Amputation

moderator: Dr Peeyush sharma

Presenter: Dr Pramod

• 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's Symposium mentions therapeutic amputation of the hand and the foot. Hippocrates provided the earliest description of therapeutic amputation in De Articularis for vascular gangrene.

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.

• 90 % amputation – peripheral vascular disease

• Young patient – trauma/ malignancy• Absolute indication – irreversible

ischaemia: disease or trauma

• 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.

• 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.

PERIPHERAL VASCULAR DISEASE+/-diabetesVascular surgery consultationMost significant predictor of amputation in

diabetes: peripheral neuropathy

measured semmes winstein5.07monof….

Infection increases in : S. alb < 3.5gm/dl WBC < 1500cells/ml

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TRAUMA : leading cause in young patientLange absolute indication type IIIc with warm ischaemia time more than 6hrsRelative indication serious associated injuries severe ipsilateral foot injuries anticipated protracted course for tibial

reconstruction

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

M.E.S.S. (Helfet, CORR, 80, 1990)

< 7 : Salvage8-12 : Amputate

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. 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.

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

• Tumors: Amputation is performed less frequently with the advent of advanced limb-salvage techniques.

• Infections: Treatment of sepsis

with 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.

Surgical Margins(Enneking)

• Intralesional

• Marginal

• Wide resection

• Radical resection

Burns : delayed aputation – local infection - systemic

infection - myoglobin

induced renal failure - death

Frostbite : injury – a. direct tissue injury- ice crystals in ECFb. Ischaemic injury- vascular endothelium clot formation inc sympathetic tone- 40-44o C - 2-6 month demarcation- Triple phase tecnetium bone scan

Pathophysiology

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

• 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.

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

Surgical definition and techniques

Trans tibial – B/KTransfemoral – A/KTransradial – B/ETranshumeral –A/E

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 45º-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.

Lab Studies

HematocritCreatinine levels should 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 calcium levels should be monitored. Elevated levels of these electrolytes may lead to cardiac arrhythmias and seizures.

White blood cell count, C-reactive protein, and ESR Expect the C-reactive protein to be the first laboratory value to respond to treatment,

Platelets23

Imaging Studies

• Anteroposterior and lateral radiography of the involved extremity is obtained.

• Computed tomography (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.

• Doppler ultrasonography is 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 ultrasonography pressure 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.

Close attention to soft tissue techniques

1. Flaps – thick2. Avoid unnecessary dissection

between skin and subcutaneous, fascial & muscle plane

3. In adult periosteum should not be stripped proximal to the level of transection

4. In children 0.5cm removal of distal periosteum prevents terminal growth.

5. Rounding and bevelling for prosthetic use.6. Stabilisation and distal insertion of muscle7. Myodesis counteract strong antagonistic8. Mobile sling of muscle causes painful bursa9. Trasection of nerves – always neuroma. But all

neuroma are not symptomatic

Open amputation:To control a sever ascending infectionGuillotine amputationSurgical planOpen knee/ ankle disarticulation

General principles for amputation surgery involve appropriate management of skin, bone, nerves, and vessels, as follows:

• The greatest skin length possible should be maintained for muscle coverage and a tension-free closure.

• Muscle is placed over the cut end of bones via a myodesis (ie, muscle sutured through drill holes in bone), a long posterior flap sutured anteriorly, or a well-balanced myoplasty (ie, antagonistic muscle and fascia groups sutured together).

• Nerves are transected under tension, proximal to the cut end of bones in a scar- and tension-free environment. This reduces the chance neuromas will form and be a source of pain. Placing the cut nerves in a more proximal scar-free environment assists in decreasing potential irritation and pain. Ligation of large nerves can be performed when an associated vessel is present.

• The larger arteries and veins are dissected and separately ligated. This prevents the development of arteriovenous fistulas and aneurysms.

• Bony prominences around disarticulations are removed with a saw and filed smooth. Diaphyseal transections can be covered with a local flexible osteoperiosteal graft. Maintaining the maximal extremity length possible is desirable. However, below-knee amputations are best performed 12.5-17.5 cm below the joint line for nonischemic limbs

• One application guide is to make a limb 2.5 cm long for every 30 cm of body height. For ischemic limbs, a higher level of 10-12.5 cm below the joint line is used because making limbs longer than this can interfere with prosthetic use and design

Standard surgical principles for amputation in the child

• Preserve the physis. Amputations through the metaphysis (such as above-knee or distal forearm level) or diaphysis are not recommended in children because of the progressive relative shortening of the residual limb. This is most critical in the femur, but it is applicable to other long bones as well.

• Disarticulate when possible. Disarticulation completely eliminates the problem of terminal overgrowth and subsequent revision surgery.

• Preserve stump shape. The pediatric amputation stump becomes conical with growth, so preservation of bony architecture such as a short segment of proximal fibula or the distal condyles of the humerus will assist in subsequent rotational control of the prosthesis.

»The split-thickness skin graft can hypertrophy and become sufficiently strong to withstand the shear forces of prosthesis use.

Post operative:1. Rigid dressing : decreses edema,

decreases post operative pain, protect limb from trauma, early mobilsation

2. In postoperative prosthesis : early training with an IPOP is believed to increase the long term acceptance and use of prosthesis

3. Epidural analgesia4. Cast to be appied at the end of the

procedure, changed on the post op day 5 + IPOP

5. Cast changed weekly6. New prosthesis around 18 months

Complication1. Failure of wound to heal : gap if wider than 1cm needs

revision2. Infection : open – flaps retract / edematous results in shortening the bone

Rx close only central 1/3 for coverage of bone.

3. Phantom sensation : diminishes over time, telescoping4. Pain and phantom pain : massage , cold packs, exercise and

neuromuscular stimulation

TENS ( trans cutaneous electric nerve stimulation) : incorporated in a prosthesis

-carbamazipine,Phenytoin,gabapentin,Amitriptylin &Mexiletine

-Preioperative analgesia can prevent or decrease the later incidence of phantom pain .(Epidural\perineural)

5. Edema mistakes :- 1) Too tightly applied cast

2) Soft spica cast – not applied in Transfemoral

cast “Stump Edema Syndrome”

-Proximal constriction-Blood in skin ,pain, Pigmentation-Elevation

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Joint contacture

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Transcarpal amputation

• At this level, supination and pronation of the forearm, as well as flexion and extension of the wrist,

• Ideally, a long full-thickness palmar and shorter dorsal flap should be created in a ratio of 2:1.

• Finger flexor and extensor tendons should be drawn, divided, and allowed to retract deep into the proximal wound. Conversely, wrist flexor and extensor tendons are identified and released from their distal insertions and reflected proximally out of the way.

• The wrist flexors and extensors should be anchored to the remaining carpus in line with their insertions to preserve active wrist motion

Wrist disarticulation• Wrist disarticulation has many of the same advantages as

transcarpal amputation with regard to providing a long lever arm and preserved supination and pronation.

• a technique to minimize postoperative pain from neuroma formation, which involves extending the incisions proximally between the pronator teres and brachioradialis just distal to the elbow flexion crease and doubly ligating the median, ulnar, and superficial radial nerves at this level. This allows a neuroma-in-continuity

» Preserving the triangular fibrocartilage ,shortening of the radial styloid process should be avoided. Preserving the radial styloid flare improves prosthetic suspension.

» Wrist disarticulation is the procedure of choice in children

Transradial amputation

• Best with equal volar and dorsal flaps.• A myodesis should be perfomed

– To prevent a painful bursa,– Facilitate physiological muscular suspension– Myoelectric prosthetic use

• Short transradial –Muenster –type socket –mould humeral condyles

Krukenberg procedure

• More than 80 years ago, Krukenberg described a technique that converts a forearm stump into a pincer that is motorized by the pronator teres muscle. Indications for this procedure have been debated; however, they generally include bilateral upper-extremity amputations, in those who are also blind.

• This procedure preserves proprioception and stereognosis in the functional stump to allow for effective maneuvering in the dark. It is important to note that this procedure is not

recommended as a primary procedure at the time of an amputation,

» To consider this surgical option, the ulna and radius must extend distal to the majority of the pronator teres (the motor for pinching) and an elbow flexion contracture of less than 70° is required.

SYME'S AMPUTATION

The Syme's amputation provides an end-bearing stump that in many circumstances allows ambulation without a prosthesis over short distances. It is an excellent amputation for children, in whom it preserves the physes at the distal end of the tibia and fibula (26).The Syme's amputation works well for tumors and trauma, assuming that the heel flap has been spared from the trauma. In the past, it has had a high failure rate in ischemic limbs because of failure of wound healing. Today, the success of amputation at this level has increased because local tissue perfusion is preoperatively determined with Doppler ultrasound measurement of blood pressures, with radioactive 133Xe clearance tests, and with transcutaneous measurement of oxygenation.

SYME'S AMPUTATION

BOYD AMPUTATIONThe Boyd procedure provides a broad weight-bearing surface of the heel by creating an arthrodesis between the distal tibia and the tuber of the calcaneus Compared to a Syme's amputation, it provides more length and better preserves the weight-bearing function of the heel pad. Its increased complexity and morbidity have made it less used now than the Syme's amputation. The Pirogoff amputation removes the anterior two thirds of the calcaneus but has no advantage over the Boyd amputation,

KNEE DISARTICULATION• Amputation through the knee offers

numerous advantages. The main advantage is the creation of an endbearing stump and preservation of the distal femoral physes, which is particularly desirable in children. Another advantage is the maintenance of a long active lever arm for control of the prosthesis, with excellent muscle attachments. The bulbous distal stump enhances suspension of the prosthesis.– In elderly dysvascular patients, the longer

stump helps prevent hip flexion contractures and it provides better balance for wheelchair activities. Knee disarticulation is most useful in young athletic amputees in whom a below-knee amputation is not feasible.

Follow-up

• Two weeks after surgery, muscle-contraction exercises and progressive desensitization of the residual extremity are initiated.

• Desensitization is started with a towel for distal residual extremity pressure, and distal-end bearing is started on a soft structure (usually a bed).

• Prosthetic management is begun 6 weeks after surgery, depending on the condition of the extremity and wound. Some patients are not candidates for prosthetic limb replacement because of poor balance, weakness, or cognitive impairment. To avoid disappointment and expense, a permanent prosthesis should not be ordered for these patients.

Osteointegration• Osteointegration has been performed in

Sweden. This technique was initially applied in dental surgery for tooth loss, and the procedure involves a metal post, treated similarly to a total joint ingrowth prosthesis, secured to bone.

• Success has been achieved with replacement for thumb amputations. Case series with transfemoral amputations have been completed; however, long-term results are unavailable.

• The potential for postoperative infection and osteomyelitis is high.

Future

• Matsen et al attempted to identify factors that correlate with the perceived amputation result.

• Residual limb length made no difference to patients' perceptions.

• Factors that appeared to influence patients' perceptions included the condition of the contralateral limb; comfort of the residual limb; comfort, function, and appearance of the prosthesis; social factors; and the ability to participate in recreational activities.

Thank you

Thank you!