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Principles of amputation
- 1. GENERAL PRINCIPLES OF AMPUTATIONS Nguyễn Quang Tôn Quyền
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- 3. • Sever limb unanesthetically • Dip open stump in boiling oil • High mortality rate • Resulting stump is poorly suited Oil on board by an unknown artist, mid nineteenth century amputation
- 4. HISTORY • Ligature:Hippocrates first use => lost during the Dark Ages => Ambroise Paré in 1529 • Ambroise Paré: artery forceps • 1674: Morel - tourniquet • 1867: Lister - antiseptic technique • The late 19th century: chloroform and ether for general anesthesia • => for the first time could fashion sturdy and functional stumps.
- 5. HISTORY • Surgeonscompletely understand • surgical principles • postoperative rehabilitation • prosthetic design • Improved prosthetic design does not compensate for a poorly performed surgical procedure. • Amputation not a failure of treatment but the first step toward a more comfortable and productive life. • Planned and performed with the same care and skill as other reconstructive procedure
- 6. INCIDENCE • 300.000amputations the United States. • The number is increasing - an aging population. • > 90% secondary to peripheral vascular disease. • In younger patients: trauma > malignancy
- 7. INDICATIONS • Theonly absolute indication irreversible ischemia • in a diseased limb • or traumatized limb • To preserve life in uncontrollable infections • Best option in some tumors • Limb is not as functional as a prosthesis, certain congenital anomalies of the lower extremity TRAUMA PERIPHE RAL VASCULA R DISEASE BURNS FROSTBI TE INFECTIO N TUMORS
- 10. PERIPHERAL VASCULAR DISEASE • Extracranial carotid and vertebral artery disease • Renal Arterial Disease • Mesenteric Arterial Disease • Lower Extremity Arterial Disease • Aneurysms of the Abdominal Aorta, Its Branch Vessels
- 11. Lower Extremity ArterialDisease • LEAD has several different presentations, categorized according to the Fontaine or Rutherford classifications - • Critical Limb Ischemia
- 12. Critical Limb Ischemia • Critical limb ischaemia is the most severe clinical manifestation of LEAD, defined • presence of ischaemic rest pain, • ischaemic lesions or gangrene objectively attributable to arterial occlusive disease.
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- 14. Critical Limb Ischemia Indication of amputation ACCF/AHA ESC Patients unsuitable for revascularization • Class I Level of Evidence: C
- 15. Critical Limb Ischemia Indication of amputation Neurologically impaired or non-ambulatory
- 16. Acute limb ischemia • Acute limb ischemia is defined as a rapid or sudden decrease in limb perfusion that threatens limb viability. • The five “Ps” suggest limb jeopardy: pain, paralysis, paresthesias, pulselessness, and pallor. • The level of emergency and the choice of therapeutic strategy depend on the clinical presentation, mainly the presence of neurological deficiencies
- 18. PERIPHERAL VASCULAR DISEASE • Keep in mind: vascular disease has progressed to the point of requiring amputation, not limited to the involved extremity. • Before performing an amputation for PAD, a vascular surgery consultation is almost always indicated • If amputation necessary, optimize surgical conditions: albumin < 3.5 g/dL or lymphocyte <1500 cells/mL => complication
- 19. TRAUMA • Whetherthe limb should undergo salvage or amputation? • 8 studies • Level III, Class IIb • Gustilo IIIA fractures are unlikely to require amputation • Gustilo IIIB and IIIC fractures may require amputation
- 20. • To removesubjectivity from the decision, available scoring systems • Mangled extremity severity score - most useful: • easy to apply, • grades the injury: the energy that caused the injury, limb isch-emia, shock, and the patient’s age, • ≤ 6 consistent with a salvageable limb, ≥ 7 amputation was the eventual result
- 22. • No scoringsystem can replace experience and good clinical judgment
- 23. • Might benecessary to preserve life • Salvage a severely injured limb may lead to metabolic overload and secondary organ failure (multiple injuries the elderly) • Injury severity score > 50: contraindication limb salvage
- 24. Indication for amputation– lower limb
- 25. The tradeoffs -limb salvage • Great cost. • Multiple operations to obtain bony union , soft tissue coverage, other areas to obtain donor tissue. • External fixation may be necessary for several years • Complications: infection, nonunion, or loss of a muscle flap. • Chronic pain and drug addiction • Isolation from family and friends, unemployment. • The limb ultimately could require amputation,
- 26. The tradeoffs -early amputation • Decreased morbidity, fewer operations, shorter hospital course, decreased hospital costs, shorter rehabilitation, earlier return to work. • Modern prosthetics better function than many “successfully” salvaged limbs. • In long term studies, patients who have undergone amputation and prosthetic fitting are more likely to remain working and are far less likely to consider themselves to be “severely disabled” than patients who have endured an extensive limb
- 27. DETERMINATION OF AMPUTATIONLEVEL • Tradeoffs • more distal level of amputation → more function • more proximal level of amputation → less complication • Patient’s general medical condition • A vascular surgery consultation: “Even if revascularization would not allow for salvage of the entire limb, it may allow for healing of a partial foot or ankle amputation instead of a transtibial amputation” • Simple screening tests
- 28. • Waters etal. studied the energy cost of walking for patients with amputations velocity energy 100% 66% 59% 44% 87% 63% normal Syme transtibial transfemoral transtibial (trauma) transfemoral (trauma)
- 29. • If ambulationis the chief concern, amputation should be performed at the most distal level possible • If a patient has no ambulatory potential, wound healing with decreased perioperative morbidity should be the chief concern
- 30. DETERMINATION OF AMPUTATIONLEVEL • Determining the most distal level for amputation with a reasonable chance of healing can be challenging • Transcutaneous oxygen measurements • Different cutoff levels, ranging from 20 to 40 mm Hg, for “good” healing potential
- 31. TECHNICAL ASPECTS •SKIN AND MUSCLE FLAPS • Flaps should be kept thick • The scar should not be adherent to the underlying bone • Muscles usually are divided at least 5 cm distal to the intended bone resection and may be stabilized by myodesis or myoplasty
- 32. TECHNICAL ASPECTS •HEMOSTASIS • Tourniquet • Major blood vessels isolated and ligated • A drain should be used in most cases for 48 to 72 hours
- 33. TECHNICAL ASPECTS •NERVES • A neuroma always forms • Becomes painful if it forms in a position subjected to repeated trauma. • Nerves: gently pulled distally into the wound, divided cleanly with a sharp knife so that the cut end retracts proximal to the level of bone resection.
- 34. TECHNICAL ASPECTS •BONE • Excessive periosteal stripping is contraindicated. • Bony prominences that would not be well padded by soft tissue always should be resected • The remaining rasped to form a smooth contour: especially important the anterior aspect of the tibia, lateral aspect of the femur, and radial styloid
- 35. TECHNICAL ASPECTS •OPEN AMPUTATIONS • infections severe traumatic wounds with extensive destruction of tissue and gross contamination by foreign material. • open amputations with inverted skin flaps and circular open amputations with postoperative skin trac-tion • technique of vacuumassisted closure
- 36. POSTOPERATIVE CARE •Requires a multidisciplinary team approach • Since the mid 1970s, there has been a gradual shift from the use of “conventional” soft dressings to the use of rigid dressings
- 38. Rigid dressings -advantages • prevent edema at the surgical site • protect the wound from bed trauma • enhance wound healing and early maturation of the stump • decrease postoperative pain, allowing earlier mobilization • transtibial amputations: prevent flexion contractures
- 39. POSTOPERATIVE CARE •Position the stump properly • Exercises for the stump • Remove rigid dressing in 7 to 10 day • Cast change weekly until the wound heal • Continue until the volume appears unchanged from the previous week • At that time, the prosthetist may apply the first prosthesis.
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Editor's Notes
- #2 1
- #4 Early surgical amputation was a crude procedure by which a limb was rapidly severed from an unanesthetized patient. The open stump was crushed or dipped in boiling oil to obtain hemo stasis. The procedure was associated with a high mortality rate. For patients who survived, the resulting stump was poorly suited for prosthetic fitting.
- #5 Hippocrates was the first to use ligatures; this technique was lost during the Dark Ages but was reintroduced in 1529 by Ambroise Paré, a French military surgeon. Paré also intro duced the “artery forceps.” He was able to reduce the mortal ity rate significantly while creating a more functional stump. He also designed relatively sophisticated prostheses. Further advances were made possible by Morel’s introduction of the tourniquet in 1674 and Lister’s introduction of antiseptic technique in 1867. With the use of chloroform and ether for general anesthesia in the late 19th century, surgeons for the first time could fashion reasonably sturdy and func tional stumps.
- #6 Now more than ever it is important that amputations be performed by surgeons who have a complete understanding of amputation surgical principles, postoperative rehabilitation, and prosthetic design. Improved prosthetic design does not compensate for a poorly performed surgical procedure. Amputation should not be viewed as a failure of treatment but rather as the first step toward a patient’s return to a more comfortable and productive life. The operative procedure should be planned and performed with the same care and skill used in any other reconstructive procedure
- #7 The National Center for Health Statistics estimated that more than 300,000 patients with amputations live in the United States. The number of amputations performed each year is increasing, mainly because of an aging population. More than 90% of amputations performed in the Western world are secondary to peripheral vascular disease. In younger patients, trauma is the leading cause, followed by malignancy.
- #8 The National Center for Health Statistics estimated that more than 300,000 patients with amputations live in the United States. The number of amputations performed each year is increasing, mainly because of an aging population. More than 90% of amputations performed in the Western world are secondary to peripheral vascular disease. In younger patients, trauma is the leading cause, followed by malignancy.
- #12 The most typical presentation of LEAD is intermittent claudication, characterized by pain in the calves, increasing with walking; the pain typically disappears quickly at rest (Fontaine stage II; Rutherford grade I). Critical limb ischaemia is the most severe clinical manifestation of LEAD, defined as the presence of ischaemic rest pain, and ischaemic lesions or gangrene objectively attributable to arterial occlusive disease.
- #14 The most typical presentation of LEAD is intermittent claudication, characterized by pain in the calves, increasing with walking; the pain typically disappears quickly at rest (Fontaine stage II; Rutherford grade I). Critical limb ischaemia is the most severe clinical manifestation of LEAD, defined as the presence of ischaemic rest pain, and ischaemic lesions or gangrene objectively attributable to arterial occlusive disease.
- #15 The most typical presentation of LEAD is intermittent claudication, characterized by pain in the calves, increasing with walking; the pain typically disappears quickly at rest (Fontaine stage II; Rutherford grade I). Critical limb ischaemia is the most severe clinical manifestation of LEAD, defined as the presence of ischaemic rest pain, and ischaemic lesions or gangrene objectively attributable to arterial occlusive disease.
- #16 The most typical presentation of LEAD is intermittent claudication, characterized by pain in the calves, increasing with walking; the pain typically disappears quickly at rest (Fontaine stage II; Rutherford grade I). Critical limb ischaemia is the most severe clinical manifestation of LEAD, defined as the presence of ischaemic rest pain, and ischaemic lesions or gangrene objectively attributable to arterial occlusive disease.
- #19 Most patients also have concomitant disease processes in the cerebral vasculature, coronary arteries, and kidneys. In addition to obtaining a vascular surgery consultation to evaluate the diseased limb, appropriate consultation is indicated to evaluate these other systems
- #20 Most patients also have concomitant disease processes in the cerebral vasculature, coronary arteries, and kidneys. In addition to obtaining a vascular surgery consultation to evaluate the diseased limb, appropriate consultation is indicated to evaluate these other systems
- #22 Other authors have attempted to remove subjectivity from the decisionmaking process
- #26 On entering the hospi tal, most patients are concerned only with saving the limb; they must be made to understand that this often comes at a great cost. They may have to face multiple operations to obtain bony union and soft tissue coverage and multiple operations on other areas to obtain donor tissue. External fixation may be necessary for several years, and complica tions, including infection, nonunion, or loss of a muscle flap, may occur. Chronic pain and drug addiction also are common problems of limb salvage because patients endure multiple hospital admissions and surgery, isolation from their family and friends, and unemployment. In the end, despite heroic efforts, the limb ultimately could require amputation, or a “successfully” salvaged limb may be chronically painful or functionless
- #30 A transtibial amputation in this setting is not a reasonable option because of the increased risk of wound problems and increased skin problems from knee flexion contractures. A knee disarticulation often provides the best function for these patients. Compared with transfemoral amputation, knee disarticulation provides a longer lever arm with balanced musculature to help with bed mobility and transfers. In addition, muscles are not divided and do not atrophy and contract over the femur as they often do after transfemoral amputation. Finally, better sitting stability and comfort are provided with a throughknee amputation