Amputations

🦵 Classification of Amputations

• By Extent:
  • 🦶 Minor: Toe, ray, transmetatarsal amputations (preserve function if possible).
  • 🦵 Major: Below-knee (BKA), through-knee (Gritti-Stokes), above-knee (AKA), hip disarticulation.
• By Timing:
  • 📅 Elective: Planned for chronic limb ischaemia, tumours, deformity.
  • 🚨 Emergency: Trauma, uncontrolled sepsis (e.g., gas gangrene, necrotising fasciitis).

📌 Indications for Amputation

• 🩸 Vascular: Critical limb ischaemia, gangrene, rest pain unsuitable for bypass/angioplasty.
• 💥 Trauma: Devastating crush/avulsion injuries, non-salvageable limb.
• 🦠 Infection: Spreading sepsis, gas gangrene, chronic osteomyelitis.
• 🎗️ Tumours: Osteosarcoma, soft tissue sarcoma, subungual melanoma.
• 🦿 Non-functional limb: Severe contractures, paralysis with pain/ulceration.

⚙️ Principles of Amputation

• 🔍 Appropriate Level Selection: Must ensure perfusion at stump (healthy bleeding muscle + viable skin).
• 🦾 Prosthetic Planning: Level should maximise prosthetic use (BKA better than AKA).
• 🦴 Bone & Joint Assessment: Consider deformity, contracture, arthritis.
• ✂️ Tissue Handling: Adequate soft tissue coverage, myoplasty/myodesis for stability.

🏥 Preparation for Amputation

🧑‍⚕️ A major amputation is life-changing. Patients require clear counselling, psychological support, and ideally a visit to a Limb Fitting Centre.
💉 Pain control: Epidural or regional block often used.
🧴 Antibiotics: IV penicillin or broad-spectrum at induction (especially if infection suspected).
💪 Prehabilitation with physio & OT improves postoperative recovery.

🦶 Minor Amputations

• Toe disarticulation or ray amputation for diabetic sepsis, Buerger’s disease, severe Raynaud’s.
• 👣 Transmetatarsal amputation for forefoot gangrene (requires long plantar flap).
• Preserve maximum foot length for ambulation.

🦵 Major Amputations

• 🦵 Below-Knee (BKA): - Gold standard for mobility — ~80% stump healing success. - Stump length: 8–12 cm tibia, fibula cut slightly higher. - Posterior flap (gastrocnemius) provides cushioning. - ⚠️ Contraindications: poor flap perfusion, severe flexion contracture.
• 🦵 Gritti-Stokes: - Through-knee amputation: femur transected above condyles, patella folded anteriorly. - 💺 Provides stable sitting in bilateral amputees. - Lower blood loss than AKA.
• 🦵 Above-Knee (AKA): - Used if distal perfusion too poor. - Stump ~25 cm from greater trochanter. - Equal anterior & posterior myoplastic flaps. - 🚶‍♂️ Much higher energy cost for walking (~60–100% more than BKA).

📊 Functional Outcomes

• 🦿 BKA: 70–80% prosthetic walking success.
• 🦿 AKA: Only ~25–40% regain community mobility, especially elderly with vascular disease.
• 🔥 Energy expenditure: BKA requires ~25% ↑ energy; AKA can require >70% ↑.

🧠 Phantom Limb Pain

• 🎭 Occurs in up to 70% of amputees.
• Described as burning, tingling, stabbing in the absent limb.
• 🛠️ Management: gabapentin, amitriptyline, mirror therapy, graded motor imagery, CBT, physiotherapy.

🤝 Multidisciplinary Care

• 👨‍⚕️ Surgeons: wound healing, stump formation.
• 🏋️ Physiotherapists: prevent contractures, build strength, gait training.
• 🛋️ Occupational therapists: home adaptations, independence aids.
• 🦿 Prosthetists: stump measurement, socket fitting, gait optimisation.
• 🧠 Psychologists: adjustment, PTSD, depression support.

📊 Quick Reference Table