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Special Topics
Amputations
| Question | Answer |
|---|---|
| Amputation Statistics | -Early centuries: -Amputations primarily from gangrene and war -Most devices were designed as “peg legs” -Present day: -Major cause is Peripheral Vascular Disease (PVD)- 54%3 -PVD- diseases of blood vessels outside the heart and brain |
| Amputation statistics cont... | -Present day: -Trauma-related amputations (45%) -MVC, gun shot wounds, & war -Usually young men -Tumors (<2%) |
| Amputation statistics cont... | -2013> 2 million living with limb loss ~185,000 amputation/yr in US -50% w/ amputation vascular disease die in 5 yrs -55% of diabetics w/ LE amputation, require amputation of second leg in 2‐3 years -Smokers- increased infection and re-amputation |
| Amputation statistics cont... | -African Americans -4x more likely to amputate than European Americans -Highest males ≥ 75 yrs -Lowered amputation rates Due to advanced diagnostics, revascularization, wound healing -Non-traumatic leg/ foot levels ↓ed 65% 1996-2008 in 40 y.o. |
| Measures to determine level of amputation through examining tissue viability | -Doppler US study of blood vessels -Transcutaneous oxygen measurement (TCOM) of skin circulation by electrodes -Skin blood flow by radioisotope scan |
| What is amputation | -Remove limb portion or segment -Allow for primary or secondary wound healing -Construct residual limb (RL) for optimal prosthetic fitting and function |
| Tissues affected by amputation | -Blood vessels -Nerves -Bones -Muscles -Skin |
| Hemostasis is achieved by | -Binding major veins and arteries |
| Cauterization is used for | -Small vessels |
| Important that care is taken to... | -Not compromise circulation to distal tissues including skin flaps |
| Nerves | -Form neuromas (nerve fiber tumors) in residual limb -Neuromas must be well surrounded by soft tissue to avoid pain & interfere with the prosthesis -Nerves are pulled down under tension, cut, allowed to retract into soft tissue for protection |
| Muscles | -Muscles stabilization to other tissues allows for max retention of function |
| Myofasical | -muscle to fascia |
| Myoplasty | -muscle to muscle |
| Myodesis | -cut muscle to bone |
| Tenodesis | -tendon to bone |
| Bones | -Left at a length to allow wound closure without excessive bone at the distal end of the RL -Sharp bone ends are smoothed and rounded |
| Ertl procedure | -Tibfib bone bridge -Facilitates natural bridging -Better load bearing -Better shaping -Less muscle retraction |
| Skin flaps are left... | -broad -equal length flaps results in incision at distal end |
| Scar should be... | -Pilable, P!less, non-adherent |
| Long posterior flaps | -Improves circulation because the posterior tissues more vascular than anterior -Scar anteriorly over the end of the tibia -Care must be taken to ensure the scar does not become adherent to the bone |
| Skew flap | -Diagonal scar for better blood circulation -Medial lower leg more vascular than lateral |
| Partial toe amputations | -Removal of part of toe(s) -Won't affect function significantly |
| Toe disarticulation | -Removal at MTP joint(s) -Most problems with great toe -May require foot orthotic for arch support because of lost medial support |
| Partial foot (more common) | -Transmetatarsal: Removal at MT level, will need prosthesis to walk normally -Transtarsal: -Chopart (shō-ˈpärz)- removal within the tarsals -Lisfranc (lis-frahnk′)- removal between tarsals and MTs |
| Ankle amputations: Syme's | -Removal just above the malleoli -Ankle disarticulation -No foot remains |
| Ankle amputation: Pirigoff | -Aka Modified Syme's -Calcaneus saved |
| Transtibial Amputations (more common) | -Aka Below Knee Amputations (BKA) -Sublevels (% of tibia remaining) -Long- > 50% -Standard- 20-50% -Short- < 20% |
| Knee disarticulation | -Perf. through tibiofemoral jt -Will need prosthesis with a special knee jt. |
| Transfemoral Amputations (more common) | -Aka Above Knee Amputations (AKA) -Sublevels: % of femur remaining -Long- >60% -Standard- 35-60% -Short- <35% |
| Hip and Pelvis Amputations | -Most perf. either for tumors or severe trauma -Represent a small percentage of the amputee population -Disarticulation- through the joint |
| Hemipelvectomy | -Lower 1/2 of pelvis removed |
| Hemicorporectomy | -Everything below L4 removed; not common |
| Guillotine amputations | -Emergency (quick) amputation -May precede secondary closure with skin flaps -Occasionally, free tissue flaps, taken from some other area of the body, may be used to cover deformities |
| Dirty trauma amputations | -Amputation in the presence of unclean tissue -Secondary Intention healing -Left open so the wound can be cleaned before closure -Trying to decrease the chance of infection |
| Post-operative dressings | -Swelling control/Increase venous return -RL formation -Prevent: -Flesh role (superomedially) -Flexion contractures -Comfort -Protection/hygiene -Desensitization -Proprioception with earlier walking |
| Immediate Postoperative Prosthesis (IPOP) | -Not removable -Then there are Removable Rigid Dressings (RRD) |
| Semi-rigid-Unna boot | -Compression dressing -100% cotton gauze -Impregnanted with a non-hardening zinc oxide paste |
| Cont...post-op dressings | -Soft: elastic wraps (ACE) -Shrinkers -Use 2-3 4” or 6” ACE bandages sewn together -Position: pt. may be supine, SL, or even standing |
| Soft dressing bandaging should be... | Properly tensed including… … decreasing tension distal to proximal … holding hip into extension/adduction with AKA ½ overlapped and void of circular turns and wrinkles |
| Soft dressing bandaging should be...cont... | -Complete and equal coverage including avoiding skin to skin contact i.e. a pinch of skin -Double coverage on distal end -High on inside of groin and lateral glutes with AKA |
| Post-op dressings extras | -Apply dry bandage to dry RL -Wear bandage at all times except for hygiene or treatment purposes -Re-wrap every several hours (4-6 hrs.) |
| Negative influences | -Infection -Smoking -Severity of vascular problems -DM -Renal Disease -Cardiac Disease -Obesity |
| Positive influences | -Earlier rehab -Longer > shorter RL -Unilateral > bilateral amputation -A well-healed, well-shaped RL without scar adhesions -Younger age -Insignificant PMH -Compliance |
| Prognosis | -Increased likelihood of OA:Sound limb- highest; RL -Not as high as sound -Higher in the remaining joints the shorter the RL -Higher likelihood of decreased bone density in RL vs. sound |
Created by:
alovedaytn
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