Three Logo Template CME...Amputations: background and epidemiology • 2 million patients with...
31
Amputations Avoiding Complications in Orthopaedic Trauma Christina Gutowski, MD MPH Friday, May 11, 2018
Transcript of Three Logo Template CME...Amputations: background and epidemiology • 2 million patients with...
Amputations
Avoiding Complications in Orthopaedic Trauma Christina Gutowski, MD MPH
Friday, May 11, 2018
Disclosures
None
1
Agenda
• Epidemiology of amputations o Incidence, indications
2
Agenda
• Epidemiology of amputations o Incidence, indications
• Limb salvage versus amputation o Outcomes, cost o How to decide
3
Agenda
• Epidemiology of amputations o Incidence, indications
• Limb salvage versus amputation o Outcomes, cost o How to decide
• Preventing complications o Tips, tricks, pearls for performing amputation
4
EPIDEMIOLOGY OF AMPUTATIONS
5
Amputations: background and epidemiology
• 2 million patients with amputations live in the US
• 185,000 lower extremity amps performed / year
• #1 cause in the western world: PVD o In young: #1 = trauma. #2 = malignancy.
6
Presenter
Presentation Notes
-There are 2 million patients with amputations living in the US, and by 2050 this number is expected to rise to 3.6 million -about 185,000 amps of the lower extremity are performed each year, which amounts to about 500 per day! -in the western world, the most common indication for amputation is peripheral vascular disease, and we see many vascular surgeons performing these surgeries for this reason. In the younger population though, PVD is less prevalent and trauma is the #1 indication for amputation, followed by malignancy. -the remainder of this talk will be focusing on amputations for traumatic reasons.
Amputations: background and epidemiology Adults Mechanism Incidence (%)
MVA 43
Industrial 26
Motorcycle 21
Other 10
Children
7
Site of amp Incidence (%)
Above elbow 11
Below elbow 19
Above knee 17
Below knee 53
Mechanism Incidence (%)
Lawnmower 34
Farm machinery 28
MVA 19
Train 20
Bomb/firework 10
GSW 3
Site of amp Incidence (%)
Above elbow 4
Elbow disartic 1
Below elbow 18
Above knee 19
Knee disartic 3
Below knee 55
AMPUTATION VS. LSS FOR ORTHOPAEDIC TRAUMA
8
Functional outcomes of LSS vs. amputation
9
• 569 patients with leg-threatening injuries
• SIP @ 2 yrs: 12.6 vs 11.8 (p = 0.58)
• Return to work @ 2 yrs: 53% vs 49.4% (p = 0.48)
Predictors of poor outcome
Rehospitalization for major complication
Low self-efficacy
Low education level Poor social support network
Nonwhite race Smoking
Poverty Disability litigation
Lack of private health insurance
Presenter
Presentation Notes
-In terms of a comparison of postop function of patients who undergo amputation versus limb salvage, the LEAP study has also provided us with good observational data. -in a New England Journal article from 2002, 569 patients who either underwent amp or LSS for leg-threatening injuries were evaluated using the Sickness Impact Profile, a multi-dimensional measure of self-reported health status after injury or illness. -The study found no difference between the two groups’ SIP scores at 2 years. There was no difference in rate of return to work. -(click) Predictors of poorer score were rehospitalization for major complication, low education level, nonwhite race, poverty, lack of private health insurance, poor social support network, low self-efficacy, smoking, and involvement in disability compensation litigation. The surgical intervention, however, was not predictive on multivariate analysis.
Economic burden of amputation
• Cost of amputation > cost of limb salvage
10
Presenter
Presentation Notes
-whenever amputation is considered, the surgeon is weighing the option against limb salvage. One interesting comparison between the two options is the financial one. -the cost of amputation in America is significant, and when you compare it to the costs associated with limb salvage for a given injury, they are much greater. -In a 2009 study of Gustilo Grade IIIB and IIIC open tibia fractures, amputation has been found to be more expensive than limb salvage, independent of varied ongoing prosthesis needs, discount rate, and patient age. -so if you look at the graph on the left, say the patient has 40 years of life left, with a discount rate of 2%, you can expect a lifetime cost of $350,000 spent towards that procedure, recovery, prosthetic fitting/maintenance/replacement every few years. This is compared to a similar patient, 40 years of life left, discount rate of 2%, who undergoes limb salvage: can expect about $125,000 in lifetime costs for the procedure, recovery, revision surgery etc. -these are interesting findings, but certainly your clinical decision shouldn’t be made based on what is cheaper, but I just wanted to present these data because they’re somewhat counterintuitive. Many of us assume amputation is a less costly decision compared to limb salvage, because there are no expensive implants, no expensive revision surgeries, etc…but the economic burden of prosthetics is important to keep in mind.
11
• New prosthesis every 2.3 years • 4-5 prosthetist visits per year • $7,784 for BKA prosthesis • $18,722 for AKA prosthesis
$100,000!
Presenter
Presentation Notes
It’s really driven by the aftercare of these patients, not the surgery and the hospitalization itself. The LEAP study showed that amputees purchase a new prosthesis every 2.3 years, with average cost of $7,000 for below-knee prosthesis and almost $19,000 for above-knee prosthesis (in 2002 dollars). They visit their prosthetist 4-5x per yr. All of this really adds up.
Clinical decision-making: LSS vs. amputation
12
Presenter
Presentation Notes
-With all that as a backdrop, let’s move into the clinical decision-making associated with amputation as an appropriate management strategy for orthopaedic trauma. -it’s important to keep in mind that the only absolute indication for primary amputation in the trauma setting is an irreparable vascular injury in an ischemic limb, where perfusion cannot be restored via either vessel repair or bypass. -in the absence of this situation, you’re left with a decision, and flow-charts like THIS disaster that are supposed to help guide your decision. -There are many scoring systems that have been developed to try to quantify the extent of bone and soft tissue injury in acute trauma, but no scoring system can replace experience and good clinical judgment. None of the scoring systems available have proven their validity in large external prospective evaluations. They also haven’t been proven to predict Sickness Impact Profile, a measure of a patient’s final functional outcome after injury, at 6mos or 2yrs.
Clinical decision-making: LSS vs. amputation
13
Presenter
Presentation Notes
-Most scoring systems are based on these factors, that have been shown in multiple separate studies in different combinations to be predictors of needing amputation. -there are some patient-related demographic and systemic factors, as well as criteria for bone injury, soft tissue injury, neurologic status, and perfusion status. -this is a good example of when big data can be really useful, because people have tried to weight these factors and create prospective prediction models for identifying injuries will eventually fail limb salvage and require amputation
MESS Type Characteristics Injuries Points Injury group
1 Low energy Stab, simple closed frx, small caliber GSW 1
2 Medium energy Open or multi-level frx, dislocation, moderate crush 2
3 High energy Shotgun blast or high-velocity GSW 3
4 Massive crush Logging, railroad, oil rig accidents 4
Shock group
1 Normotensive BP stable in field and OR 0
2 Transiently hypotensive BP unstable in field but responsive to IVF 1
3 Prolonged hypotension SBP<90mm Hg and only recoverable in OR 2
Ischemia group
1 None Pulsatile limb without signs of ischemia 0
2 Mild Diminished pulses without signs of ischemia 1
3 Moderate No pulse by doppler, sluggish cap refill, decreased motor/sensory 2
4 Advanced Pulseless without cap refill, cool, paralyzed, numb 3
Age group
1 <30yo 0
2 30-50yo 1
3 50 2
14
Presenter
Presentation Notes
-in internal prospective validation studies, a Mangled Extremity Severity Score >7 has been shown to be 100% predictive of requiring eventual amputation, and this is the most frequently-used system in clinical practice. (click) -It’s based on degree of bone and soft tissue damage, limb ischemia, shock, and age. The predictive salvage index is also used, based on level of vascular injury, warm ischemia time, and degree of muscle/bone/skin injury. These numbers assigned to each class of ischemia are doubled if the time from injury > 6 hrs.
PREVENTING COMPLICATIONS
15
Common complications
16
• Hematoma • Infection • Wound edge necrosis • Pain
Avoiding hematoma
• Meticulous hemostasis o Deflate tourniquet before closing o Attention to vessel ties/clips o Bone wax or myodesis for canal bleeding o Peroxide
• Multilayer closure • Suction drain
o Multiple • Compressive dressing
o Two ACE wraps for proper stump dressing
17
Avoiding infection
• Consider open amputation o Open amp with skin flaps vs. guillotine/circular open
• Prevent hematoma/seroma which can become nidus for infection
• All deep infections of closed stump require I&D o Leave sides of wound open to drain, but close central
portion of stump to maintain flap length/prevent retraction
18
Open amp w/rolled skin flaps vs. guillotine
19
Presenter
Presentation Notes
Rolled skin flaps can be preserved for later closure, while temporarily allowing stump to drain, undergo open wound care, and a repeat debridement. Circular open amps require either constant skin traction to pull soft tissues over end of stump in order to heal (which isn’t really practical), or a revision amp at a more proximal level. This is not ideal, therefore the former is usually the method of choice bc when wound is ready for closure you can do so without shortening stump.
Avoiding infection
• Consider open amputation o Open amp with skin flaps vs. guillotine/circular open
• Prevent hematoma/seroma which can become nidus for infection
• All deep infections of closed stump get washed out o Leave sides of wound open to drain, but close central
portion of stump to maintain flap length/prevent retraction
20
Avoiding wound edge necrosis
• Serum albumin and total lymphocyte count o Goal: albumin > 3.5g/dl; TLC > 1500 cells/ml o Nutritional supplementation
• Smokers: quit immediately • Hyperbaric oxygen • Wedge resection in large areas of wound necrosis
21
Presenter
Presentation Notes
Wound healing is contingent on several things, one big one being nutritional status. You can evaluate nutritional status using albumin and total lymphocyte count, and there is evidence that numbers below these thresholds significantly increase your risk of wound healing problems. -for this reason, all of our patients receive nutritional suppliementation in the form of Ensure TID -smokers have a 2.5x higher risk of infection and re-amputation due to compromise of cutaneous blood flow at the wound edges. -Hyperbaric oxygen can help -Necrosis of skin edges < 1cm can be treated with open wound mgmt, bedside debridements, delay in prosthesis fitting, etc. But larger areas of necrosis require wedge resection, where the surgeon regards the end of the stump as a hemisphere. Local resection of the skin edges increases local tension on already compromised tissues where as wedge resection incorporates the full diameter of the stump which will allow for re-formation of the hemisphere with a shorter radius, and minimization of local pressures
Avoiding postop pain Cause Prevention/Treatment
Residual limb pain
Poorly-fitting prosthesis Eval for hot spots, refer to prosthetist
Painful neuroma Traction neurectomy, TMI, socket modification, neurectomy
Muscle shear over bone end Myodesis
Phantom limb pain Epidural, marcaine injection into nerve
Referred pain
DJD in joint above Xrays and exam
Radiculopathy Xrays, MRI, exam
22
Presenter
Presentation Notes
It is critical to differentiate between residual limb pain, phantom limb pain, or referred pain. The residual limb can be painful if the prosthesis is fit improperly, and you must be aware that if the patient’s weight fluctuates, if swelling is going down (or up), and increased use can all change the fit of the prosthesis. These issues lead to frequent returns to the prosthetist. -The patient can also have a painful neuroma, which can be prevented by performing the neurectomy with gentle traction on the nerve and sharp proximal division, allowing the nerve to retract deep into the soft tissues. Targetted muscle innervation is another strategy at the time of amputation to minimize painful neuroma formation. If they’ve developed a painful neuroma, socket modification is the first step to try to unload the area, and if that fails surgical neurectomy may be indicated where the nerve is divided at a more proximal segment. -I’ve also seen bulbous muscle and soft tissue at the end of a stump shear over a sharp cut end of bone, which can be avoided by solid myodesis of this tissues to the bone -Phantom limb sensation will develop in such a high frequency of patients that it should be considered normal, but most patients don’t find these sensations bothersome. A phenomenon of telescoping usually occurs, whereby the phantom limb sensations gradually shortens to the end of the residual limb, usually by 6 mos. Phantom limb PAIN is far less common, and it’s more common in those who felt pain in the limb just before amputation. For this reason we usually do our amps under high-dose epidural whenever possible, and we anesthetize the nerve using an injection of 0.5% marcaine and a 25G needle into the sheath prior to neurotomy.
Tips and tricks: FOOT AMPUTATIONS
• Great toe amputation: loss of pushoff strength • 2nd toe amputation: postop hallux valgus • Syme: more energy-efficient than Chopart/Lisfranc
o Need patent PT artery for healing o Don’t overtrim dog ears
• Chopart/Lisfranc: deformity considerations
23
Presenter
Presentation Notes
-general rule of all amps: preserve length, as the longer the residual limb, the more functional and energy-efficient it will be. -single toe amps are relatively straightforward and cause little disturbance in stance/gait. However, two amps to keep in mind and warn patients about: great toe and 2nd toe. -TMA is relatively disabling in proportion to the level of amputation, due to significant loss of pushoff strength because you no longer have the ball of the foot to serve as fulcrum for pushoff -Syme (ankle disartic) is more energy-efficient than Chopart or Lisfranc, even tho it’s more proximal. You need a patent PT artery for healing, and when it fails, it fals due to posterior migration of the heel pad, and skin slough from overly vigorous trimming of dog ears. Dog ears are critical for vascularization of the skin edges, so must be maintained. -If you DO perform TMA, Chopart or Lisfranc: beware the resultant deformity from asymmetric muscle pull on residual foot: Chopart will be pulled into equinus due to unopposed force of gastroc soleus; lisfranc will be pulled into equinovarus due to CGS and tibialis posterior. -avoid these deformities by performing TAL and TA transfer to talar neck (for chopart) and by maintaining peroneus brevis (for lisfranc)
Tips and tricks: TRANSTIBIAL AMPUTATIONS
• Ideal osteotomy: 15cm distal to knee joint
• Various incisions
• (Modified) Ertl technique
24
Presenter
Presentation Notes
-ideal level of osteotomy is 15cm from knee joint. Longer than that (distal to myotendinous junction), soft tissues are relatively avascular and can be challenging for healing
Tips and tricks: TRANSTIBIAL AMPUTATIONS
25
Presenter
Presentation Notes
-classic description of the transtibial incision is the fishmouth incision, with equal anterior and posterior skin flaps. Each flap’s length is ½ the AP diameter of the leg at the level of bone transection. For example (show on diagram) -Burgess also described a long posterior flap technique that utiizes an osteotomy about 10cm from tibial plateau, an anterior flap that’s about 1cm longer than that osteotomy, and a posterior flap that’s about 13cm longer than that osteotomy. Usually indicated in an ischemic limb, where you have inadequate anterior soft tissues
Tips and tricks: TRANSTIBIAL AMPUTATIONS
• Ideal osteotomy: 15cm distal to knee joint
• Various incisions
• (Modified) Ertl technique
26
Presenter
Presentation Notes
The traditional Burgess BKA is described as a transverse cut of the tibia about 2cm longer than the fibula. The ends can be beveled to reduce painful shear. However, the Ertl technique was established with the theoretical advantage of improved end-bearing with a prosthesis in particularly active individuals. The Ertl technique uses a corticoperiosteal vascularized fibular flap to create a bone bridge, and subsequent modifications have been made using fibular allograft strut. Fixation methods include 3.5mm screws, tightrope, and nonabsorbable suture to fix the fibular bridge. -in a head to head comparison published in JBJS in 2011, a statistically significantly higher rate of complications and reoperation were found after bone bridge synostosis as compared to the traditional transtibial amp. Complics specific to the bone bridge group included nonunion/delayed union of the bridge, painful or infected hardware, and a poorly positioned bridge fragment. They also underwent reoperation more frequently for HO and neuroma excision. For all of these reasons, I believe this technique should be reserved for revisions of refractory painful Burgess transitibial amps, but should not be standard of care for primary amputations at this level.
Tips and tricks: TRANSFEMORAL AMPUTATIONS
• Ideal osteotomy: 12cm above knee joint
• Muscle stabilization by myodesis is critical
• Use sharp rasp to smooth edges of cut bone, especially flatten anterolateral aspect
27
Presenter
Presentation Notes
-for AKA, you want the stump as long as possible to provide strong lever arm for control of prosthesis. However, the ideal osteotomy is about 12cm above the knee joint, because this space is needed for appropriate prosthesis fitting in order to have equal thigh lengths -at the transfemoral level especially, myodesis to provide muscle balance is important. In the absence of myodesis of the adductor magnus, most AKA’s result in at least 70% loss of adduction power -I use fiberwire or #5 ethibond through drill holes to secure the adductor, and I also try to pull the quad around from an anterior to posterior direction as well. This helps tamponade bleeding from the canal, muscle balancing, and also provides a stable soft tissue pad over the end of the bone so the muscle pad doesn’t shear over it as the patient moves. -incision traditionally is a fishmouth with equal anterior and posterior skin flaps; length of each flap should be at least ½ the AP diameter of the thigh through the level of the bone cut -smoothing the end of cut femur to minimize pressure between bone and overlying soft tissue is critical
Tips and tricks: UPPER EXTREMITY AMPUTATIONS
• Transcarpal amp/wrist disartic > transradial o DRUJ preservation allows for normal pronosupination
• Forearm: ideal osteotomy = middle & distal 1/3
• Transhumeral: allow 4cm for elbow prosthesis
• TMI: 1) prevents neuroma; 2) myoelectric prosthesis
28
Presenter
Presentation Notes
Few pearls about upper extremity amps, which aren’t nearly as common. -in general, length is critical -whenever feasable, preserve DRUJ as this will allow for normal pronosupination. Wrist disartic for hand trauma is preferred over a long transradial amp. -if you have to go to the forearm, the ideal osteotomy is at the junction of the middle and distal 1/3. Further down, the skin is thin, subcutaneous tissue is scant, and soft tissues are relatively avascular -if you’re going transhumeral, should be at least 4cm proximal to the elbow joint to allow room for the elbow-lock and turntable mechanism of a functional prosthesis -targetted muscle reinnervation is something a little outside the scope of this talk, but if you do a good amount of amputations it’s something worth discussing with your partners who have micro experience, or the plastic surgeons in your hospitals, as this is an increasintly-popular strategy for minimizing postop neuroma formation, as well as allowing for improved use of myoelectric prostheses.
Thank you!
29
References • Canale, TS. Campbell’s Operative Orthopaedics, Mosby, 10th edition. 2002. • Ziegler-Graham K, MacKenzie EJ, Ephraim PL et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med
Rehabil 2008;89(3):422-9. • Chung KC, Saddawi-Knoefka D, Haase SC et al. A cost-utility analysis of amputation versus salvage for Gustilo IIIB and IIIC open tibia
fractures. Plast Reconstr Surg 2009;124(6):1965-73. • MacKenzie EJ, Jones AS, Bosse MJ et al. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone
Joint Surg 2007;89:1685-92. • Scalea TM, DuBose J, Moore EE et al. Western trauma association critical decisions in trauma: management of the mangled extremity. J
Trauma 2012:72:86-93. • Ly TV, Travison TG, Castillo RC et al. Ability of lower-extrmity injury severity scores to predict outcome after limb salvage. JBJS
2001;90(8):1738-43. • Swiontkowski MF, MacKenzie EJ, Bosse MJ et al. Factors influencing the decision to amputate or reconstruct after high-energy lower
extremity trauma. J Trauma Acute Care Surg 2002;52(4):641-49. • Bosse MJ, MacKenzie EJ, Kellam JF et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. New Eng J
Med 2002;347;1924-31. • Livingston DH, Keenan D, Kim D et al. Extent of disability following traumatic extremity amputation. J Trauma 1994;37:495-9. • Loder RT. Demographics of traumatic amputations in children. Implications for prevention strategies. J Bone Joint Surg 2004;86-A:923-8. • Scalea TM, DuBose J, Moore EE et al. Western trauma association critical decisions in trauma: management of the mangled extremity. J
Trauma 2012:72:86-93. • Kuiken TA, Li G, Lock BA et al. Targeted muscle reinnervation for real-time myoelectric control of multifunction artificial arms. JAMA
2009;301(6):619-28.
30
