Module Group 3

End of the stump provides weightbearing qualities and suspension. Preseves the femoral epiphysis (growing children). Cosmesis is poor and fitting a prosthesis can be hard.

Between foot and knee. Most significant and important level in dysvascular patients.

Allows patient to weight bear on the stump and to perform some menial activites without a prosthesis. No good level for patients with peripheral obstructive arterial disease due to poor circulation proximal to the ankle, because of atherosclerosis.

Anywhere in the foot. Critical consideration is the final functional result=a plantigrade, non-sensitive, painfree stump

Preservation of the upper limb as much length as possible. Supination and pronation are mostly lost in trans-radial stumps. Elbow disarticulation=difficulties in prosthetic fitting and only a few advantages over long trans-humeral amputatin.

Partial FootAnkle disarticulationTrans-tibialKnee disarticulationTranks-femoralHip disarticulationsTrans-pelvic

Preservation of the upper limb as much length as possible

Skin conditionJoint contracturesGeneral physical conditionGeneral psychological conditionpersonal factor, for example: age, sex, occupation, hobbies…

With the use of the dopple technique the systolic blood pressure can be evaluated. Thigh pressure measurement seems to have the most useful predictive value. Trans-tibial amputation is worth attempting if the thigh pressure is greater than 70-80 mmHg

A quantitative measurement of blood flow in the skin at the precise level of operation is of additional helo in predicting wound healing.

Radiated heat from the skin surface is detected by an infra-red camera and translated and enhanced using the computer system to give a colour image in which different colours indicate the varation in temperature of the skin surface. The optimum level of the amputation around the knee joint can be predicted reliably by this thermographic mapping.

This investigation asses the oxygenation of haemoglobin at the site of operation by the use of a xenon light source. Ist a very good predictor of wound healing especially at a trans-tibial level.

Systolic blood pressure studiesSkin blood flow measurementInfra-red ThermographyMicro-light guided spectrophotometry

Repositioning the muscles of the distal end of the bone that is being cut and tying them on at a more proximal level. Bleeding must be controlled and the major vessels must be ligated accurately. Skin sutures must be placed precisely to achieve accurate apposition of wound edges (the cut edges of the skin must butt against each other to allow good wound healing).

Attachment of the cut muscles to the femoral stump. Achieved by drilling holes in the bone and then threading these with string sutures to hold the muscle in position

End to end suturing of antaginistic muscle group over the end of the sectioned femur.

First the adductors and abductors, then the hamstrings and the quadriceps.

Optimum preparation of the patient for surgery with respect to associated conditions, such as chest infection, heart failure, renal failure, diabetesPre-operative preparation of the limb to prevent infectionprophylactic measures: heparin to prevent deep vein thrombosis, penicillin to prevent clostridial infection

smokinglow haemoglobin levelpoor nutritionprevious vascular surgerydiabetes mellitusan inexperienced surgeon

it provides a safe, enclosed enviroment for the woundit diminishes painit protects the stumpit reduces post-operative swellingit prevents casual insprection of the woundit reduces infectionit allows satisfactory wound healingcan only be applied at knee disarticulation and distal to that level.

Vacuum drainageOptimum preparation with respect to associated conditionsPreparation of limb to prevent infectionProphylactic measures to prevent deep vein thrombosis and clostridial infection

Knee distarticulation and distal to that level.

Stump painHaematoma formationInfection

Due to surgical trauma and lasts for approximately 48 to 72 hours.

Pesistent pain after 48-72 hours after operation. Serious condition and if not recognised and evacuated immediately, can lead to increased tension and subsequent devitaluation of the tissues and breakdown of the wound.

Produces a throbbing type of pain. Associated with raised temperature and increase in pulse and respiration rate. If infection is suspected it is necessary to inspect the wound and release any contained pus. The infection should be treated by suitable antibiotics.

Painful neuromaPhantom phenomenaSkin problemStump volume

Neuroma= a benign tumour growing from the fibrous coverings of a peripheral nerve. The nurves cut durnging amputation usually heal by the formatin of a neuroma slightly proximal to the site of the surgical cut. This type of pain may be felt during the third to fourth post-op week. The diagnosis is usually made by localised tenderness at the site of the neuroma.

Feelin of the presence or pain in the part of the limb which has been removed. Does not create significant problems for the patient. But can be difficult entity to threat. Aetiology is somewhat obscure but the following may all play a part: terminal neuroma of the nerves, psychological factors and abnormal reflexes as a consequence of removing distal nerves during surgery.

The strump tissue are sunjected to a completely new enviroment. They are compressed and expected to bear heavy loads. Air is often unable to circulate in the stump socket of the prosthesis, causing perspiration to accumulate. Venous and lymphatic stasis may lead to oedema, capillary haemorrage and blister formation. Perspiration can lead to contact dermitits and eczema. These conditions may alter the shape of the stump, which will lead to an ill-fitting prosthetic socket.

The volume of the stump often reduces markedly in the first few months because of the reduction in muscular activity. Usually, an amputee will use one or two stump socks in order to fit the prosthesis socket, but should three woolen socks be needed, it is likely that the stump volume has reduced to the point where a new socket is required.

Pre-operative counselling should also include visits from the physiotherapist, occupational therapist and prosthetist who will all be involved in the post-operative management of the amputee. Amputation is a major psychological event. Coundselling may allay the fears of both the patient and their relatives. During this initial pre-operative stage the patient's biochemical state and haematological state should be checked to ensure the patient is not anaemic, undernourished or electrolytically impalanced, for if blood chemistry is abnormal this can be dangerous to the patient, especially during an operationThorough medical assessment to ensure they are fit to undergo amputation is important, otherwise the patient may succumb during the surgical procedure.

Pain control must be adequate to relive the initial post-operative pain and is usually achived by the use of opiates for at least 24h.

The dysvasculat patient is usually elderly and frequently has other significant pathology such as diabetes mellitus, renal disease or cardiac disease.They frequently have had prescribed medications that may interfere with their biochemistry and thus careful monitoring may be required.