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CJ Atlas of Prosthetics > Chapter 2- Amputation/Limb Salvage Surgeries and techniques > Flashcards

Chapter 2- Amputation/Limb Salvage Surgeries and techniques Flashcards

1
Q

What specialists should be sought out before amputation is performed?

A

Vascular surgeon
Diabetologist
Infectious disease specialist
Surgical oncologist

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2
Q

What methods can be used to prevent amputation due to trauma?

A

Improved methods of fracture fixation
Vessel and Nerve repair
Vascularized distant muscle and skin flaps

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3
Q

What methods can be used to prevent amputation due to vascular problems?

A

Recanalization

Reconstruction of vessels

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4
Q

What method can be used to prevent amputation for infection?

A

Kritter method

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5
Q

What method can be used to prevent amputation for tumors?

A

Ablation of the tumor

Reconcstruction using allograft, endoprosthesis, or a combination

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6
Q

In 1832, what was the mortality rate for amputations?

A

52% for major amputations overall

62% for thigh amputations

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7
Q

What was the mortality rate for open fractures during the war?

A

50% transtibial

66% transfemoral

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8
Q

When did germ theory occur?

A

World War I

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9
Q

When did vascular reconstruction develop?

A

Korean War

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10
Q

How are wounds classified?

A

Based on Wound size

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11
Q

What levels of trauma should cause surgeons to consider opting for amputations?

A

Open IIIB and IIIC fractures

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12
Q

What variables can be used as basis for amputation?

A

Extent of soft tissue damage
The duration and severity of ischemia
The presence of shock
The age of Patient

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13
Q

Which variable, to determine amputation, is the most important?

A

Soft tissue grading

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14
Q

What is the index called to determine the likelihood of amputation?

A

Mangled Extremity Severity Index (MESI)

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15
Q

What score on the MESI scale indicates amputation?

A

7 or greater

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16
Q

Why does open fracture type IIIB have greater limb salvage success?

A

Vascular injury requiring repair is not present.

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17
Q

What is the most preponderant problem of type IIIB open fractures?

A

Infection

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18
Q

What is the most important treatment to prevent infection?

A

Debridement

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19
Q

What injuries should be met with an amputation of the limb?

A

Much muscle damage

Bone loss of more than 6cm

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20
Q

For patient’s facing end stage vascular problems, what percent of patient die after 2 years of amputation?

A

40 %

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21
Q

What percent of patient’s with end stage vascular problems will require a second amputation?

A

30%

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22
Q

What variables should be considered when deciding on an amputation for end stage vascular disease patients?

A

Quality of life
Ethics
Financial considerations
Informed consent

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23
Q

What four broad groups may lead to amputation?

A
  1. Peripheral vascular disease and diabetes
  2. Trauma
  3. Infection
  4. Tumor
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24
Q

What percent of patients requiring amputation are a direct or indirect consequence of CLI?

A

90%

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25
Q

What are three risk factors for PVD?

A

Smoking
Diabetes
Hypertension

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26
Q

What are the management options for PVD?

A

Nonsurgical management
Interventional radiology
Sympathectomy
Vascular reconstruction

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27
Q

What are nonsurgical management options for PVD?

A

Medications

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28
Q

What are the level of priorities for trauma in patients with vascular insuffiency?

A
  1. Vessels
  2. Nerves
  3. Bones
  4. Soft Tissue
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29
Q

What is Dry gangrene?

A

A result of reduced arterial inflow or stasis in the circulation of the limb or digit.

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30
Q

What is wet gangrene?

A

A consequence of both arterial and venous obstruction

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31
Q

What measurements should be done to determine the amputation level of the patient?

A 
Clinical assessment
Angiography
Segmental systolic pressure measurements
Skin fluorescence
Skin blood flow measurements
Transcutaneous oxygen measurements
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32
Q

Where do the majority of limb-threatening infections occur?

A

In the foot

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33
Q

What is the greatest risk factor for infection?

A

Sensory neuropathy

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34
Q

What are other causes of infection?

A

Calf abscess

Chronic osteomyelitis

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35
Q

What scale is used to grade foot lesion severity?

A

Meggitt-wagner foot lesion grading system

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36
Q

What are grades one and two of the meggitt-Wagner foot lesion system?

A

Ulcers that have not involved bone and joint

37
Q

What are grade 3 lesions in the Meggitt-Wagner foot lesion system?

A

Ulcers penetrating bone and joint

38
Q

What can be used to determine the bone exposure in an ulcer?

A

Plain Radiographs are okay

MRI are the best

39
Q

What is the best bedside test to determine blood flow in the distal part of the foot?

A

The Doppler Ultrasonic Evaluation

40
Q

What is the Doppler ultrasonic evaluation?

A

Take the blood pressure just above the malleoli, then move the cuff down to the metatarsal necks and take the blood pressure again. If the ischemic index is 0.5 or more the foot is salvageable, if not then they should be sent to a vascular surgeon.

41
Q

How long can an open wound take to heal?

A

3-6 months

42
Q

How long should a patient be non-weight bearing when healing an open wound?

43
Q

What does success of patient wounds depend on?

A

Timely presentation of the patient
Control of infection
Hyperglycemia by a combination of early and complete bridegment

44
Q

What should happen if gangrene and poor healing is based on Vascular occlusion?

A

Consultation with a vascular surgeon for vessel reconstruction

45
Q

How can a patient prevent wounds from occurring?

A

Proper footwear
Tight control of diabetes
Education in foot care
Emphasis on assumption of responsibility for self care

46
Q

When dealing with Tumors, what is the definition of limb salvage?

A

Removing a bone or soft-tissue tumor while preserving the limb with a satisfactory functional and cosmetic result.

47
Q

How do you determine the surgical stage of a tumor?

A

It is based on its histogenic type as well as on its local extent and any existing metastasis

48
Q

How do you determine the histogenic type of a tumor?

49
Q

How do you determine the metastasis of a tumor?

A 
Radiologic studies like
radiographs
Bone scan
CT
MRI
50
Q

What are the problems of a poor biopsy performed on a patient with a tumor?

A

Can prevent some limb saving procedures.

51
Q

In which direction should the biopsy incision be taken?

A

Longitudinally

52
Q

What should the deep dissections avoid during a biopsy?

A

Intermuscular planes

major neurovascular structures

53
Q

What are the three categories of benign tumors?

A

Stage 1- latent
Stage 2- Active
Stage 3- aggressive

54
Q

What are the three categories of malignant tumors?

A

Stage 1- low-grade malignancy without metastasis (intracompartmental/extracompartmental)
Stage 2- High-grade malignancy without metastasis (intracompartmental/extracompartmental)
Stage 3- Any grade with reginal or distant metastasis

55
Q

What is the ultimate goals of determining between amputation and limb salvage with a tumor?

A

Patient’s survival
Minimize risk of metastasis
Local recurrence

56
Q

What are other factors involved in deciding on amputation and limb salvage for a patient with a tumor?

A

Psychological impact

Function of limb

57
Q

What are the indications for limb saving procedure for patients with tumors?

A

A sound wide or radical resection of the tumor can be achieved
Limb reconstruction is feasible
The prognosis is not compromised
The cosmetic and functional results are better than amputation

58
Q

What types of tumors lend to limb saving?

A 
Malignant tumor (stage 1 and 2)
Recurrent aggressive benign tumors (stage 3)
59
Q

What is radical resection for bone?

A

Removing the entire bone from joint to joint

60
Q

What is wide resection of bone?

A

Removing the tumor with a wide margin of normal bone around it

61
Q

What is radical resection of soft tissue?

A

Removing the entire muscle compartment from origin to insertion

62
Q

What is wide resection of soft tissue?

A

Removing the tumor with a wide surrounding cuff of normal soft tissue in all dimensions

63
Q

Lately, what do most oncologist do when removing tumors

A

Wide resection with chemotherapy and radiotherapy

64
Q

For a wide resection, how much further should they cut around the tumor?

A

3-5cm beyond the tumor limit

65
Q

Which bones can be resected without need for reconstruction after tumor removal?

A 
Scapula (not glenoid portion)
Clavicle
Rib
Proximal radius
Distal ulna
Metacarpal
Phalanx
Ischium
Pubis
Patella
Fibula (not distal end)
Metatarsal bone
66
Q

What is reconstruction after tumor removal determined by?

A 
Location of tumor
Size of resected bone
Patient's lifestyle
Surgeon's preference
Expertise
67
Q

What are the three major skeletal reconstruction methods?

A

Intercalary (segmental) reconstruction
Arthrodesis
Arthroplasty

68
Q

What skeletal substitutes are used for skeletal reconstruction?

A

Autografts
Allografts
Metallic prostheses

69
Q

When is intercalary reconstruction needed?

A

diaphyseal resection

70
Q

What does intercalary reconstruction use for materials?

A

allografts
Autografts
Rarely metallic prostheses

71
Q

When is arthrodesis used?

A

After extra-articular resection of a joint such as the knee, shoulder, or wrist

72
Q

What materials does arthrodesis use?

A

Allografts
Autografts
Rarely metallic prostheses

73
Q

When is arthroplasty used?

A

When replacing a resected hemijoint or whole joint with an articulating joint such as knee, hip, shoulder, elbow, or wrist.

74
Q

What materials are used with an arthroplasty?

A

Allografts
Customized metallic prostheses
Allograft prosthesis composites

75
Q

Which material is the best bone substitutes?

A

Autografts

76
Q

What can autografts not be used for?

A

large bone segments

joints

77
Q

which materials can make large bone segments and joints?

A

Allografts

Prostheses

78
Q

What are the problems with surgical prostheses

A

Later, it might loosen or fatigue and frature

79
Q

What are the advantages of surgical prostheses?

A

Simple operation procedure
Quick recovery
Easy rehabilitation

80
Q

What is used for children needing reconstruction after tumor removal?

A

Expandable metallic prostheses

81
Q

What are the four types of allografting procedures?

A

Massive osteoarticular allografts
Allograft-prosthesis composites
intercalary allografts
Intercalary allograft-arthrodesis

82
Q

How do you determine which of the four types of allografting procedures you are going to perform?

A

Skeletal location and extent of tumor resection

83
Q

Which of the four allograft procedures is the most commonly used?

A

osteoarticular allografts

84
Q

What technical aspects of allografting must be heeded to achieve optimal results?

A

Size matching of the graft to the resected segment
Rigid fixation of the graft-host junction
Congruent joint fit
Reconstruction of ligaments, tendons, and joint capsule
Adequite skin and soft-tissue coverage
Local muscle trasfer
Skin grafts
Free flaps

85
Q

How long do patients have to take antibiotics after reconstruction surgery?

A

3 months due to risk of infection

86
Q

What brace should be used for patients who received a proximal femur allograft-prosthesis?

A

Abduction hip brace and crutches for 2-3 months

Followed by a cane

87
Q

What braces should be used for patients who received allografts in the knee?

A

Plaster cast for 8 weeks
Knee ankle foot orthosis (locked then slow ROM). Worn till radiologic evidence of union at the allograft-host junction.
Crutches

88
Q

What braces should be used for allografts of the humerus?

A

Shoulder abduction splint for 6 weeks

Then sling

89
Q

What braces are used for distal radius allografts?

A

Short arm plaster cast

Then volar splint

CJ Atlas of Prosthetics (7 decks)

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