Amputation Surgery Flashcards
Is incidence of CA related amputation increasing or decreasing?
Decreasing
What is the most common type of CA related amputations
LEA
What is the primary treatment for tumors?
What is the level selection based on in these cases?
limb salvage
Clean borders, biopsy. Level selection is very clear
Midfoot amputation is also called what? what does this spare
Midfoot = Lisfranc
Tarsals are spared
Midtarsal amputation is also called what? what does this spare?
Midtarsal = Chopart
Calcaneus and talus remain
Major amputations are considered what?
anything other than the foot/toes
TTA is from _____ to _____
TTA is from tibial tubercle to malleolus
Symes is what?
Ankle disarticulation which is a kind of TTA
If you get to the greater trochanter (even if you keep it) what is this considered?
hip disarticulation bc there’s not enough residual limb
TFA is from ____ to ____
greater trochanter to femoral condyles
Knee disarticulation is classified as TTA or TFA?
TFA
25-30 cal/kg increase is important for what
ulcer healing
only increase what nutritional supplement if there is a deficit?
zinc
Major cause of amputation
dysvascular disease. Trauma is not as common
What is priority one and two of amputation
1) healing of the residual limb
2) maintain as much length as possible
Healing is fast with shorter limbs so this is a problem
What shape do you want residual limb to be
cylindrical
Mortality rate is higher in higher or lower levels of amputation
higher levels of amputation have a higher mortality rate: many people are dysvascular so this makes sense
Healing rate is faster is high or low level amputations
high: the shorter the limb the faster the healing
Energy conservation is better with longer or shorter limbs
longer
Joint funciton is maintained with longer or shorter limbs
longer obviously bc you have more joints
functional mobility is higher in shorter or longer limb segments
longer
insertion of distal muscle groups are maintained with higher or lower level amputations?
lower
Weight distribution is greater with longer or shorter limbs? think within segment
longer: the more surface area you have the better
supension is easier with longer or shorter amputations
longer
Energy consumption is a lot more for TFA or TTA
TFA
People with amputations conserve energy by doing what with gait?
walking slower
The leading cause for all major amputations is
PAD
Tissue loss that is visible
End stage renal disease
poor functional status
DM are all factors that predict what
need for amputation in people with critical limb ischemia
What does the surgeon go by to pick amputation level for PAD?
clinical exam! not much else
Vascular tests have ___ sensitivity for predicting wound healing
low
If profunda femoris and superficial femoris are impacted that means what?
poor TTA prognosis
angiography used primarily for what
bypass surgery rather than picking limb length
Ankle pressure vs thigh pressure for healing levels
ankle pressure: not good
Thigh pressure: good predictor for healing at TTA
Trauma level selection “motto” is what?
what do you preserve heroically
fracture of the soft tissue/ injury zone
all heroic measures to preserve the knee
Salvage vs. amputation rates of complication, longer duration of hospital stay
Functional outcomes?
salvage: higher complication rates
Amputation: longer duration and more secondary hospitalization
Functional outcomes: no significant differences btwn
What will someone with diabetes show when they have a systemic infection?
malaise, hyperglycemia
NO fever
Systemic infections are what? and how are they treated amputation wise
medical emergency!
Two part amputation: guillotine, secondary closure
Myodesis
drill holes to attach muscles to distal bones
myoplasty
muscles form opposing groups are attached to each other: typically TFA
What happens if the length tension relationship is off at the gastroc and it’s too tight?
knee flexion contracture
Transected nerves form a ______
neuroma: small tension on the nerve and it will “bounce back” into soft tissue
True or false, toe amputation (MTP joint) does not need a shoe modification
true: maybe a different kind of shoe (wider etc) but nothing to actually accomodate for the loss of the toes
Ray resection do you need shoe modification
yes! this is where you start thinking about it
Explain cascade of length for transmetatarsal surgery
1st ray is longest, 5th ray is shortest to preserve push off
Transmetarsal, Lisfranc and Chopart amputations are susceptible to ______ due to muscle imbalance?
PF contracture, DF lost their insertion. Can cause wound right on the end of the stump. Need to fillers/high top shoe.
Achilles lengthening in surgery is common
Lisfrance and Chopart need what kind of modification?
anterior stability
- slipper prosthesis
- carbon inserts
- AFO with toe fillers
Compromise to the heel pad, cellultis that has advanced proximall or poor vascularity proximal to ankle is a contraindication for what?
symes
What happens to talus and calcaneus in symes?
they come out, fat pad gets put on
What is the advantage of symes?
end bearing possible on fat pad, better energy conservation.
Cons: they need full prosthetic device that goes up to knee
If you have gangrene/infection within 4-5 cm of tibial tubercle then what?
consider higher level than TTA
If you have a knee flexion contracture greater than 70 degrees then what does that mean for decisions needing to be made for amputation?
consider higher level than TTA
TTA surgical technique posterior or anterior?
posterior flap and long posterior flap commonly used
Fibula should be what?
equal to or shorter than
What is the muscle mostly impacted by TTA.
gastroc: they wrap it around the distal end of the strump
Major problem with posterior approach?
the incision starts to heal and its directly over the distal end of the bone
What is the ERTL procedure?
bone bridge synostasis: increases distal WB
Knee disarticulation (which is a TFA) major advantage!
ADD insertion is maintained!! it inserts in the femoral condyles
inatact growth plate for children
Alows distal end bearing
How do you extend the knee with the TF prosthesis?
extend the hip
Hamstrings during a knee disarticulation?
they are resected and are allowed to float bc of insertion on the posterior side.
Hamstring muscles are myodesed to quds tendon and posterior capsule to cover the distal femus.
Quads during knee disarticulation?
sewn to the preserved cruciate ligament
For TFA the shorter the residual limb the greater loss of ______ power
ADD
For TFA The shorter the residual limb the _____ the lever arm to control the knee
shorter the residual limb the shorter the lever arm
Major muscles involved in TFA
ADD: myodesis to distal bone
hamstrings and quads: myoplasty
What muscle is super affected by loss of ADD in TFA?`
Glute med: its in a shortened position because the femur drifts laterally. They will have so much trouble stabilizing the pelvis because its in open chain
Realigning the _____through muscle insertion is super important for the surgeon in TFA
Realigning the femur
Three ADD lost with TFA
ADD longus, brevis, magnus
FEMUR POSITION AND ADD STRENGTH ARE IMPORTANT FOR STABILIZATION
What is normal anatomical position for femur ADD
15 degrees
Prosthetic acceptance is low or higher for hip disarticulation?
low, a lot of rejections
ABD musculature is sutured to where during hip disarticulation?
joint capsule
Glute max is moved where during hip disarticulation?
anteriorly and sutured to inguina ligament
Hemi-pelvectomy muscle attachment?
no reattachment, they’re just sitting on soft tissue
