Amputation and rehabilitation

a brief account of types, indications, procedure, complications and rehabilitation of amputee

1. AMPUTATION AND REHABILITATION Dr. Rajendra n JR , Moderator: Dr. Ankita Singh Unit1

2. Outline Introduction and general principles Upper limb amputation Lower Limb amputation Rehabilitation

3. Definition Amputation :“Surgical removal of limb or part of the limb through a bone or multiple bones” Versus Disarticulation : “ Surgical removal of whole limb or part of the limb through a joint”

4. History Most ancient of surgical procedure. Stimulated by the aftermath of war. Crude procedure - limb was rapidly severed from unanesthetized patient. The open stamp was then crushed or dipped in boiling oil to obtain hemostasis. Hippocrates was the first to use ligature. Ambroise Pare ( a France military surgeon) introduced artery forceps. He also designed prosthesis

5. Etiology WHO manual of amputation and rehabilitation,2004

6. Etiology Trauma Peripheral Vascular Disease Malignant Tumors Burns Neurologic Conditions Infections Congenital Deformities Dead Deadly Dam Nuisance Put in order of frequency

7. Indications DEAD LIMB : Gangrene DEADLY LIMB Wet gangrene Spreading cellulitis Arteriovenous fistula Other (e.g. malignancy) ‘DEAD LOSS’ LIMB Severe rest pain with unreconstructable critical leg ischaemia Paralysis Other (e.g. contracture, trauma)

8. Types I. • Non end bearing/side bearing. • End bearing/cone bearing . II. • Weight bearing. • Nonweight bearing . Types of flaps • Long posterior flap in below-knee amputation. • Equal flaps in above-knee amputation.

9. Level of amputation WHO manual of amputation and rehabilitation,2004

10. Level of amputation 7.5cm to 12.5cm from tibial tuberosity

11. Level of amputation 9. Knee joint disarticulation 10.Hip diarticulatio 11.Hind quarter amp./ hemipelvectomy ( Gritti Stokes)

12. Ideal stump It should be of optimum length. S hould be rounded, smooth, with gentle contour. S hould be firm and heal adequately (thin scar). The opposing groups of muscle sutured together over the end of bone. The muscle are sutured in a such way that they will be converted into fibrous tissue and serve as in effective cushion.

13. Ideal stump…. Vascularity of flap should be normal. There should be no projecting of spur bone. The stump should not be under tension. The position of scar should be avoided of pressure and should be transverse to avoid pulling up two bones in AP scar. In case of upper limb the scar can be terminal , but in L.L. a posterior scar is desirable to avoid pressure of weight of artificial limb.

14. Ideal stump… Adequate adjacent joint movement CONICAL BEARING: healing (primary intention) non projecting bone myoplastic No neuroma Non tender scar Proximal joint supple

15. Principles Preparation Good Surgical Technique Early Prosthetic Fitting Team Approach Vocational and Activity Rehabilitation

16. Pre operative

17. Evaluation- Clinical history & examination Thorough history , past history and co morbidities GPE??- pallor, signs of sepsis etc Local examination: ??? Inspection (ulcer, gangrene, color), palpation (temperature, motor n sensory), hand held doppler if available

18. Evaluation- Lab studies Hemoglobin ,Hematocrit (control of anemia ) Creatinine levels should be monitored. Potassium and calcium levels should be monitored. Elevated levels of these electrolytes may lead to cardiac arrhythmias and seizures. White blood cell count, C-reactive protein , and ESR . (control of infection using antibiotics) C-reactive protein to be the first laboratory value to respond to treatment. Platelets ,Coagulation profile Myoglobinuria ??

19. Imaging X-ray-AP & Lat view ???? Usg doppler ( decision of level of amputation) Computed tomography (CT) scanning and magnetic resonance imaging (MRI) -osteomyelitis to ensure that the surgical margins are appropriate. Technetium-99m (99mTc) pyrophosphate -electrical burns and frostbite. 94% sensitivity and 100% specificity for demarcating viable tissues from nonviable tissues. CT Angio and MR angiography

20. Imaging (Contd.) Doppler ultrasonography –Blood pressure 15% of patients with PVD, pressure falsely elevated because of the no compressibility of the calcified extremity arteries. Minimum 70 mm Hg is believed to be necessary for wound healing. Ischemic index (II): - Site pressure/brachial pressure >=0.5 at the surgical level is necessary to support wound healing. Ankle-brachial index: - The II at the ankle level is best indicator for assessing adequate inflow to the ischemic limb. An index less than 0.45 indicates incisions distal to the ankle will not heal.

21. Pre operative preparation Informed written consent Identify patient and limb Appropriate preoperative antibiotics A tourniquet can be placed on the limb prophylactically not in PAD Vascular and bone instruments are requested. An appropriate strength saw ( gigly or mechanical)for cutting bone Vessel ligatures are obtained.

22. Site of selection Examination :- skin colour hair growth lowest palpable pulse Skin temperature Investigation :- USG Doppler/ angiography

23. General Principles Adequate blood supply of flap should be maintained Adequate flap length, ideally semicircular Proximal part of flap contains muscles but distal should have only skin & deep fascia Skin- greatest skin length possible should be maintained for muscle coverage and a tension-free closure. (proper marking)

24. General Principles Muscle- Muscle is placed over the cut end of bones via a myodesis , a long posterior flap sutured anteriorly, or a well-balanced myoplasty (i.e., antagonistic muscle and fascia sutured together ).

25. General Principles(Contd.) Nerves –pulled distally, cut sharply (knife) & allowed to retract. Ligation of large nerves can be performed when an associated vessel is present Arteries and veins - dissected and separately ligated. Prevents the development of arteriovenous fistulas and aneurysms.

26. General Principles(Contd.) Bone- Bony prominences around disarticulations are removed with a saw, whereas for distal ends cut with beveling anteriorly and filed smooth. Maintaining the maximal extremity length possible is desirable. Below-knee amputations are best performed 12-18 cm below the joint line for non-ischemic limbs For ischemic limbs, a higher level of 10-12.5 cm below the joint line is used because making limbs longer than this can interfere with prosthetic use and design

27. General Principles(Contd.) In crush injury/ entrapment injury/ sepsis- Guillotine amputation should be done. L ater definitive closure is planned. Knowledge of anatomy of respective level of limb is a must.

28. Anatomy

29. A natomy

30. Goals of Post operative care General :- Analgesia Antibiotics DVT prophylaxis Specific :- Prompt, uncomplicated wound healing Control of edema Joint positioning and exercise Drain removal Mobilization Rehabilitation

31. Upper Limb Amputation

32. Upper limb vs Lower limb Upper extremity non weight bearing Less durable skin acceptable Decreased sensation better tolerated Joint deformity better tolerated Late amputations rare Transplants now being performed

33. Upper limb

34. Trauma 90 % of Upper Extremity Amputation Male: Female = 4:1 Most Amputations at level of Digit Major Limb Amputations less common Revascularization possible for incomplete amputation Replantation possible for complete amputation

35. Amputation vs Replantation Poor Candidates for Replantation 1. Severely crushed or mangled parts 2. Multiple levels 3. Other serious injuries or diseases 4. Atherosclerotic vessels 5. Mentally unstable 6. > 6 hours ischemic time 7. Severe contamination

36. Decision Making Limb injury score Mangled Extremity Severity Score Attempts to salvage a severely injured limb may lead to metabolic overload and secondary organ failure Injury severity score > 50 : contraindication to limb salvage Mangled Extremity Severity Score( M.E.S.S. )( Helfet , CORR, 80, 1990) (most useful) < 7 : Salvage 8-12 : Amputate MESS >7  LSI >6  PSI >8  NISSSA >11   HFS-98 >11

37.  The five commonly used scoring systems are the Mangled Extremity Severity Score (MESS) 1 , 3 ; the Limb Salvage Index (LSI) 5 ; the Predictive Salvage Index (PSI) 2 ; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA) 4 ; and the Hannover Fracture Scale-98 (HFS-98) 6 ,

38. Mangled Extremity Severity Score (MESS) A. Skeletal/Soft tissue injury 1. Low energy (stab wound, simple fracture, low-energy gunshot wound) 2. Medium energy (open or multiple fractures, dislocation) 3. High energy (high-speed motor vehicle collision or rifle gunshot wound) 4. Very high energy (above plus gross contamination) B. Limb ischemia* 1. Pulse reduced or absent but perfusion normal 2. Pulseless ; paresthesia , diminished capillary refill 3. Cool, paralyzed, insensate, numb C. Shock 0. Systolic blood pressure always > 90 mm Hg 1. Systolic blood pressure transiently < 90 mm Hg 2. Systolic blood pressure persistently < 90 mm Hg D. Age (years) 0. <30 1. 30 -50 2. >50 *Score doubled for ischemia time > 6 hours

39. Aim Preservation of functional residual limb length balanced with Soft tissue reconstruction to provide a well-healed, non-tender , physiologic residual limb

40. Technique: Determination of Level Zone of Injury (trauma) Adequate margins (tumor) Adequate circulation (vascular disease) Soft tissue envelope Bone and joint condition Control of infection Nutritional status

41. Technical Consideration Wrist Disarticulation vs. Transradial Disarticulation -better active pronation and supination of forearm Disarticulation poor aesthetically Disarticulation more difficult to fit prosthetic Transradial -difficult to transmit rotation through prosthesis Transradial needs to be done 2 cm or more proximal to joint to allow prosthetic fitting Transradial usually favoured

42. Technical Consideration Transhumeral vs. Elbow Disarticulation Adults : Elbow disarticulation allows enhanced suspension and rotation control of prosthesis however retention of full length precludes use of prosthetic elbow. Long transhumeral favoured Pediatrics : Transhumeral amputation results in high incidence of bony overgrowth. Elbow disarticulation is level of choice.

43. Technical Consideration Preservation of Elbow function is a priority Consider replantation /salvage of parts to maintain elbow function 4-5 cm of proximal ulna necessary for elbow function For very proximal amputations, it may be necessary to attach bicep tendon to ulna

44. Krukenberg procedure More than 80 years ago, Krukenberg described a technique -a forearm stump into a pincer motorized by the pronator teres muscle. Used to be done for bilateral upper-extremity amputations, in those who are also blind. Not recommended as a primary procedure at the time of an amputation, To consider this surgical option, the ulna and radius must extend distal to the majority of the pronator teres (the motor for pinching) and an elbow flexion contracture of less than 70°.

45. Forequarter amputation

46. Lower Limb

47. Pathophysiology As the level of the amputation moves proximally Greater the energy expenditure that is required Walking speed of the individual decreases Oxygen consumption increases Transtibial amputations- Energy cost for walking similar to non amputee Transfemoral amputations-Energy required is 50-65% greater than that required for those who have not undergone amputations .

48. Metabolic cost of amputation

49. Minor amputation Toe amputation (through phalanx or entire toe) Distal metatarsophalangeal Ray amputation Transmetatarsal Lisfranc ( tarsometatarsal ) Chopart ( midtarsal ) Symes : Ankle disarticulation, through the malleoli . It is a weight bearing amputation because the heel pad is swung under the tibia and fibula and attached.

50. Minor amputation

51. Ray amputation Entire toe or finger with part or complete metatarsal or metacarpal respectively Very common Preservation of foot length and cosmetically acceptable

52. Minor amputation

53. Major amputation Guillotine Amputation

54. Below Knee Amputation(BKA)- Transtibial Most common secondary to PVD Different lengths Short (20% of tibia left) Standard (50% of tibia left) Long (90% of the tibia left)

55. Below Knee Amputation Ideal – 15 cm of tibia; if not possible, at least 7.5cm Anterior skin incision made; length of posterior flap made 1.5 times the diameter (circumference)of the limb at level of amputation. Ant compartment muscles (TA, EHL, EDL) cut Ant tibial artery and vein ligated and divided

56. BKA contd …. Tibia transected and bevelled anteriorly Fibula transected 1 cm more proximally (removed completely in shorter BKA) Post tibial vessels identified, ligated and cut Muscle bulk reduced in the post flap to obtain a tapered stump Ant and post fascia closed with 2-0 absorbable sutures; skin closed with 3-0 nylon

57. Incision-Burgess

58. BKA(Contd.)

59. BKA (Contd.)

60. BKA-Skew Flap

61. Above knee amputation Relatively uncommon < 1½ inches of tibia is viable Intact femur results in good weight bearing surface Lengths Long (>60% of femur left) Standard (60%-35% of femur left) Short (<35% of femur left )

62. Above knee amputation Skin and subcutaneous tissue cut Ant femoral muscles ( sartorius , quadriceps) cut first, f/b medial femoral muscles ( gracilis , pectineus , adductor) Superficial femoral art and vein ligated and cut Post femoral muscles (biceps femoris , semimembranosus , semitendinosus ) cut

63. AKA contd … Sciatic nerve (b/w adductor magnus and biceps femoris ) ligated and cut Periostium stripped and femur transected Ant and post fascia close with 2-0 absorbable; skin closed with 3-0 nylon; drain±

64. AKA

65. C omplications General :- hemorrhage hematoma infection

66. Complications Specific :- flap breakdown flexion contracture Residual pain stump pain phantom pain stump ulceration ring sequestrum formation painful scar joint contracture Others:- Scar hypertrophy, thickening, hyperkeratosis, papilloma, eczema, lympoedema , boils, bursae Spur, osteophytes formation, jactitation, aneurysm, stump # etc.

67. REHABILIATATION

68. Pain management Post op Pain:Analgesics+Limb elevation watch for infection Pain after healing: treat cause+mechanical Stimulation Prosthetic pain: best fit prosthesis Phantom Pain: Difficult to treat

69. Psychological adjustment Provide information Assess social support Address both the amputee and the family Peer Counselling and support groups Return to work and previous life roles.

70. Skin Care Skin hygiene and lubrication Skin Inspection Skin Mobilization Skin desensitization

71. Physiotherapy 1. Residual Limb Shrinkage and Shaping 2. Limb Desensitization 3. Maintain joint range of motion 4. Strengthen residual limb 5. Maximize Self reliance 6. Patient education: Future goals and prosthetic options

72. Exercises

73. Pre Prosthetic Management EXERCISES:Regain / maintain ROM & strength

74. Limb Strengthening

75. Positioning Elevation of the residual limb on a pillow following either transfemoral or transtibial amputation can lead to hip/knee flexion contractures and should be avoided.

76. Mobility Reaching for an object promotes weight shifting on/off the prosthesis. Mirror reduces tendency to look at the floor.

77. Self Care

78. Prosthesis Comfortable Functional Cosmetic Exoprosthesis -external replacement for a lost part of the limb

79. Types available Syme’s - elephant boot, canadian Syme’s prosthesis BKA-PTB (patellar tendon bearing)prosthesis, SACH (solid ankle cushion heel) AKA- suction type Hemipelvectomy - TTP (tilting table prosthesis) Bionics CAD-CAM (computer assisted designing and computer assisted manufacturing) Exo vs endoskeleton

80. Types available Round/elephant boot canadian type syme’s boots PTB prosthesis

81. Temporary Prosthesis Cosmetically unfinished prosthesis that has been fitted and aligned Used when amputee’s ability to wear a prosthesis is in doubt Can help shape limb better rather than dressing

82. Part of Prosthesis Strap or belt holding prosthesis to stump Soft Foam or silicone Contact with the skin Connects socket with foot Contact with ground

83. Classification Passive Cosmetic Body Powered Harnesses and cables Myoelectric Surface EMG Activation delay Neuroprosthetics Investigational

84. Jaipur Foot Bhagwan Mahavir Viklang Sahyata Samiti  Dr. P. K . Sethi The articulation at the 'ankle' allows not only Inversion- Eversion movements but also dorsiflexion (essential for squatting, standing up from prone position etc.) A shorter keel helps achieve this. Also, the materials used at the foot end are waterproof and moderately mimic a real foot.

85. Conclusion Fewer procedure in surgery evoke more fear in patient than a major amputation. Careful selection of level based on circulation and functional issues, attention to detail in the operating room, and careful perioperative care are required to obtain good results. Surgeon who performs a major limb amputation owes the patient debt of rehabilitation

86. Thank You Amputation is not the end of life. It is the first day of new beginning!!