Amputation Long case with examination Definition And viva
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Here is a complete, examination-ready guide on Amputation, structured as a surgical long case with viva questions.
AMPUTATION - Surgical Long Case, Examination Guide & Viva
DEFINITION
Amputation is the surgical removal of a limb or part of a limb. It is one of the oldest surgical procedures (historically performed for leprosy, ergotism, and punishment). Today it is fundamentally a reconstructive operation that should return a patient to community life with maximal function.
"Properly planned amputation is a form of reconstruction which can return a patient to the community fully mobile in a relatively short period of time."
- Pye's Surgical Handicraft, 22nd Ed.
INDICATIONS - The Classic "3 D's"
Amputation is indicated when a limb is Dead, Deadly, or a Dead Loss (Bailey & Love, 28th Ed.):
1. Dead Limb
- Gangrene - arterial occlusion (atherosclerotic, embolic, or small-vessel) causing tissue infarction
- Causes: peripheral arterial disease (PAD), diabetes mellitus, Buerger's disease, Raynaud's disease, inadvertent intra-arterial injection
2. Deadly Limb
- Wet/moist gangrene - putrefaction spreads to viable surrounding tissue
- Spreading cellulitis with severe toxaemia
- Gas gangrene - Clostridial infection
- Neoplasm - e.g., osteogenic sarcoma
- Arteriovenous fistula (life-threatening)
3. "Dead Loss" Limb
- Relentless rest pain without gangrene where reconstruction is not possible (improves quality of life)
- Paralysis or fixed contracture making the limb a hindrance, impossible to use
- Major unrecoverable traumatic damage
By Percentage (Mulholland & Greenfield Surgery, 7th Ed.):
| Indication | % |
|---|---|
| Complications of diabetes mellitus | 60-80% |
| Non-diabetic infection with ischaemia | 15-25% |
| Ischaemia without infection | 5-10% |
| Chronic osteomyelitis | <5% |
| Trauma, malignancy, frostbite | <5% |
TYPES OF AMPUTATION
By Urgency
- Elective - freedom to fashion skin flaps, select level based on blood supply
- Urgent - for fulminating infection or trauma; viability of muscle and skin are paramount; best done as for elective but wound left open, with delayed primary closure at ~5 days
By Level (Lower Limb - Common)
- Toe/digital amputation - small vessel disease with good proximal supply
- Ray amputation - digit + corresponding metatarsal (when MTP joint involved)
- Transmetatarsal amputation (TMA) - several toes affected, proximal metatarsals viable
- Syme amputation - ankle disarticulation; preserves limb length; end-bearing stump
- Below-knee amputation (BKA) / Transtibial - ~14 cm below knee joint
- Through-knee (Gritti-Stokes) - knee disarticulation
- Above-knee amputation (AKA) / Transfemoral - 25-30 cm below greater trochanter
- Hindquarter amputation - hemipelvectomy
Elective Levels (from Pye's diagram):
LONG CASE PRESENTATION
Patient Profile
"This is a [age]-year-old [male/female] who presents with an amputation of the [right/left] [below-knee/above-knee/toe...] limb, most likely secondary to [peripheral arterial disease / diabetic foot / trauma / malignancy]."
HISTORY TAKING
Presenting Complaint
- When was the amputation done? (Recent vs old)
- What was the original cause?
History of Presenting Illness
- Pre-amputation symptoms: claudication, rest pain, gangrene, non-healing ulcer, trauma, tumour
- Was revascularisation attempted before amputation?
- Was it elective or emergency?
- Level of amputation chosen and by whom?
Risk Factors / Systemic Review
- Diabetes mellitus (duration, control - HbA1c, complications)
- Peripheral arterial disease (smoking history, hypertension, hyperlipidaemia, previous MI/CVA)
- Trauma (mechanism, associated injuries)
- Malignancy (type, staging, oncology treatment)
- Buerger's disease (young male, heavy smoker, upper or lower limb)
Post-operative History
- Wound healing - primary/secondary/delayed?
- Stump complications (see below)
- Phantom limb pain/sensation?
- Prosthesis fitted? Functional level?
- Rehabilitation - physiotherapy, occupational therapy?
- Current mobility (K-level classification: K0-K4)
Past Medical History
- Cardiac disease, renal disease, stroke
- Previous vascular surgery (bypass, angioplasty)
- Contralateral limb status
Drug History
- Antiplatelet agents (aspirin, clopidogrel)
- Anticoagulants
- Antidiabetic medications
- Analgesics (for phantom pain - gabapentin, amitriptyline)
Social History
- Occupation, housing (stairs?), support at home
- Independent vs wheelchair-dependent
- Driving?
EXAMINATION
General Inspection (from end of bed)
- Patient appearance - well/unwell, comfortable?
- Obvious amputation - level, side, bilateral/unilateral
- Prosthesis present - on or off?
- Wheelchair / walking aids
- Look for signs of underlying cause: diabetic facies, cushingoid, pallor (anaemia of chronic disease)
Stump Examination (ALWAYS COMPARE WITH CONTRALATERAL LIMB)
INSPECTION:
- Level of amputation
- Shape of stump - cylindrical (ideal), conical, bulbous, redundant tissue ("dog ears")
- Skin - colour, trophic changes, oedema, scarring
- Scar - healed/unhealed, position (should not be on weight-bearing surface), keloid?
- Wound - any dehiscence, sinuses, ulceration, infection
- Muscle bulk - wasting?
- Fixed flexion deformity of proximal joint (hip flexion in AKA, knee flexion in BKA)
PALPATION:
- Skin temperature - warm (good perfusion) vs cold
- Tenderness - especially over scar/bone end
- Neuroma - small, tender, mobile nodule in scar
- Bone prominences - bony spur, inadequate bone coverage
- Sinus - probe gently if present (osteomyelitis?)
- Oedema of stump
- Proximal joint range of movement - measure any flexion contracture
VASCULAR ASSESSMENT of remaining limb:
- Skin colour, temperature, capillary refill
- Peripheral pulses (femoral, popliteal, DP, PT)
- Ankle-brachial pressure index (ABPI)
- Any ulcers, gangrene, trophic changes
Contralateral Limb
- This is CRITICAL - examine for PAD, diabetic foot, ulcers
- "The contralateral limb is at extremely high risk"
Systemic Examination
- Cardiovascular: pulse (AF?), BP, cardiac failure signs
- Eyes: diabetic/hypertensive retinopathy
- Abdomen: aortic pulsation (AAA - association with PAD)
COMPLICATIONS OF AMPUTATION
Early
| Complication | Details |
|---|---|
| Haemorrhage | Primary (operative), reactionary (24-48 h), secondary (infection, >10 days) |
| Wound infection | Common; risk higher in ischaemic patients |
| Wound dehiscence | Failure of skin flap viability |
| DVT/PE | Major risk; DVT prophylaxis essential |
| Phantom limb sensation | Almost universal - awareness of absent limb |
Late
| Complication | Details |
|---|---|
| Phantom limb pain | Distinct from sensation; burning, cramping; treated with gabapentin, amitriptyline, mirror therapy |
| Neuroma | Painful nodule in scar from nerve end regeneration |
| Bony spur | Periosteal new bone formation causing pain in prosthesis |
| Fixed flexion deformity | Hip flexion (AKA), knee flexion (BKA); prevents prosthetic fitting |
| Stump ulceration | From prosthetic socket pressure |
| Skin problems | Folliculitis, eczema, verrucous hyperplasia |
| Re-amputation | ~30-50% within 5 years for vascular causes |
| Osteomyelitis | Rare; presents with sinus |
| Psychological issues | Depression, PTSD, body image |
LEVEL SELECTION
The key principle: preserve the knee joint whenever possible - this considerably improves rehabilitation potential.
Tests used to determine level:
- Skin temperature and colour
- Transcutaneous PO2 (TcPO2) - >20 mmHg suggests healing
- Laser Doppler
- Arteriography
- Segmental pressures / ABPI
None has proved decisive in isolation; clinical judgement remains paramount.
ENERGY EXPENDITURE IN AMBULATION
(Mulholland & Greenfield Surgery)
| Level | Energy increase vs normal walking |
|---|---|
| Transmetatarsal | Minimal |
| Syme | ~10% increase |
| Below-knee (BKA) | 30-60% increase |
| Above-knee (AKA) | 60-100% increase |
| Bilateral AKA | Rarely ambulatory |
This is why preserving the knee joint is so important - AKA vs BKA doubles energy cost.
REHABILITATION AND PROSTHETICS
BKA Prosthesis
- Weight-bearing surfaces: patellar tendon and medial/lateral tibial flares
- ~75% of patients ambulatory post-BKA even with arterial insufficiency
- Various foot designs: extension, flexion, rotation, energy storage
AKA Prosthesis
- Weight-bearing surface: ischial tuberosity
- Fixed by suction socket (young patients) or belt (groin scars from previous surgery)
- Only ~40% of vascular patients achieve ambulation with AKA prosthesis
- Bilateral AKA: less than 10% ambulatory
K-Level Classification (Functional Ambulation)
- K0 - no rehabilitation potential
- K1 - household ambulator only (limited on level surfaces)
- K2 - community ambulator (limited)
- K3 - community ambulator (variable cadence)
- K4 - high activity (child, athlete)
Rehabilitation Team
- Surgeon, physiotherapist, occupational therapist, prosthetist, psychologist, social worker
VIVA QUESTIONS & ANSWERS
Q1. Define amputation and give the classic three indications.
Surgical removal of a limb or part thereof. Indicated when a limb is: Dead (gangrene), Deadly (spreading infection/gas gangrene/malignancy threatening life), or a Dead Loss (unreconstructable rest pain, paralysis, major trauma).
Q2. What is the most common cause of lower limb amputation?
Complications of diabetes mellitus account for 60-80% of lower limb amputations. Peripheral arterial disease (non-diabetic) accounts for a further 15-25%.
Q3. Why is preserving the knee joint so important?
An above-knee amputation requires 60-100% more energy to walk than normal. A below-knee amputation only requires 30-60% more. Preserving the knee dramatically improves prosthetic function, reduces energy expenditure, and increases the likelihood of successful rehabilitation and ambulation.
Q4. What is the ideal below-knee amputation stump length?
Approximately 14 cm below the knee joint. This provides adequate lever arm for prosthetic fitting. The Burgess long posterior flap technique is standard - provides well-vascularised gastrocnemius flap over the bone end.
Q5. What is phantom limb pain? How does it differ from phantom sensation?
- Phantom sensation - the patient feels that the amputated limb is still present. Almost universal post-amputation.
- Phantom pain - painful sensations perceived in the absent limb (burning, cramping, shooting). Distinct from sensation. Treated with gabapentin, tricyclic antidepressants (amitriptyline), SNRIs, mirror therapy, desensitisation techniques.
Q6. What are the immediate complications of amputation?
Haemorrhage (primary/reactionary/secondary), wound infection, wound dehiscence, DVT/PE, basal atelectasis/pneumonia. Also phantom sensation begins almost immediately.
Q7. A patient with a BKA develops a tender nodule in the scar 3 months later. What is this?
A neuroma - painful end-bulb regeneration of transected nerve axons. Management: conservative first (desensitisation, injection), surgical excision and burial of the nerve end in muscle if refractory.
Q8. A diabetic patient is about to have a below-knee amputation. What other limb should concern you most?
The contralateral limb. Repeat amputation rates are extremely high in diabetics. The risk of contralateral limb amputation within 5 years is significant. Full vascular and foot assessment of the opposite leg is mandatory. Patient education programs reduce repeat amputation rates.
Q9. What is a fixed flexion deformity post-amputation and why does it matter?
Flexion contracture of the proximal joint (hip flexion post-AKA, knee flexion post-BKA) due to unopposed muscle pull and positioning. Prevents adequate prosthetic socket fitting, impairs gait mechanics, and may make prosthetic rehabilitation impossible. Prevented by early physiotherapy and correct positioning.
Q10. What is a Syme amputation?
Ankle disarticulation preserving the heel pad, which is used to cover the bone ends. Advantages: end-bearing stump (patient can walk on it without prosthesis in the home), preserves limb length, excellent rehabilitation potential (only ~10% increase in energy). The stump has a characteristic bulbous shape. Contraindicated if heel pad is not viable or well-vascularised.
Q11. What tests help determine the level of amputation?
Transcutaneous PO2 (TcPO2 >20 mmHg suggests healing potential), Laser Doppler, skin temperature, ABPI/segmental pressures, arteriography. However, none is definitive in isolation - clinical judgement remains the gold standard.
Q12. When would you leave an amputation wound open?
In urgent amputation for fulminating infection or trauma where tissue viability is uncertain. Flaps are fashioned as for elective surgery but the wound is left open, with intended delayed primary closure at ~5 days once infection is controlled and tissue viability confirmed.
Q13. What percentage of AKA patients will achieve prosthetic ambulation?
Only ~40% of patients with arterial insufficiency who undergo AKA achieve ambulation on a prosthesis. For bilateral AKA, less than 10% are ambulatory.
Q14. What is the role of the surgeon post-amputation?
The surgeon's responsibility does not end once the wound heals. The patient must be guided through rehabilitation and return to the community. Amputation is a form of reconstruction - a multidisciplinary team (surgeon, physio, OT, prosthetist, psychologist, social worker) is needed for optimal outcome.
SUMMARY BOX - QUICK RECALL FOR VIVA
| BKA | AKA | |
|---|---|---|
| Level | 14 cm below knee | 25-30 cm below greater trochanter |
| Technique | Burgess long posterior flap | Sagittal flap / equal anterior-posterior |
| Weight-bearing surface | Patellar tendon + tibial flares | Ischial tuberosity |
| Ambulation rate (vascular) | ~75% | ~40% |
| Energy cost | +30-60% | +60-100% |
| Knee | Preserved | Lost |
Sources: Bailey & Love's Short Practice of Surgery 28th Ed., Pye's Surgical Handicraft 22nd Ed., Mulholland & Greenfield's Surgery 7th Ed., Sabiston Textbook of Surgery
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Amputation Exam Revision Guide
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What's inside the guide (11 sections):
| Section | Content |
|---|---|
| Cover Page | Visual overview with badge layout |
| 1. Definition | Historical background + modern concept of amputation as reconstruction |
| 2. Indications | The 3 D's mnemonic table + aetiology percentages |
| 3. Types & Levels | Full level table (digital to hindquarter) + elective landmarks |
| 4. Level Selection | Tests (TcPO2, Laser Doppler, ABPI) + critical judgment note |
| 5. Principles of Surgery | Operative principles + Burgess flap description |
| 6. Long Case History | Two-column structured history template |
| 7. Stump Examination | Step-by-step inspection + palpation + vascular assessment |
| 8. Complications | Early and late complications with management |
| 9. Rehabilitation | Energy cost table + BKA vs AKA prosthetics + K-level classification + MDT |
| 10. Viva Q&A | 14 model questions with full answers (colour-coded boxes) |
| 11. Quick Reference | BKA vs AKA comparison table + complications grid + 10 exam key pearls |
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