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Types of Amputation

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Classification: Minor vs. Major

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Lower Limb Amputations (Distal to Proximal)

1. Digital (Toe) Amputation

• Removal of one or more toes
• Indicated for gangrene or osteomyelitis confined to the distal phalanx
• Loss of the great toe is most functionally significant (role in propulsion)
• Loss of the 3rd toe is the most tolerable

2. Ray Amputation

• Removal of an entire toe plus its corresponding metatarsal
• Indicated when disease involves the web space or metatarsal head
• Great toe or 5th toe ray requires extended incision along the medial or lateral foot border

3. Transmetatarsal Amputation (TMA)

• Amputation through the midshaft of all metatarsals
• Indicated when tissue loss is extensive in the forefoot, or multiple toes are involved
• Lowest energy expenditure of any foot amputation - no tendon transfer required
• Elevated HbA1c increases risk of TMA failure
• Success depends on a viable posterior flap

4. Lisfranc Amputation

• Disarticulation at the tarsometatarsal (TMT) joint (the Lisfranc joint)
• The base of the 2nd metatarsal must be spared to preserve the proximal transverse arch
• Key surgical concern: peroneal tendons must be transferred to the cuboid to prevent varus deformity
• Tendo-Achilles lengthening (TAL) is needed to prevent equinus deformity
• Meticulous reattachment of tibialis anterior and peroneus longus/brevis insertions is essential

5. Chopart Amputation (Midtarsal / Transverse Tarsal)

• Disarticulation at the calcaneocuboid + talonavicular joints (the Chopart joint)
• Preserves the talus and calcaneus - results in less limb shortening than Syme
• Key surgical concern: anterior tibialis must be transferred to the talus to prevent varus
• Achilles tenectomy (removing 2-3 cm) is preferred over simple lengthening to prevent equinus
• Patient placed in slight dorsiflexion rigid dressing for 6 weeks post-op
• Complication: equinus deformity and a limited weight-bearing surface that leads to stump breakdown

6. Syme Amputation

• Ankle disarticulation with removal of both malleoli
• Preserves the heel fat pad for end-bearing - patient can ambulate short distances without a prosthesis
• Second lowest energy expenditure after TMA
• Functionally superior to both Lisfranc and Chopart in terms of energy for ambulation
• Requires an intact heel pad - contraindicated if there is a history of heel ulcers or neurotrophic/ischemic disease

7. Transtibial Amputation (Below-Knee, BKA)

• One of the most common major amputations
• Preserves the knee joint - best rehabilitation potential among major amputations
• Typically performed with a posterior flap (some prefer a skew flap for better prosthesis fitting)
• Requires ~25% more energy than baseline (trauma etiology); ~40% more (vascular etiology)
• Post-op: casting for 3-5 days, then rigid removable dressing; weight-bearing in temporary prosthesis by ~6 weeks

8. Through-the-Knee (Knee Disarticulation)

• Rarely performed as a definitive amputation
• Sometimes used as a temporizing measure in emergent ascending infection
• Often later converted to a transfemoral amputation once infection clears
• Also called Gritti-Stokes amputation (a variant where the patella is retained)

9. Transfemoral Amputation (Above-Knee, AKA)

• Reserved for patients where transtibial is not possible (extensive tissue loss, muscle ischemia, poor rehab potential)
• Highest energy cost among lower limb amputations:
  • Traumatic: ~68% more energy than baseline
  • Vascular: ~100% more energy than baseline

10. Hip Disarticulation

• Removal of the entire lower limb through the hip joint
• Very high energy cost; prosthetic ambulation is challenging

11. Hindquarter (Hemipelvectomy)

• Removal of the lower limb plus part or all of the hemipelvis
• Typically reserved for high-grade sarcomas or severe pelvic trauma

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Special / Named Types

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Energy Expenditure Hierarchy (Low to High)

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• Current Surgical Therapy, 14th Ed. - AMPUTATION TYPES chapter
• Miller's Review of Orthopaedics, 9th Ed. - Amputation Level section
• Campbell's Operative Orthopaedics, 15th Ed. 2026 - Mitigating Equinovarus Deformity after Lisfranc and Chopart Amputations

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Shalya Tantra - BAMS UG Complete Syllabus

• Theory: 2 Papers x 100 Marks each
• Practical / Viva Voce: 100 Marks
• Clinical Posting: 9 months total

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PAPER I - Ayurvedic Surgery Fundamentals & General Surgery

Part A - Ayurvedic Foundations

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Part B - General Surgery Topics (Paper I continued)

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PAPER II - Orthopaedics, Anorectal & System-based Surgery

Section A - Orthopaedics (Asthi-Sandhi Tantra)

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Section B - Anorectal Surgery (Guda Roga)

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Section C - Abdominal Surgery

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Section D - Urology & Other Systems

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PRACTICAL / VIVA SYLLABUS

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CLINICAL POSTING (9 Months Total)

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KEY REFERENCE BOOKS

1. Sushruta Samhita (primary text - Sutrasthana, Nidanasthana, Chikitsasthana, Kalpasthana, Uttarasthana)
2. Ashtanga Sangraha & Ashtanga Hridaya
3. Charaka Samhita (relevant chapters)
4. Shalya Vigyan (Part 1-2) - Dr. Surendra Kumar Sharma
5. Shalya Samanvaya (Part 1-2) - Vd. Anantaram Sharma
6. Shalya Pradeepika - Dr. Mukund Swaroop Verma
7. Clinical Shalya Vigyan - Dr. Akhilanand Sharma
8. Bhagna Chikitsa - Dr. Prabhakar Janardhan Deshpande
9. Kshara Sutra Management in Anorectal Ailments - Dr. S.K. Sharma et al.
10. Manipal Manual of Surgery - Dr. Rajgopal Shenoy (modern reference)
11. Bailey & Love's Short Practice of Surgery (modern reference)

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Important Exam Tips

• Sushruta Samhita is the backbone - Sutrasthana chapters on Yantra, Shastra, Vrana, and Saptavidha Kalpana are high-yield
• Kshara Sutra therapy for Bhagandara is a very high-yield topic in both theory and viva
• Arsha (Piles) chikitsa - all four methods (Bheshaja, Kshara, Agni, Shastra) must be known in detail
• Agnikarma vs modern cautery comparison is a frequent viva question
• Fracture management combines Ayurvedic (Sandhaniya, Rohana dravyas, splintage) with modern principles