Amputations

Amputations

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  AMPUTATIONS OF LOWER LIMB DR.DARSHANN(MS ORTHOPAEDICS)
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  Introduction • Latin amputare,"to cut away” • “Surgical removal of limb or part of the limb through a bone or multiple bones” • Should not be viewed as a failure of treatment but as the first step in Rehabilitation
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  INDICATIONS 1. Peripheral VascularDisease 2. Trauma 3. Burns 4. Frostbite 5. Infections 6. Tumours
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  Peripheral Vascular Disease •Most common indication for amputation • Peripheral vascular disease with or without diabetes • Age-50 to 75years • Disease processes in the cerebral vasculature, coronary arteries, and kidneys
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  • Vascular surgeryconsultation for improved techniques and salvageable • If amputation becomes necessary • Infection and Nutrition and Immune status should be evaluated.
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  Trauma • Leading indicationin younger patients • More common in men • The only absolute indication for primary amputation is an irreparable vascular injury
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  To predict whichlimbs will be salvageable
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  • Severely injuredlimb may lead to metabolic overload and secondary organ failure • Multiple injuries and in the elderly
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  BURNS • Thermal orelectrical injury • Tissue damage may not be apparent, especially with electrical injury • Treatment involves early débridement of devitalized tissue and wound care • Delayed amputation - increased risk of local infection, systemic infection ,AKI
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  Frostbite • Freezing oftissue in the extremities • Common problem for high-altitude climbers, skiers, and hunters • WHY IT HAPPENS • Mechanisms: 1. Ice crystals in the extracellular fluid 2. Ischemic damage to vascular endothelium, clot formation, and increased sympathetic tone
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  • Amputation forfrostbite routinely should be delayed 2 to 6 months. • Clear demarcation of viable tissue may take this long. • Triple-Phase Technetium Bone Scan
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  Infection • Acute orchronic infection that is unresponsive to antibiotics and surgical débridement. • Open amputation is indicated: 1. A guillotine amputation 2. Definitive level by initially inverting the flaps and secondary closure at 10 to 14 days
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  Kritter’s method
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  Most worrisome infections
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  • Clostridial Myonecrosis: Radical débridement of involved tissue, high doses of intravenous penicillin and hyperbaric oxygen , open amputation one joint above the affected compartment. • Streptococcal Myonecrosis: Debridement , penicillin treatment , usually allow preservation of the limb.
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  TUMOURS • Would survivalbe affected by the treatment choice? • Multimodal treatment - osteosarcoma patients has improved from approximately 20% to approximately 70%. • Osteosarcoma of the distal femur : recurrence is 5% to 10% • Salvageable s better
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  How do short-termand long-term morbidity compare? • Amputation for malignancy may be technically demanding - nonstandard flaps, bone graft, or prosthetic augmentation , periprosthetic fractures, prosthetic loosening • Limb salvage involves a more extensive surgical procedure ,infection, wound dehiscence, flap necrosis, blood loss, and deep venous thrombosis , multiple subsequent operations , amputation • Amputation s better
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  How would thefunction of a salvaged limb compare with that of a prosthesis? • The location most important factor • Upper extremity lesion - limb salvage provides better function than amputation • Resection of a proximal femoral or pelvic lesion , better function than hip disarticulation or hemipelvectomy • Sarcomas around the ankle and foot frequently are treated with amputation
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  Osteosarcoma around theknee • Wide Resection with Prosthetic Knee Replacement • Wide Resection with Allograft Arthrodesis • Transfemoral Amputation
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  SURGICAL PRINCIPLES OF AMPUTATION
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  DETERMINATION OF AMPUTATIONLEVEL • Level of amputation : increased function with a more distal level of amputation and a decreased complication rate with a more proximal level of amputation • The energy required for walking is inversely proportionate to the length of the remaining limb
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  • At self-selectedwalking velocities : tended to decrease their velocities • Compensatory mechanism to conserve energy per unit time • Anaerobic mechanisms to sustain muscle function: endurance is greatly compromised
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  • Thus mostdistal level AMPUTATION : If ambulation is the chief concern • No ambulatory potential : wound healing chief concern • Level for amputation : Best healing can be challenging • Thermography or laser Doppler flowmetry , tissue clearance of intradermally injected xenon-133 and Transcutaneous oxygen
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  TECHNICAL ASPECTS
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  Skin and MuscleFlaps • Flaps should be kept thick :Unnecessary dissection avoided • The scar should not be adherent to the underlying bone : prosthetic fitting difficult and scar breaks down • Redundant soft tissues or large “dog ears” : prosthetic fitting problem ‖
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  • Muscles dividedat least 5 cm distal to bone resection • Stabilized by Myodesis : 1. stronger insertion, help maximize strength, and minimize atrophy 2. counterbalance their antagonists, preventing contractures
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  Hemostasis • Use ofa tourniquet is desirable • Larger vessels should be doubly ligated • The tourniquet should be deflated before closure • A drain should be used in most cases for 48 to 72 hours
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  Nerves • Nerves isolated,pulled distally to the wound, and divided with a sharp knife so that the cut end retracts well proximal to the level of bone resection • Strong tension on the nerve should be avoided • Large nerves : contain relatively large arteries and should be ligated • A neuroma always forms after a nerve has been divided
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  Bone • Excessive periostealstripping : Leads to ring sequestra or bony overgrowth • Bony prominences : well padded by soft tissue , remaining bone rasped for smooth contour
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  OPEN AMPUTATION • Skinis not closed at stump • Indicated in infections and in severe traumatic wounds • First operation is to remove devitalized structures • vacuum-assisted closure : VAC is reapplied until the wound is ready for closure
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  • Second sittingis to construct a satisfactory stump by secondary closure, reamputation, revision, or plastic repair
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  POSTOPERATIVE CARE • Multidisciplinaryteam approach • Antibiotics , Analgesics ,DVT prophylaxis, pulmonary hygiene and psychiatric help • The stump is elevated by raising the foot of the bed : edema and postoperative pain • With transfemoral amputations : prevent flexion or abduction contractures
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  • If non-weightbearing ambulation : rigid dressing ( POP ) applied. • If weight bearing ambulation : true prosthetic cast with metal pylon with a prosthetic foot
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  Advantages of rigiddressing • Prevent edema at the surgical site • Protect the wound from bed trauma • Enhance wound healing • Decrease postoperative pain • Transtibial amputations : prevent knee flexion contractures
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  • Exercises, mobilizedfrom bed to chair for the stump started on POD 1 • Regardless of when prosthetic ambulation is begun, the rigid dressing should be removed and the wound inspected in 7 to 10 days • Cast should be changed weekly
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  • rigid dressingis continued until the volume appears unchanged from the previous week • If the wound is progressing well, weight bearing can progress in 25-lb increments each week
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  COMPLICATIONS
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  Hematoma • Hemostasis beforeclosure , use of a drain, rigid dressing has minimized • Delay wound healing and serve as a culture medium for bacterial infection • If it form : compressive dressing , evacuated if delaying wound healing
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  INFECTION • More commonin amputations for PVD, especially in diabetic patients. • Deep wound infection : débridement and irrigation
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  Smith and Burgess
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  WOUND NECROSIS • Necrosisof the skin edges less than 1 cm can be treated conservatively with open wound management • Severe necrosis with poor coverage of the bone end, wedge resection may be indicated. • Basic principle of wedge resection : reformation of the hemisphere, while minimizing local pressures
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  CONTRACTURES • Mild ormoderate contractures of the joints of an amputation stump treated by proper positioning of the stump, passive stretching, and exercises • Severe fixed contractures : wedging casts and surgical release
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  PAIN • 1. Mechanicallow back pain : more prevalent in amputees , proper prosthetic ambulation to minimize abnormal stresses on the lumbar spine. • 2. Residual limb pain : a. Phantom Limb Pain b. Poor fitting prosthesis c. Painful neuroma
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  Phantom Limb Pain •Silas Weir Mitchell (1829-1914) is credited with coining the term phantom limb • Caused by elimination or interruption of sensory nerve impulses • PREVALENCE: 60% to 80% • Not influenced by age in adults, gender, side, or level and cause of the amputation
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  • TIME COURSE: First week after amputation • The pain is usually intermittent • MECHANISMS: Afferent C fibers , Stump neuromas C fibers and Aδ afferents , NMDA receptor Cortical reorganization
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  TREATMENT • Amitriptyline: doseof 125 mg/day and tramadol • Oral morphine: a significant reduction in phantom pain • TNF – α antagonist : Etanercept • Memantine at doses of 20 or 30 mg/day ???? • TENS , acupuncture , massage , Mirror therapy
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  Prevention • Preoperative epiduralblockade : lower incidence • Catheter into the transected nerve sheath at the time of amputation and infused bupivacaine for 72 hours
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  Poor fitting prosthesis •Ill fitting with socket • Stump should be evaluated for areas of abnormal pressure, especially over bony prominences • Distal stump edema, often called ―”choking” , may result if the end is not completely seated in the prosthesis, and ulceration or gangrene could result.
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  Painful neuroma • Occurswhen the nerve end is subjected to pressure or repeated irritation • A painful neuroma usually is easily palpable and often has a positive Tinel sign • Socket modification , neuroma excision or a more proximal neurectomy
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  DERMATOLOGICAL • Contact dermatitis: intense itching and burning • Cause : 1.failure to rinse detergents from stump socks 2. nickel, chromates , antioxidants in rubber Treatment : steroid cream , removal of the irritant
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  Bacterial folliculitis • Areasof hairy, oily skin • Exacerbate by poor hygiene. • Improved hygiene and possibly socket modifications to relieve areas of abnormal pressure
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  Verrucous hyperplasia • Wartlikeovergrowth of the skin at the end of the stump • It is caused by proximal constriction that prevents the stump from fully seating in the prosthesis • This “choking”: causes distal stump edema followed by thickening of the skin, fissuring, ulceration
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  • Salicylic acidto soften the keratin and Socket modification to prevent recurrences • Epidermoid cysts develop at the socket brim • Treated with socket modification or Excision if required
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  AMPUTATION IN CHILDREN •Divided into two general categories : congenital (60%) and acquired (40%) • Causes of congenital amputations: Amniotic band syndrome Exposure to teratogens ( thalidomide ) Polydactyly ,Syndactyly ,Macrodactyly Congenital pseudoarthrosis of the tibia and fibula, radius and ulna Congenital deficiencies of the long bones
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  Acquired amputations • Secondaryto trauma : Power tool injuries are the most common Motor vehicle accidents • Neoplasm • Infection
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  PRINCIPLES OF CHILDHOODAMPUTATION • Preserve length AND Preserve important growth plates • Perform disarticulation rather than transosseous amputation • Preserve the knee joint whenever possible • Stabilize and normalize the proximal portion of the limb
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  Preserving length andgrowth plates • 75% of the growth of the femur occurs at the distal growth plate : transfemoral amputation performed in a young child would result in a very short stump as an adult • Conversely, even a very short transtibial stump in a young child may result in a functional stump as an adult
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  Dysarticulation • Provide well-balanced,sturdy stump capable of end weight bearing • High mechanical demands that children place on their prostheses • Secondary to preservation of the metaphyseal flares: Prosthetic outcome is improved
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  TERMINAL BONE OVERGROWTH •Appositional new bone formation and is unrelated to the growth of the physis • In a child amputee with a transosseous amputation • More common in younger children : humerus and fibula • Resulting bone is elongated and often pencil-shaped • Swelling, edema, pain , may penetrate the skin
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  • It doesnot occur after disarticulation • Prevention of overgrowth : capping by epiphyseal graft OR capping with tricortical iliac crest graft • Treated effectively with surgical resection of the excess bone
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  STUMP CAPPING PROCEDURE
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  ADVANTAGES OF AMPUTATIONIN CHILDREN • Children often can tolerate procedures on amputation stumps like 1. More forceful skin traction 2. Application of extensive skin grafts 3. Closure of skin flaps under moderate tension
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  Less severe Complications •Painful phantom sensations do not develop • Neuromas rare • Extensive scars are tolerated well • Psychological problems after amputation are rare in children
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  • Children useprostheses extremely well : High activity level • Good growth potential: Prosthetic program should be designed that parallels normal motor development • Modifications may be made, such as the addition of a knee joint, a mobile elbow joint
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  BELOW KNEE AMPUTATION •Transtibial amputations are the most common amputations performed for PVD
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  TRANSTIBIAL AMPUTATION –
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  NONISCHEMIC LIMB AMPUTATION •The optimal level of amputation determined by: Level of trauma clean end margins for tumor Anatomical factors : stumps extending to the distal third of the leg Less soft tissue for weight bearing Distal third of the leg is relatively avascular and slower to heal
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  IDEAL A stump lengththat allows a controlling lever arm for the prosthesis i.e stump is to allow 2.5 cm of bone length for each 30 cm of body height Stumps lacking quadriceps function are not useful Transecting the hamstring tendons
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  In a shortstump whether fibula should be removed or preserved is controversial as fitting of the prosthesis depends on it Sufficient ―circulation‖ for healing and soft tissue‖ for protective end weight bearing
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  PROCEDURE • Fashioning ofequal anterior and posterior skin flaps • Each one half anteroposterior diameter of leg at level of bone section
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  • Division andligation of anterior tibial vessels ,deep peroneal nerve.
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  Fashioning posterior myofascialflap
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  Suture myofascial flapto periosteum anteriorly
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  Closure of skinflaps
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  AFTERTREATMENT • An immediatepostoperative rigid dressing : control edema , limits knee flexion contracture and trauma • Mobilization with walker or crutches • Cast can be changed every 5 to 7 days for skin care • Within 3 to 4 weeks, prosthesis given
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  PROCEDURE FOR ISCHEMICLIMB • Fashioning of short anterior and long posterior skin flaps
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  Separation and removalof distal leg
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  Tailoring of posteriormuscle mass to form flaps
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  Suture of flapto deep fascia and periosteum anteriorly
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  Closure of skinflaps
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  DISADVANTAGES OF LONGPOSTERIOR FLAP The stump, in the initial stages , unsuitable due to stump oedema : delay in prosthetic fitting Suture line passes over the distal end of the tibia: vulnerable to trauma : due to the high pressure generated while using the prosthesis
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  SKEW FLAP The principle: thermographic mapping of the leg : higher temperature on anteromedial AND posterolateral aspect Indicates : Better blood flow Anteromedial ( saphenous nerve artery) Posterolateral (sural nerve artery)
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  Marking of flaps
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  Advantages of skewflap • Less of stump edema : NO Hazards of constricting bandages • Early healing of the skin incision • Early application and ambulation in a prosthetic cast • Lessened risk of wound breakdown
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  ANKLE AMPUTATION • Syme’sAmputation • Modified Syme’s Amputation ( Sarmiento) • Boyd Amputation
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  Syme’s Amputation • Amputationat the distal tibia and fibula 0.6 cm proximal to the periphery of the ankle joint and passing through the dome of the ankle centrally • The tough, durable skin of the heel flap provides normal weight bearing skin
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  • Incision atthe distal tip of the lateral malleolus • One fingerbreadth inferior to the tip of the medial malleolus • extend it plantarward and across the sole of the foot to the lateral aspect
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  • Foot inmarked equinus • Divide the anterior capsule of the ankle joint • b/w medial malleolus and the talus and lateral malleolus and the talus • Deltoid and calcaneofibular ligament
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  • Bone hookpulling talus distally, • Exposing distal articular surface of tibia and fibula
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  • Dissection ofsoft tissues from calcaneus ,tendoachilles
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  Subperiosteal removal ofcalcaneum , leaving heel pad intact
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   Division oftibia and fibula just through dome of ankle joint centrally 0.6 cm proximal to the ankle joint  cut surfaces of the tibia and fibula are parallel to the ground
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  • Holes drilledin anterior edge of tibia and fibula to anchor heel pad
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  • Edge ofdeep fascia lining heel pad is anchored to tibia and fibula
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  • Skin closureover drain, and application of above-knee cast • “Dog ears”:never be removed :they carry blood supply to the heel flap
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  SYME’S PROSTHESIS • Moldedplastic socket, with a removable medial window • solidankle, cushioned-heel (SACH) foot prosthesis attached to it