AMPUTATION

Amputation: AMBI means around, Putation means trimming.

Separation by cutting of terminal part of the body.
It is the removal of a body extremity (part or whole) by trauma, prolonged constriction,
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.
INDICATIONS OF AMPUTATION
Dead
Dead (or dying) Peripheral vascular disease accounts for almost 90 per cent of all
amputations.
Dangerous
Dangerous 'Dangerous' disorders are malignant tumours, potentially lethal sepsis
and crush injury. In crush injury, releasing the compression may result in renal
failure (the crush syndrome).
Damned Nuisance
Damned nuisance Retaining the limb may be worse than having no limb at all -
because of pain, gross malformation, recurrent sepsis or severe loss of function.
Types of Amputation
Primary amputation is carried out in the order of primary surgical debridement for the
elimination of the nonviable part of extremity
Secondary amputation is carried out when the conservative measures and surgical
treatment are ineffective.
Late amputations are those in connection with the nonhealing wounds, fistulas, at the
long course of osteomyelitis, threatening the amyloid degeneration of parenchymal organs
or functionally useless extremity.
Repeated amputations or reamputations are applied after the unsatisfactory results
of previous truncations of extremities or at the defect stumps preventing prosthetics, at
the extension of the tissues necrosis after amputation by the reason of gangrene as a
result of obliteration of the vessels or anaerobic infection progress.

Levels of Amputation
UPPER LIMB
 LEVEL DESCRIPTION
Transphalangeal May be at the distal interphalangeal,
proximal interphalangeal and
metacarpophalangeal levels
Transmetacarpal Seen less because of decreased
functional outcomes
Transcarpal
Wrist Spares the distal radial ulnar
Disarticulation arti0culation and thus preserves full
forearm supination and pronation
Transradial -Preferred in most cases
(Below Elbow) -Very Short: Residual limb length <35%
-Short: Residual limb length of 35%-55%
-Long: Residual limb length of 55% to
90%
( ideal level for patient who is expected
to perform physically demanding work)
Elbow
Disarticulation
Transhumeral -Humeral Neck Level: Residual limb
(Above Elbow) length of <30%
-Short Transhumeral: Residual limb
length of 30%
-Standard Trnashumeral: Residual
limb length of 50% to 90%
Shoulder
Disarticulation
Forequarter
Amputation
LOWER LIMB

LEVEL DESCRIPTION
Partial Toe Excision of any part of one or
more toes
Toe Disarticulation Disarticulation of the MTP joint
Partial Foot/ Ray Resection of a portion of up to
Resection three metatarsals and digits
Transmetatarsal Amputation through the
Amputation (TMA) midsection of all metatarsals
Lisfranc Amputation of the tarso-
metatarsal junction

Chopart Midtarsal amputation-=only talus

and calcaneus remain
Pirogof A vertical calcaneal amputation
(In this amputation, the lower
articular surfaces of the
tibia/fibula are sawn through)
Boyd A horizontal calcaneal amputation
(all tarsals removed except except
calcaneus/talus)
Symes Ankle disarticulation with
attachment of the heel pad .to
distal end of tibia; may include
removal of malleoli and distal
tibial/fibular flares
Long BK >50% of tibial length
(Transtibial)
BKA (Transtibial) 20%-50% of tibial length
Short BK <20% of tibial length
(Transtibial)
Knee Amputation through the knee
Disarticulation joint, femur intact
Long AKA >60% of femoral length
(Transfemoral)
AKA (Transfemoral) 35%-6% of femoral length
Short AKA <35% opf femoral length
(Transfemoral)
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,L% level

UPPER EXTREMITY AMPUTATION

 Digital Amputation Ray Amputation

Metacarpal Amputation Wrist Disarticulation

Transradial Amputation Short Transradial

Amputation

Elbow Disarticulation
Transhumeral Amputation Shoulder Disarticulation

Forequarter Amputation Krukenberg Procedure

LOWER EXTREMITY AMPUTATION

Partial Toe Amputation
Ray Articulation

Ankle Disarticulation

Symes Amputation

Long BKA
Choparts Amputation

Pyrogofs Amputation Short BKA

Knee Disarticulation

Short AKA

Gritti-Stokes Disarticulation

Hip Disarticulation

Vas-Ness Rotation

Hemipelvectomy

Long AKA
Rehabilitation of an Amputee
Rehabilitation:
It is a process by which patients abilities are utilized to make him independent
physically, mentally, socially and vocationally to make him lead a near normal
life.
Stages of Rehabilitation:
1. Pre- amputation counseling.
2. Amputation surgery.
3. Acute post amputation care.
4. Pre-prosthetic training.
5. Prosthetic fitting and training.
6. Reintegration into community.
7. Long-term follow up.
Rehabilitation team for amputee patient

Physic
Surge al
Ergonom on Therap
ist
ist

Patie
nt
Occupati
onal
Therapis Prosthet
t ist
Psycholog
ist

Pre- Amputation Counseling

The main aim of this stage is to prepare the patient physically, mentally for amputation
and post amputation period.
The stage includes:
A. Communication with patient and his family to explain about the need for surgery
and its outcomes.
B. Communication between rehabilitation team to discuss about the level of
amputation and prosthetic fitting.
C. Introductory session with patient regarding:
D. Phantom limb pain.
E. Prosthetic fitting.
F. Mode of fitting and training.
G. Time taken.
H. Cost expenditure.
I. Demonstration by a trained volunteer and discussion between patient and
volunteer.
J. Pre- rehabilitation exercise program involving: other limbs trunk muscles.

Amputation Surgery
Amputation is done when all other modalities are explored, evaluated and rejected. The
evidence suggests that the amputation is the best solution to the patients plight.
Amputation is to achieve:
A. Most distal level with clinical condition.
B. Well healed stump.
C. Less functional loss.
D. Less energy with ambulation with prosthesis.
Amputation surgery includes:
A. Removal of a part or whole limb to exclude pathology.
B. Reconstruction to create a best possible stump.

Stump
The Stump is the residual part of the limb left after the amputation. The care of the stump is very
important to provide good function in the limb.

Criteria for good stump

1. Proper length.
2. Proper shape.
3. Skin free.
4. Healthy scar.
5. Good muscle strength.
6. Joint should have full ROM.
7. No neuroma.
8. No phantom sensation or pain

A good stump should neither be too long nor too short. It should have good muscle power
with full movement in the proximal joint and a healthy non adherent scar. It should have a
fleshy end with no bony spurs.
In lower limb amputations, the functions to be restored are weight bearing and locomotion
and sensory feedback.
The care of the stump consists of:
a) Stump bandaging with crepe bandage to improve its shape for limb fitting.
b) Stump exercises to improve its motor power and movements in the proximal joint.
c) Stump hygiene to maintain the skin and scar in good condition.

Complications of Amputation
Hematomas
 Infections
Necrosis
Phantom sensations
Deep venous thrombosis
Terminal overgrowth
Bony spurs
Contractures

Flexion contracture of knee in Necrosis of wound edges caused by

below-knee amputation prevents patient's poor circulation or excessively
tight sutures

Phantom pain describes a painful

sensation that can occur in a limb
that is no longer present due to
trauma or surgical amputation. It is
often described as a shooting or
burning type pain.

Postoperative Care
The stump is maintained postoperatively by:
A. Soft dressing.
Advantages :
Allows inspection of wound.
Allows near normal ROM.
Disadvantages:
Does not prevent contractures.
Does not prevent trauma.
B. Rigid dressing.
In form of plaster cast.
It called as Immediate Postoperative Rigid Dressing (IPORD)
Advantages :
Pain is decreased.
Wound heals quickly.
Edema is prevented.
Prevent contractures.
Protect from trauma.
Disadvantages:
Require careful application.
Wound inspection cannot be done.
C. Crepe bandaging.

Bandaging is done like figure of 8

It need frequent rewrapping.

This gives pressure from distal to proximal thus reducing hematoma and
edema.
D. Controlled environment method.

This done via using of machine that supplies bacteria free environment to the
wound a with controlled humidity and temperature.

This provides the perfect environment for primary healing.

E. Immediate Postoperative Prosthetic Fitting (IPOPF).

It can be done especially for children and clean traumatic ablation.
The main aims are:
Control of pain.

Prevention of edema.

Prevention of infection.

Prevention of deformity/ stiffness.

Prevention of DVT.

Improving muscle power.

Psychological confidence.
Preprosthetic Training
This phase includes:
Active ROM exs.
Proper positioning of the stump.
Muscle strength.
Skin care.
Crutch training.
Wheel chair mobility.
Self care.
Patient and family education.

Prosthetic Training
Thus done through collaboration among physiotherapist, occupational therapist,
prosthetist.
This phase includes:
Prosthetic fitting: including alignment check, pressure point relief, color matching, etc.
Donning and doffing training: for independence in care activities.
Skin care training: to avoid pressure ulcers, skin infections.
Gait training: includes weight bearing, weight transfers, stepping training, walking with or
without assistive aids, stair climbing, etc.
Maintenance of prosthesis: Cleaning, maintaining and replacement of prosthesis.

Reintegration Into Community

This process should done gradually, and it may take weeks or months.
Organized trips for shopping, recreation or a part time job should be done.
Day hospital rehabilitation program: patient participate in rehabilitation in hospital 6
hours/ day, 5 days/week. At evening and weekend the patient return back to his home.
Modified work and restricted work according to the patients disablity.
Long-term follow-up
During the first year, follow up is advised every 3 months and thereafter as and whenever
required
INCREASE ENERGY EXPENDITURE WITH THE DIFFERENT LEVELS OF
AMPUTATION

Level of Amputation Increase in Energy Expenditure

Symes 1=WA5%

Traumatic BKA 20%-25%

Traumatic Short BKA 40%

Traumatic Long BKA 10%

Bilateral BKA 41%

Traumatic AKA 60%-70%

Traumatic AKA + BKA 118% net

Bilateral AKA >200%

Vascular AKA 100%

Vascular BKA 40%

Speed of Walking for Unilateral Amputees with Prosthesis
Normal: 3.0 mpH
BKA: 2.0-2.5 mpH
AKA: 1.5 mpH

INCREASE ENERGY EXPENDITURE WITH THE DIFFERENT LEVELS OF

AMPUTATION
Level of Increase in Energy Expenditure
Amputation
Symes 15%
Traumatic BKA 20%-25%
Traumatic Short BKA 40%
Traumatic Long BKA 10%
Bilateral BKA 41%
Traumatic AKA 60%-70%
Traumatic AKA + BKA 118% net
Bilateral AKA >200%
Vascular AKA 100%
Vascular BKA 40%

Speed of Walking for Unilateral Amputees with Prosthesis

Normal: 3.0 mpH
BKA: 2.0-2.5 mpH
AKA: 1.5 mpH