Principles of amputation

GENERAL PRINCIPLES OF AMPUTATIONSNguyễn Quang Tôn Quyền

Crude procedure

• 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

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.

HISTORY

• Surgeons completely 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

INCIDENCE

• 300.000 amputations the United States.

• The number is increasing - an aging population.

• > 90% secondary to peripheral vascular disease.

• In younger patients: trauma > malignancy

INDICATIONS

• The only 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

PERIPHERAL

VASCULAR

DISEASE

BURNS

FROSTBITE

INFECTION

TUMORS

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

Lower Extremity Arterial Disease

• LEAD has several different presentations, categorized according to the Fontaine or Rutherford classifications -

• Critical Limb Ischemia

Critical Limb Ischemia

• Critical limb ischaemiais the most severeclinical manifestationof LEAD, defined• presence of ischaemic

rest pain,

• ischaemic lesions organgrene objectivelyattributable to arterialocclusive disease.

Critical Limb Ischemia

Critical Limb IschemiaIndication of amputation

• Class I Level of Evidence: C

ACCF/AHA ESC

Patients unsuitable for revascularization

Critical Limb IschemiaIndication of amputation

Neurologically impaired or non-ambulatory

Acute limb ischemia

• Acute limb ischemia is definedas a rapid or sudden decrease inlimb perfusion that threatenslimb viability.

• The five “Ps” suggest limbjeopardy: pain, paralysis,paresthesias, pulselessness, andpallor.

• The level of emergency and thechoice of therapeutic strategydepend on the clinicalpresentation, mainly thepresence of neurologicaldeficiencies

PERIPHERAL VASCULAR DISEASE

• Keep in mind: vascular disease has progressed to thepoint of requiring amputation, not limited to theinvolved extremity.

• Before performing an amputation for PAD, a vascularsurgery consultation is almost always indicated

• If amputation necessary, optimize surgical conditions:albumin < 3.5 g/dL or lymphocyte <1500 cells/mL => complication

TRAUMA

• Whether the limb shouldundergo salvage oramputation?

• 8 studies

• Level III, Class IIb• Gustilo IIIA fractures are unlikely to

require amputation

• Gustilo IIIB and IIIC fractures may requireamputation

• To remove subjectivity from the decision, availablescoring 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 theeventual result

• No scoring system can replace experience and good clinicaljudgment

• Might be necessary to preservelife

• Salvage a severely injured limbmay lead to metabolic overloadand secondary organ failure(multiple injuries the elderly)

• Injury severity score > 50:contraindication limb salvage

Indication for amputation – lower limb

The tradeoffs - limb salvage

• Great cost.

• Multiple operations to obtain bony union , soft tissuecoverage, 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,

The tradeoffs - early amputation

• Decreased morbidity, fewer operations, shorter hospital course,decreased hospital costs, shorter rehabilitation, earlier returnto work.

• Modern prosthetics better function than many “successfully”salvaged limbs.

• In long term studies, patients who have undergone amputationand prosthetic fitting are more likely to remain working and arefar less likely to consider themselves to be “severely disabled”than patients who have endured an extensive limb

DETERMINATION OF AMPUTATION LEVEL

• 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 transtibialamputation”

• Simple screening tests

• Waters et al. studiedthe energy cost ofwalking for patientswith amputations

velocity

energy

100%

66%59%

44%

87%

63%

normal Syme transtibial transfemoral transtibial(trauma)

transfemoral(trauma)

• If ambulation is 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

DETERMINATION OF AMPUTATION LEVEL

• 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

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

TECHNICAL ASPECTS

• HEMOSTASIS

• Tourniquet

• Major blood vessels isolated and ligated

• A drain should be used in most cases for 48 to 72 hours

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.

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

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

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

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

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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