Amputations
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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
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| Amputation statistics cont... | -Present day:
-Trauma-related amputations (45%)
-MVC, gun shot wounds, & war
-Usually young men
-Tumors (<2%)
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| 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
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| 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.
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| 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
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| 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
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| Tissues affected by amputation | -Blood vessels
-Nerves
-Bones
-Muscles
-Skin
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| Hemostasis is achieved by | -Binding major veins and arteries
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| Cauterization is used for | -Small vessels
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| Important that care is taken to... | -Not compromise circulation to distal tissues including skin flaps
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| 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
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| Muscles | -Muscles stabilization to other tissues allows for max retention of function
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| Myofasical | -muscle to fascia
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| Myoplasty | -muscle to muscle
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| Myodesis | -cut muscle to bone
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| Tenodesis | -tendon to bone
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| 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
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| Ertl procedure | -Tibfib bone bridge
-Facilitates natural bridging
-Better load bearing
-Better shaping
-Less muscle retraction
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| Skin flaps are left... | -broad
-equal length flaps results in incision at distal end
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| Scar should be... | -Pilable, P!less, non-adherent
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| 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
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| Skew flap | -Diagonal scar for better blood circulation
-Medial lower leg more vascular than lateral
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| Partial toe amputations | -Removal of part of toe(s)
-Won't affect function significantly
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| Toe disarticulation | -Removal at MTP joint(s)
-Most problems with great toe
-May require foot orthotic for arch support because of lost medial support
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| 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
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| Ankle amputations: Syme's | -Removal just above the malleoli
-Ankle disarticulation
-No foot remains
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| Ankle amputation: Pirigoff | -Aka Modified Syme's
-Calcaneus saved
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| Transtibial Amputations (more common) | -Aka Below Knee Amputations (BKA)
-Sublevels (% of tibia remaining)
-Long- > 50%
-Standard- 20-50%
-Short- < 20%
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| Knee disarticulation | -Perf. through tibiofemoral jt
-Will need prosthesis with a special knee jt.
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| Transfemoral Amputations (more common) | -Aka Above Knee Amputations (AKA)
-Sublevels: % of femur remaining
-Long- >60%
-Standard- 35-60%
-Short- <35%
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| Hip and Pelvis Amputations | -Most perf. either for tumors or severe trauma
-Represent a small percentage of the amputee population
-Disarticulation- through the joint
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| Hemipelvectomy | -Lower 1/2 of pelvis removed
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| Hemicorporectomy | -Everything below L4 removed; not common
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| 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
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| 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
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| Post-operative dressings | -Swelling control/Increase venous return
-RL formation
-Prevent:
-Flesh role (superomedially)
-Flexion contractures
-Comfort
-Protection/hygiene
-Desensitization
-Proprioception with earlier walking
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| Immediate Postoperative Prosthesis (IPOP) | -Not removable
-Then there are Removable Rigid Dressings (RRD)
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| Semi-rigid-Unna boot | -Compression dressing
-100% cotton gauze
-Impregnanted with a non-hardening zinc oxide paste
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| 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
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| 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
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| 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
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| 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.)
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| Negative influences | -Infection
-Smoking
-Severity of vascular problems
-DM
-Renal Disease
-Cardiac Disease
-Obesity
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| Positive influences | -Earlier rehab
-Longer > shorter RL
-Unilateral > bilateral amputation
-A well-healed, well-shaped RL without scar adhesions
-Younger age
-Insignificant PMH
-Compliance
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| 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
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