Amputation.Dr Pramod

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  • 1.Amputation
    • moderator: Dr Peeyush sharma
  • Presenter: Dr Pramod

2.

  • The earliest literature discussing amputation is the Babylonian code of Hammurabi, inscribed on black stone, from 1700 BCE, which can be found in the Louvre.
  • In 385 BCE, Plato'sSymposiummentions therapeutic amputation of the hand and the foot. Hippocrates provided the earliest description of therapeutic amputation inDe Articularisfor vascular gangrene.

3. Problem

  • One of the greatest difficulties for a person undergoing amputation surgery is overcoming the psychological stigma that society associates with the loss of a limb.
  • Persons who have undergone amputations are often viewed as incomplete individuals. Following the removal of a diseased limb and the application of an appropriate prosthesis, the patient can resume being an active member of society and maintaining an independent lifestyle.

4.

  • 90 % amputation peripheral vascular disease
  • Young patient trauma/ malignancy
  • Absolute indication irreversible ischaemia: disease or trauma

5.

  • In 1965, the ratio of above-knee amputations to below-knee amputations was 70:30.
  • A quarter century later, the value of retaining the knee joint and the greater success in doing so was appreciated, so the ratio became 30:70.

6. 7.

  • Most amputations are performed for ischemic disease of the lower extremity. Of dysvascular amputations, 15-28% of patients undergo contralateral limb amputations within 3 years. Of elderly persons who undergo amputations, 50% survive the first 3 years.

8.

  • PERIPHERAL VASCULAR DISEASE
  • +/-diabetes
  • Vascular surgery consultation
  • Most significant predictor of amputation in diabetes: peripheral neuropathy
  • measured semmes winstein5.07monof.
  • Infection increases in : S. alb < 3.5gm/dl
  • WBC < 1500cells/ml

9.

  • TRAUMA :leading cause in young patient
  • Langeabsolute indication
  • type IIIc with warm ischaemia
  • time more than 6hrs
  • Relative indication
  • serious associated injuries
  • severe ipsilateral foot injuries
  • anticipated protracted course for tibial reconstruction

10.

  • To Remove subjectivity
  • predicive salvage index
  • limb injury score
  • mangled extremity syndrome index
  • mangled extremity severity score(most useful)
  • score 7 or >:amputation eventual
  • Attempts to salvage a severely injured limb may lead to metabolic overload and secondary organ failure
  • Injury severity score > 50 : contraindication to limb salvage

11. M.E.S.S. (Helfet, CORR, 80, 1990) < 7 : Salvage 8-12 : Amputate 12.

  • . If a digit is hanging on by a small bridge of skin or muscle, attempt to bandage it without completing the separation. If the body part can be easily recovered and the victim can be brought to a hospital within 6 hours of the injury, do the following: 1. Gently rinse the body part if the cut end is contaminated with dirt. 2. Wrap the body part in clean cloth or gauze and keep the covering moist. The ideal solution is saline (not ocean water, because of infection risk), if that is available; if not, fresh water will do. Do not immerse the part in a bag of water; merely keep the covering moist. Keep the body part cool by placing it on ice after wrapping it securely in a bandage, cloth, or towel. To avoid a frostbite injury, do not apply ice directly to the body part or immerse it in ice water. 3. Bring the body part with the victim to the hospital.

13. Congenital limb deficiency:Amputations for congenital limb deficiencies are performed primarily in the pediatric population because of failure of partial or complete formation of a portion of the limb. Congenital extremity deficiencies have been classified as longitudinal, transverse, or intercalary. Radial or tibial deficiencies are referred to as preaxial, and ulnar and fibular deficiencies are referred to as postaxial 14.

  • Tumors:Amputation isperformed less frequently with the advent of advanced limb-salvage techniques.
  • Infections:Treatment ofsepsiswith vasoconstrictor agents may at times lead to vessel occlusion and subsequent extremity necrosis, necessitating amputation. At other times, eradication of infection from many difficult sources necessitates removal of the affected digit or limbs.

15. Surgical Margins (Enneking)

  • Intralesional
  • Marginal
  • Wide resection
  • Radical resection

16.

  • Burns :delayed aputation local infection
  • - systemic infection
  • - myoglobin induced renal failure
  • - death
  • Frostbite : injury
  • a. direct tissue injury- ice crystals in ECF
  • b. Ischaemic injury- vascular endothelium
  • clot formation
  • inc sympathetic tone
  • 40-44 oC
  • 2-6 month demarcation
  • Triple phase tecnetium bone scan

17. Pathophysiology

  • Amputation of the lower extremity is often the treatment of choice for an unreconstructable or a functionally unsatisfactory limb

18.

  • The higher the level of a lower-limb amputation, the greater the energy expenditure that is required for walking
  • As the level of the amputation moves proximally, the walking speed of the individual decreases, and the oxygen consumption increases
  • For most people who have undergone transtibial amputations, the energy cost for walking is not much greater than that required for persons who have not undergone amputations.
  • For those who have undergone transfemoral amputations, the energy required is 50-65% greater than that required for those who have not undergone amputations .

19. Energy Expenditure for Amputation Amputation level Energy above baseline, % Speed, m/min Oxygen cost, mL/kg/m Long transtibial 10 70 0.17 Average transtibial 25 60 0.20 Short transtibial 40 50 0.20 Bilateral transtibial 41 50 0.20 Transfemoral 65 40 0.28 Wheelchair 0-8 70 0.16 20. 21. Surgical definition and techniques Trans tibial B/K Transfemoral A/K Transradial B/E Transhumeral A/E 22. Preoperative preparation includes the following steps:

  • Appropriate preoperative antibiotics are administered in cases of infection, and prophylactic antibiotics are administered in cases of elective amputation or those resulting from trauma.
  • A tourniquet is placed on the limb prophylactically and used on a discretionary basis.
  • Vascular and bone instruments are requested.
  • A series of 45-angled chisels are obtained for osteomyoplastic reconstruction.
  • An appropriate strength saw for cutting bone is obtained (usually a power oscillating saw).
  • Vessel ligatures are obtained.

23. Lab Studies

  • Hematocrit
  • Creatinine levelsshould be monitored. In individuals with muscle injury and necrosis, myoglobin enters the systemic circulation and can lead to renal insufficiency and failure. This is especially true in individuals with thermal and electrical burns.
  • Potassium and calciumlevels should be monitored. Elevated levels of these electrolytes may lead to cardiac arrhythmias and seizures.
  • White blood cell count, C-reactive protein , andESRExpect the C-reactive protein to be the first laboratory value to respond to treatment,
  • Platelets

24. Imaging Studies

  • Anteroposterior and lateral radiography of the involved extremity is obtained.
  • Computedtomography (CT)scanning and magnetic resonance imaging (MRI) are performed for the patient's tumor workup or for osteomyelitis to ensure that the surgical margins are appropriate.
  • Technetium-99m (99mTc)pyrophosphate bone scanning has been used to predict the need for amputation in persons with electrical burns and frostbite. A 94% sensitivity rate and a 100% specificity rate has been reported in demarcating viable tissues from nonviable tissues.

25.

  • Doppler ultrasonographyis used to measure arterial pressure; the area under the waveform is a measure of flow. In approximately 15% of patients with PVD, the results are falsely elevated because of the noncompressibility of the calcified extremity arteries. Doppler ultrasonography has been used in the past to predict wound healing. A minimum measurement of 70 mm Hg is believed to be necessary for wound healing.
    • Ischemic index (II):This index is the ratio of the Doppler ultrasonographypressure at the level being tested to the brachial systolic pressure. An II of 0.5 or greater at the surgical level is necessary to support wound healing.
    • Ankle-brachial index:The II at the ankle level is believed to be the best indicator for assessing adequate inflow to the ischemic limb. An index less than 0.45 indicates incisions distal to the ankle will not heal.

26.

  • Close attentionto soft tissue techniques
  • Flaps