LOWER LIMB AMPUTATION SO much for [1].pptx

Hh

1. LOWER LIMB AMPUTATIONS PRESENTER- Dr.S.V.Muralidhar

2. DEFINITION Amputation – Ablation of body part through one or two bone Disarticulation – Ablation of body part through joint Amputation is not a failure of surgery but a reconstructive procedure

3. INDICATION OF AMPUTATION Peripheral Vascular Disease Trauma Burns Frostbite Infection Tumors Neuropathy Congenital Limb Deficiency

4. SALVAGIBILITY OF A LIMB Various scoring system – Predictive Salvage Index Limb Salvage Index Limb Injury Score Mangled Extremity Severity Score

5. CLASSIFICATION Emergency/traumatic/elective Provisionsal /definitive Open/closed End bearing/cone bearing Eponymous/named amputation

6. GUILLOTINE/OPEN AMPUTATION An open amputation is one in which the skin is not closed over the end of the stump. The operation is the first of at least two operations required to construct a satisfactory stump. It always must be followed by secondary closure, reamputation , revision, or plastic repair.

7. OPEN AMPUTATION The purpose of this type of amputation is to prevent or eliminate infection so that final closure of the stump may be done without breakdown of the wound Open amputations are indicated in infections and in severe traumatic wounds with extensive destruction of tissue and gross contamination by foreign material

8. LEVEL OF AMPUTATION Energy required for walking is inversely proportional to length of remaining limb Higher the level of lower limb amputation,greater the energy expenditure required for walking As the level of amputation moves proximally,the walking speed of individual decreases and oxygen consumption increases

9. PRE – OP CARE: Nutritional Status of the Patient Limb Perfusion status- TcPO2 greater than 37 mm Hg Serum Albumin of at least 3.5 g/dl Total Lymphocyte count > 1500/ml Haemoglobin >10gm/dl Diabetes control Pre Operative Counselling and consent Rehabilitation Assessment Proximal Joint Function

10. INTRA – OP CARE: FLAPS Flaps should be kept thick. Unnecessary dissection should be avoided to prevent further devascularization of already compromised tissues. Covering the end of the stump with a sturdy soft-tissue envelope is crucial

11. HEMOSTASIS Except for in ischemic limb, use of tourniquet is desirable and makes amputation easier Arteries and veins should be ligated separately, and larger vessels should be doubly ligated. The tourniquet should be deflated before closure, and meticulous hemostasis should be obtained. A drain should be used in most cases for 48 to 72 hours

12. MYODESIS Transected muscle groups are sutured to bone under physiological tension. If possible, myodesis should be performed to provide a stronger insertion, help maximize strength, and minimize atrophy Myodesed muscles continue to counterbalance their antagonists, preventing contractures and maximizing residual limb function However, myodesis may be contraindicated in severe ischemia because of the increased risk of wound breakdown.

13. MYOPLASTY Muscles are divided at least 5cm distal to bone resection Transected muscle is sutured to soft tissue such as opposing muscle group or fascia Preferred in ischemic limb where myodesis is contraindicated

14. NERVES A neuroma formation is inevitable after transection as the axons are unable to locate the distal nerve stump Normal physiologic stimuli such as stretching, pressure, and vascular pulsations may be painful and, thus, limit prosthetic usage

15. NERVES Special techniques like end-loop anastomosis, perineural closure, Silastic capping, sealing the epineurial tube, ligation, cauterization, and methods to bury the nerve ends in bone or muscle have been tried in the hopes of preventing the formation of painful neuromas Most surgeons currently agree that nerves should be isolated, gently pulled distally into the wound, and divided cleanly with a sharp knife so that the cut end retracts well proximal to the level of bone resection

16. POST – OP CARE Dressing like Hydrocolloid, Hydrogel, Alginate etc. Biological dressing like Allomatrix and Graft Jacket Regenerative Tissue Matrix. Vaccum assisted closure is also beneficial in larger wounds. Measure to prevent contractures. To maximize function and to minimize complication of the amputed limb Pedorthist , Orthotist and

17. POST – OP CARE

18. DRESSING If non weight bearing ambulation-rigid dressing (pop) applied If weight bearing ambulation-true prosthestic cast with metal pylon with prosthetic foot Regardless of when prosthetic ambulation is begun,the rigid dressing should be removed and the wound inspected in 7-10 days

19. RIGID DRESSINGS ADVANTAGES Prevent edema at surgical site Protect wound from trauma Enhance wound healing Decrease post operative pain Transtibial amputation-prevent knee flexion contractures

20. GOALS OF AMPUTATION Ablation of disease tissue Reconstruction Provide physiological end organ Optimize patient function and reduce morbidity.

21. COMPLICATIONS Hematoma Infections Bony over growth Wound Necrosis Stump edema Contractures Neuroma Phantom Limb Muscle Wasting

22. PSYCHOLOGICAL COMPLICATIONS Depression Anxiety Crying spells Insomnia Loss of appetite Suicidal ideation

23. PHANTOM PAIN Phantom limb syndrome- Non painfull feeling that amputated limb is still present Phantom limb pain- Mild to extreme pain felt in amputated limb region

24. PHANTOM PAIN Painful, Disagreeable sensation with strong paresthesia in absent limb. Constant or Intermittent. Destruction of sensory fibers resulting in decrease inhibitory control by Reticular Activating System. Somatosensory projection area develop self sustaining neural activity thus causing Pain

25. PHANTOM PAIN Treatment – Drugs like Carbamazepine, Beta Blockers, Morphine, Antidepressant, Phenytoin Mirror therapy Sympathectomy Subcortical Neurectomy Anterolateral Cordotomy Electrical Stimulation of Dorsal Column

26. TYPES OF LOWER LIMB AMPUTATION: Hemipelvictomy Hip Disarticulation Transfemoral Amputation Knee Disarticulation Transtibial Amputation Foot Amputation

27. AMPUTATION OF FOOT Toe Amputation or Disarticulation Metatarsal Phalangeal Disarticulation Transmetatarsal Amputation Lisfranc Amputation Chopart Amputation Syme Amputation Boyd’s Amputation

28. TOE AMPUTATION Amputation Of Great Toe: While Standing or Walking normally - Functionally no effect While Running – Limp appears Amputation of 2 nd Toe: Causes severe hallux valgus. To prevent, screw fixation is used. Amputation of all Toe: While slow walking – Little disturbance While rapid gait – Disabling Interferes in squatting and tiptoeing No prosthesis is required other than shoe filler.

29. TERMINAL SYME AMPUTATION: Indication: Hallux terminal ulceration, chronic ingrown nails with paronychia, Hallux tuft osteomyelitis or Traumatic Injury to tip of hallux. Removing Distal Aspect of Distal Phalynx of hallux retaining extensor hallucis longus and Flexor hallucis longus insertion.

30. AMPUTATION AT BASE OF PROXIMAL PHALYNX

31. METATARSAL PHALANGEAL DISARTICULATION: Long plantar and short dorsal skin flap. For 1 st Metatarsal incision starting medially and curve it distally over the lateral and posterior aspect. For 5 th Metatarsal incision, starting laterally and curve it distally over medial and posterior aspect.

32. Transmetatarsal Amputation: Ray Amputation – Toe amputation with head of Metatarsal. Gillies’ Amputation – Transmetatarsal with proximal to neck of metatarsal,distal to base

33. PROSTHESIS FOR TOE AMPUTATION

34. MIDFOOT AMPUTATION Amputation through midfoot include Lisfranc Amputation at Tarsometatarsal Joints and Chopart Amputation at Transverse Tarsal Joint. Midfoot Amputation lead to severe Equinovarus Deformity.

35. In a TMA the tendons of extensor hallucis longus, extensor digitorum longus and peroneus tertius muscles are sectioned. These muscles act to dorsiflex the foot at the ankle, if they are sectioned, an imbalance between the anterior and posterior muscle groups exists. This leads to the Achilles tendon working unopposed, thus creating an equinus deformity To overcome this, an Achilles tendon lengthening procedure is performed.

36. LISFRANC AMPUTATION Tarsometatarsal Disarticulation Lead to severe equinovarus deformity. To prevent Equinovarus Deformity – Preserve insertion of Tibialis anterior and Peroneus longus at medial cuneiform and peroneus brevis at the base of 5 th Metatarsal. Base of 2 nd Metatarsal should be spared to preserve proximal transverse arch

37. CHOPART AMPUTATION: Disarticulation of Talo -Navicular & Calcaneo -Cuboid Joints. To prevent Equinovarus Deformity – One or more Dorsiflexors must be transferred. Decrease strength of Achilles Tendon. Position the stump in slight dorsiflexion and rigid dressing for 6 weeks. Alternatively, ankle arthrodesis may be done immediately.

38. CHOPART FRACTURE Transfer tibialis anterior tendon to lateral aspect of neck of talus, using a bone tunnel with biotenodesis screw and using a suture anchor or staple to secure fixation. Transfer extensor hallucis longus to anterior process of Calcaneus.

39. PROSTHESIS FOR CHOPART AMPUTATION

40. HIND FOOT AND ANKLE AMPUTATION Goal is to produce end bearing stump and enough space between end of stump and ground for construction of some type of ankle joint mechanism for Artificial Foot. Types – Syme Amputation Boyd Amputation Pirogoff Amputation

41. SYME AMPUTATION Bone transection at distal tibia and fibula 0.6 cm proximal to periphery of ankle joint and passing through the dome of the ankle centrally. The tough durable skin of heel flap provides normal weight bearing skin. SARMIENTO MODIFIED Syme procedure by transecting tibia and fibula 1.3 cm proximal to ankle joint and excision of medial and lateral malleolus to produce less bulbous stump and allow use of more cosmetic prosthesis.

42. SYME’S AMPUTATION Can be done in – One Stage – Original/ Classic Syme’s Amputation. Two Stage – In case of gross infection or forefoot. Modified Amputation – Modified to get a less bulbous and more cosmetic stump by removing metaphyseal flare of tibia and beveling distal end of Fibula.

43. SYME’S AMPUTATION Single long posterior flapis used, by begining incision at distal tip of lateral malleolus passing across anterior aspect of ankle joint upto one finger breadth inferior to medial malleolus, extent it directly plantward across the sole to the lateral aspect and end it at starting point. Divide capsule of ankle joint. Divide Tendo Achilles Tendon at its insertion on calcaneus Remove the entire foot. Transect tibia and fibula 0.6 cm proximal to the joint line. Heel pad is used to cover the Stump..

44. SYME’S AMPUTATION

45. SYME’S AMPUTATION

46. BOYD’S AMPUTATION To produce excellent and bearing stump and eliminates the problem of posterior migration of the heel pad that occurs after syme amputation. It involves Talectomy Excision of anterior part of calcaneus, distal to peroneal tubercle. Forward shift of calcaneus and calcaneo -tibial arthrodesis by using steinmann pin or cannulated screw

47. PIRIGOFF AMPUTATION Involves arthrodesis between tibia and part of calcaneus. Calcaneus is sectioned vertically, removing anterior part and rotating posterior portion with heel pad forward and upward 90* to meet denuded distal end of tibia.

48. PIRIGOFF MODIFICATION

49. TRANSTIBIAL AMPUTATION Most common Lower limb amputation. Energy expenditure is an important consideration in choosing the level of amputation. Depending on ischemic or non-ischemic limb, level of amputation, choice of skin flap, stabilisation techniques like myodesis or myoplasty and post operative care varies. In case of combat injuries,standard flap maybe impossible. Skin graft maybe used to cover soft tissue defect, but skin graft are not ideal for stump prosthesis interface

50. VARIOUS DESIGN OF SKIN FLAP: Equal anterior and posterior flap. Equal medial and lateral flap(Scandinavian flap). Long posterior flap(Skewed flap).

51. IDEAL LENGTH OF STUMP : In below knee amputation- Ideal bone length 12.5 to 17.5 cm distal to medial tibial articular surface. Minimum working length-9 cm <12.5 cm less efficient <6 cm do not function RULE OF THUMB for selecting level of bone section is to allow 2.5 cm of bone length for each 30 cm of body height.

52. INTRA-OPERATIVE PRECAUTION WHILE TAILORING AN IDEAL STUMP Skin flap as per cause. Muscle are divided 0.6 cm distal to level of bone section in anterior compartment of leg Nerves are divided clean with knife after gentle traction and allow to retract proximal to end of stump. Vessels are doubly ligated just proximal to the level of bone section. Bevelling of tibia to prevent sharp end which might impinge or come in direct contact with skin flap.

53. INTRA OPERATIVE PRECAUTION WHILE TAILORING AN IDEAL STUMP Fibula should be sectioned 1.0 cm proximally to tibial end Release the tourniquet and achieve hemostasis before closure Place a drain Closure must be done with no tension at margin Immediate post operative rigid dressing should be done

54. TRANSTIBIAL AMPUTATION NON ISCHEMIC LIMB ISCHEMIC LIMB Use of tourniquet advocated. Equal anterior and posterior flap preffered . Level of amputation- 12.5 to 17.5 cm. Myoplasty is commonly done, but in young age group myodesis is advocated Refraining from use of tourniquet . Long posterior flap and short anterior one is preffered Level of amputation- 8.8 to 12.5 cm. Tension myodesis is contraindicating because it causes further compromise in blood supply

55. NON-ISCHEMIC LIMB

56. ISCHEMIC LIMB

57. POST OPERATIVE CARE: Immediate post operative rigid dressing. Change of rigid dressing every 5-7 days. Weight bearing is limited initially with support. After 3-4 weeks, rigid dressing can be changed to removable temporary prosthesis if there is no skin complication. Prosthesis to be given after 2-3 months.

58. PROSTHESIS FOR TRANSTIBIAL AMPUTATION

59. KNEE DISARTICULATION ADVANTAGE Result in excellent end bearing stump Creation of long lever arm controlled by strong muscles Stability of prosthesis Knee flexion contractures and associated distal ulcer with transtibial amputation are also avoided In non-ambulatory patient additional extremity length provide adequate support and balance Benefit in chindren and young adults

60. KNEE DISARTICULATION BATCH, SPITTLER,AND MCFADDIN TECHNIQUE Fashion long broad anterior flap from inferior bone of patella and short popliteal flap from popliteal crease. Anterior flap elevated including insertion of patellar tendon and PES Anserinus. Divide cruciate ligaments and posterior capsule. Divide tibial nerve slightly proximally. Attempt to fuse patella to the femoral condyle. Patellar Tendon sutured to cruciate ligaments and Gastrocnemius muscle.

61. BATCH, SPITTLER,AND MCFADDIN TECHNIQUE

62. MAZET AND HENESSEY DISARTICULATION OF KNEE Debulking stump by resecting protruding medial,lateral and posterior surfaces of femoral condyles for which is more cosmetically acceptable prosthesis can be constructed. Requires smaller skin flap , which may be beneficial for wound healing in ischemic limb.

63. KJOBLE DISARTICULATION OF KNEE Medial and lateral skin flap. Better technique for healing in ischemic limb.

64. PROSTHESIS FOR KNEE DISARTICULATION

65. TRANSFEMORAL AMPUTATION: Can be classified as Short trans femoral Medial transfemoral Long transfemoral Supracondylar amputation Extremely important for the stump to be as long as possile to provide a strong lever arm for control of the prosthesis

66. TRANSFEMORAL AMPUTATION NON-ISCHEMIC LIMB Use of tourniquet advocated. Equal anterior and posterior flap preffered . Level of amputation 12 cm from medial joint line or 18 cm from greater trochanter tip. Myoplasty is commonly done, but in young age group myodesis is advocated. ISCHEMIC LIMB Refraining from use of tourniquet. Equal anterior and posterior flap preffered . Level of amputation- 12 cm from medial joint line or 18 cm from greater trochanter tip. Tension myodesis is contraindicating because it causes further compromise in marginal blood supply.

67. TRANSFEMORAL AMPUTATION Fashion equal anterior and posterior flap at the level of amputation. Myofascial flap fashioned from Quadriceps muscle and fascia. Attaching adductor and hamstring muscle to end of femur through drilled hole and bring quadricep fascia over end of bone and suture with posterior fascia.

68. TRANSFEMORAL AMPUTATION

69. GOTTSCHALK TECHNIQUE: DIVIDE ADDUCTOR MAGNUS FROM ADDUCTOR TUBERCLE AND ATTACH IT TO LATERAL ASPECT OF DISTAL ASPECT OF FEMUR USING DRILLED HOLES KEEPING FEMUR IN MAXIMUM ADDUCTION.

70. PROSTHESIS FOR TRANSFEMORAL AMPUTATION

71. PROSTHESIS FOR TRANSFEMORAL AMPUTATION

72. HIP DISARTICULATION Different techniques- Anatomic method of boyd hip disarticulation Posterior flap method of slocum . Inguinal or iliac lymph node are not routinely removed.

73. HEMIPELVECTOMY In contrast to hip disarticulation hemipelvectomy remove inguinal or iliac lymph node. Different techniques: Standard hemipelvectomy. Extended hemipelvectomy. Conservative hemipelvectomy. Gordon- taylor called hindquarter amputation “ One of the most collosal mutilations practiced on human frame. ”

74. HEMIPELVECTOMY STANDARD HEMIPELVECTOMY CONSERVATIVE HEMIPELVECTOMY EXTENDED HEMIPELVECTOMY Employs a posterior or gluteal flap an disarticulates the symphysis pubis and sacroiliac joint and ipsilateral limb. Resection of adjacent musculoskeletal structures, such as sacrum or part of lumbar spine. Bony section divide ilium above the acetabulum ,preserving the crest of the ilium.

75. PROSTHESIS FOR HEMIPELVECTOMY

76. AMPUTATION IN CHILDREN Categories- Congenital (60%)- phacomelia , hemimelia,polydactly Congenital pseudo arthrosis Gross congenital malformations Acquired (40%)- secondary to trauma, neoplasm and infection. Dysvascular amputation is rare in children.

77. GENERAL PRINCIPLES OF CHILDHOOD AMPUTATION BY KRAJBICH Preserve Length Preserve important growth plates Perform Disarticulation rather than transosseous Amputation whenever possible. Preserve knee joint whenever possible. Stabilize and normalize the proximal portion of the limb. Be prepared to deal with issues in addition to limb deficiency in children with other clinically important condition.

78. COMPLICATION IN CHILDHOOD AMPUTATION TERMINAL OVERGROWTH- More common after traumatic amputation. Treatment- capping the bone with epiphyseal graft harvested from amputated limb or tricortical iliac crest graft.

79. ADVANTAGE IN CHILDHOOD AMPUTATION Less incidence of phantom limb. Extensive scars are tolerated well. Psychological problems are rare. Functions well with simple prosthesis. Spur may develop but almost never require resection.

80. REFERENCES Campbell’s Operative Orthopaedics, 13th edition Rockwood and Green's Fractures in Adults,8 th edition