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Transcript of amputation
GENERAL PRINCIPLES OF AMPUTATION
DR NIKHIL DROLIA
JR I
INTRODUCTION
Amputation : Loss of a limb or part of a limb
The word amputation is derived from the Latin word amputare, "to cut away"
Should not be viewed as a failure of treatment but as the first step in Rehabilitation
Should be performed by the most experienced surgeon in team
HISTORY
Earliest amputation were done on unanesthetized patients & haemostasis attained by crushing or dipping the open stump in boiling oil
Hippocrates was the first to use ligatures Morel’s introduced torniquet in 1674 Lister’s introduced antiseptic technique in
reducing mortality
AMPUTATION
Indications Scoring Surgical Principles
Amputation level Technical Aspects Open Amputations Post operative care
Amputation in children Complications
INDICATIONS
Dead limb – Gangrene
Deadly limb- Wet gangrene ,Spreading cellulitis , Arteriovenous fistula, Other (e.g. malignancy)
‘Dead loss’ limb -Severe rest pain , Paralysis ,Other(e.g. contracture, trauma)
Only absolute indication : irreversible ischemia in diseased or traumatized limb
Peripheral vascular disease Trauma Burns Frostbite Infections Tumors
PERIPHERAL VASCULAR DISEASE
Most common age group 50 to 75 yrs Most patients have concomitant disease processes in
cerebral vasculature, coronary arteries & kidney. Co morbid conditions-diabetes, smoking, prior stroke, prior
major amputation, decreased transcutaneous oxygen levels, decreased ankle-brachail blood pressure index, ulcers.
Most significant predictor of amputation in diabetics is peripheral neuropathy as measured by insensitivity to the Semmes Weinstein 5.07 monofilament.
Perioperative mortality rate-30 % & 40% die within 2 yrs.
TRAUMA
Most common in young patients Male >Female Lange’s absolute indications for amputation in type III C tibial
injuries :o Crush injury with warm ischemia time of > 6 hrs
Relative indications :o Serious associated injurieso Severe ipsilateral foot injuries
Decision as to a limb which can be saved , should be saved or not
Early amputation and prosthetic fitting :◦ Decreased morbidity◦ Fewer operations◦ Shorter hospital stay◦ Decreased hospital costs◦ Shorter Rehabilitation◦ Earlier return to work
Acute trauma : functional stump length of stump must be maintained whenever possible
Necessary for acute or chronic infections which are unresponsive to antibiotics and surgical debridement
Most worrisome infection produced by gas forming bacteria( eg. Clostrdium,streptococcal)
Disability from non healing trophic ulcer , chronic osteomyelitis , infected nonunion
Squamous cell carcinoma from chronic discharging sinus
INFECTION
Limb salvage vs. Amputation◦ Would survival be affected by treatment choice◦ Comparison of short term and long term morbidity◦ Function of salvaged limb◦ Psychosocial consequences
Amputation for malignancy is technically demanding Limb salvage : Disadvantages◦ More extensive surgical procedure ◦ Greater risk of infection ◦ Wound dehiscence◦ Flap necrosis
TUMORS
◦ Increased blood loss◦ Deep venous thrombosis
Late complications :◦ Periprosthetic fractures◦ Prosthetic loosening◦ Graft host nonunion◦ Allograft fractures◦ Leg length discrepancy◦ Late infection
Increased function by increased length of stump vs. Increased complications with shorter stump
Revascularization may aid in increasing length of stump but peripheral bypass surgery may compromise wound healing of a future transtibial amputation
More proximal level of amputation promotes slower walking velocity in order to conserve energy
Amputation should be performed at most distal level if ambulation is main concern
Potential for wound healing best measured by transcutaneous O2 measurement
LEVEL OF AMPUTATION
Ideal length of amputation stump
Above knee amputation : 23-27 cm from greater trochanter or 12 cm from knee
Below knee amputation : 12 -17 cm stump length
2.5cm for every 30 cm of height
Above elbow amputation : 20 cm from shoulder
Below elbow amputation : 18 cm from olecranon
Factors affecting level of stump
Section of bone above a joint may prevent use of best type of artificial joint
Retention of limb remnants below joint which cannot move distal part is not justified
When B/K amputation not possible , disarticulation favored
In ischaemic limbs , level just below distal most pulsation
Ideal stump Conical shape ( ideal shape ) Ideal length Good muscle power Joint should be supple Non adherent scar No fixed deformity Absence of neuroma Bone well covered by muscles Muscular and not flabby Bone covered by muscles , free from infection
What a stump should look like
What a stump should not look like
Efforts should be aimed at
Stump drainage and removal of drain in time
Stump splinting
Proper stump bandaging
Early starting of stump exercises
Stump hygiene and intermittent exposure to air
Tourniquet : Advantageous, contraindicated in ischaemic limbs.
Exsanguinations contraindicated in infected limbs & tumors
Skin Flap Flaps should be kept thick◦ Posterior skin flap should be => anterior skin flap◦ With modern total contact prosthesis , location of scar not important◦ Flap should not be adherent to the underlying bone◦ Preferable to have atypical skin flap than higher level amputation◦ Large dog ears are to be avoided◦ Combined length of flaps should be 1/3 of circumference of limb at level of
amputation
SURGICAL TECHNIQUE
Muscles
◦ Muscles sectioned 5 cm distal to level of intended bone resection
◦ May be stabilized by myoplasty or myodesis
◦ Myoplasty : Suturing muscle to periosteum or fascia of opposing musculature
◦ Myodesis : Suturing muscle or tendon to bone
◦ Myodesis should be performed to have stronger insertion , help maximize strength , minimize atrophy
◦ Myodesed muscle counterbalance antagonists and prevent contractures and maximize residual limb function
◦ Myodesis contraindicated in severe ischemia due to increased risk of wound breakdown
Advantages of Myoplasty/Myodesis
Shape of stump is good
Muscles insulate cut nerve endings and bone from prosthesis
Muscles originating proximally to joint produce better stump mobility and increase leverage
Muscles not acting on joint contract isometrically and assist in venous return
Prevent retraction and painful muscle contractions Phantom pain prevented
Blood vessels
Larger vessels doubly ligated Tourniquet should be deflated before closure Drain preferable for 48-72 hrs
Nerves
After nerve is divided it almost always forms neuroma
Neuroma is painful if traumatized repeatedly
Techniques to prevent neuroma formation : end loop anastomosis , perineural closure , Silastic capping , sealing epineurial tube with butyl-cyanoacrylate , ligation , cauterization or burying nerve ends in muscle /bone
Strong tension should be avoided while stretching
Larger nerves may need ligation for blood vessels
Bone
Excessive periosteal stripping contraindicated
May result in formation of ring sequestrum or bony overgrowth
Bone should be rasped to form a smooth contour- over anterior aspect for below knee , lateral aspect of femur and over radial styloid
Fibula cut slightly proximally to produce conical stump
Skin not closed over level of amputations
First of the at least 2 surgeries used to create functional stump
Required in : Extensive contaminated injuries Infection
Guillotine amputations : all tissue from skin to bone cut at same level ; wound left open for further management ; done as an emergency procedure
Open amputations with flaps where wound open , flaps covered later
OPEN AMPUTATIONS
Treatment of stump crucial from time amputation is completed till definitive prosthesis is fitted
Gradual shift from conventional soft dressings to rigid dressing
Rigid dressing :
POP cast applied to stump at conclusion of surgery ◦ Appropriate padding of all bony prominences◦ Avoiding proximal constriction of ring◦ Use of dependable cast suspension methods
If immediate weight bearing intended , true prosthetic cast should be applied by certified prosthetist
POST OPERATIVE CARE
Advantages of Rigid dressings
Prevent edema at surgical site Protect wound from bed trauma Enhance wound healing Early maturation of stump Decrease postoperative pain Allow early mobilization from bed Prevent formation of knee flexion contractures
Drains removed at 48 hrs post op
Stump is elevated by raising foot end
`Avoid leaving stump in dependent position
RIGID DRESSING
Prevent flexion or abduction contractures of hip
2nd post op day : muscle setting and joint mobilization exercises begun
Time for prosthesis application depends upon : Age Strength Agility Patient’s ability to protect stump from excessive weight bearing
Early unprotected weight bearing may lead to sloughing of skin or delayed wound healing
Cast should be removed after 7-10 days
POST OPERATIVE CARE
Hematoma Infection Wound Necrosis Contractures Pain Phantom limb sensation Dermatological problems
COMPLICATIONS
Hematoma: Prevented by rigid dressing , meticulous hemostasis May delay wound healing Serve as nidus for infection
Infection : More common in ischemic ,diabetic limbs Deep wound infection should be treated with immediate debridement Delayed closure may be difficult because of edema Smith and Burgess method of closing central 1/3 of wound and leaving rest
packed open Wound Necrosis:
Nutritional supplementation , TLC , albumin counts Necrosis of skin edge < 1 cm can be treated conservatively Discontinue prosthetic until wound healed If severe necrosis with loss of bone coverage , wedge resection indicated
Contractures: Prevented by proper stump positioning , gentle passive stretching , exercises Increased ambulation reduces contractures May need wedging casts or surgical release of contracted sutures
Dermatological problems : Contact Dermatitis Bacterial folliculitis Epidermoid cysts Verrucous hyperplasia
Pain : Phantom limb , Phantom pain, residual pain , pain from distant site Back ache more common in amputees Residual pain more often due to improper fitting Painful neuroma usually is easily palpable Phantom limb :
Very common Usually not very bothersome Telescoping Phantom limb pain bothersome , present mostly in proximal level amputations Conservative measures tried
Infection Wound necrosis
Most often due to trauma followed by neoplasms , infection General body growth and stump growth important Considerations :
Preserve length as much as possible Preserve important growth plates Prefer disarticulation rather than amputation Preserve knee joint whenever possible Stabilize and normalize proximal portion of limb
To prevent stump overgrowth , myodesis must be preferred at the time of surgery
Terminal overgrowth : appositional spike like new bone formation Regular prosthetic checking
AMPUTATIONS IN CHILDREN
REFERENCES
Campbell Apley’s Google