Indications
- Dead: ischaemia (atherosclerosis), gangrene, infection (clostridium), trauma
- Deadly: tumours of bone (osteosarcoma) / soft tissue (malignant melanoma)
- Dead weight (excess fingers/toes)
Aim is to produce most practical/functional limb for prosthetics - therefore through knee (Gritti-stokes) are not favoured.
Through knee - when previous orthopaedic surgery precludes it (ie, long intramedullary femoral nail)
Can be performed under GA / LA
Double check side of operation
Isolate areas of gangrene
Generous flaps can be trimmed later
If tissue does not bleed (it will not heal properly) - therefore move proximally with amputation
Mobilise early to avoid contractures
Workup
- Patient
- Condition and mobility of patient (AKA more easy to transfer bed-bound patient)
- Ability for patient to be rehabilitated
- Psychological counselling
- Disease
- Pathology / severity of disease
- Viability of flaps
- Health-care related
- OT / Physiotherapy
- Limb fitting / prosthetics (end-bearing amputation may be suitable to allow simple prosthesis)
Deciding level of amputation
- Joint contractures - AKA
- Severely reduced mobility - AKA affords better transfer, less risk of stump pressure sores
- Knee OA - AKA
- Infection
- Viability of distal limb
Types of Amputation
- Upper limb
- Upper arm
- Supracondylar (above elbow)
- Extraarticulation (thorugh elbow)
- Proximal forearm (below elbow)
- Distal forearm
- Wrist
- Metacarpophalangeal
- Proximal interphalangeal
- Distal interphalangeal
- Lower limb
- Hindquarter
- Above knee - equal anterior-posterior flap
- Supracondylar
- Through knee (Gritti-stokes)
- Below knee - long posterior flap
- Symes (Tibia/Talus)
- Chopart (Talus/Navicular)
- Lisfranc (Navicular/Metatarsal) - posterior plantar flap
- Transmetatarsal
- Ray
Above knee amputation
- One hand's breadth (8-10cm) above upper border or patella: site of femur division
- Equal length flaps
- Divide skin + tissues along planned lines
- Divide soft tissue
- Ligate veins using2/O absorbable suture
- Deepen incision to bone
- Divide quadriceps tendon (to patella)
- Divide hamstrings posteriorly
- Double-Ligate femoral artery
- Apply tension to nerves before ligating so they retract (femoral/sciatic)
- Retract thigh muscles
- Divide Bone
- Divide femur, remove lower leg, place clean towel under stsump
- Smooth edges of femur using a rasp + bone wax (stop bleeding)
- Close defect
- Bring anterior-posterior muscles together using 1/O interrupted sutures
- Place suction drain under muscle layer
- Place second layer of sutures in superfical muscles
- Suture skin edges with interrupted 2/O sutures
- Cover stump with gauze + crepe bandage
Below knee amputation
- 14cm from tibial plateau: tibial division / 12cm from tibial plateau: fibular division 2cm proximal
- Burgess Long posterior myocutaneous gastrocnemius flap (extending down to achilles tendon)
- Robinson skew flap when posterior flap area compromised
- Incise along marked lines
- Divide soft tissue
- Divide achilles tendon posteriorly
- Divide posterior muscles
- Ligate vessels, divide (ie. don't tie them) nerves
- Divide Bone
- Cut fibula obliquely (with Gigli saw) + divide tibia 2cm distal to this
- Clear muscle off bone with periosteal elevator
- Close defects
- Oppose muscle flaps + suture
- Unite skin edges with 2/O interrupted
- Trim edges
- Apply crepe/cotton-wool bandaging
Allows for pressure to be put on stump with smaller risk of dehiscence
Complications
- Early
- Haematoma
- Wound infection
- Dehiscence, flap necrosis
- DVT / PE
- Phantom limb pain
- Late
- Neuroma
- Bone spurs
- Stump ulceration
- Psychological distress