Surgical Considerations in Lower Extremity Amputation · –Malleoli excision –Incision. Symes...

SurgicalConsiderationsinLowerExtremityAmputation

TinaDreger,MDOrthopaedic TraumaFellow

UniversityofMissouri

Disclosures

–None–OriginalpresentationbyBrettCrist,MD

Objectives

• Understandtheindicationsforlowerextremityamputation

• Understandtheprinciplesandgoalsoflowerextremityamputation

• Reviewspecificlevelsofamputationandimportantconsiderationsforeach

• Reviewspecialconsiderationsinvolvinglowerextremityreconstruction

LowerExtremity:Purpose

• Ambulation/locomotion

IndicationsforAmputations

• Trauma–Acute

–Chronic

• MedicalCo-morbidities

AmputationDuetoTrauma

• Trauma–20-40y/omales–16%ofamputations–45%ofamputees

IndicationsforAmputation

• LEAP–569patientsfollowedprospectively–Ampvs.limbsalvage–2and7yeardata–Hospitalization–Whitecollar–=?

Bosseetal.NEJM2002;JBJS2005

IndicationsforAmputation

• Lackofplantarsensation– Notequalautomaticamputation

– >50%ofsalvageswithinitiallackofplantarsensationrecoveredby2years

Bosseetal.JBJSAm2005

IndicationsforAmputation

• Military–Pushingtheenvelope–ExtremityWarInjuriesSymposia

AmputationsAmongMilitary

• Increasednumberof3and4extremityamputees

• IED’s=infection• Soldierswithtourniquets

• Significantpsychologicalandsocietalimplications

IndicationsforAmputations

• Infection– 2⁰todiabetes

• PeripheralVascularDisease– 2⁰todiabetes(71%)– 80%oflowerextremityamputees

IndicationsforAmputations

• Neurologicaldisorders– Peripheralneuropathy2⁰todiabetes– Lackofprotectivesensation

• Burn

• Congenitaldeformities

• Malignanttumors– Clearmargin

SuccessfulAmputation

• Removalofdysfunctional/devitalizedtissue– easy

• Reconstructionofadurableresiduallimb– challenging

GoalsofAmputationSurgery• PreservationofLength

– Preventionofadjacentjointcontractures

• Preservationoffunction– Minimizeenergyexpenditure

• Earlyreturntofunction– Earlyprostheticfittingwhenpossible

• Painlessresiduallimb– Preventionofsymptomaticneuromas– Minimizephantomlimbpain

• PreservationofLife

EnergyExpenditure• Normalenergyexpenditure–Walking–O2consumption

• Levelofamputation–Higher=moreenergy

Gottschalk,Frank;Rehabilitation:Gait,Amputations,Prostheses,Orthoses,andNeurologicInjury,Chpt.10.

GeneralAmputationPrinciples

• Skin• Muscle• Nerves• BloodVessels• Bone

Skin

• Painless,pliable,nonadherentscar

• Scarplacementandprostheticwear– Viablelevel

• Coverage:–Flapcoverage–Skingraft

Muscle

• Myofascialclosure– Providesminimalmusclestabilization

• Myoplasty– Balancesopposingmusclegroups

• Myodesis– Attachmuscletobone

• Tenodesis– Attachtendontobone

Nerves

• Avoidingpainfulneuromas1. Separatenervefromvessels

2. Tractionnerveandsharplytransect-Retractstosafety

3. Nervepreparation-Injectionofalcohol

BloodVessels

• Sutureligatemajorvessels

• Full-thicknessskinflaps–Minimizewoundnecrosis

• Hemostasispriortoclosure–Drains

Bone• Minimizesharpedges– Beveling/filing

• Narrowmetaphysealflare/condyles

• Capintramedullarycanal–Minimizebleeding

• Minimizeperiostealstripping– Exostosis

LevelsofAmputation

LevelsofAmputation• Toe

• Rayresection

• Partialforefoot

• Transmetatarsal

• Symes

• ModifiedSymes

• BKA

• Throughknee

• AKA

• HipDisarticulation

• Hemipelvectomy

Toe

• Interphalangeal– Leavecartilage– Trimcondyles

• Transecttendonsandnerves– Donotsewtendonstogether

• Greattoe– Leave1cm– Footbalanceandfunction

RayResectionandPartialFoot

• Includestoeandpartofmetatarsal

• Preserve1st MTlength–Orthosis–Footbalance

• Avoidsharpbonyprominences

• Multiplelateralrays

Transmetatarsal

• Considered– 2ormoremedialrays– Morethanonecentralray

• Preservelength• Maintainarchandmetatarsalcascade

• AvoidAchillescontracture– Achilleslengthening

Transmetatarsal

Ngetal.JAAOS2010

NegativesforTransmetatarsal

–Footbalance–Prostheticfit–Woundhealing•33%primarywoundclosure•56%mayrequirerevisiontohigherlevel

Symes

• Ankledisarticulation

• Required–Viableheelpad

• Modifications–Malleoliexcision– Incision

Symes

Benefits– Longerlimb/lessenergy–Highlevelwalkers– Endbearingforobesepatients–Ambulatewithoutprosthesis

Negatives–Woundhealing–Compliance–Heelpadinstability

Symes

• Mustpreserveposteriortibialarterialsupply

Ngetal.JAAOS2010

BelowKneeAmputation

• Mostcommon

• Longerisbetter– Always?– Softtissue

• MinimumtoutilizeBKAprosthesis– 2.5cmper30cmptheight– 5cmdistaltothetubercle

BelowKneeAmputation:Techniques

• Longposteriormyocutaneousflap

• Modifyskinflapsbaseduponavailableskin

• IDneurovascularstructures

• Isolatefibulaandtransect1.5cmabovetibia

• Tibialcut

• Bevelbonecuts

• Ligatevesselsandtransectnerves

• Myodesisvs.myoplasty

BelowKneeAmputation

Staged– Traumaticorinfection

– Guillotine• Allowssofttissuesandbonetodeclare

ErtlProcedure

• Tibiofibularsynostosis

• Indication– Young– Proximaltib/fibinstability– Highactivitylevel

• Outcomes– Functionalscores=nobenefit(Ngetal.JAAOS2010)

Technique

– Fibulacutatsamelevel– Leavemedialperiostealhinge–Connecttotibia•Metal• Suture

Ngetal.JAAOS2010

CaseExample

• 45y/os/pMCC• Policeofficer• Rightopenfemurfx• Rightopentib/fibwithvascularinsufficiency

• Ex-fix• Multipledebridements• Progressivenecrosis

CaseExample

CaseExample

CaseExample

CaseExample

• Femurinfected– ABXbeads– IVabx– debridements

• 2STSG• Sutureremoval

• 11mo

Afterprosthesis

• c/okneepainandcrepitance

BKAatallcosts

• Improvedenergyexpenditure

• Softtissuereconstructiontomaintainlengthandkneefunction– Skingraftorsubstitute–Muscleflap

• Morefunctionalprosthesis

CaseExample

• 40y/omales/pBKAduetomangledlowerextremityaftergo-cartaccident

• Within2weeksofBKAandDPC– Infected–Necroticskin

Options

• RevisiontoAKA

• Reconstructsofttissueweight-bearingsurface

CaseExample

• Multipledebridements

• Negativepressurewoundtherapy(NPWT)

CaseExample

• STSGlowprobability

• Muscleflaprequired–Gracillisrotationflap

CaseExample

• Gracilliscoveringtibia

• STSGovermuscle

ThroughKneeAmputation/KneeDisarticulation

• Prosthetists– Thumbsupordown

• Endbearingresiduallimb

• Softtissuecoverage– Improvedwithposteriorflaptechnique

Indications

• Trauma

• Infection

• Dysvascular

• Nonambulatory

– *RiskofkneecontractureswithBKA

ThroughKneeAmputation/KneeDisarticulation

Benefits– Endbearingsurface– Sittingcomfort– Longerleverarm–Balancedthighmuscles–Prostheticsuspension(femoralcondyles)

Negatives–Kneeheight– Softtissuecoverage

Technique• Suturepatellartendontocruciates

• Patellanotdistaltofemur

DougSmith,MD

ThroughKneeAmputation/KneeDisarticulation

• LEAPstudy– Slowestwalkingspeed– Leastsatisfaction

–12/18nogastroc coverage->poorprosthetictolerance

Mackenzieetal.JBJS2004

AboveKneeAmputation

• Maintainlength

• Energyexpenditure

• Recurrentinfectedtotalkneearthroplasty–Alternativetokneefusion

Technique

• Fishmouthincision-Modifytopreventweightbearingonincision

• Myodeseadductors

• Myodesequadandhamstrings

• Nomyodesis=poorfunctionandpain– Femurmoveswithinmuscularsleeve

AboveKneeAmputation

CaseExample:Maintainlengthatallcost

• 32y/os/pMCC• Leftopentibialshaftfx• Leftopenbicondylartibialplateaufx

• Leftopenfemoralshaftfx

• Leftfemoralneckfx• Leftclaviclefx• Leftulnafx

CaseExample

CaseExample

CaseExample

• Rideshorses

• Noresidualpain

HipDisarticulation

Indications– Preservationoflife– Co-morbidptwithinfectionandsepsis– Necrotizingfasciitis– Non-ambulators(paraplegics)– Advancedischemicdisease– Tumor

HipDisarticulation

• Problems–Woundmanagement– Sittingbalance–Noprosthesis?•Maychoosenottowear• Usecrutchesanyway

Technique• Lateralposition

• Medialandlateralskinflaps

• Usemusclestofilldeadspace

• Woundcomplications

Hemipelvectomy

• Indications– Sameashipdisarticulation– Tumormorecommon–Morecommoninmilitaryrecently

• Procedureoflastresort• Poorfunctionaloutcome

Technique

• Semi-lateralposition

• Largeposteriorflap

• Keepasmuchofthehemipelvisaspossibleforsittingbalance

Complications

AmputationSiteBreakdownEarly• Delayedwoundhealing– Immunocompromised–Malnourished– Infection

• Marginalnecrosis–Appropriatesurgicaltechnique

AmputationSiteBreakdown

Late• Deepinfection–UsuallyassociatedwithPVD/DM/amputationforinfectedhardware

• Adherentskin

• Poorprostheticfit

Infection

• Debridement• Antibiotics• Localwoundcare• Secondaryhealing–Prolongedwoundhealing

• Revisionamputation

AmputationSiteProminence

• Overgrowth• Bonespur• Muscleatrophy• Failedmyoplasty/myodesis• Skinhypertrophy• Bursitis• Bulbous/floppyresiduallimb– Poorsurgicaltechnique

IndicationsforRevisionAmputation

• Tissueprominence–Poorprostheticfit–Limitedfunction–Pain–Skinatrisk

HeterotopicOssification/BoneSpur

• Associatedwith:– Severetrauma– Excessivemanipulationofperiosteum

– Residualboneafterosteotomy

• Mayrequiresurgicalresectionifproblematic– RecurrenceofHO

IndicationsforRevisionAmputation

• NeurologicComplications– Neuroma– Phantomlimbsensation

Neuroma• Allnervetransectionsformneuromas

• Painful–PositiveTinel’s

• Causes–Poorsurgicaltechnique–Highpressurearea–Crushinjury

PhantomLimbPain

• Maybenonpainful

• Painful–Upto85%inLE–~40-69%inUE

PhantomLimbPain

• Surgical– Dehydrogenatedalcoholandmarcaineintoepineureum

• Non-surgical– Neurontin• Showneffective

– VitaminC?– Regionalanestheticsperioperatively?

JointContracture

• Usuallyrelatedtoshortleverarm

• Contracturereleaseandtenolysismayberequirediffixeddeformity

Summary

• Lowerextremityamputationsaremuchmorecommonthanupperextremity

• Restoringfunctionisimportant– Reconstruction– Prosthesis

• Preservelengthandjointmotion• Avoidcomplications• Patientcounseling/support

Questions?

ThankYou

Email:dregert@health.missouri.edu

References

1. SmithDG,MichaelJW,BowkerJH,AmericanAcademyofOrthopaedicSurgeons.Atlasofamputationsandlimbdeficiencies:surgical,prosthetic,andrehabilitationprinciples.3rded.Rosemont,IL:AmericanAcademyofOrthopaedicSurgeons;2004.

2. Scottetal.TraumaticandTrauma-relatedAmputationsIandII.JBJSAmDec2010

3. NgandBerlet.EvolvingTechniquesinFootandankleAmputations.JAAOSApril2010