Chapter 112 - Lower extremity amputation operation Flashcards
The first use of tourniquet for amputation
1674 Morell (France) in battle of Besancon
Use of antiseptic for amputation
1867 Lister prior to this 50% died from infection
General principles of amputation surgery
1) atraumatic tissue handling 2) excise all nonviable/infected tissue 3) tourniquet for blood loss 4) eliminate sharp bone edge/fragments 5) minimize number of cuts 6) sharp transect nerve allow retraction 7) minimize cautery 8) tension free closure 9) myodesis/myoplasty to stabilize antagonistic muscle group 10) drain to reduce dead space
Myoplasty in amputation
Suture fixation of antagonistic muscle group
Myodesis in amputation
Direct suturing of musculotendinous unit to bone
Ring sequestra
Devitalized area of bone from excessive periosteal stripping
bones of the ankle
1) 7 tarsal bone 2) 5 metatarsal bone 3) D1 has two phalanges 4) others have 3 5) medial + lateral sesamoid bone in flexor of D1 provides stability 6) joint capsules are around interphalangeal and metatarsophalangeal hinge joints 7) ligamentous and tendinous attachment work with planta fascia for integrity
Bone anatomy of the foot and ankle
FIGURE 112.1
Ray amputation
digit amputation + metatarsal head amputation
Risk of ulceration in D1 ray amputation
60%
Lisfranc joint
Tarsometatarsal joint joins the midfoot and forefoot
Stability of metatarsal maintained by
1) deep transverse metatarsal ligament distally 2) plantar ligament distally 3) plantar metatarsal ligaments proximally 4) articulate with 3 cuneiform bones (D1-3) and cuboid laterally (D4-5)
TMA key points
1) metatarsal cut each 3mm shorter than the last from D1 to D5 2) 30-45 degree plantar bevel helps with ambulation 3) Achilles tendon lengthening or transection? - avoid risk of recurrent ulceration
Proximal/hind foot amputations
Lisfrank tarsometatarsal Chopart midfoot Syme Boyd Pirogoff
Talocrural joint
Talus with tibia and fibula Supported by 1) deltoid ligament 2) anterior and posterior talofibular ligament 3) calcaneofibular ligament
Subtalar joint
talus with calcaneus Supported by 1) medial and lateral talocalcaneal ligament 2) cervical ligament
Talocalcaneonavicular joint
multiaxial joint supported by 1) talonavicular ligament 2) plantar calcaneonavicular ligament
Supination of ankle
Inversion Produced by tibialis anterior and posterior
Pronation of ankle
eversion Produced by peroneus longus and brevis
Lisfranc amputation first described in
1815 Lisfranc
Lisfranc steps
1) release tendon and synovial sheaths at level of skin incision 2) 1, 3, 4, 5 tarsometatarsal joints disarticulated 3) 2nd metatarsal dividied 1-2 cm distal to medial cuneiform 4) modified* preserve base of 5th metatarsal for peroneus brevis insertion 5) Achilles tendon release transection/Z-plasty 6) plantar fascia approximated to dorsal periosteum
Chopart amputation first described in
1814 Chopart
Chopart steps
1) incision through talocalcaneonavicular joint and calcaneocuboid joint 2) achilles tenectomy 3) extensor hallucis longus and tibialis anterior tendon reattached to talar neck 4) extensor digitorum longus attached to calcaneus
Post op key points for lisfranc and chopart amputation
1) short leg plaster cast molded to ensure talus dorsiflexed in relation to tibia 2) ensure calcaneal tuberosity is parallel to long axis of tibia 3) weight bearing in 6 weeks 4) lisfrank will need toe filler 5) chopart will need custom ankle-foot orthosis and filler
Syme amputation first described in
1843 Syme
Syme steps
1) anterior incision across ankle distal to top of malleoli 2) posterio incision extends from malleoli vertically down and across sole of foot 3) extensor tendon divided at level of skin 4) dorsalis pedis artery ligated and divided 5) ankle joint capsule incised while plantar flexing the foot before dividing medial and lateral ankle ligaments 6) transect posterior tibialis and flexor hallucis longus 7) avoid injury to posterior tibial nerve 8) heel fat pat dissected carefully but stay close to calcaneus to avoid buttonhole 9) disarticulate ankle 10) malleoli divided at level of articular surface of tibia and reduce width 11) drill holes in medial, anterior and lateral part of distal tibia and fibula to secure heel pad under tibia
Two stage syme difference
1) wound closed by suturing heel flap to dorsal fascia 2) 6 weeks later malleoli removed through separate vertical incision
Syme amputation key considerations
1) preserve limb length 2) leg-length discrepancy 3) cosmetically not as appearling
Anterior compartment contents
1) tibialis anterior 2) extensor hallucis longus 3) extensor digitorum longus 4) anterior tibial artery 5) anterior tibial vein 6) deep peroneal nerve
Lateral compartment contents
1) peroneus longus 2) peroneus brevis 3) superficial peroneal nerve
Superficial posterior compartment contents
1) soleus 2) gastrocnemius 3) plantaris muscle
Deep posterior compartment
1) flexor digitorum longus 2) tibialis posterior 3) flexor hallucis longus 4) popliteus muscle 5) posterior tibial artery 6) posterior tibial vein 7) peroneal artery 8) peroneal vein 9) tibial nerve
Perforator arteries that supply the posterior flap
Musculocutaneous perforator from sural artery
Source of sural artery
popliteal artery
Types of BKA flaps
1) posterior flap 2) skew flap 3) sagittal flap 4) medial flap
Posterior flap BKA first description
Burgess
Posterior flap BKA steps
1) divide tibial 12-15 cm (4 finger breadth) distal to tibial tuberosity 2) 2/3-1/3 technique: anterior incision encompass 2/3 of the circumference 3) posterior flap length 1/3 of circumference 4) fibula divided 1-2 cm proximal to tibia 5) soleus can be cut, gastroc and fascia must be preserved 6) sural nerve transect 5 cm proximal to skin edge to prevent neuroma
Myodesis of gastrocnemius
1) two holes drilled into anterior surface of tibia 2) gastrocnemius fixted to tibia with nonabsorbable suture
Sagittal flap to BKA steps
1) Equal length medial and lateral myocutaneous flap 2) myoplasty to cover tibia by suturing anterior and lateral compartment muscles to medial component of gastroc and soleus
Skew flap to BKA steps
1) equal anteromedial and posterolateral fasciocutaneous flap 2) posterior flap is same as usual posterior flap 3) each flap is 1/4 circumference long
Fish-mouth flap for BKA
Not used anymore because of vulnerability of anterior flap to ischemia
Medial flap for BKA
Long medial flap short lateral flap
Evidence 2014 Cochrane on superior method of BKA
no difference
Ertl procedure
Tibiofibular bone bridging leaving 2-4 cm of tibia length at first then cutting it flush but leaving blood supply attach parallel and screw in place no clear evidence
Rate of BKA healing at 100 days and 200 days
55% and 83%
Rate of BKA that needs conversion to higher level
9.4-19.6%
Through knee amputation steps
1) fish mouth incision with corners at level of mid condyles of femur 2) anterior flap extended to tibial tuberosity 3) posterior flap to same length 4) medial and lateral collateral ligaments divided 5) patellar ligament divided from attachment to tibial tuberosity 6) skin and deep fasia dissected off knee capsule 7) excise knee capsule and divide cruciate ligament 8) ligate popliteal vascularture and nerves 9) popliteus and gastroc divided 10) lateral 1/3 of condyle and medial 1/2 of condyl trimmed 11) hamstring approximated to patellar ligament incorporating cruciate ligaments
Mazet vs Gritti-Stokes TKA
Mazet: distal femur preserved and condyles trimmed Gritti-Stokes: transect articular head of femur; preserve patella as end-cap
Thigh compartments
Anterior Medial Posterior
Anterior thigh compartment muscles
1) quadricep femoris 2) sartorius 3) tensor fascia latae
Medial thigh compartment muscles
1) adductor longus 2) adductor brevis 3) adductor magnus 4) gracilis 5) pectineus
Posterior thigh compartment muscles
Hamstrings 1) biceps femoris (long and short heads) 2) semitendinosus 3) semimembranosus
Linea aspera
Adductor inserts into the posterolateral femur along this
Adductor tubercle
Adductor magnus inserts into this = bony prominence on medial epicondyle of femur
AKA technique
1) 12 cm proximal to femoral condyles or junction of middle and distal 1/3 of femur 2) fishmouth incision 3) SFA and FV divided 4) transect femur 5) sciatic nerve cut
Natural tendency of the AKA stump to deviate and myodesis involved to prevent his
Hip flexor to abduct and flex thigh 1) Quatriceps detached proximal to patella leaving some tendon 2) vastus medialis reflected laterally off intermuscular septum to expose adductor magnus 3) adductor magnus divide at its attachment to adductor tubercle on medial epicondyle 4) vessels in Hunter canal ligated 5) remaining muscles divided 1-2cm distal to femur transection 6) drill holes into lateral cortex of femur and posterior cortex 1-2 cm from end adductor magnus wrapped over end of bone and femur held in max adduction before anchoring no clear studies
Ligament of the head of the femur
1) iliofemoral 2) ischiofemoral 3) pubofemoral 4) transverse acetabular ligaments
Muscles anterior to hip joint
1) rectus femoris 2) iliopsoas 3) pectineus muscle 4) tensor fascia lata 5) sartorius
Muscles posterior to the joint
1) piriformis muscle 2) obturator internus 3) obturator externus 4) superior gemelli 5) inferior gemelli 6) quadratus femoris
Hip disarticulation steps
1) semilateral position of patient 2) anterior racket incision 2.5 cm medial to ASIS towards pubic tubercle 3) continue posteriorly distal to ischial tuberosity and gluteal crease 4) continue incision anterioly, medial to greater trochanter and anterior inferior iliac spine then join back 5) cut down to external oblique and deep fascia of thigh 6) femoral vessels suture ligated and femoral nerve transected 7) divide sartorius at origin and iliopsoas at insertion site 8) pectineus divide at origin from superior pubic ramus 9) gracilis and 3x adductor divided at origin on pubic rami 10) obturator neurovascular bundle divided 11) obturator externus divided at insertion to trochanteric fossa 12) hamstring transected at ischial tuberosity 13) divide tensor fasciae latae, gluteus maximus, rectus femoris 14) divide remaining muscles on greater trochanter 15) divide all ligament to hip joint capsule 16) transect sciatic nerve 17) posterior quadratus femoris sutured to anterior iliopsoas 18) lateral gluteus medius sutered to medial obturator externus
Operative mortality of major amputation
6-13%
Operative mortality of minor amputations
2-4%
Guillotine amputation mortality compared to other types
double 14.3 vs 7.8%
5 year mortality after major amputation
44.4% AKA 60% BKA
1 year survival after BKA vs AKA
BKA 64.5-80.4% AKA 49.6-64.6%
K-level
Classification system by US center for medicare and medicaid Stratify potential functional ability in amputee TABLE 112.2
Rate of foot/ankle amp conversion to higher amp in 1 year
35%
Risk factors for amputation related problems
1) diabetes 2) ESRD 3) index BKA
Complication of major amputation
1) Bleeding 3-8% 2) Infection 13-40% 3) Contracture 3-5% 4) CHF 4.2% 5) MI 3.4% 6) arrhythmia 2.6% 7) pulmonary 8) DVT 10% 9) renal failure 0.6-2.6% 10) stroke 0.28-1.4% 11) PTSD 5% 12) suicidal ideation 16% 13) chronic pain 95% 14) phantom pain 5-85%
Boney anatomy of foot
FIGURE 112.1
