Amputation

Amputation : removal of a limb or other appendage or outgrowth

of the body

Residual limb : portion of the limb that remains after amputation

Prosthesis : a device that is designed to replace, as much as

possible, the function or appearance of a missing limb or body part
 Indikasi amputasi
• Penyakit pembuluh darah

• Tumor

• Trauma

• Infeksi kronis

• Paralysis, deformity, limb discrepency

• Congenital limb deficiency

 Penyakit Pembuluh Darah Perifer

Pemeriksaan
• Causa terbesar Penunjang
amputasi
• plethysmography
• oscilometry
Penyakit • skin temperature
pembuluh darah test Penentuan level
perifer • arteriography amputasi

Arteriography memberikan penilaian paling realistis

mengenai viabilitas jaringan
 Sirkulasi Level amputasi
Onset awal&lambat
kolateral lbh distal

Tnpa sirkulasi Level amputasi

Onset akhir dan cepat
kolateral lbh proksimal
TECHNIQUE OF AMPUTATION

Myodesis : direct suturing of

residual muscle or tendon to bone
/ periosteum

Myoplasty : suturing of agonist-

antagonist muscles pairs to each
other
 Level Amputasi Ekstremitas Bawah

hemycorporectomy

Hindquarter

Hip disarticulation

Thigh amputation

Knee disarticulation

Below-knee amputation

Syme’s procedure

Distal amputation
 Tabel Level amputasi
Excision of any part of one or more toes
Partial toe
Toe disarticulation Disarticulation at the MTP joint
Partial foot/ray resection Resection of a portion of up to three metatarsals and digits

Transmetatarsal amputation (TMA) Amputation through the midsection of all metatarsals

Lisfranc Amputation at the tarso-metatarsal junction

Chopart Midtarsal amputation—only talus and calcaneus remain

Syme’s Ankle disarticulation with attachment of heel pad to distal

end of tibia; may include removal of malleoli and distal
tibial/fibular flares
Long BKA (transtibial) > 50% of tibial length
Short BKA (transtibial) < 20% of tibial length
Knee disarticulation Amputation through the knee joint, femur intact
Long AKA (transfemoral) > 60% of femoral length
AK (transfemoral) 35%–60% of femoral length
Short AKA (transfemoral) < 35% of femoral length
Hip disarticulation Amputation through hip joint, pelvis intact
Hemipelvectomy Resection of lower half of the pelvis
Hemicorporectomy Amputation of both lower limbs and pelvis below L4, 59level
Tabel Peningkatan metabolik sesuai level amputasi

Level of amputation Increase Metabolic Cost

Above Normal

Syme’s 15 %
Traumatic TT (BKA) 25 %
Traumatic TF (AKA) 68 %
Vascular TT (BKA) 40 %
Vascular TF (AKA) 100 %

10
Below knee amputation

idealnya menyisakan panjang stump 5,5” dari plateu

tibia

stump pendek tetap fungsional, tetapi kurang efektif

jika panjang < 3,5”
 Below knee amputation
Panjang stump 1/3 dr panjang tibia sebelumnya, panjang
fibula sedikit lbh pendek (1,5cm di atas )

stump tll pendek (<2”) akan menghasilkan short lever arm

pd penggunaan proteesa, shg akan menyulitkan.

Stump tll panjang (>8”) akan fitting mnjadi sulit, bntuk

bantalan yg kurang baik, krn 1/3 distal kaki sbagian besar
mrp tendon→ kulit mudah rusak
Pre OP OP Post OP
• Nutrisi, koreksi • Teknik OP • Pencegahan
anemia edema masif
• Latihan jalan • Pencegahan
dg pylon deformitas
fleksi stump
 complications

Hematom Infeksi Nekrosis

Phantom
Kontraktur Neuroma
pain

Phantom
sensation
REHABILITATION TREATMENT OF THE
AMPUTATION PATIENT

Pre-operative management

• planning amputation level

• medical rehabilitation team conselling the
patient and the family
• cardiovascular check up and lungs function
• neuromusculosceletal check out
• daily activity evaluating
• exercises program (strengthening all of the
muscles, ROM exercise, ambulation with
assistive device)
Post-operative management

• underlying cause & date of amputation

• General Condition (Mental status and physical
condition)
• healing process of the operated wound
• prevent post operation complication
• pain control
• see performance of ADL
• mobility
• maintain ROM at the amputee limp
• prepare the stump for the prosthesis
• explain how to care the prosthesa
• psychology support
 Stump treatment

to prevent edema,
covered from
trauma, decrease of
pain, and accleration
of stump maturity Cleaned the stump
Notice the patient
can be given rigid with warm water, Massage the stump
nutrient status,
dressing from fiber soft soap, and to prevent
hemoglobin, diabetic
glass or a plester of antiseptic. Stump development of scar
and give the adequat
Paris or can use must be dried before tissue
antibiotic
elastic bandage or bandage.
elastic stockinetee
for 24 hours, except
when bath or clean
the wound
CONSIDERATIONS WHEN CHOOSING A
PROSTHESIS

Amputation level
Countour of the residual limb
Expected function of the patient
Vocation of the patien
Avocational interests of the patient
Cosmetic importance of the prosthesis
Financial resources of the patient
 PROTESA AMPUTASI BAWAH LUTUT

Komponen dasar :
• Foot ankle
assembly
 SACH
 Single axis
 Multiple axis
• Shank :
Endoskeletal
(dari metal/plastik)
lbh ringan,kosmetis
tp lbh mahal & pe-
rawatan lbh sulit
Eksoskeletal
(dr kayu/bhn rigid)
lbh tahan lama,tp lbh
berat & fixed.
 …protesa amputasi bawah lutut

• Socket
 …protesa amputasi bawah lutut

• Suspension devices
Luka
Tujuan: sembuh, cegah perlekatan

Metode:
-Dressing: soft, semi rigid, rigid
-Cegah kontaminasi: cuci
-Nutrisi (Eneroth)
-Infeksi: medikamentosa
Kulit
Tujuan: penyembuhan luka, cegah perlekatan, desensitisasi, cegah
komplikasi

Metoda:
- hidroterapi : 20-30 mnt
- friction massage
- tapping: 4 x / hr
- cuci : jaga higienis
- atasi komplikasi: uv, hidroterapi,
heating,hiperbarik
- edukasi
 Edema
Tujuan: cegah eksesif edema, menunjang penyembuhan dan
pembentukan (shaping)

Cara:
1. IPOP – rigid dressing :
- ambulasi diri
- protesa definitif cepat
bandaging
- shaping cepat
2. Semi rigid dressing
3. Soft dressing: elastic bandage ,
elastic shrinker
4. Lingkungan: massage, latihan,
stump board, elevasi

massage
 Bandaging Technique
Fx: support jaringan lunak stump
Mengontrol edema
Shaping stump utk fitting protesa
-dipakai setiap hari , dilepas jika pakai protesa. Dipakai
selama skitar 1thn
- Dimulai ketika luka sdh sembuh, walaupun jahitan blm
diangkat
elastic stockinet

Rigid dressing

IPOP
 Sendi dan Otot
Tujuan: jaga lgs; cegah: kontraktur, atrofi, kelemahan; shaping;
fx protesa

Metoda:
1. Positioning:
-Lurus sejajar yg sehat tanpa bantal
-Hr 1: telentang lurus
-Drain lepas: tengkurap 10 mnt – 30 mnt 3x/hr
-Kursi : stump board, hindari fleksi
2. Latihan
- Latihan lgs segera paska op
- Latihan isometrik otot quadriceps hr 2-3
post drain lepas
- Latihan penguatan bertahap

Latihan stretching
Latihan luas gerak sendi
Latihan penguatan
Pelvic tilt
Partial sit up
Neuroma
Cara:
Tujuan: kontrol nyeri
-Modifikasi socket
-Injeksi lidocain-steroid
-USD
-Desensitisasi: tapping, vibrasi

Phantom Sensation
Tujuan: mencegah jatuh
Cara: protesa pylon
Phantom Pain
Sifat :
-Temporer
-Akibat hilangnya inhibisi
-Dipicu: kontak puntung, fx Cara:
otonomik -Analgesik preoperatif
-Gangguan emosi -Desensitisasi
Tujuan tx: hilangkan nyeri -Protesa dini
-Injeksi lokal trigger point
-TENS
-Akupunktur
-Usd
-Perkusi
-Simpatektomi
-Konseling
Diabetic Foot
 AMPUTATIONS IN DIABETES
Common:
• Worldwide – amputation 2 to diabetes q 30 sec.
• U.S.A. – 80,000 amputations/y (2002)
– Higher rates in men, racial/ethnic minorities

Costly:
• $60,000/amputation
• $2 billion/y total costs

Lancet 2005; 366:1719 Diabetes Care 2004; 27:1598 Diabetes Care 2003;
26:495

©2006. American College of Physicians. All Rights Reserved.

 AMPUTATIONS IN DIABETES

Tragic: “Rule of 50”

• 50% of amputations transfemoral/transtibial level

• 50% of patients 2nd amputation in  5y

• 50% of patients Die in  5y

Clinical Care of the Diabetic Foot, 2005

©2006. American College of Physicians. All Rights Reserved.

 Pathophysiology
• Vascular disease?
• Neuropathy
– Sensory
– Motor
– autonomic
• Damage to blood vessels and impairment of
the immune system from diabetes make it
difficult to heal these wounds. Bacterial
infection of the skin, connective tissues,
muscles, and bones can then occur. These
infections can develop into gangrene. Because
of the poor blood flow, antibiotics cannot get
to the site of the infection easily.
 Neuropathy
• Changes in the vasonervorum with resulting
ischemia ? cause
– Increased sorbitol in feeding vessels block flow
and causes nerve ischemia
– Intraneural acculmulation of advanced products of
glycosylation
• Abnormalities of all three neurologic systems
contribute to ulceration
 Autonomic Neuropathy
• Regulates sweating and perfusion to the limb
• Loss of autonomic control inhibits
thermoregulatory function and sweating
• Result is dry, scaly and stiff skin that is prone
to cracking and allows a portal of entry for
bacteria
 Motor Neuropathy
• Mostly affects forefoot ulceration
– Intrinsic muscle wasting – claw toes
– Equinous contracture
 Sensory Neuropathy
• Loss of protective sensation
• Starts distally and migrates proximally in
“stocking” distribution
• Large fibre loss – light touch and
proprioception
• Small fibre loss – pain and temperature
• Usually a combination of the two
 Sensory Neuropathy
• Two mechanisms of Ulceration
– Unacceptable stress few times
• rock in shoe, glass, burn
– Acceptable or moderate stress repeatedly
• Improper shoe ware
• deformity
 Ulcer Classification
• Wagner’s Classification
0 – Intact skin (impending ulcer)
1 – superficial
2 – deep to tendon bone or ligament
3- osteomyelitis
4 – gangrene of toes or forefoot
5 – gangrene of entire foot
Type 2-3 Type 4
 Treatment
• Wagner 0-2
– Total contact cast
– Distributes pressure and allows patients to
continue ambulation
– Principles of application
• Changes, Padding, removal
– Antibiotics if infected
– Surgical if deformity present that will reulcerate
• Correct deformity
• exostectomy
Treatment
 Treatment
• Wagner 3
– Excision of infected bone
– Wound allowed to granulate
– Grafting (skin or bone) not generally effective
• Wagner 4-5
– Amputation
• ? level
 Indications for Amputation
• Uncontrollable infection or sepsis
• Inability to obtain a plantar grade, dry foot
that can tolerate weight bearing
• Non-ambulatory patient
• Decision not always straightforward
• Skin temperature test
• plethysmograph is an instrument for measuring
changes in volume within an organ or whole
body (usually resulting from fluctuations in the
amount of blood or air it contains).
• Angiography or arteriography is
a medical imaging technique
used to visualize the inside, or
lumen, of blood vessels and
organs of the body, with
particular interest in the arteries,
veins and the heart chambers.
This is traditionally done by
injecting a radio-opaque contrast
agent into the blood vessel and
imaging using X-ray based
techniques such as fluoroscopy
 Charcot Foot
• More dramatic – less common 1%
• Severe non-infective bony collapse with
secondary ulceration
• Two theories
– Neurotraumatic
– Neurovascular