Principles of Amputation

transcript

R. Richard Coughlin MD, MSc

Director of Institute for Global Orthopaedics and

Traumatology (IGOT)

San Francisco General Hospital/OTI

University of California, San Francisco

Introduction

What is the Global Burden

of Amputation?

Introduction

Strictly speaking:

We don’t know

What we do know

In US, there are over

80,000 Amputations/yr

Globally, estimate of

over 1,000,000

Amputations/yr

Care of the Amputee

Surrogate marker for

the adequacy of a

Health System

Amputation Surgery

Reconstructive Surgery

E.Burgess

Introduction/Goals

Review of the history of amputations

Review of lower extremity amputations

Review of basic principles

Discuss controversies/key points

History of Amputations 1800BC Indian Warrior Queen

Vishpla, leg amputated after a battle

Fitted with an Iron Prosthesis,

returned to lead troops

History of Amputations

Judicial amputations of criminals

sanctioned by both

Babylonian Code of Hammurabi and

Mosaic law.

Hippocrates “war is the only proper

school for surgeons”

Recommended cutting through the

insensate gangrene

25-50 BC Celsus-

Trans-osseus at level of viable and necrotic tissue

Ligation of vessels/cautery last resort

History of Amputation

Middle Ages-Leprosy and Ergotism

St. Anthony’s Fire-ingestion bread made of

fungus infected rye flour bread. Arterial

vasoconstriction + burning sensation hands/feet

Renaissance-Ambroise Pare

reintroduced Celsus

Amputation through viable tissue

Using ligatures for hemostasis

Abandoned boiling oil

Napoleonic Era

Dominique-Jean Larrey

“Flying ambulances”

American Civil War Union Army

Experience with 20,500 amputations

35.7% Mortality Rate

Joseph Lister

○ Using principles of “antisepsis”

Handwashing/clean instruments/carbolic acid spray

- Reduced mortality to 15%

World War II

Introduction of Sulfonimides/Penicillin

Marked the beginning of “antibiotic era”

Burgess Technique

Ernest M. Burgess, MD, PhD (1911-2000)

Tripler Hospital, Honolulu, 1944

1968: Popularized the long posterior flap

○ Skin over the posterior leg has

better blood supply that of

anterior/lateral leg.

Kendrick, 1956 “The posterior flap is made twice as long

as the anterior, because gangrene in our

experience has affected only the anterior

flap.”2

2Kendrick RR. “Below-knee amputation in arteriosclerotic gangrene.” British J of Surgery. 1956;44:13-17.

Burgess Technique

Source: Burgess EM, et al. “Amputations below the knee.” p.9-10.

Burgess Technique

Paradigm shift:

“Amputation must be considered plastic and

reconstructive in nature. The need to create a

dynamic and sensory motor end-organ should be

foremost in the surgeon’s mind….The atrophic,

wasted, boney, below-knee stump so commonly

encountered in years past is no longer

acceptable.”

-EM Burgess, 1969

Burgess Technique

Source: Skinner HB: Current Diagnosis & Treatment in Orthopedics, 4th Ed. http: //www.accessmedicine.com.

Burgess technique: gold-standard for soft

tissue coverage in transtibial amputation.

Cushioned, dynamic stump, well-suited for

prostheses.

With improvements in prostheses, it has

revolutionized amputation surgery:

amputation surgery = reconstructive surgery.

first step in a rehabilitation process that allows

patients to return to a fully active life.

Burgess: Disadvantages

Requires intraoperative assessment of

muscular viability.

if overestimated in patients with vascular

disease (i.e. amputation is too distal)

wound healing problems, necrosis, and

infection revision

Bruckner modification.

Source: Stahel PF, et al. “Concepts of transtibial amputation.” p.943.

Burgess: Disadvantages

Incision is directly over the anterior aspect of the distal

part of the residual tibia:

↑ potential for adherent scarring of skin to tibia

Local discomfort, blistering or tissue breakdown from pistoning

between the residual limb and the prosthetic socket during

walking.

An extended posterior flap

provides improved

cushioning and comfort.

Source: Pinzur MS et al. “Controversies in lower-extremity amputation.” p.1125.

Ertl Procedure

1920s Professor Janos Ertl Sr. MD, of

Hungary

Osteointegration

Bone anchored vs traditional socket

Lower Limb Levels

1. Foot

- Hallux amputation

- Lesser toes

- Transmetatarsal

- Hinfoot

Chopart, Boyd, Pirogoff

2. Ankle - Syme

3. Leg – BKA

4. Knee disarticulation

5. Transfemoral – AKA

6. Hip disarticulation

Partial Foot Amputations/Foot

Salvage

Lower Limb Levels

Surgeon’s goals

Removal of diseased,

damaged, and dysfunctional

Reconstruction of residual

Must Establish

Reasonable functional goal

Disease process

Unique needs of the patient

Considerations

Limb salvage vs amputation

Which has better outcomes

Leap Study (569 consecutive mutilating

injuries)

Realistic expectations

Costs of care

Considerations

Optimal length

Reasonably functional proximal joint

Durable soft tissue envelope (avoid

adherence)

Protective sensation (STSG?)

Disarticulation vs Transosseous

“To Ertl vs not to Ertl”

Bone bridge

Enhanced surface area for load transfer

Proponents vs detractors

Young and active

Considerations Good Scar

Painless, pliable, non adherent, placement

Bad Scar

Tender, adherent, thin, non durable

Considerations

Good stump

Cylindrical, muscle padding

Bad stump

Boney, atrophied, tapered

Indications

Peripheral Vascular disease

Trauma

Tumors

Frostbite

Infection

Peripheral Vascular Disease

PVD most common indication for amputation

Diabetes – 50%

Age 50-75

Medical consult for concomitant disease processes

Most significant predictor of amputation in diabetics is peripheral neuropathy

Trauma Trauma is the leading cause of amputation in younger patients

Absolute indication for primary amputation is an irreparable

vascular injury in an ischemic limb

The mangled extremity severity score is the most useful and grades

the injury on the basis of the energy causing the injury, limb

ischemia, shock, and the patient's age

Tumors Limb salvage increasingly popular

Consider:

1. Would treatment choice affect survival

2. Short and long-term morbidity

3. Function of limb salvage versus a prosthesis

4. Psychosocial consequences

Thermal and electrical injury produces tissue damage

Early debridement and possible fasciotomy

Early amputation for unsalvageable limb

Frostbite Freezing of tissue -direct tissue injury with formation of

ice crystals in the ECF and ischemic injury from damage to vascular endothelium, clot formation and increased sympathetic tone

Amputation should be delayed for 2-6 months due to long period of time for clear demarcation of viable tissue

Infection

Acute or chronic infection unresponsive to debridement or

antibiotics

Gas forming organisms are most worrisome in acute

setting

Anaerobic cellulitis, clostridial myonecrosis, streptococcal

myonecrosis

Goals for Amputation

Removal of diseased, injured, or

nonfunctioning limb

Restore function

Preserve length and strength

Muscular balance to provide stable

residual limb

Preoperative Assessment

Check skin integrity, soft tissues, motor and

sensory exam, and joint mobility

Vascular status

Nutrition and immune competence

Psychological preparation

amputation as a step for recovery

early prosthetic fitting

counseling for patient

amputee support group

Vascular status

Doppler with ABI: > .45 correlates with 90% healing

Toe systolic pressure: min 55mm Hg

Transcutaneous oxygen tension: PO2 > 35 for healing

Skin blood flow measurement: Xenon 133

Arteriography: patency of vessels

Nutrition and immune competence

Total lymphocyte count > 1500/ml

Serum albumin > 3g/dL

86% healing rate in Symes amputations in

patients with serum albumin > 3.5 g/dL and total

lymphocyte count > 1500/ml

Technical Aspects

Skin and muscle flaps

Hemostasis

Nerves

Technical Aspects

Scar location

Flaps should be thick

Avoid adherent skin to bone

Myodesis/myoplasty if possible

Skin and Muscle Flaps

Technical Aspects

Tourniquet (except ischemic limb)

Exsanguination with Esmarch (not with infection/tumors)

Major vessels identified and ligated

Tourniquet deflated prior to closure

Hemostasis

Technical Aspects

Neuromas=Pain=Frequent cause of Failure Must identify nerves

-gentle traction and sharp division

Neuroma resection can be

Gratifying

Nerves

Technical Aspects

Avoid excessive periosteal stripping

- ring sequestra

- bony overgrowth

Resect bony prominences

Heterotopic Ossification

Post Op Care

1. Multi-disciplinary team approach

2. Conventional soft dressing > rigid dressing

Plaster of Paris cast applied immediately, change weekly

3. Drains removed at 48 hours

4. Avoid dependency

5. PT to mobilize joints, prevent contractures, ambulate

6. Early weight bearing

- Suitable in some cases

- prosthetic cast should be applied

Complications

Delayed wound healing

Meticulous hemostasis

Rigid dressing

Hematoma

Complications

- More common in PVD patients with DM

- Antibiotics

- Surgical debridement

Infection

Complications

Consider pre-operative selection of amputation level

Transcutaneous oxygen level

Nutritional assessment

Nutritional supplements promote healing

Smoking cessation

Small areas of necrosis < 1 cm treated with wound management

Wound necrosis

Complications

Proper positioning

Gentle passive stretching

Exercises to strengthen muscles controlling joint

Ambulation

Contractures

Complications

- Accurate diagnosis

- Mechanical LBP more common in amputees

- Phantom limb pain vs. residual limb pain

- Poorly fitting prosthesis

- Neuroma

- Phantom limb sensation very common

- Phantom limb pain < 10%

Many treatment options

Complications

- Contact dermatitis/ Bacterial folliculitis

- Epidermoid cysts at socket brim

- Verrucous hyperplasia – wartlike overgrowth at end of stump

- Prevention of skin problems by properly fitted prosthesis

- Prevention of skin problems with good stump hygiene daily

Dermatological problems

Conclusion

Amputation is Reconstruction

Surgical Planning is paramount

Surgical Technique is essential

It takes a Team Approach

Thanks for your attention!

References

Arangio, GA and Trepman, E “Instructional Course Lectures Foot and Ankle”, 71-

79,AAOS

Burgess EM and Zettl JH. “Amputations below the knee.” Artificial Limbs.

1969;13:7-12.

Burgess EM, et al. “Amputations of the leg for peripheral vascular insufficiency.” J

Bone Joint Surg Am. 1971;53:874-890.

Carnesale PG. “Ch. 11: Amputations of the Lower Extremity.” From

Campbell’s Operative Orthopaedics, 10th ed, edited by S. Terry Canale.

Mosby: 2003; 575-579.

Pinzur MS, et al. “Controversies in lower-extremity amputation.” J Bone Joint Surg

Am. 2007;89:1118-1126.

Smith, DG “ Atlas of Amputations and Limb Deficiencies” AAOS Third Edition

Stahel PF, et al. “Concepts of transtibial amputation: Burgess technique versus

modified bruckner procedure.” ANZ J Surg. 2006;76:942-946.

Tisi PV and Callam MJ. “Type of incision for below knee amputation.” Cochrane

Database of Systematic Reviews 2004; Issue 1, Art. No.:CD003749.

Principles of Amputation

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