• Non end bearing/side bearing.
• End bearing/cone bearing.
• Weight bearing.
• Nonweight bearing.
Types of flaps
• Long posterior flap in below-knee amputation.
• Equal flaps in above-knee amputation.
Ideal Stump
1. Should heal adequately.
2. Should have rounded, gentle contour, with adequate muscle padding.
3. Should have sufficient length to bear prosthesis.
4. For B-K 7.5 (minimum) to 12.5 cm from tibial tuberosity
5. For above and below elbow 20 cm stump.
6. For A-K 23 cm from greater trochanter.
7. Should have thin scar which does not interfere with prosthetic function.
8. Should have adequate adjacent joint movement.
9. Should have adequate blood supply.
Conical bearing
• Here healing is by primary intention
• Bone should not be projecting
• Myoplastic
• No neuroma
• Scar should not be tender
• Proximal joint should be supple
Different incisions for amputation
1. Circular incision amputation– skin and muscles are divided circularly at a lower level than that of
2. Elliptical/oval incision amputation
3. Racquet incision amputation – for digital disarticulation
4. Amputation using flaps – it may be of equal flap (above knee amputation) or with long posterior
single flap (below knee amputation). Total length of single flap or combined length of two flaps should be
equal to 11/2 times the diameter of the limb at the line of amputation. Flap should be semicircular to get a
conical stump, not rectangular
Principles in Amputation
Adequate blood supply of the flap should be maintained.
Proper marking of the skin incision is essential.
Tourniquet should not be used if amputation is done for vascular diseases.
Proximal part of the flap contains muscle component but distal part should contain only skin and
deep fascia.
Flap length should be adequate; not short. It should be ideally semicircular not rectangular to get
a conical stump.
Nerve should be pulled down and cut using a sharp knife and allowed to retract into the soft
tissue otherwise neuromas may develop.
In crush injury/entrapment injury/sepsis – guillotine amputation is done. Later skin is pulled down
by using skin traction, eventually to have better skin coverage.
Bone should be cut with beveling and all sharp margins should be rounded.
Postoperatively regular dressings are done. Patient is mobilised using axillary crutches. After 3
10. once scar has matured and stump has become supple, proper prosthesis is fit. Berlamont first
started immediate postoperative fitting of prosthesis to leg for early mobilisation. Plaster pylon is
applied to the stump and a prosthetic extension is fit to facilitate partial weight bearing
immediately after surgery. It as got more stump complications and so it has not become popular.
11. Stumps can be side bearing (sutures are on the side); end bearing/conical (sutures are on the
end) or cylindrical.
12. Postoperatively active exercise should be given to the proximal joint so that prosthesis can be fit
to it properly.
13. If there is sepsis especially in gangrene limb, flaps should be left open or loosely sutured
otherwise flap necrosis occurs.
14. Proper anatomy of muscles and neurovascular bundle around should be known in all amputations
• RAY amputation – Amputation of toe with head of metatarsal or metacarpals.
• Lisfranc‘s amputation (Tarso metatarsal amputation) Here tarso metatarsal joint is disarticulated
with a long volar flap.
• Chopart‘s amputation (Midtarsal amputation) – Here talonavicular joint and calcaneo cuboid joints
disarticulated. Tibialis anterior muscle is sutured to drilled talus bone. A long volar flap is used and
immobilised for 6 weeks after surgery.
• Syme’s amputation – It is removal of the foot with calcaneum and cutting of tibia and fibula just above
the ankle joint with retaining heel flap (dividing both malleoli). Heel flap is supplied by medial and lateral
calcaneal vessels (branches of posterior tibial artery). Elephant boot is used for the limb after Syme’s
which is inexpensive. Many patients walk well with Syme’s stump without difficulty. It is presently mainly
used in trauma (crush injury) and malignancies in distal part of the foot. In vascular diseases, calcaneal
vessels may not be adequate to maintain the viability of the flap. While raising the flap, knife should be
very close to the calcaneum so as to avoid injury to calcaneal vessels and to maintain the viability of the
Modified Syme‘s amputation – Here heel flap is elliptical. Tibia and fibula are divided slightly higher. But
variation here is the elliptical flap.
Pirogoff‘s amputation – It is like Syme’s amputation except posterior part of the calcaneum is retained
along with heel flap. It provides longer stump than Syme’s amputation
Below-knee amputation – Here we use a long posterior flap with scar placed over anterior aspect is
Prosthesis placement is better here with greater range of movements without limp and without support. It
is also called as Burgess amputation. Fibula should be divided first, higher than the proposed site of cut
of tibia otherwise its sharp end will press on the skin flap. Tibial stump should be beveled anteriorly.
Posterior muscles are sutured across the bone end, to the periosteum in front. In more proximal type of
below knee amputation, fibula often is removed to allow the proper use of flap. Length of the flap should
be 11/2 times the circumference of the site (around 12 cm). Stump length is 14-17 cm from knee joint.
Minimum length required for prosthesis is 8 cm. If need to extend more proximally, it is better to do above
knee amputation. Modern artificial limbs like suction socket prosthesis are used now.
‘Peg-leg’ amputation – It is amputation 5 cm below the knee level – proximal most below knee
It is not practiced nowadays. Here anterior flap is rotated posteriorly like a hood and patient kneels and
bears weight which is well-accustomed to pressure. It is done whenever prosthesis cannot be used
probably due to economic causes (in developing countries).
Transcondylar-Gritti-Stokes amputation with long posterior flap. Femur is divided just above the
articular surface and patella is anchored to the divided femur. There is risk of nonunion between patella
and femur. This procedure is no longer performed.
• Above-knee amputation – Usually equal anterior and posterior flaps are used. Lower third and middle
third level amputations are done. Ideally the required length of the femur as stump is 25 cm from the tip
of the trochanter. Femur length lesser than 10 cm is not possible and here one needs to do hip
disarticulation. In children as growing epiphysis of femur is in lower end, it is essential to preserve as
much length of femur as possible.
Hip disarticulation– It is done whenever it is not possible to save the minimum 10 cm length of the
femur. Incision used is either single posterior flap – Solcum’s approach (better) or anterior racquet
incision – Boyd’s approach.
• Hind quarter amputation – Inter innominato abdominal amputation (Sir Gordon Taylor’s amputation):
Removal of one side pelvis with innominate bone, pubis, muscles and vessels. Original ligation of
common iliac artery is modified to individual ligations of external and internal iliac vessels. Internal iliac
artery is ligated beyond the origin of the superior gluteal artery to keep the large posterior flap
Now hind quarter name is replaced by hemipelvectomy. It may be standard hemipelvectomy with classic
gluteal flap;
extended hemipelvectomy with removal of posterior part of the sacrum;
conservative hemipelvectomy with retaining part of the pubis, ilium bones on that side.
Internal hemipelvectomy is new method wherein hemipelvectomy is done with preserving the limb.
• Krukenberg’s amputation is done in upper limb following any trauma. Here forearm amputation is
done in such a way that it creates a gap between radius and ulna like a claw to have a hold or grip.
• Inter scapulo thoracic amputation (Forequarter amputation) (Little wood’s posterior approach or
Berger’s anterior approach): It is removal of entire upper limb with scapula and lateral 2/3rd of the
clavicle and muscles attached to it. It is done in malignancies involving scapula, upper part of humerus
and near shoulder joint.
• In emergency conditions like severe sepsis, gas gangrene and machinery entrapment, Guillotine
amputation is done without suturing. Suturing is done at later period. All tissues are divided at same
It is the substitution to a part of the body to achieve its optimum function.
(Orthroses are supplement for limb function.)
Prosthesis Types
A• Exoskeletal prosthesis.
B• Endoskeletal prosthesis with modular system. Internal prostheses are one used inside. They are
placed by open surgery. They are nonreactive, long durable materials, e.g. hip prosthesis in total hip
1. Syme’s amputation: Elephant boot, Canadian Syme’s prosthesis.
2. Below-knee amputation: Patellar tendon bearing (PTB) prosthesis and solid ankle cushion heel
3. Above-knee amputation: Suction type prosthesis. It is placed above the stump. It is better and
4. Nonsuction type prosthesis: It is placed at the ends. It requires additional support.
5. Hind-quarter amputation: Tilting table prosthesis (TTP) or Canadian prosthesis is used here.
In Upper Limb
1. Above elbow prosthesis is a high technology prosthesis. It is sophisticated device with harness, socket,
elbow joint unit, control cable, forearm and wrist device
2. Below elbow prosthesis. Krukenberg’s amputation does not require any prosthesis.
Advantages of Prosthesis
• Cosmetic.
• Function of the part relatively can be got.
• Ambulation in lower limb prosthesis.
• Infection.
• Pressure ulcers.
• Joint disability.
Wagner’s grading/classification of ulcer
Grade 0 – preulcerative lesion/healed ulcer
Grade 1 – superficial ulcer
Grade 2 – ulcer deeper to subcutaneous tissue exposing soft tissues or bone
Grade 3 – abscess formation underneath/osteomyelitis
Grade 4 – gangrene of part of the tissues/limb/foot
Grade 5 – gangrene of entire one area/foot
BAZIN’S DISEASE (Erythrocyanosis Frigida)
• It is also called as Erythema induratum.
•Cause-It may be due to tuberculosis.
• It is localised area of fat necrosis affecting exclusively adolescent girls.
• Symmetrical purple nodules develop in the ankles and calves which eventually break down forming
indolent ulcers with pigmented scars.
• Antitubercular drugs and sympathectomy are the treatment.
1. Mode of onset
2. Duration
3. Pain – its time of onset, progress, severity
4. Discharge from ulcer
5. History suggestive of associated disease /treatment history
Local examination of an ulcer
1. Site of ulcer – arterial ulcer over the digits; venous ulcer over the malleoli; trophic ulcer over heel /
pressure points
2. Size of ulcer
3. Shape of ulcer
4. Number
5. Margin whether regular/irregular/welldefined/ill-defined
6. Edge of ulcer
7. Floor of the ulcer – floor is the one what is seen. It rests on the base. (Base is not seen; it is only
felt). Red color in floor – healing ulcer; slough with pale/purulent discharge – nonhealing ulcer
or tubercular; wash leather slough – syphilitic ulcer/proliferative and nodular floor – squamous
cell carcinoma; pigmented – melanoma, pigmented basal cell carcinoma
8. Discharge from ulcer bed – serous, serosanguinous, bloody, purulent;
9. color of discharge – greenish in pseudomonas infection
10. Surrounding area to be examined for inflammation, oedema, eczema, scarring, pigmentation
11. Inspection of the entire part/limb
12. Palpation
13. Tenderness over edge, base and surrounding area
14. Warmness over surrounding area
15. Edge palpation for induration
16. Palpation of base for induration/fixity
17. Depth of ulcer – trophic ulcer is deep with bone as its base – often it is measured gently in mm
18. Bleeding on palpation and touching
19. Palpation for deeper structuresand its relation to ulcer
Right subclavian artery begins from brachiocephalic trunk (innominate artery) whereas left subclavian
artery arises directly from the arch of aorta. From underneath the sternoclavicular joint artery arches over
the pleura and apex of lung about 2.5 cm above the clavicle and then reaches the lateral border of first rib
to continue as axillary artery.
Subclavian artery is divided into three parts by scalenus anterior muscle.
Axillary artery is divided into three parts by pectoralis minor muscle.
At the lower border of teres major muscle it enters the arm and continues as brachial artery.
About 2.5 cm below the crease of the elbow joint, it bifurcates into radial and ulnar arteries which run in
the forearm.
Ulnar artery forms the superficial palmar arch which is completed by superficial palmar branch of radial
Radial artery after passing through the anatomical snuff box enters the dorsum of hand and first
intermetacarpal space to form deep palmar arch. It is completed by deep palmar branch of ulnar artery
and is 1 cm proximal to superficial palmar arch.
Abdominal aorta bifurcates at the level of fourth lumbar vertebra (corresponds to the level of the umbilicus
in anterior abdominal wall) into two common iliac arteries.
Common iliac artery is about 5 cm in length passes downward and laterally; and at the level of
lumbosacral intervertebral disc, anterior to sacroiliac joint, it divides into external and internal iliac arteries.
Internal iliac artery supplies pelvic organs.
External iliac artery continues as common femoral artery at the level of inguinal ligament. About 5 cm
below the inguinal ligament common femoral divides into superficial femoral and deep femoral
(Profunda femoris) arteries. Deep femoral provides collateral circulation around
the knee joint and also communicates above with gluteal vessels to maintain collateral circulation around
the gluteal region.
Superficial femoral artery at the hiatus in the adductor magnus, continues as popliteal artery up to the
inferior angle of the popliteal fossa where it divides into anterior and posterior tibial arteries.
Anterior tibial artery supplies anterior compartment of leg and ankle, continues as dorsalis pedis artery
which forms dorsal arterial arch of the foot.
Posterior tibial artery supplies posterior compartment of leg and ends as medial and lateral plantar
arteries which forms plantar arterial arch of the foot.
Posterior tibial artery gives peroneal artery which runs close to fibula supplying calf muscles.
It occurs due to rapid decompression from high altitude, aircraft, compressed air chambers, deep sea
divers causing bubbling of nitrogen which blocks the small vessels.
1. In joints and muscles it causes excruciating pain (bends).
2. Spinal cord ischaemia causing neurological deficits.
3. Lungs may be affected causing choking with chest pain, tightness and dry cough.
1. Oxygen therapy.
2. Recompression and gradual decompression in special chamber.
It is mainly used in peripheral vessels like femoropopliteal, renal, coronary, cerebral vessels.
1. Balloon angioplasty: It is useful in short segment stenosis in large vessles like renal vessels, iliofemoral, coronary vessels. It is less effective compared to open surgery.
2. Intravascular stenting: Balloon expandable and selfexpanding stents are used at stenosed area.
3. Endovascular grafts (PTFE, DACRON).
4. Endovascular atherectomy.
5. Angioscopy: Flexible, small, fibreoptic scopes to visualise vessel wall with sufficient irrigation to
avoid opacification by blood.
6. Intravascular ultrasound: To evaluate the vessel wall morphology.
1. Aneurysm for stenting and grafting
2. Aorto-iliac constrictive disease
3. Renal artery stenosis
4. Carotid occlusive disease
5. AV fistulas
6. Management of pseudo-aneurysm
1. Thrombosis.
2. Rupture.
3. Sepsis.
4. Fluid overload.
5. Air embolism.
It is a rare entity compared to lower limb ischaemia but important because of its difficulty in managing.
Higherlevel amputations are rare in upper limb ischaemia.
1. Thoracic outlet syndrome.-commonest cause.
2. Raynaud‘s disease and phenomenon.
3. Embolism due to causes like atrial fibrillation and endocarditis.
4. Trauma – commonest cause.
5. TAO upper limb (along with lower limb TAO).
6. Atherosclerosis of upper limb vessels.
7. Takayasu‘s arteritis.
8. Poly arteritis nodosa.
9. Scleroderma.
10. Infection.
1. Upper limb claudication and ischaemic rest pain.
2. Ischaemic features.
3. Ulcers and gangrene commonly in fingers.
4. Wasting of hand and forearm muscles.
5. Mass in the neck, bruit in the neck in supraclavicular region.
6. Adson test, hyperabduction test, Roos test, Allen‘s tests are important.
7. -Opposite limb, lower limbs should be examined
8. Cardiovascular system should be examined
9. Neck should be examined
10. Wasting/girth should be checked
11. Auscultation over neck/axilla/carotids for bruit
1. Arterial Doppler.
2. Subclavian angiogram.
3. Investigations to confirm vasculitis.
4. Blood sugar.
5. Lipid profile.
6. Cardiac evaluation.
7. X-ray neck to find out cervical rib.
8. CT scan—neck and thorax.
9. nerve conduction studies.
1. Treatment of the cause.
2. Extraperiosteal resection of the cervical rib.
3. Cervical sympathectomy.
4. Drugs like vasodilators, pentoxiphylline, ticlopidine. Small dose of aspirin.
5. Arterial reconstruction of the subclavian artery.
6. Arterial embolectomy when there is an embolus.
7. therapy for cervical rib; scalenotomy;
8. Digital amputation may be required