TraumaticAmputations

Douglas G. Smith, MD

Harborview Medical Center and the University of Washington

Prosthetics Research StudyAmputee Coalition of America

I Sometimes Hear - Very Few Patients- Not a Big Deal- Just save Everything You Can

TraumaticLimb Loss

All Not True !!

Ischemia 75-80%Half of These Folks Have Diabetes

Trauma 10-15%

Tumors 5%

Congenital 5%

Incidence Data(We’ve All Seen These Numbers)

Prevalence DataUniversity of Washington Survey of Pacific Northwest, 2000

Upper Limb (N=108) Lower Limb (N=747)

Trauma 85.2% 52.3%

Infection 10.2% 23.2%

Vascular Disease 3.7% 21.7%

Gangrene 8.3% 20.9%

Diabetes 0.0% 16.2%

Tumor 1.9% 4.3%

Congenital Deformity 1.0% 3.1%

(Patients Frequently Identified More Than One Etiology)

“Dysvascular” 10.2% (11 / 108) 36.9% (276 / 747)PVD, Diabetes, Diabetic Infection or Ulcer

Incidence versus Prevalence Data:

Estimate of Incidence Data in United States

UE Amputation from: Trauma - 15%

Dysvascular Issues - 80%

Prevalence Data from University of Washington Survey

LE Amputation from: Trauma - 52%

Dysvascular Issues - 37%

Trauma Is A Big Deal !

Limb Salvage

High TechGlamorousMedia Attention

Profound EffectsLife StyleEmotionalMaritalFinancialAddictive

After 18 Months and after Multiple Surgeries:

The docs are very happy as they look at the x-rays.

The man looks at his leg and says - This is it? I thought it would be normal. This is lousy.

Over the 18 months, the man’s life has totally unraveled, and he has no clue which why to go !!

Hansen ST: The type IIIC Tibial Fracture. J Bone Joint Surg (Am) 1987; 69:799-780.

Hansen ST: Overview of the Severely TraumatizedLower Limb. Reconstruction versus Amputation. Clinic Orthop 24: 17-19, 1989.

Dr Sig Hansen has Pointed Out the Danger of“Saving Limbs and Ruining Lives”

Sometimes Amputation Can Be a Better Path

Care of Patient With Traumatic Amputation

Care of the Amputated Part

Care of Patient With a Mangled Limb

In the Field(What to Tell the Team)

Care of Patient With Traumatic Amputation

Control Hemorrhage1. Compression Dressing2. Dangers of Tourniquet3. Dangers of Clamping

Splints1. Decrease Pain2. Protect Soft Tissues3. Help Control Hemorrhage

Care of the Amputated Part

Place Part in Plastic Bag and Seal

Put Bag in Ice:Water (1:3)

Do Not Soak in Water - Maceration

Do Not Place Part Directly on Ice- Direct Thermal Injury

Care of Patient with a Mangled Limb

Control Hemorrhage1. Compression Dressing2. Dangers of Tourniquet3. Dangers of Clamping

Splints1. Decrease Pain2. Protect Soft Tissues3. Help Control Hemorrhage

If Perfusion Exists Do Not Cool in(Ice:Water)

Decision Making

Traumatic Amputations

Major Differences Between Mangled

Upper and Lower Limbs

Upper Limb

Non-Weight BearingCan Function with Decreased SensationAssistive Upper Limb Often Functions Better than Prosthesis

Decision to Salvage:Based on the Technical Possibility

andThe Chance of Maintaining Some Useful Function

Lower Limb

Weight Bearing is MandatoryIncreased Risks with Decreased SensationModern Prosthesis Often Better than Salvaged Lower Limb

Decision to Salvage:Based on Providing a Limb that can Tolerate Weight BearingHave Some Protective SensationHave Durable Skin and Soft Tissue

M MangledE ExtremityS SeverityS Score

Skeletal & Soft Tissue InjuryLimb Ischemia

ShockAge

Initial Reports: Score 1-6 : All SavedScore > 7: All Amputated

Later Report: Not Quite So Confident

Bosse MJ, MacKenzie EJ, Kellam JF, et al: A Prospective Evaluation of the clinical utility of the lower-extremity injury-severity scores.J Bone Joint Surg 83(1): 3-14.

Many Situations that Lead to Amputation Simply are Not 100% Predictable:

Severe InfectionChronic OsteomyelitisNonunionChronic Pain and “Dysfunction”Patient Choice

Best Indicators are Hard to Measure:Severity of Soft Tissue InjuryVolume of Muscle Loss

It Makes Sense(That We Do NOT Have a Great Crystal Ball)

Do What You Feel Is Right !On the First Night !

Do Not Delay an Inevitable Amputation

I Believe that Only Makes the Emotional Process Harder for Both the Patient and the Doctor

Common Scenario:

Doctor: “I Know that it Needs to Come Off,But, We’ll Just Keep the Limb On So That We Can Talk with the Patient Again, and Let Them Decide”

Patient: “If it Really Is that Bad, Why Didn’t They Cut it Off Yesterday”

End Result: Confusion, Doubt, Loss of Trust in Surgical Team

Tips in the Emergency Room:

Ask the Patient if They Saw Their Foot or Leg

Ask if They Know Anyone with an Amputation

Tell the Patient that You Will CarefullyExamine the Limb in the OR, That You WillSave the Limb if it is Possible to Give Thema Foot They Can Use, BUT that an AmputationCould Well Be Required.

Criteria for Amputation:

Absolute- Non-Reconstructable Vascular Injury- Severe Bone and Soft Tissue Loss with

Tibial Nerve Disruption

Relative- Shock and Elderly with Mangled Limb- Massive Muscle Loss associated with Bone Loss- MESS ≥ 7, Especially with No Plantar Sensation

Unknown Long Term (dogma being questioned)- Isolated Tibial Nerve Disruption

The Sicker the Patient, the More Urgent the Need for Amputation

Details of MESS

Skeletal and Soft Tissue InjuryLow Energy (Closed 0,1, Open 1) = 1 ptMed Energy (Closed 2, Open 2) = 2 ptsHigh Energy (Open 3A, 3B) = 3 ptsVery High E (Open 3C, Mangled) = 4 pts

Limb IschemiaPulse Decrease, Perfusion Normal = 1 ptPulse Absent, Decreased Refill = 2 ptsPulse Absent, Cool, Paralyzed, Ins = 3 pts

(Double Ischemia Score is > 6 Hours)

Johansen K: J of Trauma, 1990

Details of MESS

Age0 to 29 years = 1 pt30 to 49 years = 2 ptsOver 50 years = 3 pts

ShockSystemic BP > 90 mm Hg = 1 ptTransient BP < 90 mm Hg = 2 ptsPersistent BP < 90 mm Hg = 3 pts

Can Have 11 Points if Ischemia is Less than 6 Hours(or Up to 14 Points if Greater than 6 Hours)

Johansen K: J of Trauma, 1990

M MangledE ExtremityS SeverityS Score

Bottom Line:

- Useful Tool in the Thought Process

- NOT a “Crystal Ball”

Open Amputation versus Guillotine

Bone Length versus Soft Tissue Coverage

Saving the Knee

Skin Grafts and Amputations

Few Thoughts on “Traumatic Amputations”

Open AmputationsAvoid the Word and Technique of Guillotine Amputation

Guillotine Amputation:Developed in War Time to Prevent InfectionsAll Tissue Transected at One LevelThe Post-operative Goal is Not Delayed ClosureTreatment Plan is Open Wound Care, Skin Traction, and Late Revision

Open Amputations: Done With Careful Planning for Early Conversion to a Definitive AmputationRetain All Viable TissueDebride All Non-viable TissueDelay Final Bone Cuts Until Definitive ProcedureBone Can Help Splint and Stabilize the Soft TissuesTrend Nationally is Towards Longer BKA's If Suitable Soft Tissue Exists

(Bowker)

If Not a “Guillotine”Then What?

“Open, Length Preserving Amputation”

Bone is a Great Internal SplintDebride Non-Viable TissueRepeat Debridements

Final Bone Cuts - At Time of Definitive Amputation

Bone Length versus

Soft Tissue Coverage

Soft Tissue is More Important

than Bone

Bone Length versus Soft Tissue Coverage

A Durable Soft Tissue Envelope that is Not Adherent is Far More Important Than any Specific Bone Length

A Short Transmetatarsal Amputation with Good Soft Tissue is Infinitely Better Than a Scarred, Painful Forefoot Amputation

A Well Done Transtibial Amputation, Above the Zone of Injury is Far More Functional Than a Syme with a Damaged Heel Pad or a Scarred Hindfoot Amputation

If the Knee is Good (ie: NO Severe Tibial Plateau, NO Severe Arthritis)

If the Extensor Mechanism is Intact

If You Have a Reasonable Way to Cover the Tibia that will Avoid Adherent Scar and Retain Knee Motion

Obtaining Full Extension is Far More Important to the Transtibial Amputee than Full Knee Flexion

Extraordinary Measures are OK to Save the Knee

Severe Contusion of the Posterior Flap Soft Tissue Loss Anterior AspectPosterior Flap Failed

41 y.o. Female, Motorcycle Accident Alaska Sept 2000

Transverse Abdominal Free Flap to Save Knee Joint

41 y.o. Female, Motorcycle Accident in Alaska Sept 2000

Why Is This OK?Good Muscle Coverage that is Not AdherentProblem is No Sensation, but has good PaddingProximal Tibial Not FracturedHealthy Knee Joint

Is It Great - No !Better Than a Transfemoral - Yes !

25 y.o. Logger - Crush InjurySevere crush anterior and lateralSup Posterior Muscle - Much better than expected! Soleus brought over the distal tibial Gastroc split and wrapped medial and lateral

Why Is This OK?Good Muscle Coverage and Padding, With Healthy MuscleSkin Graft Applied Over Muscle, Not to Bone

(Even with this, he still gets breakdown over hamstring tendons)

Proximal Tibial Not FracturedHealthy Knee Joint

Is It Great - No ! Better Than a Transfemoral - Yes !

Skin Grafts and Amputation:

Can Hold Up if Not Adherent to Bone

Need Good Underlying Muscle Padding

Donor Site - Use the Opposite Leg

Donor Scars on the Amputated Limb Can Interfere with Suspension

Elasotomeric Suspension Sleeves Can HelpWith or Without Pin Locks

Problem -Both Men had Major Trouble with Skin Graft Donor Site Scars - Can Limit the Choices for Suspension

DO NOT Take STSG FromIpsilateral Thigh

(Usually happens during thesalvage efforts !)

Partial Foot

Syme

Transtibial

Knee Disarticulation

Transfemoral

Hip Disarticulation

Few Thoughts on Different Levels

MTP Amputations

Through MTP Joints

Leave the CartilageBarrier to InfectionBetter End Bearing

Gait - More Normal Progression Sequence than TMTMost Normal Dynamics of all Partial Foot GaitMost Active Ankle Motion and Calf Musculature

Mick Dillon Queensland Univ.., AustraliaPh.D. Thesis

Prosthetic DeviceEveryone Wants This Cosmetic Slipper Style DeviceRare that Anyone Uses it for More than a Few Months

Ray Amputations

Toe and Some or All of Corresponding Metatarsal

With Each Ray Removed - Increasing Loss of Distal Weight Bearing

1st Ray 2 Sesmoids - “2/6 ths”Rays 4-5 1 Point of Contact - “1/6 th each”

Ray Amputations that Usually Work

Isolated 2,3,4,5

Rays 4 and 5 in Combination

First Ray - Can be ToughSecond MT Head OverloadMedial Edge of Residual First RayMuch Care Needed in Orthosis

Transmetatarsal / LisFranc Amputation

Think of Both as Midfoot Amputations Very Similar Surgery, Rebalancing, Post-op, and Function

Shorten Bone Level so Flap is Well Padded and has No Tension

Can do First MT/Cuneiform Disarticulation plus TM at Base of 2,3,4,5

Keeps Peroneus Brevis Attachment

Always Consider Tendon Achilles Lengthening

Cast Post-Op to Prevent Equinus

In Diabetes - Can Have Fairly Healthy Flaps -

In Trauma “The Situation is Different”

Prosthetic Device Blocks MotionPush off HurtsLacks Shock AbsorptionToo Long

Better Off with Transtibial ?Probably Yes

End Result - ONLY FAIRWalking - Just OK Unable to RunImpact Activity HurtsROM - Not FunctionalCannot “Push Off”

Hindfoot Amputations

Chopart - Saves Talus and Calcaneus

Boyd - Talectomy + Calcaneal / Tibial FusionForward Translation of Calcaneus

Pirgoff - Talectomy + Calcaneal / Tibial FusionForward Rotation of Calcaneus

Boyd and Pirgoff used primarily in children as alternative to the Syme. Preserves physeal growth and provides a more secure heel pad attachment

Chopart - Saves Talus and Calcaneus

Old TechniqueAnt Tib Tendon to TalusAchilles ReleaseNo Bevel

New TechniqueAnt Tib Tendon to CalcaneusFull Achilles ReleaseBevel Distal, Inferior Calcaneus

New TechniqueAnt Tib Tendon to CalcaneusBevel Distal, Inferior CalcaneusFull Achilles Release

Partial Foot Amputation In Trauma

Harris WR, Silverstein EA: Partial Amputations of the Foot: a Follow-up Study. Can. J Surg. 7:6, 1964

Millstein SG, McCowan SA, and Hunter GA: Traumatic Partial Foot Amputations in Adults - A Long Term Review. J of Bone and Joint Surgery, Vol 70-B, p 251-254, 1988;

Quality of the Soft Tissue Padding is MUCH More Important to the Outcome

than Any Particular Length of Bone !!

Partial Calcanectomy

“An Amputation of the Back of the Foot”

Free Flaps on the Foot ?

Can Be Done, But Leads to Predictable ProblemsTissue Without Sensation - can lead to ulcerationExcess Mobility - often dramaticUnstable in Weight Bearing

Devices - Many Possible DesignsGoals - Contain, Protect, Keep Centered, PadOur Best Success - Custom Leather Lacers

Circumferential ControlLeather is skin friendlyStays can add extra Support and Control of FootSilicon Pads in Select Areas

We Have Not Had Great Success with Rigid Devices

Syme’s Amputation

One or Two Stage SurgeryWagner - Recommended two stage

Current - One stage if experienced with techniques

Stabilization of the Heel PadSuture of Achilles to Posterior Tibia

Excision of Subchondral Bone - Scar

Temporary Pin Stabilization

Attach Anterior Tendons to Fat Pad

Stabilization of the Heel Pad with Achilles Tenodesis

Used Much More in Diabetes than in Trauma !

Bulbous Shape -makes Socket fit more challenging.

“Dog-ears” - left to avoid narrowing the waist of the Flap.

Historically, physicians probably have overstated the actual ability for a person with a Syme level amputation to walk without a prosthesis.

While some individuals can take a few steps without their artificial leg, especially when transferring, getting around the bathroom, and a few steps around the house, most need a prosthesis for routine walking.

A person with a transtibial-level amputation is unable to do this at all, and must resort to hopping or crawling. With the Syme, some very limited walking without a prosthesis is possible

(My Personal Experience and Opinion, Published In the Amputee Coalition of America’s inMotion Magazine, May-June 2003, DG Smith, )

Syme’s Amputation

This Level is Fairly Rare in Trauma !!!

Usually the Heel Pad is Sufficiently Damaged and in the Zone of Injury

Tender Heel Pad - Leads to Very Limited Function !

In This Situation - Transtibial Level is Better

Transtibial Amputation

Posterior Flap is Standard- Cylindrical Not Conical Shaped Limb- Tolerates Total Contact Type Fit- More Durable

But In Trauma - Sometimes there is nogood posterior tissue.

- Flap Length = Diameter + 1cm- Ideal Limb Length

Think End of Flap- Slight Angle Back to Incisions- Fibula 1 to 2 cm Shorter-Myodesis to Anterior Tibia

Periosteum or Drill Holes

Transtibial Amputation Surgical Tips

BKA with Only Fasciocutaneous Flaps, and Very Limited Muscle Can Be Functional

Especially With the Addition of Elastomeric (Silicone)Suspension Sleeve inside of the Pelite Liner

Optimal Transtibial Amputation Length

Old School: "Always Cut the Tibia One Hands Breadth Below the Tibial Tubercle"

John Bowker - the Value of Longer Transtibial AmputationsStronger Lever Arm More Surface Area for Prosthetic InterfaceMore Balanced Muscles

Do Not Amputate in the Distal 1/3 to 1/4 of the Tibia:No Suitable Soft Tissue PaddingLimits Space Below the Residual LimbProsthetic Components can Absorb Shock and Provide Elastic Response

Ideal Length - Is For the Distal End of a Long Posterior Flap Technique to be at the Junction of the Soleus and the Achilles Tendon

Long BKA can Better Distribute the Forces on the Pre-Tibial Regions, and Improve Comfort and Function.

Note: Pedal Out Under the Toe on the Sound Limb, and Back Near the Hindfoot on the Amputated Side.

Knee Disarticulation

Amazing Historical Love / Hate Relationship

SurgeonsProsthetistsPatientsTechnology

First Described in Literature 1830BenefitsDisadvantages

“ Current Technology Has Overcome All the Prosthetic Objections ”

S. Perry Rogers, MDChicago, ILJBJS Vol. 22, 1940

Must Consider:• How Will the Patient Transfer• What Contractures are Present• What Contractures will Occur• Surface Area and Support for Sitting

(Protect the Back Side)

Non - Ambulatory PatientsDifferent Concerns and Goals

• Longer Lever Arm• Balanced Thigh Muscles• Improved Suspension• End Bearing• Lower Proximal Socket Brim• Sitting Comfort

For Ambulatory PatientsKnee Disarticulation is Usually More

Functional Than a Transfemoral Amputation

Posterior Flap Technique

North American Experience with Knee Disarticulation with Use of a Posterior Myofasciocutaneous Flap. Healing Rate and

Functional Results in Seventy-Seven Patients.

80 KDs in 77 Patients Age 19 - 92 y.o. (average 64)31 Diabetes 29 PVD 14 Trauma 2 Sarcoma 1 Ollie's Disease

RESULTS:5 Patients Died Early in Post-op Period

67 Healed (89%) --- 63 primarily (84%)7 Major Dehiscence revised to Transfemoral (9%)

22 of 27 who walked Pre-op Successfully Used a Prosthesis and Walked Post-op

Technique Provided a Comfortable, Well Padded, End-Bearing Residual Limb

Bowker JH, San Giovanni TP, Pinzur MSJ Bone Joint Surg Am 2000 Nov;82-A(11)

Sagittal Technique

Sagittal Flap Technique:

38 of 46 (83%) Healed Overall

30 of 34 (88%) Healed in Non-ambulators felt to have the potential to heal a BKA8 of 12 (67%) Healed in Ambulators felt not to have the potential to heal a BKA

Pinzur, Smith, Daluga, OstermanJBJS Vol. 70-A, 1988

Pinzur 1992

BKA TKA AKA(n=24) (n=17) (n=18)

Don and Doff Prosthesis 100% 70% 56%Daily Use of Prosthesis 96% 76% 50% > 9 Hours / Day 54% 41% 22% 6- 9 Hours / Day 17% 11% 6% 3-6 Hours / Day 16% 24% 22% < 3 Hours / Day 13% 24% 28%No Use for Prosthesis 4% 12% 39%

Function after Through-Knee Compared with Below-Knee and Above-Knee Amputation

Hagberg E, Berlin OK, Renstrom P. -- University of Gothenburg, Sweden.

Prosthet Orthot Int 1992 Dec;16(3):168-73

LEAP Study:

With Outcome Tools Used: (SIP)

No Difference Between Salvage, BKA and AKA

Knee Disarticulation (n=18) Scored Worse- Case Review Could Not Find Why Looked at Patallectomy, Condylar Trimming, Muscle Coverage- There are several unique patients circumstances that makes analysis tricky.

- Small numbers make definitive conclusions difficult.

Knee Disarticulation versus the Supracondylar

AmputationKnee Disarticulation With Good Soft Tissue Envelope:

Longer Lever ArmBalance Thigh MusclesEnd BearingSuspension of the Prosthesis on the Femoral Condyles

BUT: If the Flap Is Traumatized, Likely to Be Scarred, Painful, or Adherent …

Then a Supracondylar Amputation Is Much Better

Transfemoral (Above Knee) Amputation

Muscle Stabilization is Extremely Important

Deforming Force into Flexion (Iliopsoas) and Abduction (Abductors)

Myodesis with Post / Medial Muscle (Adductors)Stronger LimbFemur Centered in Muscle MassLess Adductor Roll

Transfemoral - with No Muscle Stabilization - Ouch!

Transfemoral - with Good Muscle Stabilization !

Intra-Op Ace Wrap SpicaUp Around Waist

At Day 3-5 Post-op Shrinker with Waist Belt

Simple WrapRolls DownHard To Re-Wrap b/o Pain

“Extra Turn at the Top -To keep it in Place”

Tourniquet Effect

Transfemoral Positioning

Worry - Hip Flexion Contracture

Post-Op PreventionLeg Flat on Bed

Not Elevated

Early Proning

Extraordinary Measures toSave the Hip

19 y.o. Female, Victim of Shark AttackTransferred - South Pacific - Panama - Seattle

Occasionally Use TractionTechniques in Amputations

Skin Traction

Dates Back Over 100 years

Used Over Open Wounds to Save Length

Elastomeric Sleeves Can be Used Instead of Glued Stockinette

Home Set-up Possible

Start at 2 lbs, Slowly Work Up Towards 5 lbs

Decrease Weight if Skin Blisters

Traction facilitated closure and preservation of length.Revision performed after 18 months because of scar irritation.

Hip Disarticulation andTranspelvic Amputations

(Hemi-Pelvectomy)

Tumor or Severe Trauma

Last Resort in Vascular Disease

Prosthesis is Heavy and Difficult

Many Patients Still Require Crutches or Walker

Many Choose Not to Use Prosthesis

Works pretty well while walking

Ouch !!- Sitting is Not Comfortable- Chooses Not to Wear Prosthesis

Occasionally, Heterotopic Bone can help - Hip disarticulation fit as transfemoral amputee

Post-Operative Amputation Dressings

Partial Foot, Syme, Transtibial, and Knee Disarticulation:

Rigid Dressing - Avoids Knee Contractures, Protects the End of the Amputation, Documented Less Pain, Ability to Facilitate Rehabilitation

Soft Dressings - Pain Response is for the Patient to Hold the Leg With Knee and Hip Flexion, This Can Cause Contractures. If ACE Bandages Are Applied Poorly, They Can Cause Congestion, Edema, and Wound Problems

Removable Splints - Very Useful for Open Wounds, STSG, Post-operative Amputation Infections. The Splint Needs to Hold the Knee in Extension, and Protect the Distal End of the Amputation

Post-Operative Amputation Dressings

Transfemoral and Hip Disarticulation Levels

Rigid Dressing Techniques Are Available and While They Facilitate Standing and Walking They Can Make Sitting, Transfers and Toilet Activity Very Difficult

Shrinker Socks With Waistband or Spica ACE Wrap Work Well

Avoid the Middle of the Night, Isolated AKA Wrap That Puts “An Extra Turn at the Top to Keep It On”

Active Young Trauma Victim

Early Weight BearingIn Immediate Post-Operative Prosthetic Cast and Foot Attachment

Amputee Rehabilitation

Traumatic Amputation Above The Zone Of Injury:Casting and Early Weight Bearing Protocols

Traumatic Amputation Involving the Zone Of Injury:Commonly These Amputations have some Marginal Tissue or Recent Skin Grafts

A Rigid Dressing of Cast or Splints Is Used to Prevent Knee Flexion Contractures, and Protect the Limb From Outside Injury

If Open Wound Care is Required, a Thermoplastic Posterior Amputation Splint can be Fabricated to Allow Wound Care but Provide the Benefits of Contracture Prevention and Pain Relief

Amputee Removable Split

Prosthetic Components:

Don’t Think:High Tech versus Low Tech

Think:First Year Modular Prosthesis

then

Prosthesis after Rehabilitation

Employment, Sports, and Recreational Activities

Never Say Never -

You Will Be Proved Wrong

Many Amputees Prefer Non-ImpactSports and Activities

Although Running and Impact SportsAre Possible

Many Choose OtherActivities because of the Discomfort and Sores that Can Result from Repeated Impact

Employment, Sports, and Recreational

ActivitiesThe Concept of "Good Days and Bad Days" Makes Defining Work Conditions Difficult.

What Will the Amputee Do on the 2 to 4 Days a Month When They Have a Skin Sore, Soreness From Overexertion, or Cannot Wear their Prosthesis.

Dr Burgess UnderstoodThe Ancient Philosophers

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The Purpose of LifeIs To

Create Enthusiasm

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