This document provides an outline on below knee (transtibial) amputation. It discusses the relevant anatomy, classification, indications, preoperative preparations, intraoperative procedure, postoperative care/rehabilitation, complications, prosthesis, and situation in the subregion. The goal of amputation is to find an adequate level for healing and prosthetic fitting while addressing the patient's medical conditions through a multidisciplinary approach to rehabilitation.
different type of lower limb amputation with indication, peri-operative care, surgical steps, post op care complication and different type of prosthesis
different type of lower limb amputation with indication, peri-operative care, surgical steps, post op care complication and different type of prosthesis
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Debridement is an important component of the wound bed preparation (WBP) management Model.
Cause of the wound and patient-centered concerns, debridement is a necessary step in local wound care.
Debridement is the removal of necrotic tissue, exudate, bacteria, and metabolic waste from a wound in order to improve or facilitate the healing process
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Amputation in simple definition is defined as cutting of bone which can be differentiated from Disarticulation as cutting through a joint.
Amputation is derived from latin words Amputare.
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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%
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.
12. 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.
13. 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
15. 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
16. 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.
17. 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.
19. 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.
20. 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.
21. 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.
22.
23.
24. 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.
25. 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.
26. 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
27.
28. 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.
30. 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
31.
32. 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.
33. 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
34. of treatment but rather as the 1st step towards a patient’s
return to a more comfortable & productive life.