AMPUTATION

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