AMPUTATIONS OF LOWER LIMBS [Autosaved] copy.pptx

Types of amputations and brief description

1. AMPUTATIONS OF LOWER LIMBS Presented by: Dr. Prayash Paudel (JR2) Department of Orthopedics KMCTH Sinamangal , Kathmandu

2. Mangled extremity severity score Points Skeletal /soft tissue groups Shock groups Ischemia groups Age groups Normotensive None <30 years 1 Low energy Transient hypotensive Mild 30-50 years 2 Medium energy Prolonged hypotension Moderate >50 years 3 High energy Advanced 4 Very high energy Points multiplied by 2 if ischemia time exceeds > 6 hours Score: 3-6 = viable 7-12 = requires amputation

3. Predictive salvage index Points Level of arterial injury Degree of bone injury Degree of muscle injury Interval between injury till arrival to OT < 6 hours 1 Suprapopliteal Mild Mild 2 Popliteal Moderate Moderate 6-12 hours 3 Infrapopliteal severe severe 4 > 12 hours

4. Others Limb salvage index Ganga scoring system

5. Indications Trauma Peripheral vascular diseases Neuropathy Infection Tumour

6. Indicators of adequate perfusion Ankle brachial index > 0.5 Transcutaneous oxygen perfusion pressure > 40mm Hg

7. Prerequisite for adequate healing Serum albumin > 3.5 g/dl Total lymphocyte count > 1500/ml

8. Phantom limb pain Point prevalence : 6.7%–88.1% Period prevalence 1 to 3-month : 49%-93.5%, Lifetime prevalence : 76%–87%. Telescoping - 24.6% within a 1-month prevalence period Phantom limb sensation Point prevalence: 32.4%- 90%, Period prevalence 1 month - 65% 3 months - 56.9% and Lifetime prevalence - 87%.

9. Mean of reamputation 20.14% at 1 year 29.63% at 3 years 45.72% at 5 years

10. Ray amputation

11. Hallux valgus deformity

12. Smith fixation

13. No need of flap while removing sesamoid

14. TERMINAL SYME AMPUTATION

15. Cont …

16. Custom shoe

17. Transmetatarsal amputation Cascading fashion

18. Cont …

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20. Chopart amputation

21. Cont …

22. Cont …

23. Postoperative care Sutures: 4-6 weeks Splints: 4-6 weeks Prevent equinus contracture Ankle foot orthosis

24. Chopart amputation

25. Equinus deformity

26. How to prevent equinus deformity Burgess and lieberman et al. Recommendation Division of the Achilles tendon and Placement in a rigid dressing in slight dorsiflexion for 6 weeks

27. Treatment Tibiotalocalcaneal arthrodesis

28. Pirogoff amputation

29. Cont …

30. Requirements for a successful midfoot amputation Palpable posterior tibial pulse Distal infections not extending proximally to the midfoot level, Tcpo2 > 37 mm Hg, Hemoglobin level > 10 g/dl, and Serum albumin level > 30 g/L.

31. Syme amputation

32. Cont …

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35. Cont …

36. Postoperative care

37. Wagner- Syme amputation First stage Ankle disarticulation Preserving the tibial articular cartilage and the malleoli, and Syme -type closure over a suction-irrigation system. Second stage procedure After 6 weeks Stump need should heal Performed to remove the malleoli and narrow the stump for good prosthetic fitting.

38. Wagner- Syme second stage

39. Postoperative care Walking cast after 10-12 days Change cast every 2 weeks. Prosthesis about 8 weeks after surgery.

40. Boyd amputation

41. Cont …

42. Postoperative care Sutures removed after 2 weeks Steinmann pin removed after 4 weeks. Weight bearing on the stump is prohibited until 8 weeks. A walking cast applied until arthrodesis is complete

43. Energy expenditure in locomotion Transtibial amputee: 40-50% Transfemoral amputee: 90-100%

44. Transtibial amputation

45. Non ischemic limbs Ideal length : 12.5- 17.5 cm For each 30 cm body height – add 2.5 cm Most satisfactory level -15 cm distal to the medial tibial articular surface. A stump < 12.5 cm long is less efficient. In a short stump of < 8.8 cm, entire fibula together with some of the muscle bulk be removed

46. Transtibial amputation

47. Cont …

48. Modified Ertl amputation

49. Cont …

50. Cont …

51. Ischemic limbs Recommendation: Tension myodesis contraindicated Osteomyoplasty contraindicated Use long posterior myocutaneous flap Short or absent anterior flap

52. Cont … Amputations performed are at a higher level than amputations in nonischemic limbs 10 -12.5 cm distal to the joint line Use of tourniquet doesnot increase risk of vascular and wound related complications.

53. Burgess amputation

54. Cont …

55. Rehabilitation Nonischemic amputation Nonweight bearing with bilateral upper extremity support Within 3 to 4 weeks, the rigid dressing can be changed to a removable temporary prosthesis Ischemic amputation Well padded cast to avoid constriction of limb proximally

56. Disarticulation of knee Advantages Preservation of the large end-bearing surfaces of the distal femur Creation of a long lever arm controlled by strong muscles, and Stability of the prosthesis.

57. Knee disarticulation

58. Cont ….

59. Cont …

60. Mazet and hennessy disarticulation of knee

61. Transfemoral amputations

62. Transfemoral (above-knee) amputation of nonischemic limbs

63. Cont …

64. Myodesis

65. Hip disarticulation 0.5% of lower extremity amputations. For treatment of bone or soft-tissue sarcomas

66. Boyd hip disarticulation

67. Cont …

68. Modified hemipelvectomy

69. Standard hemipelvectomy

70. Cont …

71. Cont …

72. Postamputation pain management

73. Others Duloxetine ( cymbalta ) FDA-approved For both depression and neuropathic pain which are associated with diabetes. 60 mg/day Avoided in patients with hepatic impairment, severe renal disease, or serious or unstable medical conditions. In patients with an inadequate therapeutic response to duloxetine 60 mg/day, addition of pregabalin or gabapentin is recommended Nausea, dizziness, somnolence, fatigue, sweating, dry mouth, constipation, and diarrhea

74. Polycentric hip joints

75. Microprocessors knees

76. Thank you