Download RTC AMPUTATION

Amputation
Mamoun Nabri
Trauma Fellow
03/23/2010
History
• 1700 BC, Babylonian
code of Hammurabi, the
earliest literature
discussing amputation
• Hippocrates,
therapeutic
amputation for vascular
gangrene
History
• The patient would be
held down by a number
of assistants and be
given alcohol (usually
rum).
• The patient would
essentially be awake
and aware during the
procedure.
History
• 1st century, cautery,
ligatures, removal of
gangrenous extremity
through the viable tissue
edge with a bone cut
shorter than the soft
tissues
• 1529 - Ambroise Pare,
thick ligature used as a
tourniquet
• 1588 – William Cloves –
1St AKA
History
• 1781 – John Warren
successful shoulder
amputation
• 1943 – Major General
Norman T. Kirk,
guillotine amputations
Introduction
• USA, 30,000-40,000 amputations are performed
annually.
• 1.6 million individuals living with the loss of a limb in
2005; expected to be 3.6 million year 2050
• Dysvascular amputation , 15-28% contralateral limb
amputations within 3 years.
• Elderly, amputations, 50% survive the first 3 years.
• 1965, above-knee amputations to below-knee
amputations was 70:30, the value of retaining the knee
joint, so the ratio became 30:70.
Pathophysiology
• The higher the level of a lower-limb amputation,
the greater the energy expenditure.
• As the level of the amputation moves proximally,
the walking speed of the individual decreases,
and the oxygen consumption increases.
• The soft-tissue envelope of the residual limb now
becomes the proprioceptive end organ for the
interface between the residual extremity and the
prosthesis
Pathophysiology
• For effective ambulation, this envelope should
consist of a sufficient mass of mobile
nonadherent muscle and full-thickness skin
and subcutaneous tissue that can
accommodate axial and shear stress within
the prosthetic socket.
• Load Transfer/Weight-Bearing
• Pain is still a problem for many patients who
have undergone lower-extremity amputations.
Metabolic cost of walking with an
amputation
Indications
• Circulatory disorders
– Diabetic foot infection or gangrene (the most common reason for nontraumatic amputation)
– Sepsis with peripheral necrosis
• Neoplasm
• Trauma
– Severe limb injuries
– Traumatic amputation
• Deformities
– Deformities of digits and/or limbs
– Extra digits and/or limbs (e.g. polydactyly)
• Infection
– Soft tissue
– Bone infection (osteomyelitis)
• Burn, Frostbite
When to Amputate
• Trauma is the leading indication for
amputations in younger patients
• Scores:
– The Predictive Salvage Index (PSI)
– The Limb Injury Score (LIS)
– The Limb Salvage Index (LSI)
– The Mangled Extremity Syndrome Index (MESI)
– The Mangled Extremity Severity Score(MESS)
Predictive Salvage Index (PSI)
• Combined orthopaedic and vascular injuries.
• Intent to help prevent the attempted salvage
of a doomed or useless limb.
• A limb-salvage score was developed that
weighted:
– Level of the vascular injury
– Degree of osseous injury
– Degree of muscle injury
– Warm ischemia time
Limb Salvage Index (LSI)
• Limb trauma associated with vascular injury.
• Absolute indications for amputation included a score of 6
or more.
• Seven components related to injury:
–
–
–
–
–
–
–
Arterial
Nerve
Bone
Skin
Muscle
Deep venous injury
Warm ischemia time
Mangled Extremity Severity Score (MESS)
• Skeletal / soft-tissue injury
Low energy (stab; simple fracture; pistol gunshot wound):
Medium energy (open or multiple fractures, dislocation):
High energy (high speed MVA or rifle GSW):
Very high energy (high speed trauma + gross contamination):
Limb ischemia
Pulse reduced or absent but perfusion normal:
Pulseless; paresthesias, diminished capillary refill:
Cool, paralyzed, insensate, numb:
Shock
Systolic BP always > 90 mm Hg:
Hypotensive transiently:
Persistent hypotension:
Age (years)
< 30:
30-50:
> 50:
* Score doubled for ischemia > 6 hours ,
Johansen et.al. 1990
1
2
3
4
1*
2
3*
0
1
2
0
1
2
Surgical Principles
• Determination of Amputation Level
• Technical Aspects
– Meticulous attention to detail and gentle handling of soft tissues
• Skin and Muscle Flaps
– stabilized by myodesis (suturing muscle or tendon to bone)
– at their normal resting functional length.
– Jaegers et al. showed that transected muscles atrophy 40% to 60% in
2 years if they are not securely fixed
• Hemostasis
– a tourniquet is highly desirable, pressures of 135 to 255 mm Hg for
the upper extremity and 175 to 305 mm Hg for the lower extremity
were satisfactory for maintaining hemostasis. Younger et al
– Major blood vessels should be isolated and individually doubly
ligated
– A drain should be used in most cases for 48 to 72 hours.
Surgical Principles
• Nerve;
– Gentle traction,
– Nerves should not be clamped, as this iatrogenic
crush injury might lead to late neurogenic pain, even
if the crushed nerve is removed.
• Bone ; avoid excessive periosteal stripping
• Wounds should not be repaired under tension,
since doing so risks infection, tissue failure, or a
nonresilient soft-tissue envelope.
• Open amputation
Surgical Principles
• Bony prominences around disarticulations are removed
with a saw and filed smooth.
• Maintaining the maximal extremity length possible is
desirable.
• One application guide is to make a limb 2.5 cm long for
every 30 cm of body height.
• However, below-knee amputations are best performed
12.5-17.5 cm below the joint line for nonischemic
limbs.
• For ischemic limbs, a higher level of 10-12.5 cm below
the joint line is used because making limbs longer than
this can interfere with prosthetic use and design.
Complications
•
•
•
•
•
•
Hematoma
Infection
Wound necrosis
Contractures
Pain
Dermatological problems
Pain
• Chronic pain appears to be more related to the
crushing nature of the injury than to the
amputation itself.
• The pain literature suggests that early neural
blockage is the best method to minimize late,
residual or phantom limb, or neurogenic pain.
• This is probably best accomplished with an
indwelling epidural catheter placed at the time of
the initial treatment or with postoperative
infusional continuous regional anesthesia (PICRA)
“High-technology” transfemoral
prosthesis
• Lightweight prosthesis
has a flexible ischial
containment socket,
• High-performance
hydraulic knee
• Dynamic elastic
response prosthetic
foot with a shock
absorber to dissipate
the stresses of weight
bearing
References
• Murdoch G, Wilson AB Jr, eds. Amputation: Surgical Practice
and Patient Management. St Louis, Mo: ButterworthHeinemann Medical; 1996.
• Tooms RE. Amputations. In: Crenshaw AH, ed. Campbell's
Operative Orthopedics. Vol 1. 7th ed. St. Louis, Mo: MosbyYear Book; 1987:597-637.
• http://www.wheelessonline.com/ortho/mangled_extremity_sev
erity_score_mess
• Pinzur, M.S., Gold, J., Schwartz, D., et al. Energy demands
for walking in dysvascular amputees as related to the level of
amputation. Orthopaedics 15:1033–1037, 1992
• Browner: Skeletal Trauma, 4th ed
• Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed