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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 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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