Lower limb Amputations (PART I)

Jibran Mohsin

Resident, Surgical Unit I

SIMS/Services Hospital, Lahore

Outline

PART I -PRINCIPLES OF SURGERY

• Background• Introduction

– Definition– Etymology– Classification

• Epidemiology• Indications and contraindication• Investigations• Surgical principles• Complications• Prognosis

Outline

PART II- OPERATIVE SURGERY

• Foot amputations– Forefoot Amputations

• Toe amputation• Amputation at the base of

proximal phalanx• Metatarsophalangeal

disarticulation• Border Ray amputation• Central Ray amputation• Transmetatarsal amputation

– Midfoot amputations• Lisfranc amputation• Pirogoff amputation• Chopart amputation

– Hindfoot (ankle) amputations• Syme amputation• Boyd amputation

• Transtibial (below-knee) amputations

• Disarticulation of knee

• Transfemoral (above-knee) amputations

• Disarticulation of Hip

• Hemipelvectomy

BACKGROUNDAmputation surgery is the most ancient of surgical procedures dating back to prehistoric times

Neolithic(New stone Age; 10,200 BC to 4500-2000 BC) humans are known to have survived traumatic, ritualistic, and punitive rather than therapeutic amputations.

Cave-wall hand imprints have been found that demonstrate the loss of digits.

Unearthed mummies have been found buried with cosmetic replacements for amputated extremities

BACKGROUNDThe earliest literature discussing amputation is the Babylonian code of Hammurabi*, inscribed on black stone, from 1700 BC, which can be found in the Louvre**

In 385 BC, Plato's Symposium*** mentions therapeutic amputation of the hand and the foot

Hippocrates provided the earliest description of therapeutic amputation in De Articularis for vascular gangrene• Hippocrates describes amputation at the edge of the

ischemic tissue, with the wound left open to allow healing by secondary intention

*6th Babylonian king, who enacted the code consisting of 282 laws of scaled punishment(eye for eye, limb for limb)** one of world largest museums and historic monument in Paris*** Philosophical text concerned with genesis, purpose and nature of love

BACKGROUND

• The main risks described in the early history of amputation surgery were hemorrhage, shock, and sepsis

• Before the discovery of anesthesia, the procedure itself was quite difficult/crude.– Patient would be held down by a number of assistants and be given

alcohol (usually rum)– Patient would essentially be awake and aware during the procedure– Open stump was crushed or dipped in boiling oil to obtain hemostasis– Associated with high mortality rate and poorly suited stump for

prosthesis in survivors

• Advancements in surgical technique and prosthetic design historically were stimulated by the aftermath of war.

BACKGROUND

• Due to a lack of analgesics and narcotics the operation had to take only a few minutes.– Therefore the amputation was completed in one cut (i.e., detachment

of the skin, muscles, and bone at the same level). – This technique, known as "classic circular cut”

• Petit recommended that we transect the skin first and the muscles and bone more proximally ("two-stage circular cut," 1718), and

• Bromfield approved that the skin be cut first, the muscles more proximally and the bone most proximal ("three-stage circular cut," 1773).

• Lowdham (1679), Verduyn (1696), and Langenbeck (1810) changed the operative technique in that they used a soft-tissue flap to cover the bone without tension ("flap amputation").

BACKGROUND1st century AC

Use of cautery for large vessels (Celsus)first mention of ligatures,

removal of gangrenous extremity through the viable tissue edge with a bone cut shorter than the soft tissues

1529 Ambroise Pare (French military surgeon)

ligature reintroduced,

also thick ligature used as a tourniquet (also introduced the artery forceps)

1588 William Cloves 1st successful above-knee amputation

1674 Morel (Battle of Borodino)

tourniquet

BACKGROUND

1679 Younge and Lowdham introduction of local flaps for wound closure without tension –flap amputation(animal bladders used previously)

1781 John Warren

Continental Army surgeon (1753-1815) during the America Revolutionary War

first successful shoulder amputation

1802 Dominique Jean-Larrey

French military surgeon(1766-1842) in the services of napoleon; he introduced field hospitals, first aid and ambulance services

removal of 200 limbs in a 24-hour period at the Battle of Beresina;

also, disarticulation of 11 shoulders in 24-hour period, with 9 complete recoveries

1806 Walter Brashear first successful hip joint amputation

BACKGROUND

1825 Nathan Smith through-knee amputation described

1843 Sir James Syme Syme amputation

1857 Gritti •patella placed over the end of the transected femoral condyles.

1870 Stokes Stokes and Grittis procedures modified (ie, Gritti-Stokes amputation)

1890 Jaboulay and Girard first successful hindquarter amputation

1920 Ertl introduction of osteomyoplastictechnique and the flexible bone graft for both transfemoral and transtibial levels

1943 Major General Norman T. Kirk

indicated guillotine amputations in war setting should be completed as distal as possible and completed later under calmer conditions

1960-1980

Recommendation to salvage knee in vascular amputations

Robert Liston(1794-1847)

• Pioneering Scottish surgeon.

• Famous for his skill in an era prior to anaesthetics, when speed made a difference in terms of pain and survival.

• able to perform the removal of a limb in an amputation in 28 seconds

Liston's most famous case• Amputated the leg in under 21⁄2 minutes

– Patient died afterwards in the ward from hospital gangrene– He amputated in addition the fingers of his young assistant (who died afterwards in the ward

from hospital gangrene).– He also slashed through the coat tails of a distinguished surgical spectator, who was so terrified

that the knife had pierced his vitals he dropped dead from fright.– That was the only operation in history with a 300 percent mortality.

Robert Liston(1794-18477)

Second most famous case

– Amputated the leg in 21⁄2 minutes, but in his enthusiasm the patient's testicles as well

BACKGROUND

BACKGROUND

J. McKnight, who lost his limbs in a railway accident in 1865, was the second recorded survivor of a

simultaneous triple amputation

Zil-e-Huma (21 February 1944 – 16 May 2014)

• Youngest of the 3 children of famed singer Noor Jehan

• Known case of Diabetes Mellitus and Chronic kidney Disease

• Leg amputated on 9 May 2014

• Died of Sepsis

Definition

Removal of an extremity or appendage from the body

Etymology

Derived from Latin amputare, "to cut away",

i.e. ambi- ("about", "around") and

putare ("to prune").

_____________________________________________English word "amputation" was first applied to surgery in the 17th century, possibly first in Peter Lowe's A discourse of the Whole Art of Chirurgerie (published in either 1597 or 1612)

Classification

In Utero Amputation Acquired amputationACCORDING TO ETIOLOGY

– Therapeutic/prophylactic– Ritual– Traumatic(war, RTA) (direct result of

accident)– Self-amputation– Auto-amputation– Criminal(e.g. Hand amputation of theft in

Saudia/Iran/Yemen/Nigeria/Sudan)

ACCORDING TO SITE– Lower limb– Upper limb– Facial (ear/nose/eye/teeth/tongue)– Breast(Mastectomy)– Genital (penis/scrotum/clitoris/foreskin)– Hemicorporectomy (amputation at waist)– Decapitation (amputation at neck)

• Constriction of fetal limbs by fibrous bands of amnion leading to strangulation of limb– Due to amniotic band

syndrome i.e. rupture of inner amnion without rupture of outer chorion

– ETIOLOGY: teratogenic drugs, ionizing radiation, infections, trauma

Self-amputation

• When a person has become trapped in a deserted place, with no means of communication or hope of rescue– 127 HOURS :

• 2010 British-American biographical survival drama film • Film stars James Franco as real-life canyoneer Aron Ralston, who

became trapped by a boulder in an isolated slot canyon in Blue John Canyon, southeastern Utah, in April 2003.

• Performed for criminal or political purposes:– On March 7, 1998, Daniel Rudolph, the elder brother of the

1996 Olympics bomber Eric Robert Rudolph videotaped himself cutting off one of his own hands with an electric saw to "send a message to the FBI and the media”

• Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb.

Self-amputation

REAL TIME STORY Body integrity identity disorder

Autoamputation

• Spontaneous detachment of an appendage from the body.

• Usually due to destruction of the blood vessels feeding an extremity such as the finger tips

• Seen in– Ainhum (dactylolysis spontanea)

• Painful constriction of the base of the fifth toe frequently followed by bilateral spontaneous autoamputation a few years later.

– Cryoglobulinemia

– Thromboangiitis obliterans(Buerger Disease/presenilegangrene)

Ainhum (dactylolysis spontanea)

Epidemiology(2008 data)

Estimates of Amputee Population

World population 6.7 billion

Incidence of amputation 1.5 per 1000

World population of amputees 10 million

ABSOLUTE INDICATION

Irreversible ischemia in a diseased or traumatized

limb

RELATIVE INDICATIONS

Burns

Frostbite

Infection

Tumors

Certain congenital anomalies(limb deficiencies)

Peripheral Vascular Disease• Most common indication for amputation

• Most frequently occurs in individuals age 50-75

• About 50 % cases are diabetic– Most significant predictor of amputation: Peripheral neuropathy

• that progresses to trophic ulcers and subsequent gangrene and osteomyelitis

– Others: prior stroke, prior major amputation, low transcutaneous oxygen levels, and low ABI, smoking,

• PREVENTION:– Foot care and shoe wear and frequent self examination– Ulcers treated with off-loading, orthoses, total-contact casting, wound care,

and antibiotics

REMEMBERIf vascular disease has progressed to point of amputation, it is not limited to involved

extremity. So appropriate consultation is indicated to evaluate other systems( kidneys, coronary and cerebral vasculature)

Peripheral Vascular Disease

• Pre-amputation vascular surgery consultation is ALMOST ALWAYS indicated

– However, revascularization is not without risk– MERIT: even if whole limb cant be salvaged, it may allow healing

of partial foot or ankle amputation instead of a transtibialamputation

– DEMERIT: compromise wound healing of a future transtibialamputation

• All effort must be expended to optimize surgical conditions

– Control of infection, evaluation of nutrition and immune status– RISK FACTORS: albumin < 3.5 mg/dL, total lympocyte count <

1500 cells/mL (82 % healing rate if above 2 parameters normal)

Peripheral Vascular Disease

INDICATIONS

• Uncontrollable soft-tissue or bone infection,

• Nonreconstructable disease with persistent tissue loss, or

• Unrelenting rest pain due to muscle ischemia.

Trauma

• Leading indication for amputation in younger patients– With profound effects on their lives

• More common in men because of vocational and avocational hazards– Otherwise healthy and productive

• ONLY ABSOULUTE INDICATION: irreparable vascular injury in an ischemic limb

Lange’s Indications for primary amputation in trauma*

ABSOLUTE INDICATION

• Type III-C open tibialfractures with – complete disruption of tibial

nerve or

– crush injury with warm ischemia time of > 6hours

RELATIVE INDICATION

• Serious associated injuries

• Severe ipsilateral foot injuries

• Anticipated protracted course to obtain soft-tissue coverage and tibialreconstruction

*DEMERIT: Involves Subjective Assessment

Mangled Extremity Severity Score(MESS)*

• Predictor of salvageable limb.• Score 6 or less salvageable limb• Score 7 or more amputation eventual result

Trauma

• No scoring system can replace experience and good clinical judgment– Attempts to salvage severely injured limb may cause reperfusion injury

syndrome and MOF• More common in multiple injuries and in elderly with comorbid medical

conditions

• Once it is decided that limb can be saved, next step is decide whether it should be saved– Decision made in concert with patient– Patient counseled about merits and demerits of salvage and

amputation• Early amputation and prosthetic fitting are associated with decreased

morbidity, fewer operations, shorter hospital course, decreased hospital cost, shorter rehabilitation and earlier return to work

• Treatment course and outcome more predictable in comparison to protracted treatment course of limb salvage with high rate of complications and financial burden and multiple salvages procedures ending in amputations

………………………………………..

“Correct” decision are based on the patient as a whole, not solely on the extent of the limb injury

Trauma

• Amputation in settings of acute trauma

– follow all standard principles of wound management

• Debridement and irrigation of contaminated tissue followed by open wound management

• Removal of all devitalized tissue

– Functional stump length should be maintained wherever possible

Burns

• Thermal or electrical injury to an extremity

• Full extent of tissue damage may not be apparent at initial presentation especially electrical injury

TREATMENT• Early debridement of devitalized tissue• Fasciotomies when indicated• Aggressive wound care, including repeat debridements

REMEMBER• Early amputation is preferred over Delayed amputation of an

unsalvageable limb (as already discussed with trauma)• Performing inadequate debridement with hope to save limb put

patient in undue danger

Frostbite

• Denotes actual freezing of tissue in the extremities, with or without central hypothermia

• Historically, most prevalent in wartime;– but also seen in high-altitude climbers, skiers and hunters. Also

at risk are homeless, alcoholic and schizophrenic individuals

• Mechanism of tissue injury;– Direct tissue injury through formation of ice crystals in the ECF– Ischemic injury resulting from damage to vascular endothelium,

clot formation, and increased sympathetic tone• Also due to decreased blood flow to extremities in order to maintain

central body temperature

FrostbiteTREATMENT

• Restoration of core body temperature– Rapid rewarming of affected extremity in a water bath at 40oC to 44oC

• Requiring IV analgesia(low dose aspirin or ibuprofen*) and sedation

– Tissue plasminogen activator or regional sympathetic blockade

• Tetanus prophylaxis mandatory

• Systemic antibiotics- controversial

• Blebs left intact– Closed blebs treated with aloe vera*– Open blebs treated with silver sulfadiazine

• Physiotherapy– Maitianence of range of motion____________________________________________________________________________

* Help to stop progressive dermal ischemia mediated by vasoconstricting metabolites of AA in frostbite wound

Frostbite

TREATMENT• In stark contrast to traumatic, thermal or electrical injury,

amputation for frostbite routinely should be delayed 2 to 6 months– Clear demarcation of viable tissue may take this long

– Deep tissues still may be recovering even after complete demarcation• Triple-phase technetium bone scan help to delineate deep tissue viability

• Premature amputation often results in greater tissue loss and increased risk of infection– EXCEPTION: removal of a circumferentially constricting eschar

Infection

• Indicated for acute or chronic infection that is unresponsive to antibiotics and surgical debridement– Open amputation is indicated and performed using 1 of 2

methods• Guillotine amputation with later revision to a more proximal level

after infection is under control• Amputation at definitive level by initially inverting the flaps and

packing the wound open with secondary closure at 10-14 days

– Kritter partial foot amputation with primary closure• Wound closed loosely over a catheter through which an antibiotic

irrigant is infused• Constant infusion continued for 5 days• Loose enough to allow fluid to escape into the dressings• Dressing changed frequently till 5 day• MERIT: Allow for primary wound healing, while avoiding

protracted course of wound healing by secondary intention

3 distinct gas-forming infections must be differentiatedFactor Anaerobic cellulitis Clostridial

MyonecrosisStreptococcal Myonecrosis

Incubation >3 days(several days after closure of contaminated wound)

< 3 days (within 24 hours of closure of a deep contaminated wound)

3-4 days

Onset Gradual Acute Subacute

Toxemia Slight Severe(mental awareness of impending death)

Severe(late)

Pain Absent Severe Variable

Swelling Slight Severe Severe

Skin Little change Tense, white/bronze Tense, copper colored

Exudate Slight Serosanguineous Seropurulent

Gas Abundant Rarely abundant Slight

Smell Foul Variable, mossy Slight

Muscle involvement

No change Severe Moderate

Acute Infection

CLOSTRIDIAL MYONECROSIS

• Immediate radical debridement of involved tissue

• High doses of IV penicillin(clindamycin if allergic to penicillin)

• Hyperbaric oxygen

• Emergency open amputation as a life-saving measure– One joint above affected compartments

Acute Infection

STREPTOCOCCAL MYONECROSIS• Debridement of involved muscle compartment• Open wound management• Penicillin treatment

– Allows preservation of the limb

ANAEROBIC CELLULITIS/NECROTIZING FASCITIS

• Debridement• Broad spectrum antibiotics• Amputation(rare)

Chronic Infection of limb

INDICATIONS FOR AMPUTATION

• Treatment of sepsis with vasoconstrictor agents leading to vessel occlusion and subsequent extremity necrosis

• Systemic effects of a refractory infection

• Disability from a nonhealing trophic ulcer

• Chronic osteomyelitis

• Infected nonunion

• Chronic draining sinus with development of SCC

Amputation in Tumors

MERITS• Limb salvage associated with

greater perioperative morbidity– High risk of infection, flap

necrosis, wound dehiscence, blood loss and DVT

– Long term: periprostheticfractures/loosening/ dislocation, non union of graft-host junction, allograft fracture,leg length discrepencyand late infection

– and eventual ending in amputation (1/3rd cases)

DEMRITS

• Technically demanding– Need nonstandard flaps

– Bone graft

– Prosthetic augmentation

Amputation in Tumors

Location of tumor Procedure of choice

Upper extremity lesion Limb salvage better than amputation(even with sacrifice of a major nerve)

Proximal femur or pelvic lesion Limb salvage better than disarticulation or hemipelvectomy

Sarcoma around knee • Wide resection with prosthetic knee replacement• Wide resection with allograft arthrodesis• Transfemoral amputation

Sarcoma around ankle and foot Frequently treated with amputation followed by prosthetic fitting

Amputation in Tumors

• Cancerous bone or soft tissue tumors – Osteosarcoma– chondrosaroma– fibrosarcoma– Epithelioid sarcoma – Ewing's sarcoma– synovial sarcoma– sacrococcygeal teratoma– Liposarcoma

• Melanoma

Amputation in tumors

INDICATIONS

• Palliative measure in metastatic disease and pain refractory to standard surgical treatment, radiotherapy, chemotherapy, and narcotic pain management

• Recurrent pathological fracture in which stabilization is impossible

• Malignancy with massive necrosis, fungation, infection or vascular compromise

Congenital Anomalies

• Indications

– Proximal femoral focal deficiency

– Polydactyly etc

CONTRAINDICATION

• Poor health that impairs the patient's ability to tolerate anesthesia and surgery.

• BUT, the diseased limb is often at the center of the patient's illness, leading to a compromised medical status. – i.e. removal of the diseased limb is necessary to

eliminate systemic toxins and save the patient's life.

INVESTIGATION

HEMATOLOGICALHemoglobin(>10 g/dL), CRP , albumin(>3.5) ,

Lymphocyte count(>1500 cell/mL)

RADIOLOGICAL• AP and lateral radiography of the involved extremity

• CT or MRI for tumor or osteomyelitis– to ensure that the surgical margins are appropriate.

• Technetium-99m (99m Tc) pyrophosphate bone scanning– to predict the need for amputation in persons with electrical burns and

frostbite– 94% sensitivity and 100% specificity

• Doppler USG

• CT angiography

SURGICAL PRINCIPLES of amputation

• Determination of amputation level

• Technical Aspects– Skin and Muscle flaps– Hemostasis– Nerves– Bone

• Open amputations

• Postoperative Care

………………………………………………..

The original surgical principles as described by Hippocrates remain true today.

Refinements of surgical technique such as hemostasis, anesthesia, and improved perioperative conditions have occurred,

but only relatively small technical improvements have been made

Determination of amputation level

• Involves balance between increased function with a more distal level versus decreased complication rate with more proximal level

– Patient’s overall well-being, general medical condition and rehabilitation also important

– Adverse effect of malnutrition less detrimental in more proximal amputations

• As the level of the amputation moves proximally, the walking speed of the individual decreases, and the oxygen consumption increases

Table: Energy expenditure for amputation

Amputation level Energy above baseline, %

Speed, m/min Oxygen cost, mL/kg/m

Long transtibial 10 70 0.17

Average transtibial 25 60 0.20

Short transtibial 40 50 0.20

Bilateral transtibial 41 50 0.20

Transfemoral 65 40 0.28

Wheelchair 0-8 70 0.16

Determination of amputation level

Determination of amputation level

• Preoperative clinical assessment of skin color, hair growth, and skin temperature provides valuable initial information

• Preoperative arteriograms are of little help in determining potential for wound healing

• Segmental SBP offer little useful information– Falsely elevated owing to noncomplaint walls of arteriosclerotic vessels

• Measurement of skin perfusion pressures by– Thermography OR laser Doppler flowmetry– Tissue uptake of IV fluorescein– Tissue clearance of Intradermally injected Xenon-133– Transcutaneous oxygen measurement(MOST BENEFICIAL/RELIABLE and

SENSITIVE)• 88 %sensiive and 84 % specific

Determination of amputation level

TRANSCUTANEOUS OXYGEN MEASUREMENT• PROCEDURE

– insert a probe that is heated to 45OC for 10 minutes before oxygen tension measured

– Allow for maximum vasodilatory response and more accurate determination of perfusion potential

• INTERPRETATION– 20-40 mmHg for “good” healing potential

• But NO absolute cutoff• Falsely low in decreased diffusion: cellulitis or edema or venostasis

– Increase of 10 mmHg before and after inhalation of 100 % oxygen– Decrease of greater than 15 mmHg after 3 minutes of elevation of

involved limb; poor prognostic indicator for healing

Technical AspectsSKIN AND MUCLE FLAPS

• Flaps should be kept thick– soft-tissue envelope of the residual limb becomes the proprioceptive end organ for the

interface between the residual extremity and the prosthesis.– For effective ambulation, this envelope should consist of a sufficient mass of mobile

nonadherent muscle and full-thickness skin and subcutaneous tissue that can accommodate axial and shear stress within the prosthetic socket.

• Avoid excessive pressure on skin edges with forceps– skin is the most important tissue for healing of the amputation wound

• Avoid unnecessary dissection to prevent further devascularisation of already compromised tissues

• Cover the end of the stump with sturdy soft-tissue envelop

• Atypical flaps always preferable to amputation at more proximal level

• Location of scar rarely important but should not be adherent to underlying bone– Adherent scar makes prosthetic fitting extremely difficult, and often breaks down after

prolonged prosthetic use.

Technical Aspects

SKIN AND MUCLE FLAPS• Redundant soft tissues or large “dog ears” also creates problems in prosthetic

fitting and may prevent maximal function of an otherwise well-constructed stump

• Greatest skin length possible should be maintained for muscle coverage and a tension-free closure

• Muscles usually divided at least 5 cm distal to intended bone resection

• Muscles stabilized by myodesis(muscle sutured through drill holes in bone) or by myoplasty(antagonistic muscle and fascia groups sutured together) or long posterior flap sutured anteriorly

– 40-60 % chances of atrophy after 2 years in transected muscles not fixed

– MERIT: Myodesed muscle continue to counterbalance their antagonists, preventing contractures and maximizing residual limb function

– Contraindicated in severe ischemia because of increased risk of wound breakdown

Technical Aspects

SPLIT THICKNESS SKIN GRAFT

• Sometimes used to complete wound coverage or decrease tension on the wound closure, while maintaining the limb length.

• When placed over soft tissue with avoidance of bone scarring, these grafts can function quite well.

• However, most often these skin-grafted areas do not tolerate the axial and shear stresses within the prosthesis and may require removal at a later date

Technical AspectsHemostasis

• Except in severely ischemic limbs, use of tourniquet is highly desirable

• Limb exsanguinated by wrapping it with an Esmarch bandage before tourniquet is inflated– Avoid in infection or malignancy

• Do elevation of limb for 5 minutes

• Major blood vessels should be isolated and individually ligated– To prevents the development of AV fistulas and aneurysms

• Larger vessels doubly ligated

• Tourniquet deflated before closure and meticulous hemostasis obtained

• Drain placed for 48 -72 hours

Technical Aspects

NERVES• Neuroma ALWAYS form after a nerve is divided

– Become painful if at position where subjected to repeated trauma

• Nerves should be isolated, gently pulled distally into wound, and divided cleanly with a sharp knife– So that cut end retracts well proximal to the level of bone amputation in a

scar- and tension-free environment– Avoid strong tension on nerve; otherwise amputation stump may be painful

even after wound has healed– Avoid crushing

• Others techniques– End-loop anastomosis, perineural closure, silastic capping, sealing the

epineurial tube with butyl-cyanoacrylate, ligation, cauterization, and burying of nerve ends in bone or muscle

• Large nerves(e.g. Sciatic nerve) often contain relatively large arteries and should be ligated

Technical Aspects

BONE

• Excessive periosteal stripping is contraindicated– May result in formation of ring sequestra or bony overgrowth

• Bony prominences that would not well padded by soft tissue and around disarticulation always be resected– And remaining bone should be rasped to form a smooth contour– Especially in locations such as anterior aspect of tibia, lateral

aspect of femur and radial styloid

• Diaphyseal transections can be covered with a local flexible osteoperiosteal graft

OPEN AMPUTATIONS

• First of at least 2 operations required to construct a satisfactory stump

• MUST be followed by secondary closure, reamputation, revision or plastic repair

• INDICATION:– Infections– Severe traumatic wounds with extensive destruction of tissue and

gross contamination by FB

• PURPOSE: to prevent or eliminate infection so that final closure of stump may be done without breakdown of wound

OPEN AMPUTATIONS

• Techniques:

– Inverted skin flaps

– Circular open amputations with post operative skin traction

– VAC ( Vacuum-assisted closure)• Applied to open stump immediately after initial debridement• Subsequent debridements scheduled at 48-hour intervals• VAC reapplied after each debridement until wound is ready for

closure

POSTOPERATIVE CARE

• Requires multidisciplinary team approach – Bio-psycho-social model– Surgeon, physical medicine specialist, physical therapist, occupational

therapist, psychologist, social worker, internist(DM, Coronary and cerebral diseases), support groups

– Overcome the psychological stigma that society associates with the loss of a limb. Persons who have undergone amputations are often viewed as incomplete individuals

• Perioperative antibiotics

• DVT prophylaxis

• Pulmonary hygiene

• Pain management– Brief use of IV narcotics followed by oral pain medicine– Continuous postoperative perineural infusional anesthesia for several days

POSTOPERATIVE CARE

DRESSING• Since 1970s, there has been a gradual shift from the use of

“conventional” soft dressings to use of rigid dressings(Plaster of Paris cast applied to stump at end of surgery)– Can be employed at all levels of amputations in lower and upper limbs

and in all age groups

• Early weight bearing is NOT an essential part of post-operative management

.

OBJECTIVE CAST

If ambulation not planned rigid dressing applied (standard cast application precautions observed)

If ambulation planned true prosthetic cast applied by certified prosthetist

4 generic types of postoperative dressings

TYPE OF DRESSING DESCRIPTION

Soft dressings do not control postoperative edema

Soft dressing with pressure wrap

require an even distribution of pressure to avoid possible limb strangulation

Semi-rigid dressings include plaster splints and Unna Paste Bandages* held in place with a stockinette• same advantages of rigid dressings, except no immediate

postoperative prosthesis can be used

Rigid dressings MERIT (NEXT SLIDE)DEMRIT: poor access to the wound and excessive pressure, leading to wound necrosis.

*compression dressing, usually made of cotton, that contains zinc oxide paste (helps ease skin irritation and keeps the area moist)

POSTOPERATIVE CARE

MERITS OF RIGID DRESSING

• Prevent edema at surgical site• Protect wound from bed trauma• Enhance wound healing• Early maturation of stump• Decrease postoperative pain, allowing earlier mobilization from bed

to chair and ambulation with support– Physiological benefits to respiratory, CV, urinary and GI systems of

upright position

• Prevention of contractures( in transtibial amputation)

– Hence decreased hospital stay and cost of care with– Earlier definitive prosthetic fitting possible and higher percentage of

patients successfully rehabilitated

POSTOPERATIVE CARE

• Drains usually removed at 48-72 hours

• Educate the patient about the proper position of stump while in bed, while sitting, and while standing

– Stump elevated by raising foot of the bed, helps to manage edema and post operative pain

– Cautioned against leaving stump in dependent position

– Cautioned against placing pillow between thighs or beneath the stump i.e. Avoid keeping stump flexed or abducted ( in transfemoral amputation)• Help to prevent flexion or abduction contractures

POSTOPERATIVE CARE

• Exercises for stump started under supervision of physical therapist the day after surgery or as soon as tolerated

– Consist of muscle-setting exercises followed by exercises to mobilize the joints

– Patient mobilized from bed to chair on 1st POD

– In case of Lower limb amputation, ambulation using parallel bars followed by walker or crutches as soon as patient can control limb and are comfortable enough

POSTOPERATIVE CARE• Optimal time to begin prosthetic ambulation with protected weight

bearing depends on

– Age, strength, and agility of the patient and the patient’s ability to protect stump from injury due to excessive weight bearing

• Gradual application of functional mechanical stress in appropriate distribution can enhance wound healing

– Avoid early unprotected weight bearing resulting in sloughing of skin or delayed wound healing

– Traumatic amputation above zone of injury begin 25-Ib partial weight bearing immediately postoperatively

– Traumatic amputation through zone of injury or ischemic amputation should wait until early wound healing is documented

– Weight bearing status checked with each subsequent cast change– If wound progressing well weight bearing can progress in 25-ib increments

each week– Supervision required if patient has peripheral neuropathy, causing difficulty in

assessing weight bearing.

POSTOPERATIVE CARE

• Rigid dressing should be removed and wound inspected in 7-10 days

– Earlier cast removal in case of cast loosening, fever, excessive drainage, or systemic symptoms of wound infection

– If wound healthy, apply new rigid dressing and ambulation continued

– Cast should be changed weekly until wound healed

– Once wound healed, rigid dressing may be removed for bathing and stump hygiene• Elastic stump shrinker at night or stump sock can also be used

– Rigid dressing continued until volume appears unchanged from previous week• This is the time when prosthesis can be first applied

• Hematoma

• Infection

• Wound necrosis

• Contractures

• Pain

• Dermatological Problems

• Edema

• Psychosocial Problems

Hematoma

• PREVENTION– Meticulous hemostasis before closure– Use of drain– Rigid dressing

• Delays wound healing and serve as culture for bacterial infection

• MANAGEMENT:– Compressive dressing– Evacuation (if associated with delayed wound healing with

or without infection)

Infection

• More common in amputations for peripheral vascular disease, especially in diabetic patients than in trauma or tumor amputations

• Deep wound infection

– Immediate debridement and irrigation– Open wound management– Antibiotics according to intraoperative cultures– Smith and Burgess method

• Central one third of wound closed and remainder of wound is packed open

• MERIT: Allows continued open wound management, while maintaining adequate flaps for distal bone coverage

Wound Necrosis

• First step: reevaluate the preoperative selection of the amputation level– Transcutaneous oxygen studies – Serum albumin and lymphocyte count– Immune and nutritional status– Smoking cessation

• Necrosis of skin edges less than 1 cm– Conservative: open wound management(local debridements)– Discontinuing prosthetic use until wound has healed

• Necrosis of skin edges >1 cm– Same as above– Wedge resection( if poor coverage of bone end)– Hyperbaric oxygen therapy– Transcutaneous electrical nerve stimulation– Revision of amputation(shortening of the bone, and closure without tension)

Contractures

• may occur at the time of surgery or postoperatively from lack of activity and prolonged sitting or wheelchair ambulation

– Prevented by• avoiding over tightening of the muscles and appropriate postoperative

positioning maintained.– prolonged sitting with the hip and knee flexed should be avoided– TRANSFEMORAL : lie in the prone position multiple times during the day to stretch

the hip musculature

• gentle passive stretching,• Exercises to strengthen the muscles controlling the joint

– Managed by:• Increased ambulation at knee joint• Prosthetic modification• Wedging casts or surgical release( severe fixed contracture)

Pain

• Residual limb pain– Often caused by poorly fitting prosthesis

• Stump evaluated for areas of abnormal pressure, especially over bony prominences

• Distal stump edema(=choking), ulceration, gangrene• Prevented by socket modification

– Painful neuroma• At the level of the amputation, which become adherent to skin,

muscle, and bone leading to – direct nerve-end stimulation or pain from traction with extremity

motion. – Continuous pulsatile arterial stimulation of the nerve occurs when the

neurovascular structures are ligated together– compression of the nerve between the mobile fibula against the tibia

• Easily palpable with Tinel sign positive• TREATMENT:

– desensitization therapy– Socket modification

Pain

– Painful neuroma(TREATMENT)• CONSERVATIVE

– desensitization therapy, – progressive and continued prosthetic wear, – intermittent compression, – medications, – transcutaneous nerve stimulation, or – a trial of proximal nerve blocks.

• Reconstructive surgery – to remove the neuromas and place them in an area free of

scarring and adhesions and – to reorganize the tissues to the most anatomic position possible

through osteomyoplasty.

• Excision of neuroma or proximal neurectomy

Pain• Residual Limb Pain(continued..)

– Osteoarthritis of hip• Conservative, total hip arthroplasty

– Osteoarthritis of knee• Add knee joint and thigh corset to the prosthesis to allow load haring

with thigh

– Miscellaneous Causes• incompetent soft-tissue envelope, • prominent bone ends and spurs with associated bursitis,• deep tissue scarring, or • ischemia in patients with vascular disease who have undergone

amputations

Pain

• Herniated lumbar disc referred pain

• Mechanical low back pain• Instructed on proper prosthetic ambulation to minimize abnormal

stresses on the lumbar spine

• Phantom limb sensations– So common that should be considered normal– Education of patient– Over 1st year after amputation, many patients experience a

phenomenon called “telescoping”, i.e. phantom limb gradually shortens to end of residual limb

Pain

• Phantom limb pain– more common than previously thought

– described as a painful burning sensation in the amputated limb

– More often with proximal amputation

– More common in patients who felt pain in limb before amputation

– Diverse measures: massage, ice, heat, increased prosthetic use, relaxation training, biofeedback, sympathetic blockade, local nerve blocks, epidural blocks, ultrasound, TENS, and placement of dorsal column stimulator.

– No one specific method is universally beneficial

Dermatological Problems

• Wash stump with mild soap at least once a day– Stump thoroughly rinsed and dried before donning prosthesis– Prosthesis kept clean and dried before donning

• Contact dermatitis– Intense itching and burning when wearing socket– Due to failure to rinse detergents from stump socks thoroughly– Other sensitizers: Nickel, chromates used in leathers, skin creams, antioxidants

in rubber, topical antibiotics, and topical anesthetics– Treatment: Removal of irritant, soaks, steroid cream, and compression

• Bacterial folliculitis– May occur in areas of hairy, oily skin– Exacerbated by shaving and by poor hygiene– TREATMENT:

• improved hygiene and possibly socket modifications to relieve areas of abnormal pressure

• Antibiotics for cellulitis• Incision and drainage of abscess

Dermatological Problems

• Epidermoid Cyst – Develop late at socket brim

– TREATMENT: • socket modification

• Excision

• Verrucous hyperplasia– Wartlike overgrowth of skin at end of stump

– Caused by proximal constriction that prevents the stump from fully seating in the prosthesis(=choking)• Causes distal stump edema followed by thickening of skin, fissuring, ulceration and

possibly subsequent infection

– TREATMENT: directed toward treating infection• Soaks and salicylic acid to soften the keratin

• Socket modification mandatory

Edema

• Postoperative bulbous swelling of the distal residual extremity– due to tight proximal dressings or prosthesis too tight proximally or

medical problems– leading to congestion(Verrucous hyperplasia), poor wound healing,

cellulitis and prosthetic-fitting difficulties

• PREVENTION:– minimized by performing medullary canal closure by bone glue and

myoplasty.

• TREATMENT:– total-contact socket with frequent alterations

as needed to accommodate volume changes

Psychosocial Problems

• Posttraumatic stress disorder,

• Sexual dysfunction,

• Depression(25-35 % cases),

• Social isolation and

• Job loss(financial problems)

AMPUTATIONS FOR PERIPHERAL VASCULAR DISEASE

PARAMETER MORTALITY RATE

Perioperative mortality rate 30 %

2 year mortality rate 40 %

Critical ischemia in remaining limb 30 % of remaining cases

…………..THANK YOU……….…

Amputation should not be viewed as a failure of treatment, but rather as

• a reconstruction procedure,

• treatment of choice for an unreconstructable or a functionally unsatisfactory limb and

• first step toward a patient’s return to a more comfortable and productive life