Amputation

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1. Amputation (from campbell) Dr Anurag Mittal MS Ortho UCMS & GTBH 2. Indication ã Trauma ã Ischaemia ã Peripheral vascular disease ã The most significant…
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  • 1. Amputation (from campbell) Dr Anurag Mittal MS Ortho UCMS & GTBH
  • 2. Indication • Trauma • Ischaemia • Peripheral vascular disease • The most significant predictor of amputation in diabetics is peripheral neuropathy as measured by insensitivity to the Semmes Weinstein 5.07 monofilament • Tumour • Congenital anomalies/non functional limb • Uncontrollable infection • Burns
  • 3. risk for wound complications • serum albumin is less than 3.5 g/dL or • whose total lymphocyte count is less than 1500 cells/mL
  • 4. Energy consumption • The energy required for walking is inversely proportionate to the length of the remaining limb.
  • 5. Limb salvage vs Amputation Limb salvage • metabolic overload and secondary organ failure • multiple operations to obtain bony union and soft-tissue coverage and • multiple operations on other areas to obtain donor tissue. • External fixation may be necessary for several years, and • complications, including infection, nonunion, or loss of a muscle flap, may occur. • Chronic pain and drug addiction • multiple hospital admissions and surgery, • isolation from their family and friends, and • unemployment. • In the end, despite heroic efforts, the limb ultimately could require amputation, or • a “successfully” salvaged limb may be chronically painful or functionless. Amputation • decreased morbidity, • fewer operations, • a shorter hospital course, • decreased hospital costs, • shorter rehabilitation, and • earlier return to work. • The treatment course and outcome are more predictable. • Modern prosthetics often provide better function than many “successfully” salvaged limbs.
  • 6. Frostbite • Frostbite denotes the actual freezing of tissue in the extremities, with or without central hypothermia • When heat loss exceeds the body's ability to maintain homeostasis, blood flow to the extremities is decreased to maintain central body temperature. • Actual tissue injury occurs through two mechanisms: (1) direct tissue injury through the formation of ice crystals in the extracellular fluid and (2) ischemic injury resulting from damage to vascular endothelium, clot formation, and increased sympathetic tone.
  • 7. • The first step in treatment is restoration of core body temperature. • Treatment of the affected extremity begins with rapid rewarming in a water bath at 40°C to 44°C. • parenteral pain management and sedation. • After initial rewarming, if digital blood flow is still not apparent, treatment with tissue plasminogen activator or regional sympathetic blockade may be indicated. • Tetanus prophylaxis • prophylactic systemic antibiotics are controversial.
  • 8. • Blebs should be left intact. • Closed blebs should be treated with aloe vera. • Silver sulfadiazine (Silvadene) should be applied regularly to open blebs. • Low doses of aspirin or ibuprofen also should be instituted. • Oral antiinflammatory medication and topical aloe vera help to stop progressive dermal ischemia mediated by vasoconstricting metabolites of arachidonic acid in frostbite wounds. • Physical therapy should be started early to maintain range of motion. • In stark contrast to traumatic, thermal, or electrical injury, amputation for frostbite routinely should be delayed 2 to 6 months. • Clear demarcation of viable tissue may take this long. • Even after demarcation appears to be complete on the surface, deep tissues still may be recovering. • Performing surgery prematurely often results in greater tissue loss and increased risk of infection. An exception to this rule is the removal of a circumferentially constricting eschar.
  • 9. Infection • Any contaminated wound that is closed without appropriate débridement is at high risk for the development of gas gangrene.
  • 10. Treatment-clostridial • associated with a mental awareness of impending death • immediate radical débridement • high doses of intravenous penicillin (clindamycin may be used if the patient is allergic to penicillin), and • hyperbaric oxygen. • Emergency open amputation one joint above the affected compartments often is needed as a lifesaving measure, but may be avoided if treatment is initiated early.
  • 11. Tumour • Amputation • technically demanding, • often requiring nonstandard flaps, • bone graft, or • prosthetic augmentation to obtain a more functional residual limb • Limb salvage • greater risk of infection, • wound dehiscence, • flap necrosis, blood loss, and deep venous thrombosis. • periprosthetic fractures, prosthetic loosening or dislocation, • nonunion of the graft-host junction, allograft fracture, • leg-length discrepancy, and • late infection.
  • 12. SURGICAL PRINCIPLES OF AMPUTATIONs
  • 13. Determination of Amputation Level • clinical assessment • skin color, • hair growth, and • skin temperature. • skin perfusion pressures • skin flap perfusion • thermography or • laser Doppler flowmetry. • the tissue uptake of intravenously injected fluorescein or • the tissue clearance of intradermally injected xenon-133. • transcutaneous oxygen measurements to be most beneficial
  • 14. Transcutaneous oxygen measurements • probe that is heated to 45°C for 10 minutes - allows for a maximum vasodilatory response. • 20 to 40 mm Hg, “good” healing potential. however, no absolute cutoff • The measurement can be falsely decreased in circumstances that decrease the diffusion of oxygen, such as cellulitis or edema. • The test can be improved by comparing the transcutaneous oxygen level before and after the inhalation of 100% oxygen. • An increase of 10 mm Hg at a particular level is a good indicator for healing potential. • Accuracy also can be improved by comparing supine and elevation of the extremity measurements in patients who fall into the 20 to 40 mm Hg gray zone. • A decrease of greater than 15 mm Hg after 3 minutes of elevation of the involved limb is a poor prognostic indicator for healing. • this information must be used in light of other patient variables, including age, concomitant medical problems, and ambulatory potential
  • 15. Technical Aspects • Skin • Thick flap • No unnecessary dissection • Sturdy soft tissue envelop for stump • No adherent scar • No dog ears
  • 16. • Muscles • divided at least 5 cm distal to the intended bone resection. • myodesis (suturing muscle or tendon to bone) : • stronger insertion, • help maximize strength, and minimize atrophy , • counterbalance their antagonists, • preventing contractures and • maximizing residual limb function • myoplasty (suturing muscle to periosteum or to fascia of opposing musculature). • Myodesis may be contraindicated, however, in severe ischemia because of the increased risk of wound breakdown.
  • 17. • Nerves :preventing the formation of painful neuromas. These include • end-loop anastomosis, • perineural closure, • Silastic capping, • sealing the epineurial tube with butyl-cyanoacrylate, • ligation, • cauterization, and • methods to bury the nerve ends in bone or muscle • nerves should be isolated, gently pulled distally into the wound, and divided cleanly with a sharp knife so that the cut end retracts well proximal to the level of bone resection.
  • 18. • Bone : • Excessive periosteal stripping is contraindicated -may result in the formation of ring sequestra or bony overgrowth. • Bony prominences that would not be well padded by soft tissue always should be resected, and • the remaining bone should be rasped to form a smooth contour.
  • 19. Rigid dressing • prevent edema , • protect the wound from bed trauma, • enhance wound healing and • early maturation of the stump, and • decrease postoperative pain, • allowing earlier mobilization from bed to chair and ambulation with support. • For transtibial amputations, rigid dressings prevent the formation of knee flexion contractures. • The physiological benefits of upright posture to the respiratory, cardiovascular, urinary, and gastrointestinal systems • the hospital stay can be decreased and the cost of care reduced accordingly. • Finally, earlier definitive prosthetic fitting is possible, and a higher percentage of patients are successfully rehabilitated
  • 20. Rehab • A young patient with a traumatic amputation above the zone of injury probably could begin 25-lb partial weight bearing immediately postoperatively. • A patient with a traumatic amputation through the zone of injury or a patient with an amputation performed secondary to ischemia probably should wait until early wound healing is documented before gradually beginning partial weight bearing. • Weight bearing status should be reevaluated with each subsequent cast change. • If the wound is progressing well, weight bearing can progress in 25- lb increments each week
  • 21. Complications • Haemotoma • Infection • Wound necrosis • Contractures • Pain:phantom pain,mechanical low backache,residual limb pain,neuroma(tinel sign) • Dermatological problems
  • 22. Local resection produces uneven tension; this is reduced and evenly distributed after wedge resection
  • 23. AMPUTATIONS IN CHILDREN • congenital and acquired • Krajbich general principles of childhood amputation • (1) preserve length, • (2) preserve important growth plates, • (3) perform disarticulation rather than transosseous amputation whenever possible, • (4) preserve the knee joint whenever possible, • (5) stabilize and normalize the proximal portion of the limb, and • (6) be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions
  • 24. Terminal bone overgrowth • In transosseous amputation • does not occur after disarticulation. • caused by appositional new bone formation and is unrelated to the growth of the physis. • bone is elongated and often pencil-shaped. • swelling, edema, pain, and bursa formation and in severe cases may penetrate the skin. • Humerus>fibula> tibia> femur>radius>ulna.
  • 25. • Treatment: • surgical resection of the excess bone. • Epiphysiodesis has been unsuccessful and is contraindicated. • Capping the bone with a synthetic device -limited success and complicated by infection or fracture of the implant or bone. • capping the bone with an epiphyseal graft harvested from the amputated limb at the index procedure • capping with tricortical iliac crest graft at a revision operation.
  • 26. Toe amputation • Amputation of a single toe-little disturbance in stance or gait. • Amputation of the great toe -a limp while runing because of the loss of push- off. • Amputation of the second toe -severe hallux valgus • Treatment:second ray amputation and narrowing the foot then Screw fixation • Amputation of any of the other toes causes little disturbance. • Amputation of all toes causes little disturbance in ordinary slow walking, but is disabling during a more rapid gait and when spring and resilience of the foot are required. • It interferes with squatting and tiptoeing. • Usually, amputation of all toes requires no prosthesis, other than a shoe filler • Amputation of more than two rays often is more disabling than a transmetatarsal amputation.
  • 27. Midfoot amputation • (1) Lisfranc amputation at the tarsometatarsal joints, -equinus deformity -severe equinovarus deformity • (2) Pirogoff amputation, in which the calcaneus is rotated forward to be fused to the tibia after vertical section through its middle.
  • 28. Preventing equinus • Transfer of dorsiflexors • Achillis tenotomy/tenectomy • dorsiflexion rigid dressing for 6 weeks
  • 29. Chopart • “fish-mouth” flap that is slightly longer on the plantar surface. Begin the incision at the transtarsal joints medially and laterally. • Identify the transverse tarsal (calcaneocuboid and talonavicular) joints, and disarticulate by releasing the dorsal and plantar ligaments • perform a tenotomy of the Achilles tendon. Excise 2 cm of tendon, and attempt to preserve the sheath of the Achilles tendon • Transfer the anterior tibial tendon/EHL to the neck of the talus • peroneus brevis/EDL to the anterior process of the calcaneus
  • 30. HINDFOOT AND ANKLE AMPUTATIONS • Pirigoff • arthrodesis between the tibia and part of the calcaneus; • the calcaneus is sectioned vertically, its anterior part is removed, and its remaining posterior part and the heel flap are rotated forward and upward 90 degrees until the raw surface of the calcaneus meets the denuded distal end of the tibia. • Boyd • eliminates the problem of posterior migration of the heel pad • talectomy, forward shift of the calcaneus, and calcaneotibial arthrodesis • Syme • Semiento modification of syme • tibia and fibula approximately 1.3 cm proximal to the ankle joint and excision of the medial and lateral malleoli. • cosmetic
  • 31. Boyd
  • 32. Syme • end-bearing stump, • enough space between the end of the stump and the ground for the construction of some type of ankle joint mechanism for the artificial foot • distal tibia and fibula 0.6 cm proximal to the periphery of the ankle joint and passing through the dome of the ankle centrally • Complications: • posterior migration of the heel pad and • skin slough resulting from overly vigorous trimming of “dog ears.” • Non cosmetic:window required in prosthesis for bulbous end
  • 33. prevent migration of the heel pad on the end of the stump • such as taping the heel flap to the leg with adhesive strips, • skewering the heel flap to the bone with a Kirschner wire, or • leaving a small sliver of calcaneus attached to the heel flap, which fuses to the end of the tibia. • The technique of Wagner is simple and has been effective in his hands. • Drill several holes through the anterior edge of the tibia and fibula, and suture the deep fascia lining the heel flap to the bones through these holes • “dog ears,” are found at each end of the suture line; these should never be removed because they carry a large share of the blood supply to the heel flap and disappear later under bandaging. , •
  • 34. TRANSTIBIAL (BELOW-KNEE) AMPUTATIONS • stumps extending to the distal third of the leg have been considered suboptimal because • there is less soft tissue available for weight bearing and • less room to accommodate some energy storage systems. • The distal third of the leg also has been considered relatively avascular and • slower to heal than more proximal levels
  • 35. Non ischemic limb • ideal bone length stump :12.5 to 17.5 cm, depending on body height. • 2.5 cm of bone length for each 30 cm of body height. • the most satisfactory level is about 15 cm distal to the medial tibial articular surface. • A stump less than 12.5 cm long is less efficient. • Stumps lacking quadriceps function are not useful. • In a short stump of 8.8 cm or less, it has been recommended that the entire fibula together with some of the muscle bulk be removed so that the stump may fit more easily into the prosthetic socket. • Many prosthetists find, however, that retention of the fibular head is desirable because the modern total-contact socket can obtain a better purchase on the short stump
  • 36. • measure distally the desired length of bone, and mark that level over the tibial crest with a skin marking pen. • Outline equal anterior and posterior skin flaps, the length of each flap being equal to one half the anteroposterior diameter of the leg at the anticipated level of bone section • Begin the anterior incision medially or laterally at the intended level of bone section, and swing it convexly distalward to the previously determined level and proximally to end at a similar position on the opposite side of the leg
  • 37. • When crossing the tibial crest, deepen the incision, and mark the periosteum with a cut to establish a point for future measurement • Divide the muscles in the anterior compartment of the leg at a point 0.6 cm distal to the level of bone section so that they retract flush with the end of the bone • Before sectioning the tibia, bevel its crest with a saw: begin 1.9 cm proximal to the level of the bone section, and cut obliquely distalward to cross this level 0.5 cm anterior to the medullary cavity. • section the fibula 1.2 cm proximally • Divide the muscles in the deep posterior compartment 0.6 cm distal to the level of bone section • bevel the gastrocnemius-soleus muscle mass so that it forms a myofascial flap long enough to reach across the end of the tibia to the anterior fascia
  • 38. ischemic limbs:burgess
  • 39. • Because the skin's blood supply is much better on the posterior and medial aspects of the leg than on the anterior or anterolateral sides, transtibial amputation techniques for the ischemic limb are characterized by skin flaps that favor the posterior and medial side of the leg. • The long posterior flap technique popularized by Burgess is most commonly used, but medial and lateral flaps of equal length as described by Persson, skew flaps, and long medial flaps are being used. • amputations performed in ischemic limbs are customarily at a higher level (e.g., 10 to 12.5 cm distal to the joint line) than are amputations in nonischemic limbs. • Tension myodesis and the osteomyoplasty procedure of Ertl, which may be of value in young, vigorous patients, are contraindicated
  • 40. Amputation osteomyoplasty: Ertl procedure • Amputation osteoplasty transforms the typical transosseous amputation site into an end-bearing limb • Advantages • Decreased pain, • better proprioception with ambulation, • preservation of tissue quality and • prevention of tibiofibular instability. • The Ertl procedure consists of a periosteal sleeve sutured over the osseous transections. • This functions to seal the medullary canal and form a bone bridge between the tibia and fibula. • A modification of the technique has been described with use of a fibular osteotomy rotated and fixed to the tibia.
  • 41. Knee disarticulation • Advantages • 1) The large end-bearing surfaces of the distal femur covered by skin and other soft tissues that are naturally suited for weight bearing are preserved, • (2) a long lever arm controlled by strong muscles is created, and • (3) the prosthesis used on the stump is stable • ideal for nonambulating patients who require amputation because additional length of the extremity provides adequate sitting support and balance. • Knee flexion contractures and associated distal ulcers common with transtibial amputations also are avoided.
  • 42. • from the inferior pole of the patella anterior flap about equal in length to the diameter of the knee • from the level of the popliteal crease, fashion a short posterior flap equal in length to one half of the diameter of the knee. • Place the lateral ends of the flaps at the level of the tibial condyles. • Include in the flap the insertion of the patellar tendon and the pes anserinus • Do not excise the patella or attempt to fuse it to the femoral condyles. Do not disturb the articular cartilage of the femoral condyles and patella. Perform a synovectomy only if specifically indicated. • Suture the patellar tendon to the cruciate ligaments and the remnants of the gastrocnemius muscle to tissue in the intercondylar notch
  • 43. • Mazet and Hennessy recommended a method that features resection of the protruding medial, lateral, and posterior surfaces of the femoral condyles for creating a knee disarticulation stump for which a more cosmetically acceptable prosthesis can be constructed. • tolerances within the socket are greater, • more adduction of the stump is permitted in the alignment of the prosthesis, and • the decreased bulk of the stump permits greater ease in the application and removal of the prosthesis.
  • 44. TRANSFEMORAL (ABOVE-KNEE) AMPUTATIONS • stump to be as long as possible to provide a stron
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