Makindo Medical Notes

Indications for Amputation

• Vascular Causes: Severe rest pain with arteries unsuitable for reconstruction, gangrene.
• Trauma: Irreparable damage to a limb due to injury.
• Infection: Conditions like gas gangrene or chronic osteomyelitis.
• Tumors: Osteogenic sarcoma, soft tissue sarcomas, or subungual melanoma.
• Non-functional Limb: Conditions such as poliomyelitis or severe brachial plexus injuries, especially when associated with vascular damage.

Principles of Amputation

• Appropriate Level Selection: Ensure adequate circulation at the chosen amputation level to guarantee healing. Healthy bleeding tissue should be observed during surgery.
• Prosthetic Considerations: The amputation level should allow for optimal fitting of a prosthetic limb.
• Joint Assessment: Joint conditions like contractures or arthritis may influence the chosen level of amputation.

Preparation for Amputation

A major amputation is a life-altering procedure that requires detailed explanation and emotional support for the patient, who may take time to accept its necessity. Preoperative physiotherapy and occupational therapy are crucial, and a visit to a Limb Fitting Centre is highly recommended.
Ensure the patient is comfortable and pain-free, with epidural anesthesia being an option for pain management. Prophylactic antibiotics, such as penicillin, should be administered during anesthesia induction to protect against infections like Clostridium perfringens (gas gangrene).

Minor Amputation

Minor amputations involve the removal of a digit at the base or "ray" amputation, such as the removal of the metatarsal head and tendons in the foot. These procedures are commonly used for conditions like diabetes, Buerger's disease, or severe Raynaud's. In cases where all toes are ischaemic, a transmetatarsal amputation may be performed, requiring a long plantar skin flap for success.

Major Amputation

• Below-Knee Amputation (BKA): Often offers the best chance for successful prosthetic use. Healing is successful in 80% of cases. Suitable for patients with diabetes and a palpable popliteal pulse, Buerger's disease, or some forms of arteriosclerosis. Contraindicated if ischaemia affects the posterior skin flap, if fixed flexion contractures are present, or if profunda femoris artery occlusion occurs. The typical tibial stump is 8-12 cm long, with the fibula transected slightly higher. A long posterior muscle flap is folded over to cushion the bone end. However, less than 50% of patients may remain independently mobile at two years.
• Gritti-Stokes Amputation: Involves the opening of the knee joint, transecting the femur above the femoral condyles, and folding the anterior patella over the femur's end. This procedure results in reduced blood loss compared to above-knee amputation and provides a more stable sitting position in bilateral amputees.
• Above-Knee Amputation (AKA): Common in patients with advanced arteriosclerosis. The femoral stump is typically 25 cm long, measured from the greater trochanter. Equal anterior and posterior myoplastic flaps are sutured over the bone end. Recovery and mobility outcomes depend on the patient's overall health and condition.

Postoperative Care

• Pain Management: Preventive pain relief is essential to avoid breakthrough pain.
• Care of the Remaining Limb: Physiotherapy is crucial for maintaining the health of the remaining limb. Patients should be nursed on sheepskin or air mattresses to avoid pressure ulcers.
• Physiotherapy: Early physiotherapy is vital to build muscle strength, improve coordination, and prevent contractures. Rehabilitation should continue in a gym once the patient is comfortable to promote rapid mobilization with a prosthetic.
• Prosthetic Fitting: Measurement for a prosthetic should begin once the stump has stabilized and reduced in size.

Complications

• Early Complications: May include hemorrhage, hematoma, abscess formation, gas gangrene, wound dehiscence, ischaemic flaps, and fat embolism.
• Late Complications: May involve pain, sinus formation, osteomyelitis, neuroma, phantom limb sensations, and skin ulceration due to prosthetic pressure or continued ischaemia.