Tbilisi State Medical University

Amputation
Dr. Levan Labauri M.D., Ph.D.
Assistant Professor of Surgery
1

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: 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
5

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
6
etc.).

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.
7

Contraindications
Shock
The patient should be relieved from the
shock but no more than 2-4 hours
should be spent.

According to the terms of

Intervention
Early (Primary & Secondary)
Delayed

Repeated
9

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 lifethreating conditions (such a postligation necrosis, anaerobic infection
etc.) may set on;
Can be done in cases of deep (IV D)
burns and freeze
11

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 (reamputation)
Re-amputation can be done in the case
of fallacious stump formation,
(incompatible for prosthesis).

13

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

14

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)
15

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).
16

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
17

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.

18

Anaesthesia
General (narcosis)
Local (infiltrative)

19

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

22

According to the stages of the

tissue incision/excision
One moment (guillotine)
Two moment
Three moment (conoid-circular)
Scarp rule
Oval (ellipsoid)
23

Upper Extremity Amputation

24

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

for vascular and nerve grafts

Rapid Bone Stabilization

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

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.