Introduction to amputations & examination of patients with amputations

Question 1

Main cause of amputations

Answer 1

Non-healing ulcer (85%)

Question 2

Dysvascular or neuropathy related complications

Answer 2

Includes PAD, PVD, and Diabetes 81%

Question 3

Preventing dysvascular causes of amputations

Answer 3

• 25% of patients with diabetes will undergo amputation
• 50% of patients undergo contralateral amputation in 5 years
• Prevention: exercise, smoking cessation, diet, pharm interventions, foot wear, skin care

Question 4

Non-dysvascular causes of amputation

Answer 4

• Trauma (17%)
• Vehicular or work related accidents
• Violence or warfare
• Burns
• Cancer (1%)
• Congenital (1%)

Question 5

Incidence

Answer 5

• Lower limb 11 times more likely than upper limb
• Of lower limb amputations: toes (33%), transtibial (28%), transfemoral (26%), Foot/ankle (11%), knee disarticulation (<1%)

Question 6

Surgical process of amputation

Answer 6

• Incisions made distal to amputation
• Veins and arteries clamped at most distal point
• Nerves & tendons are allowed to retract
• Bones are beveled
• Opposing muscle groups may be sutured to each other (myoplasty) or to the bone (myodesis)
• Incisions are sutured on non-WB surfaces whenever possible

Question 7

Toe levels

Answer 7

• Phalangeal
• Metatarsal head,
• Ray resection (generally performed on non-healing ulcer)

Question 8

Toe process

Answer 8

• Sesamoids removed
• May be at metatarsophalangeal, interphalangeal, or through phalanx
• Incisions sutured along anterior or dorsal aspect of foot

Question 9

Foot levels

Answer 9

• Transmetatarsal (TMA)
• Lisfranc procedure - tarsometatarsal disarticulation
• Chopart procedure - midtarsal disarticulation

Question 10

Foot process

Answer 10

• Tendons are transferred to promote muscle balance, heel cord may be lengthened
• Incision sutured along anterior or dorsal aspect of foot

Question 11

Ankle Levels

Answer 11

• Symes procedure - talocrural disarticulation

Question 12

Ankle Process

Answer 12

• Tendons are transected, except the achilles
• Talus is disarticulated & malleoli are trimmed
• Soft tissue heel pad is anchored to tibia & fibula
• Likely to have drain

Question 13

Transtibial (TT or BK) levels

Answer 13

• Ideal length is approximately 15 cm (33-50% of original length) - mechanical advantage is 40-50%
• Short residual tibia - improved comfort with increased surface for weight bearing; mechanical disadvantage
• Long residual tibia - prosthetic options limited

Question 14

Transtibial (TT or BK) process - long posterior flap

Answer 14

• Anterior and distal tibia smoothed
• Fibula generally 2 cm shorter than tibia
• Incision approximated anteriorly
• Highly vascular gastroc can be pulled forward to protect distal end of tibia, tendon secured to anterior compartment fascia
• Will likely have drain placed

Question 15

Transtibial (TT or BK) process - Modifications

Answer 15

1. Removal of fibula, particularly for short limbs
2. Removal of soleus and anterior tib most common, but may remove all lateral and anterior compartments, lateral gastroc
3. Alternate incision lines - ERTL - osteomyoplatic (create bony bridge between tibia and fibula, closing intramedually canal; heterotopic ossification (abnormal bone growth, normally at distal end of amputation)

Question 16

Knee Disarticulation levels

Answer 16

• Most leave femoral condyles intact

- Transcondylar - remove condyles and flatten distal femur; mechanical advantage to increased length and weight bearing

Question 17

Knee Disarticulation Process

Answer 17

• Quad tendon transected at tibial tubercle
• Collateral & cruciate ligs transected at distal attachment
• Muscle stability: ITB, biceps femoris, quad tendon
• Distal gastroc is attached to anterior joint capsule

Question 18

Transfemoral (TF or AK) level

Answer 18

• Ideal length preserves 50-66% of femoral length
• Shorter length difficulty with suspension
• Longer length difficulty with prosthetic options

Question 19

Transfemoral (TF or AK) Process

Answer 19

• Incisions should be made to preserve adductor magnus

- Incision along distal residual limb or slightly anterior is most common

Question 20

Hip & Pelvis levels

Answer 20

• Hip disarticulation - pelvis intact; femur dislocated from acetabulum
• Hemipelvectomy - External = removal of half of pelvis; Internal - removal of portion of pelvis

Question 21

Hip & Pelvis Process

Answer 21

• Incision made for long posterior flap
• Neurovascular structures are stabilized
• Hip disarticulation - muscles crossing hip joint detached; gluteal muscles detached from greater troch; posterior flap sutured anteirorly

Question 22

Post-op Care

Answer 22

• Pain
• Wound care
• Skin care
• Edema management
• Limb shaping
• Post-op dressing

Question 23

Phantom sensation & pain

Answer 23

• Almost all patients experience phantom sensations

- 50% of patients will have phantom pain

Question 24

Reason for phantom sensation

Answer 24

• Peripheral neuroma
• Spinal cord mechanisms
• Central mechanisms and cortical remapping

Question 25

Interventions for pain

Answer 25

1. Nerve block
2. Prescription medications
3. Physical therapy

Question 26

Surgical incision

Answer 26

• Initial post op dressing for 2-5 days
• Staples or sutures for at least 2 weeks
• Wounds are usually covered as long as they are draining
• Antibiotics to prevent infection but 25% of patients get them
• Complicated wounds or poorly healing ones may have skin grafts or wound VACs

Question 27

Skin Care

Answer 27

• Patient education for regular skin checks
• Moisture
• Sound side considerations: increased shearing, weight, skin checks

Question 28

Edema control benefits

Answer 28

• Decreased pain
• Increased wound healing
• Protection during mobility
• Desensitization
• Shaping for prosthesis (cylindrical to conical)

Question 29

Soft Dressings & Compressions

Answer 29

• Ace wrap
• Shrinker socks
• Custom pressure garments

Question 30

Ace wraps

Answer 30

• Can be used at amputations of all levels
• Helps control post-op edema
• Inexpensive
• Easily removed
• Does not offer a lot of protection
• Reapply frequently (every 4-6 hours)

Question 31

Ace wrapping precautions

Answer 31

• Severe pain
• Infection
• Wound dehiscence
• Impaired sensation
• Elevated BP
• DO NOT use on patient with wound vac

Question 32

Ace wrap application

Answer 32

• Figure 8/diagonal pattern
• Must cover all skin, smooth application, no wrinkles
• Distal to proximal graded pressure

Question 33

Shrinker socks

Answer 33

• Can use when suture line is healed enough to tolerate shearing forces
• May be shaped at bottom or tubular
• Measured for proper fit
• Generally twisted at the end and reflected back up the residual limb
• Continued use during prosthetic phase

Question 34

Custom pressure garments

Answer 34

• Jobst
• May be beneficial for long term wear if shrinker socks are challenging
• Difficult to develop early post-op due to significant volume changes initially

Question 35

Non-removable rigid dressings

Answer 35

• Common for TT amputations
• Helps to protect residual limb and maintain position of knee
• Potential for skin breakdown
• Unable to monitor wound healing
• Appropriate for patients with good sensation and lower risk for infection

Question 36

Removable rigid dressings

Answer 36

• May be bi-valved non-removable rigid dressing or plaster/fiberglass cap
• Benefits = ability to monitor wound and skin

Question 37

Semi-rigid dressings

Answer 37

• Similar to removable rigid dressings except made from polyethylene
• Requires prosthetist for fabrication, higher costs associated
• Able to be cleaned
• Can be found pre-fab with adjustable straps

Question 38

Immediate post-op prosthesis

Answer 38

• For patients who are partial WB
• Allows patients to ambulate earlier following amputation
• Dressings with ability for pylon attachment
• Non-removable rigid dressing
• Pneumatic compression

Question 39

Patient education

Answer 39

• Positioning (*hip extension)
• Skin care/checks
• Pain management
• Exercise program
• Safety