Intro - Surgical Techniques Flashcards
What gender has a higher risk for dysvascular and trauma related amputations? What races?
males > females
AA, Hispanics, and Native Americans
What are the 4 causes of amputation? (leading cause to least likely cause)
- diabetes and peripheral artery disease (PAD)
- Trauma
- cancer
- congenital deficiencies
What are the clinical signs of peripheral neuropathy?
- deficits of sensation
- motor impairments
- autonomic dysfunction
What are some examples of autonomic dysfunction with peripheral neuropathy?
- inadequate hemodynamics of the foot
- trophic changes - sweeling, color changes, etc.
What type of distribution pattern does loss of sensation occur in? Does it follow a dermatomal pattern?
- Lose sensation in a stocking glove distribution pattern
- Does NOT follow dermatomes
- Follows in a circular distribution
What are classic symptoms of PAD?
- intermittent claudication
- loss of one or more LE pulses
- leg numbness
- trophic changes
What is intermittent claudication? How do you differentiate from a lumbar/spine condition?
- cramping in the calf that general eases with rest, caused from impaired blood flow (oxygen)
- lumbar conditions usually get better in a flexed position so you can put the patient on the bike and if the symptoms continue then you will know it is not for a lumbar condition
What are recommendatioons for patients with diabetes and PAD?
- daily foot checks
- work on flexibility so they can check their feet
- leather shoes that have support and protection
- white cotton socks so they can see if skin breakdown is occurring
- don’t cut their own toenails - have it done by a pediatrist
What determines limb length and shape with PAD amputations? Traumatic amputations?
- PAD - amount of sensation that is left
- Traumatic - amount of trauma that has occurred
Who is the most common patients for amputations due to cancer?
males in late childhood through early adulthood
What should you look for that may be osteosarcoma?
- pain with weightbearing
- Hx of worsening, deep local pain
- Fractures
Who is most likely for traumatic amputations?
males - 20-29 years old
Myoplasty vs myodesis. What are the benefits of each?
myoplasty - Attachment of anterior and posterior compartment muscles to each other over the end of the bone
- results in better blood flow and is better in the presence of ischemia
myodesis - anchoring of muscles to bone
- increased stability and muscular control
- causes a better line of pull for the muscle
What type of closed amputation will be used when vascularity is of concern?
long posterior flap
What is dehiscence?
surgical closure has opened back up after being initially closed
What type of closed amputation is used for severe dysvascular cases? How does it work?
skew sagittal flaps
- takes advantage of saphenous nerve artery and sural nerve
- removes anterior placement of scar from high prosthetic pressures
- helps with blood flow laterally
What is the shortest level of transtibial amputation that is compatible with knee function?
tibial tubercles
What shape do you want the residual limb in a transtibial amputation?
cylindrical
- DO NOT want conical
What is important to maintain with transfemoral amputations? Why is it difficult to maintain? What type of muscle attachment do surgeons suggest to maintain normal alignment?
femoral shaft axis
- difficult to maintain because of loss of adductor attachment
- myodesis of adductor magnus to femur at the level of amputation for maintaining more normal alignment
What position is the limb maintained during a transfemoral amputation? Why?
- limb maintained in extension and adduction
- done to maintain proper tension and alignment
What type of skin flap is used with transfemoral amputations?
- equal length
- long medial flap in the sagittal plane
What are common issues with all amputations?
- pain
- wound healing
- fluid collection/edema
- heterotrophic ossification
- trauma
What is heterotrophic ossification?
excessive bone growth where it is not supposed to
– really painful, changes where they bear weight, pressure, and often times comes back if removed so it is often left as is
What are common issues with transtibial amputations?
knee flexion contracture
What are common issues with transfemoral amputations?
- hip adductor roll
- hip flexor contracture
- hip abduction contracture
- glute weakness
How is a contracture different than spasticity?
spasticity is velocity dependent and a contracture is NOT velocity dependent
What is a contracture caused by? What can it lead to?
Caused by - Immobility which leads to connective tissue proliferation into the joint space combined with change in muscle and cartilage composition
Can lead to - pain, pressure ulcers, further immobility and functional deficits
What are the benefits of osseointegration?
- eliminates the need for a socket
- short residual limb
- more natural feeling
- improved gait
- allows for normal swelling
What are the downsides of osseointegration?
- multiple surgeries
- prolonged period of no ambulation
- risk of fracture, infection
- reduction in activities that require high torque or axial stress
- not well known in the US
hemicorporectomy
below waist amputation - B LE amputated
transpelvic
amputation of portion of the pelvis and LE
Hip disarticulation
amputation through hip joint capsule including the entire LE
What is the goal with hip disarticulations and transpelvic amputations?
provide the patient with good soft tissue flap for pressure tolerance and comfort with sitting
What are the indications of knee disarticulation?
- inability to provide adequate transtibial residual limb secondary to trauma
- knee flexion contracture > 45 degrees
- infection of soft tissue close to knee joint
- congenital deformities
- rarely used in individuals with vascular compromise
What is a Symes amputation? What must the patient have?
Amputation through the ankle preserving the heel pad
- must have circulation to heel pad to be successful
What is the most significant factor for positive adjustment after an amputation?
premorbid coping mechanism
What are the 4 stages of emotional adjustment to amputation? Does everyone follow the stages or experience each stage?
- 1st prior to surgery - initial shock
- immediately after surgery
- after initiation of post-op program
- reintegration into functional lifestyle
- May or may not follow this sequence or experience each stage
When is stage 1 of emotional adjustment to an amputation? What statement should you avoid and what statement should you use?
- prior to surgery
- awareness that amputation may occur
- Greif likely the first reaction
Refrain from - “Oh no, no, don’t even think that.”
Utilize more reflective response - “I understand your concerns about your foot.”
When is stage 2 of emotional adjustment to amputation?
- immediately after surgery
- grief likely
- Individuals may experience insomnia, restlessness and difficulty concentrating
When is stage 3 of emotional adjustment to amputation? What should be avoided and what may be helpful?
- acknowledgment of amputation - post-op program
- Many individuals mourn not only the loss of the limb but also anticipated loss of previous lifestyle (job, activity, etc)
- Feelings can alternate between hopelessness, despondency, bitterness and anger
- Avoid overwhelming patient with information
- Private or group sessions with individuals who have made successful adjustments may be helpful
What is stage 4 of emotional adjustment to amputation? What are concerns?
- adaptation
- reintegration into functional lifestyle
Concerns regarding prosthesis
- appearance
- functionality
- unrealistic expectations
