4. (-) dog ears, painless, (-) wound, mobile
5. contracture, (-) edema , good mm tone
ž Functional well-fitted prosthesis
ž Pre operative management – prior to amputation instruct pt to post operative ROM EX. One – handed technique for ADL.
ž Post – operative: purpose shorten the period of stump conditioning and help reduce psychological depression.
POST-OPERATIVE MANAGEMENT:
ž ROM EX
ž Proper skin care technique
ž TENS
ž Hydrotherapy
ž UV lights
ž US
ž Limb load monitor
ž Soft tissue manipulation
ž Application of elastic stump shrinkers or elastic bandage
ž Figure of 8 wrapping technique reapplied every 4 to 6 hours.
REFERENCES:
Physical Rehabilitation(5th ed)
By Susan O’ Sullivan & Thomas Schmitz
Physical Medicine and Rehabilitation by Braddom
Physical Medicine and Rehabilitation by Delisa
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