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#4 Surg > 59 - Lower Extremity Amputation > Flashcards

59 - Lower Extremity Amputation Flashcards

1
Q

Indications for lower extremity amputation

A
  • Acute infection
  • Chronic infection
  • Ischemic limb
  • Gangrene
  • Charcot deformity
  • Trauma
  • Tumors
  • Congenital Abnormalities
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2
Q

Reasons for distal limb salvage

A
  • Superior Function (transmet amputation is much more functional than BKA)
  • Better Cosmesis
  • Enhance Lifestyle
  • Lower Energy Consumption
  • Increased Sensory Input
  • Better Weight-bearing Surface
  • Less Distortion of Body Image
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3
Q

Considerations for successful limb salvage

A
  • 1 = Ensure good blood flow
  • 2 = Control infection
  • 3 = Aim for good biomechanical result
  • 4 = Create a stable soft tissue envelope***
    o We typically use some of the plantar soft tissue structures – very protective
    o Not only so the patient can heal, but also so they can protect it
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4
Q

Successful amputations

A
  • “Remove all necrotic, painful, or infected tissue.”
  • “Must be able to fit amputation stump with a functional and easily applied prosthesis.”
  • “Blood supply at the level of the proposed amputation must be sufficient to allow primary skin healing.”
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5
Q

Major factors to consider for amputation level - VASCULAR status

A

o Determining the level of adequate blood flow can help predict success of healing
o Not meeting criteria is not always considered a contraindication to performing amputation at a certain level

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6
Q

Prediction of healing based on vascular status

A
  • Still speculative and work continues (“I have cut many things that have bled poorly and healed well, and I have cut many thing that have bled well and healed poorly”)
  • Doppler Ultrasound
  • Segmental Blood Pressure
  • Ankle Brachial Index
  • Toe Blood Pressure
  • Plethysmography
  • Transcutaneous Oxygen Pressure
  • Spy technology – intra operative evaluation with dye and imaging (Emerging technology)
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7
Q

Timing of surgery after vascular intervention

A

STUDY – Attinger et al recommended that you do surgery…
o 4 to 10 days after a bypass vascular procedure
o 10 to 30 days after an angioplasty vascular rocedure

Personal experience
o My experience with local vascular surgeons and interventionalists
o Definitive procedure as quickly as possible
o Typically can keep patients vascular medications: Plavix, etc.
o If the patient has an INR of 3 or above, they are not a candidate for surgery due to too much bleeding, but if it is a minor procedure, you will likely be able to control the bleeding with an INR of 2 – It doesn’t always need to be under 1/5 in order to operate

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8
Q

Angiosomes and healing potential

A
  • Angiosomes: composite vascular territories providing
    blood supply to skin, nerves, muscle, tendon, and bone
  • The angiosome concept was derived from plastic
    surgery to evaluate healing potential of flaps.
  • Entire body is divided into 40 angiosomes.
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9
Q

Angiosomes in the foot

A

The foot is divided into 6 angiosomes total
o The posterior tibial artery feeds 3 angiosomes
o The anterior tibial artery feeds 1 angiosome
o The peroneal artery feeds 2 angiosomes

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10
Q

Posterior tibial artery

A
  • The posterior tibial artery gives rise to a calcaneal branch, which supplies the medial ankle and lateral plantar heel, a medial branch that feeds the medial plantar instep, and a lateral branch that supplies the lateral forefoot, plantar midfoot, and entire plantar forefoot
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11
Q

Anterior tibial artery

A
  • The anterior tibial artery continues on to the dorsum of the foot, as the dorsalis pedis
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12
Q

Peroneal artery

A
  • The peroneal artery supplies the lateral ankle and plantar heel via the calcaneal branch and the anterior upper ankle via an anterior branch
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13
Q

Major factors to consider for amputation level

A
  • Rehabilitation Potential
  • Ambulatory Status
  • Medical considerations
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14
Q

Rehabilitation Potential

A

o Ambulatory Status at time of presentation
o Motivation
o Family /Social Support
o Other comorbidities – cardiac, pulmonary, neurological, musculoskeletal

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15
Q

Ambulatory Status

A

o If not ambulatory, BKA or AKA may be better level

o Even if patient is not ambulatory, maintaining limb can be advantageous for transfers

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16
Q

Medical considerations

A

o NOTE: In planning appropriate consultation for perioperative medical care, the podiatric surgeon should be aware of the evaluation of physical status completed by the anesthesiologist before surgery – Consider ability to undergo ANESTHESIA***
o The surgeon should ensure that appropriate medical consultation, clearance, and follow-up have been obtained to provide for the perioperative medical care of a diabetic patient who will undergo surgery for an infected foot

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17
Q

Anesthesia classes of patients

A
  • Class 1
  • Class 2
  • Class 3
  • Class 4
  • Class 5
18
Q

Class 1 anesthesia patient

A

Class 1 patients have no medical problems, other than the pathologic condition associated with the surgery, no diabetic patient will fit this category

19
Q

Class 2 anesthesia patient

A

Class 2 patients have a stable, chronic medical problem that is well controlled such as stable diabetes

20
Q

Class 3 anesthesia patient

A

Class 3 patients are more seriously ill, with unstable medical problems, and are more likely to need intensive, or at least close, medical supervision in the perioperative period

21
Q

Class 4 anesthesia patient

A

Class 4 patients are very seriously ill, perhaps at risk for septic shock, or other major cardiovascular complications and definitely require intensive perioperative care

22
Q

Class 5 anesthesia patient

A

Class 5 patients are not expected to survive surgery or the perioperative period

23
Q

Rehabilitation team model for lower extremity amputation

A
  • Surgeon
  • PT/OT
  • Family support, hospital nurses and paramedical personnel
  • Referring physician, community resources, prosthetist
  • Patient needs to do the things that they are responsible for – You can do as many consults as you want, but if the patient is not responsible, there will be issues
24
Q

Amputation levels

A
  • Toes (partial, complete)
  • Partial rays (1st ray, middle ray, 5th ray)
  • Transmetatarsal
  • Lisfranc’s (NOT preferred – do a transmetatarsal amputation instead)
  • Hindfoot (Choparts, Boyds and Pirogoff, Symes)
  • Calcanectomy
  • Below knee (BKA)
  • Above knee (AKA)
25
Q

Lisfranc’s amputation = BAD PROCEDURE

A
  • Poor outcomes compared to a transmetatarsal amputation
  • This is because the tendon attachments for supination and pronation are all within the tarsal-metatarsal joints (1st and 5th metatarsal)
  • If you can do a transmetatarsal, definitely do that instead
  • If you can’t do a transmetatarsal procedure, go more proximal to a hindfoot procedure such as a Choparts amputation
26
Q

Toe amputation

A
  • Toe amputation is frequently performed through the base of the proximal phalanx
  • This is left in place to maintain intrinsic muscle stability around the metatarsal phalangeal joint
  • Resection at the proximal metaphysis allows for closure over raw cancellous bone, which is an area that is better vascularized than the cartilage of the metatarsal head
  • Skin incisions are made with medial and lateral flaps fashioned around the base of the digit
27
Q

Ray resections

A
  • Ray section is defined as amputation of a digit and most, or all, of its associated metatarsal
  • This is an excellent procedure for drainage of an acute infection
  • It is usually performed in the presence of either abscess or osteomyelitis of a toe and its MPJ
  • Extensive necrosis of skin, soft tissue, or bone in the involved digit may necessitate ray resection to obtain adequate viable skin for closure
  • If you probe the bone and it feels hard, that is a good level to amputate
  • If you probe the bone and it feels soft, you need to continue amputating more proximal
28
Q

CASE STUDY 1

A
  • 63 year old male s/p partial ray resection of the left 2nd
  • S/P angiogram w/ stent
  • Recent hallux amputation with additional partial 3rd ray resection
29
Q

CASE STUDY 2

A
  • 59 year old male with a history of psoriasis, and s/p kidney transplant
  • Developed a verruca of the 4th digit. The toe was amputated, but patient retained the verruca
  • 2 months s/p biopsy and surgical treatment
30
Q

Transmetatarsal amputation indications

A

o Gangrene of one or more toes, provided the gangrene has stabilized and does not involve the dorsal or plantar aspect of the foot
o Stabilized infection or open wound of the distal portion of the foot
o An open infected lesion in a neuropathic foot
o Extension of an infectious process to the web space or plantar aspect of the foot is an indication for an open transmetatarsal amputation. (This may be closed at a later time or allowed to heal by second intention.)

31
Q

Details of transmetatarsal amputation

A
  • This amputation maybe performed at any level of the metatarsals, provided the insertion of the tibialis anterior tendon is preserved
  • Preservation of the tendon cannot be overemphasized as loss of function will result in an equinus deformity
  • With a transmetatarsal amputation, you want to do a gastroc recession or tendo calcaneus lengthening, reducing the risk for callus at the stump site
32
Q

Hindfoot amputations

A
  • Choparts = Disarticulation at Talonavicular and calcaneal cuboid joint
  • Boyd – tibial – calcaneal fusion or Modified Boyd’s – utilize talus as interposition bone graft if viable
  • Pirogoff – tibial – calcaneal fusion = Calcaneus is positioned vertical to help alleviate limb length discrepancy
  • Symes – Full ankle disarticulation = Significant limb length discrepancy will result
33
Q

Surgical considerations

A
  • Check Hemaglobin and Hematocrit
  • Many patients have had a LE bypass or stent, so general consensus is not to utilize tourniquet
  • Expect blood loss, take your time but have at least 2 units of blood available at time of surgery
34
Q

Stabilization of hindfoot

A
  • Need to stabilize hindfoot fusions in most cases for long term success
  • Steinman pin or K-wires
  • Screws, external fixation or IM Rod
35
Q

Choparts amputation

A
  • Diabetes Mellitus, Peripheral Neuropathy, multiple amputations Left foot
  • Chronic ulcers, osteomyelitis
  • Does not result in a limb length disparity which is an advantage of this procedure
36
Q

STUDY – Boyd

A
  • Boyd, H. R., Amputation of the Foot, with Calcaneotibial Arthrodesis
  • Developed the amputation for the patient who cannot afford an artificial leg, or for the laborer to give an excellent WB stump and relieve the patient of having to use an artificial limb

Advantages
o A natural, painless stump is provided
o Operation is more advantageous from an anatomical and physiological standpoint over other amputations through the region of the ankle or tarsus
o Recognized problems in other amputations

37
Q

Modified Boyd’s

A
  • Kornah, 1996

- Utilize talus as graft to help fill defect at fusion site

38
Q

CASE STUDY 3

A
  • 55 year old diabetic male
  • ESRD – kidney transplant
  • PVD – Right LE bypass
  • Left below knee amputation
  • Retinopathy
  • Charcot arthropathy with 5th ray amputation
  • Neuropathic lateral ankle ulcer
  • Unstable, un-braceable ankle varus deformity
39
Q

Syme’s amputation

A
  • Disarticulation at ankle – outside of scope of practice in most states
  • Advocated for alternative to BKA, but may be better off doing a BKA
    o Full length extremity that can be used in emergency ambulation
    o Boyd Amputation
    o Symes with tibialcalcaneal fusion
    o Allows for more length of limb
  • Single Stage procedure or double Stage procedure
  • When done, 2nd stage is to remove malleoli and to remodel stump for prosthesis
  • Controversy surrounds the stability of the amputation and difficulty related to prosthetic construction
40
Q

Calcanectomy

A
  • Partial or complete removal of calcaneus
  • Advantageous for large heel ulcers with calcaneal osteomyelitis and a stable midfoot and forefoot
  • Patients are typically able to ambulate well with or without an assistive device (ankle foot orthosis –AFO)
  • Good alternative to BKA or AKA
41
Q

CASE STUDY 4 – Partial calcanectomy

A
  • 65 year old female presents with a necrotic wound of the left heal.
  • Patient states of 2 ½ weeks duration.
  • PMH: IDDM, Venous stasis, lymph edema
  • 1 month s/p debridement of bone and soft tissue, with wound vac assisted closure
  • 4 month s/p procedure wound is healed.
  • Patient currently ambulates with an AFO and a walker

#4 Surg (14 decks)

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