Amputation and Different Types in Orthopedics

What is Amputation?

Amputation is a surgical procedure in which a damaged or diseased body part is removed, often involving the cutting through one or more bones.

Disarticulation: Disarticulation is Surgical ablation of the body part through the joint.

Indications of Amputation 

• Peripheral vascular disease - Most common indication
• Trauma
• Burns
• Infection
• Tumors

Principles of Amputation 

1. Decide the level of amputation and desired length of the stump.
2. Separate ligation and coagulation of arteries and veins, respectively, to avoid AV fistula.
3. Usage of Tourniquet
   • Except for an ischemic limb.
   • Tourniquet is desirable in trauma and makes amputation easier.
4. Dealing with the Nerves
   • Nerves should be pulled.
   • Should be cut at the highest level possible to prevent neuroma.
5. Bones ends should be rounded.
6. Myoplasty: Transected muscle is sutured to soft tissue such as the opposing muscle group of fascia.
   • Myoplasty is Preferred in:
     • Young individuals
     • Ischemic limb
   • Muscles are usually divided at least 5 cm distal to the intended bone resection.
7. Myodesis
   • Transacted muscle groups are sutured to bone under physiological tension.
   • Purpose:
     • Provide stronger insertion
     • Maximize strength
   • Minimize atrophy
   • Contraindicated in:
     • Young individuals
     • Ischemic limb
8. An ideal stump required for optimal outcomes.
   • Above knee: 23 cm or 9 inches from hip joint
   • Below knee: 14 cm and 5.5 inches from knee joint

Pre-OP Assessment

• Assess the nutritional status
• Assess the limb perfusion
• Serum albumin should be at least 3.5 g/dl
• Total lymphocyte count > 1500/ml
• Hb > 10 mg/dl
• Strict diabetic control
• Assess the proximal joint function
• Preoperative counselling - The most important

Intra-OP Principles

• Avoid excessive pressure on skin edges - To avoid skin necrosis.
• Take thick skin flap
• Remove bony prominence
• Control haemostasis
• Closure should be done without tension at the margins
• Persevere as much length as possible

Post-OP Care 

• Dressing should be done with
  • Hydrocolloid
  • Hydrogel
  • Alginate
  • Allomatrix (biological)
• Vacuum-assisted closure (VAC) in large wounds
• Measures to prevent contracture

Goals of Amputation 

• Ablation of diseased tissue
• Reconstruction
• Providing a physiological end organ
• Optimizing patient's function
• Reducing morbidity

Complications of Amputation 

• Haematoma
• Skin necrosis
• Stump edema
• Contracture
• Neuroma
• Phantom limb (Due to the un-ablation of cortical representation)
• Phantom pain (It may be constant or intermittent)
• Muscle wasting
• Psychological trauma

Phantom limb

• Due to the un-ablation of cortical representation.
• Automatically disappears with time.

Phantom pain

• Painful, disagreeable sensation with strong paraesthesia in an absent limb.
• It may be constant or intermittent.

Cause

• Destruction of sensory fibers resulting in decreased inhibitory control by the reticular activating system (RAS)

Treatment

• Early fitting of a prosthesis
• Drugs: Carbamazepine, Beta-blockers, Amitriptyline
• Sympathectomy
• Subcortical neurectomy
• Anterolateral cordotomy
• Electrical stimulation of dorsal column

Upper Limb Amputation

Forequarter amputation

• Forequarter amputation is done at the level of the shoulder.
• Both the shoulder blade and collarbone are removed.
• Usually done for tumors in the proximal humerus.

Shoulder disarticulation

• Shoulder disarticulation is Done at the level of the shoulder.
• Shoulder blade and clavicle are not removed.

Transhumeral amputation

• Above elbow amputation
• Amputation of upper arm - From elbow to the shoulder.
• Ideal stump length: 20 cm or 8 inches from the shoulder.

Transradial amputation

• Below elbow amputation.
• Amputation at forearm from elbow to wrist.
• Ideal stump length: 18 cm or 7 inches from the elbow.

Wrist disarticulation: 

• Amputation at the level of the wrist.

Hand and partial hand amputations: 

• Finger, thumb, or portion of hand below wrist.

Lower Limb Amputation

• Hemipelvectomy: Similar to forequarter amputation.
• Hip disarticulation: Similar to shoulder disarticulation.
• Above knee amputation: 23 cm or 9 inches from hip joint.
• Through knee amputation, aka disarticulation of the knee.
• Below knee amputation: 14 cm or 5.5 inches from knee joint.
• Ankle disarticulation
• Partial foot amputation
  • Chopart's amputation
  • Lisfranc amputation
  • Pirogoff amputation
  • Syme's amputation
  • Boyd's amputation

Chopart's Amputation

• Named after Francois chopart.
• Disarticulation of talonavicular and calcaneocuboid joints.
• Disadvantage: Equinovarus deformity.

Lisfranc Amputation

• Tarso-metatarsal disarticulation.
• Disadvantage: Severe equinovarus deformity

Pirogoff Amputation

• Named after Nikolay Ivanovich Pirogoff.
  • Introduced in 1854.
  • Heel is preserved and used as a base.
• Parts removed are
  • Forefoot
  • Midfoot
  • Talus
  • Distal part of calcaneus
  • Distal tibial articular cartilage

Syme's Amputation

• Through the ankle 0.6 cm above the talar dome.
• Most widely used amputation
• Heel pad and part of the calcaneus are present in Pirogoff's amputation whereas absent in Syme's amputation.

Boyd's Amputation

• Done by creating an arthrodesis between the distal tibia and tuber of calcaneus after talectomy.
• Involves
  • Talectomy
  • Excision of the anterior part of calcaneus distal to the peroneal tubercle forward shift of calcaneus and calcaneotibial arthrodesis by using Steinman pin.
• Advantages
  • Provides a broad weight-bearing surface of the heel.
  • Eliminates the problem of posterior migration of the heel pad that occurs after Syme's amputation.
  • Provides more length and better weight-bearing.

Points to Remember

• Peripheral vascular disease  is the most common  indication.
• Separate ligation and coagulation of arteries and veins, respectively, to avoid AV fistula.
• Myoplasty is Preferred in:
  • Young individuals
  • Ischemic limb
• Shoulder blade and clavicle are not removed in shoulder disarticulation
• Chopart's Amputation is disarticulation of talonavicular and calcaneocuboid joint

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