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Below knee amputation

  4. 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. 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. 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. 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%
  9. 9. CLASSIFICATION  1) Emergency or Elective.  2)Provisional or Definitive.  3)End bearing or Non end bearing.
  10. 10. INDICATIONS Colloquially 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. 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. 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. 13. inadequate circulation & can become painful or ulcerate.
  14. 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. 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. 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. 17.  6)Should have adequate blood supply.
  18. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 29. of treatment but rather as the 1st step towards a patient’s return to a more comfortable & productive life.