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Below knee amputation

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  • 1. BELOW KNEE (TRANSTIBIAL) AMPUTATION
  • 2. OUTLINE INTRODUCTION EPIDEMIOLOGY RELEVANT ANATOMY CLASSIFICATION INDICATIONS LEVEL OF AMPUTATION PREOPERATIVE PREPARATIONS INTRAOPERATIVE PROCEDURE
  • 3.  POSTOPERATIVE CARE/REHABILITATION COMPLICATIONS PROSTHESIS SITUATION IN OUR SUBREGION CONCLUSION
  • 4. INTRODUCTION Amputation is the surgical removal of a limb or part of a limb by cutting through the shaft of the bone. It is the most ancient surgical procedures. Early surgical amputation was a crude procedure by which a limb was rapidly severed from an unanaesthesized patient,the open stump was crushed or dipped in boiling oil to obtain haemostasis.
  • 5.  Hippocrates 1st to use ligature which was lost during the dark ages. 1529:Pare reintroduced it & artery forceps. 1674:Morel introduced tourniquet. With the introduction of general anaesthesia & antiseptic technique in the late 19th century surgeons could now fashion a functional stump.
  • 6. EPIDEMIOLOGY More than 300,000 patients with amputations live in the U S according to NCHS and about 65,000 amputations are performed annually. >90% of amputations performed in western world are secondary to PVDx. In younger patient trauma is the leading cause followed by malignancy. 1965, AK : BK = 70 : 30
  • 7.  1980, AK : BK = 30 : 70. In FMC Owerri,41 BKA were done in the last 2years with M : F = 1.7 : 1. Diabetic foot gangrene 88%, Trauma & TBS 5% each, others 2%
  • 8. RELEVANT ANATOMY
  • 9. CLASSIFICATION 1) Emergency or Elective. 2)Provisional or Definitive. 3)End bearing or Non end bearing.
  • 10. INDICATIONSColloquially 3 D’s Dead (or Dying)  Dangerous limb  Gangrene  Malignant tumours  Peripheral Vascular disease  Osteosarcoma Atherosclerosis  Marjolins ulcer Embolism  Melanoma DM  Potentially lethal sepsis  Crush Injury  Damn Nuisance Severe Trauma  Pain Burns  Gross malformation Frost bite  Recurrent Sepsis Bone setters gangrene  Severe loss of function  Madura foot  Elephantiasis
  • 11. LEVEL OF AMPUTATION Determined by : a) Disease process b) Viability of tissues and c) Prosthesis available. Determination of adequate blood flow: Clinical : i.) lowest palpable pulse ii.)skin colour and temperature iii)bleeding at surgery Others : .Doppler ultrasonography: Ankle : brachial index > 0.5.
  • 12.  Compression pressure at the calf >65mmHg. Transcutaneous oxygen measurement >40mmHg. Skin perfusion pressure measurement by infrared thermography or laser doppler flowmetry. Too short a stump may tend to slip out of prosthesis. Too long a stump may have
  • 13. inadequate circulation & can become painful or ulcerate.
  • 14. PREOPERATIVE PREPARATION Assessment and resuscitation Investigate & address co-morbid conditions in consultation with physicians, Anaesthetists & Physiotherapist(multidisciplinary). FBC, FBS, Se/u/c, urinalysis, chest x-ray, ECG, serum albumin(>3.5g/dl). Informed consent –pathology, inevitability of amputation, complications, availability of prosthesis
  • 15.  Determine the level of amputation. Goal of the surgeon is to: a)Find a place where healing is mostly to be complete. b)To have an ideal stump for prosthesis fitting.
  • 16. QUALITIES OF AN IDEAL STUMP 1)Should heal adequately. 2)Should have rounded, gently contour with adequate muscle padding. 3)Should have sufficient length to bear prosthesis. 4)Should have thin scar which does not interfere with prosthetic function. 5)Should have adequate adjacent joint movt.
  • 17.  6)Should have adequate blood supply.
  • 18. INTRAOPERATIVE PROCEDURE ANAESTHESIA : GA/Spinal POSITION : Supine PREINCISION : prophylactic antibiotics, exsanguinate, tourniquet, skin prep & draping. PROCEDURE: .An incision to outline a long posterior flap & a short anterior one --- combined length 1 ½ times the diameter of the leg at the level of amputation.
  • 19.  Deepened to the bone. Periosteum raised. Section tibia at level of incision, bevel anterior surface. Fibular 2-3cm proximally. Smoothen round sharp margins. Vessels isolated and double ligated,Nerves pulled down & cut with a sharp knife & allowed to retract into the soft tissue. Irrigation with N/S, Removal of tourniquet to meticulously secure haemostasis.
  • 20.  Myoplasty or Myodesis done over a drain after trimming the muscle to size. Close skin with interrupted non absorbable sutures. Wound dressing- soft or rigid.
  • 21. POSTOP CARE/ REHABILITATION General care: Control of pain, prevention oedema, prevention of infection, DVT prevention, care of concurrent medical conditions., Suture removal. Physiotherapy: Muscles exercised, joints kept mobile, patients taught how to use crutches & prosthesis.
  • 22.  Stump dressing: .Soft dressing: gauze, cotton wool, bandage. Teach patient or relative stump bandaging. .Rigid dressing: POP cast can be used with stump socks & padding. A jig could be applied that allows attachment and alignment for early pylon use where limited weight bearing with BAC is possible.
  • 23.  Cast changed every 5-7 days for skin care. Within 3-4 wks rigid dressing can be changed to a removable temporary prosthesis. Benefits: a)prevention of oedema b)enhanced wound healing c)early maturation of stump d)decreased post op pain e)allow early ambulation f)position stump to avoid contracture
  • 24.  Rehabilitation of the patient is a multidisciplinary approach. Aim is to bring the patient to an optimum of physical , mental, emotional, social, vocational, & economic efficiency.
  • 25. COMPLICATIONS Early  Haemorrhage  Haematoma  Infection Late  depression  Stump ulceration  Flap necrosis  Painful scar  Phantom limb  Phantom pain  Joint stiffness  Osteomyelitis  Osteoporosis & tendency to fracture
  • 26. PROSTHESIS Is the substitution of a part of the body to achieve optimum function. Eg BKA prosthesis A)patellar tendon bearing B)solid ankle cushion heel Advantages: i) Cosmesis ii)Ambulation iii) Function of the part. Disadvantages: i)infection ii)pressure ulcer iii) cost
  • 27. SITUATION IN OUR SUBREGION Socio-cultural belief a)re-incarnation b)Husband authority over wife c)Children never have authority d)Males usually decides Traditional bone setters Few prosthetic centers Poverty Few centers for microvascular surgeries.
  • 28. CONCLUSION Amputation should be done by surgeons who have knowledge of amputation surgical principles,postop rehabilitation, & prosthetic design. Improved prosthetic design does not compensate for a poorly performed surgical procedure. Amputation should not be viewed as a failure
  • 29. of treatment but rather as the 1st step towards a patient’sreturn to a more comfortable & productive life.