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| AMPUTATION |
AMPUTATION
Amputation is a procedure where a part of the limb is removed through one or more bones.Amputations of lower limb are performed more commonly than that of upper limb.
*INDICATIONS
1. injury is commonest cause of amputation in developing countries. Common cause in adults (25- 30 yrs)
2. Peripheral vascular diseases including DM - common in elderly (50- 75 yrs)
3. Infections eg. Gas gangrene
4. Tumours
5. Nerve injuries
6. Congenital anomalies
* TYPES
A) Guillotine or open amputation
skin is not closed over wound as wound is not healthy
Operation done after some period to construct stump:-
1. Secondary closure
2. Plastic repair
3. Revision of stump
4. Re-amputation
B) Closed amputation
Skin is closed primarily
Surgical Principles:-
1. Torniquet - except in ischaemic limb.
2. Ex-sanguination - limb is squeezed with Esmarch bandage before torniquet application.
Contraindicated in malignancy & infection
3. Level of amputation :-
decided on the basis of
- Disease :- disease for which amputation is indicated. Be conservative with dry gangrene & trauma, but liberal with acute life-threatening infection & malignancy
- Anatomy :- joint must be saved
- Suitability for proper functionig :- sometimes length is compromised for efficient functionig.
4) Skin flaps :- skin over stump should be mobile & normally sensitive.
5) Muscles :- muscles are cut distal to level of bone with
- Myoplasty :- opposite group of muscles sutured together
- Myodesis :- muscles sutured to end of stump
6) Nerves :- are gently pulled distally into wound & divided with a sharp knife. Large nerves like sciatic nerve contain large vessel & should be ligated before dividing
7) Major blood vessel should be isolated & doubly ligated using non-absorbable sutures. Torniquet should be before closure
8) bone level is decided. Sharp edges of cut bone should be made smooth.
9) Drain :- corrugated rubber drain is used for 48-72 hours.
10) After Rx
- Dressing :- two types of dressings are used 1) Soft
2) Rigid
soft dressing is advantageous for wound healing & early prosthetic fitting
- Positing & elevation of stump to prevent contracture & promote healing.
- Exercises :- for maintaining range of motion of proximal joint
- Wrapping the stump with crepe-bandage helps in healing, shrinkage & maturation
- Prmsthetic fitting & gait-training started after 3 months
*COMPLICATIONS
1. Haematoma :- due to
- inadequate haemostasis
- loosening of ligature
- inadequate drainage
- it results in delayed wound healing & infection
- Rx aspiration & a pressure bandage
2. Infection :-
- due to PVD, DM or haematoma
- Rx wth AMA
3. Skin flap necrosis :-
- indicates insufficient blood
circulation
- avoided by taking care at time of designing
4. Deformities of joints :-
- improper positionig of amputation stump leads to contracture
- Rx passive stretching exercises
5. Neuroma
- always forms at the end of but nerve
- adhesion to scar makes it painful
- prevented by dividing the nerves sharply at proximal level & allowing it to retract proximally
- Rx excision at more proximal level
6. Phantom sensation :-
- sensation of amputed limb being still present
- most prominent immediately after amputation gradually diminish with time
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