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AMPUTATIONSAMPUTATIONS
INDICATIONSINDICATIONS
DEAD
DEADLY
DEAD LOSS
DEADDEAD
Gangrene
large vessel – Atherosclerosis– embolus
small vessel – Diabetes– Buerger,s disease– Raynaud,s disease
DEADLYDEADLY
moist gangrene with surrounding putrefaction and infection
spreading cellulitis
neoplasm (osteogenic sarcoma)
AV fistula
DEAD LOSSDEAD LOSS
severe trauma
severe contracture or paralysis
severe rest pain
TYPES OF AMPUTATIONSTYPES OF AMPUTATIONS
MINOR– Ray– Trans-metatarsal
MAJOR
CONE BEARING END BEARING
Below knee
Above knee
Gritti-Stokes
Through knee
Syme,s
MINOR AMPUTATIONMINOR AMPUTATION
RAY AMPUTATION– excision of phalanges with head of
metatarsal– tendons are cut back– wound left open– Commonly done for diabetic foot
MAJOR AMPUTATIONMAJOR AMPUTATIONPreoperative preparationPreoperative preparation
Informed consent Improvement of general condition of the
patient Physiotherapy Antibiotics Analgesia Assessment of joints
Choice of operationChoice of operation
Cone bearing– Stump should be of sufficient length
• ( below knee 10-12cm)• (above knee > 20 cm)
– Stump must not be too long• Below knee7.5 cm above the ankle joint• Above knee 12.5 cm above the knee joint
– Stump with gentle rounded contour– Adequate muscle padding over the bone
Below Knee AmputationBelow Knee Amputation
2 types:– Long posterior flap– Skew flap
RULE:
length of flap must be at least one and a half times the diameter of the leg at the point of bone section.
Below Knee AmputationBelow Knee Amputation
LONG POSTERIOR FLAP: Incision deepened to bone anteriorly Bulk of gastrocnemiuas left with flap
laterally and posteriorly Blood vessels identified and ligated Nerves transected as high as possible. Vessels in nerves ligated Fibula divided 2 cm proximal to tibia
Below Knee AmputationBelow Knee Amputation
Tibia divided at desired levelWound washed with N/SBoner covered with muscles of
posterior flapSuction drain placedInterrupted skin sutures appliedPressure dressing done
Above Knee AmputationAbove Knee Amputation
Curved equal ant. and post. flaps made
Skin and muscles are divided in same line
Vessels are ligatedSciatic nerve ligated and cut high Bone is divided
Above Knee AmputationAbove Knee Amputation
Hemostasis securedBone covered with musclesSuction drain placedWound closed with interrupted
stitchesPressure dressing done
End Bearing AmputationsEnd Bearing Amputations
Rarely performed now Gritti-Stokes amputation: trans-condylar Through knee amputation: less complex Syme’s amputation:
– Preserves blood supply of heel flap– Dissection of calcaneum done– Tibia and fibula divided as low as possible
Syme’s AmputationSyme’s Amputation
POST OPERATIVE CAREPOST OPERATIVE CARE
pain relief with opiates
care of good limb
exercises and mobilization
Use of artificial limb
COMPLICATIONSCOMPLICATIONS
EARLY– Reactionary haemorrhage– Hematoma formation– Abscess formation– Gas gangrene– Wound dehiscense– Gangrene of flaps– DVT and pulmonary embolism
COMPLICATIONSCOMPLICATIONS
LATE– unresolved infection (sinus, osteitis,
sequestrum)– bone spur– amputation neuroma– phantom limb– Phantom pain– ulceration of stump