Surgical Considerations in Lower Extremity Amputation · –Malleoli excision –Incision. Symes...
Transcript of Surgical Considerations in Lower Extremity Amputation · –Malleoli excision –Incision. Symes...
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SurgicalConsiderationsinLowerExtremityAmputation
TinaDreger,MDOrthopaedic TraumaFellow
UniversityofMissouri
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Disclosures
–None–OriginalpresentationbyBrettCrist,MD
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Objectives
• Understandtheindicationsforlowerextremityamputation
• Understandtheprinciplesandgoalsoflowerextremityamputation
• Reviewspecificlevelsofamputationandimportantconsiderationsforeach
• Reviewspecialconsiderationsinvolvinglowerextremityreconstruction
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LowerExtremity:Purpose
• Ambulation/locomotion
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IndicationsforAmputations
• Trauma–Acute
–Chronic
• MedicalCo-morbidities
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AmputationDuetoTrauma
• Trauma–20-40y/omales–16%ofamputations–45%ofamputees
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IndicationsforAmputation
• LEAP–569patientsfollowedprospectively–Ampvs.limbsalvage–2and7yeardata–Hospitalization–Whitecollar–=?
Bosseetal.NEJM2002;JBJS2005
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IndicationsforAmputation
• Lackofplantarsensation– Notequalautomaticamputation
– >50%ofsalvageswithinitiallackofplantarsensationrecoveredby2years
Bosseetal.JBJSAm2005
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IndicationsforAmputation
• Military–Pushingtheenvelope–ExtremityWarInjuriesSymposia
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AmputationsAmongMilitary
• Increasednumberof3and4extremityamputees
• IED’s=infection• Soldierswithtourniquets
• Significantpsychologicalandsocietalimplications
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IndicationsforAmputations
• Infection– 2⁰todiabetes
• PeripheralVascularDisease– 2⁰todiabetes(71%)– 80%oflowerextremityamputees
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IndicationsforAmputations
• Neurologicaldisorders– Peripheralneuropathy2⁰todiabetes– Lackofprotectivesensation
• Burn
• Congenitaldeformities
• Malignanttumors– Clearmargin
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SuccessfulAmputation
• Removalofdysfunctional/devitalizedtissue– easy
• Reconstructionofadurableresiduallimb– challenging
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GoalsofAmputationSurgery• PreservationofLength
– Preventionofadjacentjointcontractures
• Preservationoffunction– Minimizeenergyexpenditure
• Earlyreturntofunction– Earlyprostheticfittingwhenpossible
• Painlessresiduallimb– Preventionofsymptomaticneuromas– Minimizephantomlimbpain
• PreservationofLife
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EnergyExpenditure• Normalenergyexpenditure–Walking–O2consumption
• Levelofamputation–Higher=moreenergy
Gottschalk,Frank;Rehabilitation:Gait,Amputations,Prostheses,Orthoses,andNeurologicInjury,Chpt.10.
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GeneralAmputationPrinciples
• Skin• Muscle• Nerves• BloodVessels• Bone
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Skin
• Painless,pliable,nonadherentscar
• Scarplacementandprostheticwear– Viablelevel
• Coverage:–Flapcoverage–Skingraft
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Muscle
• Myofascialclosure– Providesminimalmusclestabilization
• Myoplasty– Balancesopposingmusclegroups
• Myodesis– Attachmuscletobone
• Tenodesis– Attachtendontobone
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Nerves
• Avoidingpainfulneuromas1. Separatenervefromvessels
2. Tractionnerveandsharplytransect-Retractstosafety
3. Nervepreparation-Injectionofalcohol
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BloodVessels
• Sutureligatemajorvessels
• Full-thicknessskinflaps–Minimizewoundnecrosis
• Hemostasispriortoclosure–Drains
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Bone• Minimizesharpedges– Beveling/filing
• Narrowmetaphysealflare/condyles
• Capintramedullarycanal–Minimizebleeding
• Minimizeperiostealstripping– Exostosis
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LevelsofAmputation
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LevelsofAmputation• Toe
• Rayresection
• Partialforefoot
• Transmetatarsal
• Symes
• ModifiedSymes
• BKA
• Throughknee
• AKA
• HipDisarticulation
• Hemipelvectomy
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Toe
• Interphalangeal– Leavecartilage– Trimcondyles
• Transecttendonsandnerves– Donotsewtendonstogether
• Greattoe– Leave1cm– Footbalanceandfunction
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RayResectionandPartialFoot
• Includestoeandpartofmetatarsal
• Preserve1st MTlength–Orthosis–Footbalance
• Avoidsharpbonyprominences
• Multiplelateralrays
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Transmetatarsal
• Considered– 2ormoremedialrays– Morethanonecentralray
• Preservelength• Maintainarchandmetatarsalcascade
• AvoidAchillescontracture– Achilleslengthening
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Transmetatarsal
Ngetal.JAAOS2010
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NegativesforTransmetatarsal
–Footbalance–Prostheticfit–Woundhealing•33%primarywoundclosure•56%mayrequirerevisiontohigherlevel
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Symes
• Ankledisarticulation
• Required–Viableheelpad
• Modifications–Malleoliexcision– Incision
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Symes
Benefits– Longerlimb/lessenergy–Highlevelwalkers– Endbearingforobesepatients–Ambulatewithoutprosthesis
Negatives–Woundhealing–Compliance–Heelpadinstability
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Symes
• Mustpreserveposteriortibialarterialsupply
Ngetal.JAAOS2010
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BelowKneeAmputation
• Mostcommon
• Longerisbetter– Always?– Softtissue
• MinimumtoutilizeBKAprosthesis– 2.5cmper30cmptheight– 5cmdistaltothetubercle
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BelowKneeAmputation:Techniques
• Longposteriormyocutaneousflap
• Modifyskinflapsbaseduponavailableskin
• IDneurovascularstructures
• Isolatefibulaandtransect1.5cmabovetibia
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• Tibialcut
• Bevelbonecuts
• Ligatevesselsandtransectnerves
• Myodesisvs.myoplasty
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BelowKneeAmputation
Staged– Traumaticorinfection
– Guillotine• Allowssofttissuesandbonetodeclare
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ErtlProcedure
• Tibiofibularsynostosis
• Indication– Young– Proximaltib/fibinstability– Highactivitylevel
• Outcomes– Functionalscores=nobenefit(Ngetal.JAAOS2010)
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Technique
– Fibulacutatsamelevel– Leavemedialperiostealhinge–Connecttotibia•Metal• Suture
Ngetal.JAAOS2010
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CaseExample
• 45y/os/pMCC• Policeofficer• Rightopenfemurfx• Rightopentib/fibwithvascularinsufficiency
• Ex-fix• Multipledebridements• Progressivenecrosis
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CaseExample
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CaseExample
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CaseExample
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CaseExample
• Femurinfected– ABXbeads– IVabx– debridements
• 2STSG• Sutureremoval
• 11mo
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Afterprosthesis
• c/okneepainandcrepitance
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BKAatallcosts
• Improvedenergyexpenditure
• Softtissuereconstructiontomaintainlengthandkneefunction– Skingraftorsubstitute–Muscleflap
• Morefunctionalprosthesis
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CaseExample
• 40y/omales/pBKAduetomangledlowerextremityaftergo-cartaccident
• Within2weeksofBKAandDPC– Infected–Necroticskin
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Options
• RevisiontoAKA
• Reconstructsofttissueweight-bearingsurface
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CaseExample
• Multipledebridements
• Negativepressurewoundtherapy(NPWT)
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CaseExample
• STSGlowprobability
• Muscleflaprequired–Gracillisrotationflap
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CaseExample
• Gracilliscoveringtibia
• STSGovermuscle
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ThroughKneeAmputation/KneeDisarticulation
• Prosthetists– Thumbsupordown
• Endbearingresiduallimb
• Softtissuecoverage– Improvedwithposteriorflaptechnique
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Indications
• Trauma
• Infection
• Dysvascular
• Nonambulatory
– *RiskofkneecontractureswithBKA
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ThroughKneeAmputation/KneeDisarticulation
Benefits– Endbearingsurface– Sittingcomfort– Longerleverarm–Balancedthighmuscles–Prostheticsuspension(femoralcondyles)
Negatives–Kneeheight– Softtissuecoverage
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Technique• Suturepatellartendontocruciates
• Patellanotdistaltofemur
DougSmith,MD
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ThroughKneeAmputation/KneeDisarticulation
• LEAPstudy– Slowestwalkingspeed– Leastsatisfaction
–12/18nogastroc coverage->poorprosthetictolerance
Mackenzieetal.JBJS2004
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AboveKneeAmputation
• Maintainlength
• Energyexpenditure
• Recurrentinfectedtotalkneearthroplasty–Alternativetokneefusion
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Technique
• Fishmouthincision-Modifytopreventweightbearingonincision
• Myodeseadductors
• Myodesequadandhamstrings
• Nomyodesis=poorfunctionandpain– Femurmoveswithinmuscularsleeve
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AboveKneeAmputation
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CaseExample:Maintainlengthatallcost
• 32y/os/pMCC• Leftopentibialshaftfx• Leftopenbicondylartibialplateaufx
• Leftopenfemoralshaftfx
• Leftfemoralneckfx• Leftclaviclefx• Leftulnafx
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CaseExample
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CaseExample
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CaseExample
• Rideshorses
• Noresidualpain
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HipDisarticulation
Indications– Preservationoflife– Co-morbidptwithinfectionandsepsis– Necrotizingfasciitis– Non-ambulators(paraplegics)– Advancedischemicdisease– Tumor
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HipDisarticulation
• Problems–Woundmanagement– Sittingbalance–Noprosthesis?•Maychoosenottowear• Usecrutchesanyway
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Technique• Lateralposition
• Medialandlateralskinflaps
• Usemusclestofilldeadspace
• Woundcomplications
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Hemipelvectomy
• Indications– Sameashipdisarticulation– Tumormorecommon–Morecommoninmilitaryrecently
• Procedureoflastresort• Poorfunctionaloutcome
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Technique
• Semi-lateralposition
• Largeposteriorflap
• Keepasmuchofthehemipelvisaspossibleforsittingbalance
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Complications
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AmputationSiteBreakdownEarly• Delayedwoundhealing– Immunocompromised–Malnourished– Infection
• Marginalnecrosis–Appropriatesurgicaltechnique
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AmputationSiteBreakdown
Late• Deepinfection–UsuallyassociatedwithPVD/DM/amputationforinfectedhardware
• Adherentskin
• Poorprostheticfit
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Infection
• Debridement• Antibiotics• Localwoundcare• Secondaryhealing–Prolongedwoundhealing
• Revisionamputation
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AmputationSiteProminence
• Overgrowth• Bonespur• Muscleatrophy• Failedmyoplasty/myodesis• Skinhypertrophy• Bursitis• Bulbous/floppyresiduallimb– Poorsurgicaltechnique
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IndicationsforRevisionAmputation
• Tissueprominence–Poorprostheticfit–Limitedfunction–Pain–Skinatrisk
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HeterotopicOssification/BoneSpur
• Associatedwith:– Severetrauma– Excessivemanipulationofperiosteum
– Residualboneafterosteotomy
• Mayrequiresurgicalresectionifproblematic– RecurrenceofHO
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IndicationsforRevisionAmputation
• NeurologicComplications– Neuroma– Phantomlimbsensation
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Neuroma• Allnervetransectionsformneuromas
• Painful–PositiveTinel’s
• Causes–Poorsurgicaltechnique–Highpressurearea–Crushinjury
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PhantomLimbPain
• Maybenonpainful
• Painful–Upto85%inLE–~40-69%inUE
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PhantomLimbPain
• Surgical– Dehydrogenatedalcoholandmarcaineintoepineureum
• Non-surgical– Neurontin• Showneffective
– VitaminC?– Regionalanestheticsperioperatively?
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JointContracture
• Usuallyrelatedtoshortleverarm
• Contracturereleaseandtenolysismayberequirediffixeddeformity
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Summary
• Lowerextremityamputationsaremuchmorecommonthanupperextremity
• Restoringfunctionisimportant– Reconstruction– Prosthesis
• Preservelengthandjointmotion• Avoidcomplications• Patientcounseling/support
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Questions?
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References
1. SmithDG,MichaelJW,BowkerJH,AmericanAcademyofOrthopaedicSurgeons.Atlasofamputationsandlimbdeficiencies:surgical,prosthetic,andrehabilitationprinciples.3rded.Rosemont,IL:AmericanAcademyofOrthopaedicSurgeons;2004.
2. Scottetal.TraumaticandTrauma-relatedAmputationsIandII.JBJSAmDec2010
3. NgandBerlet.EvolvingTechniquesinFootandankleAmputations.JAAOSApril2010