Amputation-Dr.Kushal Khanal 2nd Year .pptx

Orthopaedics

1. PRINCIPLES OF AMPUTATION Presenter- Dr.Kushal Khanal 2 nd Year Resident Moderator- Dr.Sharad Adhikari

2. Content Introduction Classification Indications Surgical Principles Complications Rehabilitation Prosthesis

3. Introduction Amputation - Surgical removal of limb or part of the limb through a bone or multiple bones Disarticulation - Surgical removal of whole limb or part of the limb through a joint

4. Most ancient of surgical procedure Crude procedure Associated with high complications and mortality rate Improved surgical technique, post-operative rehabilitation and greatly improved prosthetic design “Amputation should not be viewed as a failure of treatment but rather as the first step toward a patient’s return to a more comfortable and productive life”

5. Epidemiology Western world: PVD(>90%) Younger: Trauma > Malignancy Trauma: M>F LL>UL

6. Classification of amputation Provisional/ Definitive Open / closed

7. Types of Amputation Provisional amputation -Unlikely primary healing -Amputated as distal as possible -Skin flap loosely sutured - Reamputation later Definitive end-bearing amputation -Stump bear weight or pressure -Scar: not terminal -Bone end: solid, not hollow -e.g. Syme amputation

8. Definitive non-end bearing amputation: -Commonest variety -All upper limb and most lower limb amputation -Scar: terminal Open Amputation: - Skin:not closed over the end of the stump -Always followed by secondary closure,reamputation,revision or plastic repair -Indications: infection or contaminated severe traumatic wound

9. Indications Alan Apley : Dead/Dying: -Peripheral vascular disease(>90%) -Severe trauma -Burns -Frostbite Dangerous/Deadly: -Malignant tumour -Lethal Sepsis -Crush Injury

10. Dead like/Damned nuisance: -Gross malformation -Recurrent sepsis -Severe loss of infection -Severe pain Only Absolute indication: Irreversible Ischemia

11. Peripheral Vascular Disease M/C indication in 50 to 75 years Half associated with DM Risk Factors: Peripheral neuropathy, prior stroke, prior major amputation, smoking, poor glucose control Vascular Surgery consultation for possible revascularization Pre-op optimization: -Infection control -Medical control -Wound Complications: S.albumin <3.5 gm/dl / TLC <1500 cells/ml

12. Level of Amputation: Evaluation: Cognitive function,balance,strength and motivation level Energy required for walking is inversely proportionate to the length of remaining limb Ambulatory Patient: Most distal level offering reasonable chance of healing to maximize function Non-ambulatory Patient: Transfemoral amputation or knee disarticulation

13. Trauma MC in younger patient Male>Female Absolute indication: Irrepairable vascular injury in ischaemic limb Salvage vs Amputation: -Patient’s pre-injury status -injury factors (soft tissue injury, location, contamination and physiological status) -patient’s wish and available resources Salvaging severely injured limb: Metabolic overload and secondary organ failure

14. Salvageable vs Non-salvageable *Points X2 ischemic time exceeds 6 hours. Score: 6 or less: salvageable / 7 or more: non-salvageable

15. Educating the patient Protracted treatment course limb salvage vs immediate amputation and prosthetic fitting. Multiple admission & operations on affected and non affected areas. External fixation with its complication Chronic pain and drug addiction Isolation from family, friend and unemployment End result of Salvage: -Unsuccessful---> Amputation -Successful---> Functionless or chronically painful

16. Early amputation and prosthetic fitting Decrease morbidity Fewer operation Shorter hospital stay Decreased hospital cost Shorter rehab Earlier return to work. Treatment outcome and course predictable. Advances in limb salvage surgery have been paralleled by advances made in amputation surgery and prosthetic design

17. Decision making Patient views: Cosmesis Function Body image Handling uncertainty Dealing with prolong immobilization Accepting social isolation Bearing financial burden The “correct” decision are based on the patient as a whole, not solely on extent of injury

18. Thermal or Electrical Burn Initial presentation: Full extent of tissue damage may not be apparent Early aggressive debridement Fasciotomy when indicated Early amputation: -Decrease risk of infection ( local and systemic) -Myoglobin induced renal failure and death

19. Frostbite Risk groups: -High attitude climbers, skiers -Alcoholic, schizophrenic and homeless Delayed for 2 to 6 months: -For clear demarcation of viable tissue -Recovery of deep tissue Indication of early surgery: removal of circumferentially constricting eschar Premature surgery: greater loss and increased risk of infection

20. Infection:Acute Open amputation: -Acute or chronic infection unresponsive to antibiotics and surgical debridement -Wound closed loosely -Infusion of antibiotics irrigants Acute setting: infection by gas forming organisms Clostridial myonecrosis: Emergency open amputation one joint above the affected compartment is life saving measure Any contaminated wound that is closed without appropriate debridement is at high risk for the development of gas gangrene

21. Infection :Chronic Individual basis Systemic effect of refractory infection may justify amputation. Disability reaching a point- pt. better served by amputation and prosthetic fitting -Nonhealing trophic ulcer -Chronic osteomyelitis -Infected nonunion -Chronic draining sinus:squamous cell carcinoma

22. Tumor Limb salvage: -Acute complication: extensive procedure, greater risk of infection, wound dehiscence, flap necrosis, blood loss, DVT -Long term complication: Periprosthetic #, prosthetic loosening or dislocation, nonunion of graft host junction, allograft #, LLD and late infection Amputation for malignancy:technically demanding -Nonstandard flaps, bone graft, prosthetic augmentation Patient with salvage limb is likely to need multiple operation for treatment of complications and 1/3rd ultimately require amputation

23. Location UL: salvage even with sacrifice of major nerve Proximal femoral and pelvic lesion: resection and local reconstruction better function than hip disarticulation or hemipelvectomy. Sarcomas around ankle and foot: amputation + prosthesis Sarcomas around knee: individualized -Wide resection with prosthetic knee replacement -Wide resection with allograft arthrodesis -Transfemoral amputation

24. Indications for Amputation Palliative measure for metastatic disease Refractory pain-radiation, chemotherapy, standard surgical treatment Recurrent pathological fracture Massive necrosis, Fungation Infection Vascular compromise The ultimate decision must be taken by patient based on long term goals and lifestyle Although cure is not goal, improve pain and functional status for remaining month of life

25. Surgical Principles of amputation Determination of amputation level: Increased function with more distal level of amputation Decreased complication rate with a proximal level of amputation For LL : Chief concern- Ambulation: most distal level No ambulatory potential :wound healing with decreased perioperative morbidity

26. Determining most distal level of amputation Preop clinical assessment: Skin color, hair growth, skin temperature Skin perfusion pressure Thermography/laser doppler flowmetry Transcutaneous oxygen measurement

27. Surgical principle: Technical aspect Skin and muscle flap: -Thick -Avoid unnecessary dissection -Sturdy soft tissue envelope -Non adherent scar Muscle: -Divided 5cm distal -Stabilized by: a) Myodesis : -Strong insertion,maximize strength,minimize atrophy -Contraindication: severe ischemia b) Myoplasty : Compromised vascularity

28. Hemostasis Torniquet use- except severely ischaemic status Major blood vessels- isolated and doubly ligated Torniquet deflation before closure Drain: 48 to 72 hour

29. Nerves Neuroma formation: Unevitable Painful :If in position of repeated trauma Normal physiological stimuli: painful. Best way: isolated, gently pulled and divided with sharp knife Avoid: strong tension, crush Large nerve: ligated as often contain relatively large arteries

30. Bone Bony prominence: -Rasped for smooth contour -Resected if not well padded by soft tissue: -Anterior aspect of tibia -Lateral aspect of femur -Radial styloid Periosteum: -Excessive striping contraindicated :ring sequestra / bony overgrowth

31. Open amputation Goal: To prevent or eliminate infection Indication: -Infected wound -Severe traumatic wounds with extensive destruction of tissue - Gross contaminated traumatic wounds Require: -Repeated debridement -Appropriate antibiotics use -Vacuum assisted closure -At least 2 operations to construct satisfactory stump

32. IDEAL STUMP Ideal length – for prosthesis fitting Ideal shape – Conical & smooth Good muscle power Joint should be supple Non adherent scar No fixed deformity Adequate muscle padding Absence of neuroma Free from infection Adequate blood supply

33. Ischemic vs Non Ischemic Limb Amputation

34. Amputation in Children: Principle Congenital limb deficiency :60% Acquired conditions: 40% Preserve length (70% of the growth of the femur occurs at the distal growth plate) Preserve important growth plates Perform disarticulation rather than transosseous amputation whenever possible Preserve the knee joint whenever possible Stabilize and normalize the proximal portion of the limb, and Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions

35. Post operative care Multidisciplinary team Precaution: Antibiotics, DVT prophylaxis, pulmonary hygiene, pain management Treatment of stump Conventional soft dressing Rigid dressing

36. Rigid Dressing POP: Weight bearing is not planned immediately Advantages: -Prevent edema -Protect wound from bed trauma -Enhance wound healing -Decreased postoperative pain -Allow early mobilization from bed to chair and ambulation with support -Prevent knee flexion contracture in transtibial amputations -Decreased hospital stay -Earlier definitive prosthetic fitting

37. Physiotherapy Start as soon tolerated. Muscle setting exercise – exercise to mobilize joints Bed to chair – Day 1 Parallel bars – walker/crutches Cast changed weekly/ additional stump sock When volume appear unchanged from previous one week Prosthetist may apply the first prosthesis

38. Complications Hematoma Infection Wound necrosis Contracture Pain Dermatological problem

39. Hematoma Prevent by: -Meticulous hemostasis before closure -Drain -Rigid dressing Hematoma: Delay wound healing, serve as culture medium Treatment: Compressive dressing Delayed wound healing with/without infection: Evacuation

40. Infection Most common in Peripheral vascular disease with DM Deep infection: -Immediate debridement & irrigation -Open wound management Antibiotics usage a/c to C&S Smith and Burgess method: central 1/3rd closed and the remainder of the wound packed open

41. Wound Necrosis Preop evaluation: -Transcutaneous oxygen studies, - S. albumin(<3.5 gm/dl) - TLC(<1500 cells/ml) - Avoid tobacco use(2.5 fold rise) Nutritional Supplementation Management: <1cm: conservative with open wound management >1cm: local debridement + nutritional support Sever necrosis with poor coverage: wedge resection+hyperbaric oxygen+TENS

42. Contracture Mild/Moderate: -Proper positioning of the stump -Gentle passive stretching -Strengthening the muscles controlling the joint -Prosthetic modification Severe: -Surgical release of the contracted structures -Wedging cast application

43. Pain Post op Pain: -Multimodal analgesia -Effective postoperative analgesia: -Promote function -Psychological well being -Minimize developing chronic pain

44. Chronic Pain Residual limb pain -Poorly fitting prosthesis -Painful neuroma Management: -Socket modification -Simple neuroma excision or more proximal neurectomy -Sealing the epidural sleeve Phantom limb sensation -Present in almost all patient -Educate patient regarding these sensation -Disappear over a year by a phenomenon called “ Telescoping”

45. Approach to Pain

46. Management of Phantom Pain

47. Dermatological problem Contact dermatitis Bacterial folliculitis Cellulitis Epidermoid cyst Verrucous hyperplasia

48. Prosthesis Prosthesis are devices used to replace a missing limb and to restore or provide function. Features of Ideal Prosthesis: -Perform its function -Be easy to maintain, don and doff, -Be comfortable to bear -Preferably light weight, durable and cosmetic to look at

49. Component of prosthesis -Socket made of plastic or resin -Body of prosthesis -Harness / suspension system -Control system -Terminal device: Hand , Foot

50. Upper limb Prosthesis Components - Socket - Suspension system - Elbow unit for A/E - Forearm - Wrist unit - Terminal device: Hand/hook - Power Transmission system

51. Lower limb Prosthesis Above knee Amputation Components: - Suspension - Socket - Knee joint - Shank/shin piece - Ankle foot assembly

52. Below knee Amputation Components: - Suspension - Socket - Shank - Ankle foot assembly

53. Thank You