Amputation Flashcards
Most common causes of amputation
- Peripheral Vascular Disease (54%)
- Trauma (45%)
- Malignany (<1%)
- Congenital limb deficiency (<1%)
People with DM2 are ____x more likely to have an amputation
10
Consequences of Type 2 DM
- PVD
- Peripheral neuropathy - insensate
- Non-healing neuropathic ulcers
3 most common predisposing factors for LE amputation
- DM2 w/HTN (10x+ risk)
- DM2 w/o HTN
- HTN w/o DM2
Most at risk ethnicity for amputation
- Native Americans
Likely due to lack of access to healthcare
Most individuals who have an amputation from trauma are due to
- MVA
- Accidents with machines
- war
- GSW (Gunshot wounds)
Most individuals who have a trauma amputation are very ____ and active prior to amputation.
healthy
What is a more common trauma amputation for civilians? UE or LE?
UE
____ is a more common amputation for military than civilans
LE
What type of malignancy often results in amputation?
- Osteogenic Sarcoma (Tumors in the muscles, tissue and bone)
- Adolescence/young adults
- Femur, tibia and humerus account for 85% of cases
What is more common for people with Osteogenic Sarcoma: Amputation or limb salavage technique?
- Limb Salvage Technique (plus chemotherapy)
- Survival rate for this condition is low
What is a congenital limb deficiency? Why does it require amputation?
- Genetic variation due to environmental exposure to teratogens (hot tubs)
- Most commonly seen in the UE
Types of Congenital Limb Deficiency
- Transverse Amelia: Complete loss of limb (Ex: Arm or Leg)
- Transverse Hemimelia: Loss of limb below level of next joint (Ex: Keep humerus, lose elbow distal; Keep Tibia, lose knee distal
- Paraxial Terminal: Complete loss of one bone in a region (Ex: Have fibula, not tibia)
- Paraxial Intercalary: Portion of a bone is absent
How is the level of amputation determined?
Goals:
* Maintain greatest bone length and save all possible joints while providing adequate soft tissue coverage
* Produce a comfortable and functional residual limb (RL)
Levels of Amputation: Transmetatarsal
Amputation through the midsection of all metatarsals
LOA: Transtibial
How many types?
- Below Knee
- 3 (Long Trans, Trans, Short Trans)
For people who have the big toe amputated, what deficits will you see?
- Balance and gair training needed.
- Most common compensation is short step length on the left if right amputation
Ankle Disarticulation
- Also called Symes
- Amputation through the ankle joint
- Foot removes, heel pad preserved and placed on the bottom to help with weight bearing
Goal:
* Remove diseased tissues or non-usable foot
* Create functional painless limb
Transtibial Amputation
- “below-knee amputation”
- Superior tibiofibular joint preserved (distally gone)
- Preservation of knee joint
- Amputations distal to the lower thrid of the leg are avoided due to lack of soft tissue (think of gastrocnemius muscle belly)
Knee Disarticulation
- Also known as “through knee amputation”
- Directly at the knee joint, leaving femur and patella intact
- No dissection of bone or muscle
- Quadriceps muscle preserved
- Stump permits total end bearing and easy/firm attachment of the prothesis
- Weight Bearing for Bilateral
Anyone who can weight bear with an amputation can only weight bear for ____
Short Distances
Rotationalplasty
- Van Nes Procedure
- Portion of the leg is removed, the remaining lower leg is rotated and reattached.
- Converts knee into hip and the ankle into knee
- Hip is stable as the femur is fused to the pelvis
- Dorsiflexion is now bending knee, Plantarflexion is now extending knee
- Most commonly seen with Ewing’s Sarcooma or osteosarcoma in children
Transfemoral Amputation
- “Above knee amputation”
- Amputation of the femur of some length
- Presevation of the distal 1/3 of adductor magnus preserved for biomechanical alignment.
- The longer this is, the less energy expenditure needed
What amputation uses the most energy expenditure?
- Transfemoral (65% increase)
- This is more than Bilateral Transtibial
Hip Disarticulation
- Removal of the entire lower limb by transection through the hip joint
Indications:
* * Malignant tumor of bone/soft tissue of the thigh, hip or pelvis
* Extensive trauma
* Uncontrolled infections
* Congenital limb anomaly (rare)
Hemipelvectomy
- “transpelvic amputation”
- Amputation of the affected bone of the hip and the ipsilateral extremity
- Rarest form of LE amputations
- Indications: Malignant tumor/sarcome or trauma
Factors Affecting Selection of Amputation level:
- Conservation of RL length
- Uncomplicated wound healing
- Creation of a pain free limb that can be fitted with a prosthesis that maximizes the individual’s functional mobility
Types of skin graft types for amputation surgery
- Equal length skin flap
- Long posterior flap
- Skew flap
Equal length skin graft
- Anterior and posterior flaps equal length; incision is in the middle at the base of the amputation
- Disadvantage: location of scar and pressure do not mix well
Long posterior flap
- Fold the posterior muscle tissue anterior; scar in front
- Advantage: Full weight is not directly sitting on the scar and posterior muscles is thicker and has better blood supply
Skew Flap
- Angular medial-lateral incision
- Scar placed away from bony prominences
- Rarely seen
What amputation skin graft type is best?
- Research hasn’t been conducted so we can’t saw but in theory long posterior flap is best
- Largely based on what the surgeon wants and what the tissue allows.
What is special about the surtures being taken out for amputes?
- When removing sutures, 1 out of 3 is removed every few days. This allows for them to stress the tissue and see how it responds.
- Removal of all sutures could lead to many issues with wound healing if done improperly.
What are some types of reassemably of the amputation area?
- Myofascial closure (Muscle to fascia; TTA and TFA)
- Myoplasty (Muscle to muscle; TTA and TFA)
- Myodesis (Muscle attaches to periosteum or bone
- Tenodesis (Tendon attached to bone)
What reassembly is best?
- Myodesis: Stable, contracts and relaxes without effecting other structures. The best!
Other and why not these?
* Myofascial: Everytime a muscle contract it moves fascia, not very stable
* Myoplasty: dual opposing contractions of muscle, slightly more stable. Not ideal.
* Tenodesis: 2nd most stable, LONG healing times
Nerve Care
- Nerve must be surrounded by soft tissue
- Pulled under tension and then cut to allow it to retract back into soft tissue; helps prevent neuroma (nerve irritated because too close to the base)
Bone Care
- Sectioned at length to allow wound closure
- Bone end is smoothed/rounded (w/o stripping periosteum)
- Ertle/Osteoplasty: cut fibula shorter than tibia to decrease pressure; bone is then place between tibia and fibula and fused.
Alternative amputation technique - Osteointegration
- Prothesis surgically conencted into residual bone
- Fixture placed in the center of the bone and secured
- Benefit: Elimination of socket residual limb fit and improved sensory feedback (proprioception)
- Problems: High risk of infection at site of metal at bone and high facture rates in long bone when running and jumping.
Surgical consideration for the PT
- Type of flap (How does this effect WB)
- Type of Closure (How does this effect muscle function; Certain stabilizations have protocols)
- Bone and nerve care during and after surgery
What amputations are allowed to remain open?
- Dirty wounds!
- Can’t close until clean and ensure no infection
____ weeks post-amputation is the average time to posthetic
12
