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L18 le amputations
1. Traumatic
Amputations
Douglas G. Smith, MD
Harborview Medical Center
and the University of Washington
Prosthetics Research Study
Amputee Coalition of America
2. I Sometimes Hear
- Very Few Patients
- Not a Big Deal
- Just save Everything You Can
Traumatic
Limb Loss
All Not True !!
3. Ischemia 75-80%
Half of These Folks Have Diabetes
Trauma 10-15%
Tumors 5%
Congenital 5%
Incidence Data
(We’ve All Seen These Numbers)
4. Prevalence Data
University of Washington Survey of Pacific Northwest, 2000
Upper Limb (N=108) Lower Limb (N=747)
Trauma 85.2% 52.3%
Infection 10.2% 23.2%
Vascular Disease 3.7% 21.7%
Gangrene 8.3% 20.9%
Diabetes 0.0% 16.2%
Tumor 1.9% 4.3%
Congenital Deformity 1.0% 3.1%
(Patients Frequently Identified More Than One Etiology)
“Dysvascular” 10.2% (11 / 108) 36.9% (276 / 747)
PVD, Diabetes, Diabetic Infection or Ulcer
5. Incidence versus Prevalence Data:
Estimate of Incidence Data in United States
UE Amputation from: Trauma - 15%
Dysvascular Issues - 80%
Prevalence Data from University of Washington Survey
LE Amputation from: Trauma - 52%
Dysvascular Issues - 37%
Trauma Is A Big Deal !
8. After 18 Months and after Multiple Surgeries:
The docs are very happy as they look at the x-rays.
The man looks at his leg and says -
This is it? I thought it would be normal. This is lousy.
Over the 18 months, the man’s life has totally unraveled,
and he has no clue which why to go !!
9. Hansen ST: The type IIIC Tibial Fracture.
J Bone Joint Surg (Am) 1987; 69:799-780.
Hansen ST: Overview of the Severely Traumatized
Lower Limb. Reconstruction versus Amputation.
Clinic Orthop 24: 17-19, 1989.
Dr Sig Hansen has Pointed Out the Danger of
“Saving Limbs and Ruining Lives”
Sometimes Amputation Can Be a Better Path
10. Care of Patient With Traumatic Amputation
Care of the Amputated Part
Care of Patient With a Mangled Limb
In the Field
(What to Tell the Team)
11. Care of Patient
With Traumatic Amputation
Control Hemorrhage
1. Compression Dressing
2. Dangers of Tourniquet
3. Dangers of Clamping
Splints
1. Decrease Pain
2. Protect Soft Tissues
3. Help Control Hemorrhage
12. Care of the Amputated Part
Place Part in Plastic Bag and Seal
Put Bag in Ice:Water (1:3)
Do Not Soak in Water
- Maceration
Do Not Place Part Directly on Ice
- Direct Thermal Injury
13. Care of Patient
with a Mangled Limb
Control Hemorrhage
1. Compression Dressing
2. Dangers of Tourniquet
3. Dangers of Clamping
Splints
1. Decrease Pain
2. Protect Soft Tissues
3. Help Control Hemorrhage
If Perfusion Exists
Do Not Cool in
(Ice:Water)
15. Upper Limb
Non-Weight Bearing
Can Function with Decreased Sensation
Assistive Upper Limb Often Functions Better than Prosthesis
Decision to Salvage:
Based on the Technical Possibility
and
The Chance of Maintaining Some Useful Function
16. Lower Limb
Weight Bearing is Mandatory
Increased Risks with Decreased Sensation
Modern Prosthesis Often Better than Salvaged Lower Limb
Decision to Salvage:
Based on Providing a Limb that can Tolerate Weight Bearing
Have Some Protective Sensation
Have Durable Skin and Soft Tissue
17. M Mangled
E Extremity
S Severity
S Score
Skeletal & Soft Tissue Injury
Limb Ischemia
Shock
Age
Initial Reports: Score 1-6 : All Saved
Score > 7: All Amputated
Later Report: Not Quite So Confident
Bosse MJ, MacKenzie EJ, Kellam JF, et al:
A Prospective Evaluation of the clinical utility of the lower-extremity injury-severity scores.
J Bone Joint Surg 83(1): 3-14.
18. Many Situations that Lead to Amputation Simply
are Not 100% Predictable:
Severe Infection
Chronic Osteomyelitis
Nonunion
Chronic Pain and “Dysfunction”
Patient Choice
Best Indicators are Hard to Measure:
Severity of Soft Tissue Injury
Volume of Muscle Loss
It Makes Sense
(That We Do NOT Have a Great Crystal Ball)
19. Do What You Feel Is Right !
On the First Night !
Do Not Delay an Inevitable Amputation
I Believe that Only Makes the Emotional Process
Harder for Both the Patient and the Doctor
20. Common Scenario:
Doctor: “I Know that it Needs to Come Off,
But, We’ll Just Keep the Limb
On So That We Can Talk with the Patient
Again, and Let Them Decide”
Patient: “If it Really Is that Bad,
Why Didn’t They Cut it Off
Yesterday”
End Result: Confusion, Doubt, Loss of Trust in Surgical Team
21.
22. Tips in the Emergency Room:
Ask the Patient if They Saw Their Foot or Leg
Ask if They Know Anyone with an Amputation
Tell the Patient that You Will Carefully
Examine the Limb in the OR, That You Will
Save the Limb if it is Possible to Give Them
a Foot They Can Use, BUT that an Amputation
Could Well Be Required.
23. Criteria for Amputation:
Absolute
- Non-Reconstructable Vascular Injury
- Severe Bone and Soft Tissue Loss with
Tibial Nerve Disruption
Relative
- Shock and Elderly with Mangled Limb
- Massive Muscle Loss associated with Bone Loss
- MESS ≥ 7, Especially with No Plantar Sensation
Unknown Long Term (dogma being questioned)
- Isolated Tibial Nerve Disruption
The Sicker the Patient,
the More Urgent the Need for Amputation
24. Details of MESS
Skeletal and Soft Tissue Injury
Low Energy (Closed 0,1, Open 1) = 1 pt
Med Energy (Closed 2, Open 2) = 2 pts
High Energy (Open 3A, 3B) = 3 pts
Very High E (Open 3C, Mangled) = 4 pts
Limb Ischemia
Pulse Decrease, Perfusion Normal = 1 pt
Pulse Absent, Decreased Refill = 2 pts
Pulse Absent, Cool, Paralyzed, Ins = 3 pts
(Double Ischemia Score is > 6 Hours)
Johansen K: J of Trauma, 1990
25. Details of MESS
Age
0 to 29 years = 1 pt
30 to 49 years = 2 pts
Over 50 years = 3 pts
Shock
Systemic BP > 90 mm Hg = 1 pt
Transient BP < 90 mm Hg = 2 pts
Persistent BP < 90 mm Hg = 3 pts
Can Have 11 Points if Ischemia is Less than 6 Hours
(or Up to 14 Points if Greater than 6 Hours)
Johansen K: J of Trauma, 1990
26. M Mangled
E Extremity
S Severity
S Score
Bottom Line:
- Useful Tool in the Thought Process
- NOT a “Crystal Ball”
27. Open Amputation versus Guillotine
Bone Length versus Soft Tissue Coverage
Saving the Knee
Skin Grafts and Amputations
Few Thoughts on
“Traumatic Amputations”
28. Open Amputations
Avoid the Word and Technique of Guillotine Amputation
Guillotine Amputation:
Developed in War Time to Prevent Infections
All Tissue Transected at One Level
The Post-operative Goal is Not Delayed Closure
Treatment Plan is Open Wound Care, Skin Traction, and Late Revision
Open Amputations:
Done With Careful Planning for Early Conversion to a Definitive Amputation
Retain All Viable Tissue
Debride All Non-viable Tissue
Delay Final Bone Cuts Until Definitive Procedure
Bone Can Help Splint and Stabilize the Soft Tissues
Trend Nationally is Towards Longer BKA's If Suitable Soft Tissue Exists
(Bowker)
29.
30. If Not a “Guillotine”
Then What?
“Open, Length Preserving Amputation”
Bone is a Great Internal Splint
Debride Non-Viable Tissue
Repeat Debridements
Final Bone Cuts - At Time of Definitive Amputation
32. Bone Length versus
Soft Tissue Coverage
A Durable Soft Tissue Envelope that is Not Adherent is
Far More Important Than any Specific Bone Length
A Short Transmetatarsal Amputation with Good Soft
Tissue is Infinitely Better Than a Scarred, Painful Forefoot
Amputation
A Well Done Transtibial Amputation, Above the Zone of
Injury is Far More Functional Than a Syme with a
Damaged Heel Pad or a Scarred Hindfoot Amputation
33. If the Knee is Good
(ie: NO Severe Tibial Plateau, NO Severe Arthritis)
If the Extensor Mechanism is Intact
If You Have a Reasonable Way to Cover the Tibia that will
Avoid Adherent Scar and Retain Knee Motion
Obtaining Full Extension is Far More Important to the
Transtibial Amputee than Full Knee Flexion
Extraordinary Measures are OK
to Save the Knee
34. Severe Contusion of the Posterior Flap
Soft Tissue Loss Anterior Aspect
Posterior Flap Failed
41 y.o. Female, Motorcycle Accident
Alaska Sept 2000
35. Transverse Abdominal Free Flap to Save Knee Joint
41 y.o. Female,
Motorcycle Accident
in Alaska Sept 2000
36. Why Is This OK?
Good Muscle Coverage that is Not Adherent
Problem is No Sensation, but has good Padding
Proximal Tibial Not Fractured
Healthy Knee Joint
Is It Great - No !
Better Than a Transfemoral - Yes !
37. 25 y.o. Logger - Crush Injury
Severe crush anterior and lateral
Sup Posterior Muscle - Much better than expected!
Soleus brought over the distal tibial
Gastroc split and wrapped medial and lateral
38. Why Is This OK?
Good Muscle Coverage and Padding, With Healthy Muscle
Skin Graft Applied Over Muscle, Not to Bone
(Even with this, he still gets breakdown over hamstring tendons)
Proximal Tibial Not Fractured
Healthy Knee Joint
Is It Great - No ! Better Than a Transfemoral - Yes !
39. Skin Grafts and
Amputation:
Can Hold Up if Not Adherent to Bone
Need Good Underlying Muscle Padding
Donor Site - Use the Opposite Leg
Donor Scars on the Amputated Limb
Can Interfere with Suspension
Elasotomeric Suspension Sleeves Can Help
With or Without Pin Locks
40. Problem -
Both Men had Major Trouble
with Skin Graft Donor Site Scars -
Can Limit the Choices for Suspension
DO NOT
Take STSG From
Ipsilateral Thigh
(Usually happens during the
salvage efforts !)
42. MTP Amputations
Through MTP Joints
Leave the Cartilage
Barrier to Infection
Better End Bearing
Gait -
More Normal Progression Sequence than TMT
Most Normal Dynamics of all Partial Foot Gait
Most Active Ankle Motion and Calf Musculature
Mick Dillon
Queensland Univ.., Australia
Ph.D. Thesis
Prosthetic Device
Everyone Wants This Cosmetic Slipper Style Device
Rare that Anyone Uses it for More than a Few Months
43. Ray Amputations
Toe and Some or All of Corresponding Metatarsal
With Each Ray Removed
- Increasing Loss of Distal Weight Bearing
1st Ray 2 Sesmoids - “2/6 ths”
Rays 4-5 1 Point of Contact - “1/6 th each”
44. Ray Amputations that Usually Work
Isolated 2,3,4,5
Rays 4 and 5 in Combination
First Ray - Can be Tough
Second MT Head Overload
Medial Edge of Residual First Ray
Much Care Needed in Orthosis
45. Transmetatarsal / LisFranc Amputation
Think of Both as Midfoot Amputations
Very Similar Surgery, Rebalancing, Post-op, and Function
Shorten Bone Level so Flap is
Well Padded and has No Tension
Can do First MT/Cuneiform Disarticulation
plus TM at Base of 2,3,4,5
Keeps Peroneus Brevis Attachment
Always Consider Tendon Achilles Lengthening
Cast Post-Op to Prevent Equinus
50. Prosthetic Device
Blocks Motion
Push off Hurts
Lacks Shock Absorption
Too Long
Better Off with Transtibial ?
Probably Yes
End Result - ONLY FAIR
Walking - Just OK
Unable to Run
Impact Activity Hurts
ROM - Not Functional
Cannot “Push Off”
51. Hindfoot Amputations
Chopart - Saves Talus and Calcaneus
Boyd - Talectomy + Calcaneal / Tibial Fusion
Forward Translation of Calcaneus
Pirgoff - Talectomy + Calcaneal / Tibial Fusion
Forward Rotation of Calcaneus
Boyd and Pirgoff used primarily in children as alternative to the
Syme. Preserves physeal growth and provides a more secure
heel pad attachment
52. Chopart - Saves Talus and Calcaneus
Old Technique
Ant Tib Tendon to Talus
Achilles Release
No Bevel
New Technique
Ant Tib Tendon to Calcaneus
Full Achilles Release
Bevel Distal, Inferior Calcaneus
53. New Technique
Ant Tib Tendon to Calcaneus
Bevel Distal, Inferior Calcaneus
Full Achilles Release
54. Partial Foot Amputation In Trauma
Harris WR, Silverstein EA: Partial Amputations of the Foot: a
Follow-up Study. Can. J Surg. 7:6, 1964
Millstein SG, McCowan SA, and Hunter GA: Traumatic Partial
Foot Amputations in Adults - A Long Term Review. J of Bone
and Joint Surgery, Vol 70-B, p 251-254, 1988;
Quality of the Soft Tissue Padding
is MUCH More Important to the Outcome
than Any Particular Length of Bone !!
57. Free Flaps on the Foot ?
Can Be Done, But Leads to Predictable Problems
Tissue Without Sensation - can lead to ulceration
Excess Mobility - often dramatic
Unstable in Weight Bearing
Devices - Many Possible Designs
Goals - Contain, Protect, Keep Centered, Pad
Our Best Success - Custom Leather Lacers
Circumferential Control
Leather is skin friendly
Stays can add extra Support and Control of Foot
Silicon Pads in Select Areas
We Have Not Had Great Success with Rigid Devices
58. Syme’s Amputation
One or Two Stage Surgery
Wagner - Recommended two stage
Current - One stage if experienced with techniques
Stabilization of the Heel Pad
Suture of Achilles to Posterior Tibia
Excision of Subchondral Bone - Scar
Temporary Pin Stabilization
Attach Anterior Tendons to Fat Pad
61. Bulbous Shape -
makes Socket fit more challenging.
“Dog-ears” - left to avoid narrowing
the waist of the Flap.
62. Historically, physicians probably have overstated the actual ability
for a person with a Syme level amputation to walk without a
prosthesis.
While some individuals can take a few steps without their artificial
leg, especially when transferring, getting around the bathroom, and
a few steps around the house, most need a prosthesis for routine
walking.
A person with a transtibial-level amputation is unable to do this at
all, and must resort to hopping or crawling. With the Syme, some
very limited walking without a prosthesis is possible
(My Personal Experience and Opinion, Published In the
Amputee Coalition of America’s inMotion Magazine,
May-June 2003, DG Smith, )
63. Syme’s Amputation
This Level is Fairly Rare in Trauma !!!
Usually the Heel Pad is Sufficiently Damaged and in
the Zone of Injury
Tender Heel Pad -
Leads to Very Limited Function !
In This Situation - Transtibial Level is Better
64. Transtibial Amputation
Posterior Flap is Standard
- Cylindrical Not Conical Shaped Limb
- Tolerates Total Contact Type Fit
- More Durable
But In Trauma - Sometimes there is no
good posterior tissue.
65. - Flap Length = Diameter + 1cm
- Ideal Limb Length
Think End of Flap
- Slight Angle Back to Incisions
- Fibula 1 to 2 cm Shorter
-Myodesis to Anterior Tibia
Periosteum or Drill Holes
Transtibial Amputation Surgical Tips
66. BKA with Only Fasciocutaneous Flaps,
and Very Limited Muscle Can Be Functional
Especially With the Addition of Elastomeric (Silicone)
Suspension Sleeve inside of the Pelite Liner
67. Optimal Transtibial Amputation Length
Old School:
"Always Cut the Tibia One Hands Breadth Below the Tibial Tubercle"
John Bowker - the Value of Longer Transtibial Amputations
Stronger Lever Arm
More Surface Area for Prosthetic Interface
More Balanced Muscles
Do Not Amputate in the Distal 1/3 to 1/4 of the Tibia:
No Suitable Soft Tissue Padding
Limits Space Below the Residual Limb
Prosthetic Components can Absorb Shock and Provide Elastic Response
Ideal Length - Is For the Distal End of a Long Posterior Flap Technique to be at
the Junction of the Soleus and the Achilles Tendon
68. Long BKA can Better Distribute the Forces on the Pre-Tibial
Regions, and Improve Comfort and Function.
Note: Pedal Out Under the Toe on the Sound Limb, and
Back Near the Hindfoot on the Amputated Side.
70. First Described in Literature 1830
Benefits
Disadvantages
“ Current Technology Has Overcome
All the Prosthetic Objections ”
S. Perry Rogers, MD
Chicago, IL
JBJS Vol. 22, 1940
71.
72. Must Consider:
• How Will the Patient Transfer
• What Contractures are Present
• What Contractures will Occur
• Surface Area and Support for Sitting
(Protect the Back Side)
Non - Ambulatory Patients
Different Concerns and Goals
73. • Longer Lever Arm
• Balanced Thigh Muscles
• Improved Suspension
• End Bearing
• Lower Proximal Socket Brim
• Sitting Comfort
For Ambulatory Patients
Knee Disarticulation is Usually More
Functional Than a Transfemoral Amputation
75. North American Experience with Knee Disarticulation with
Use of a Posterior Myofasciocutaneous Flap. Healing Rate and
Functional Results in Seventy-Seven Patients.
80 KDs in 77 Patients Age 19 - 92 y.o. (average 64)
31 Diabetes 29 PVD 14 Trauma 2 Sarcoma 1 Ollie's Disease
RESULTS:
5 Patients Died Early in Post-op Period
67 Healed (89%) --- 63 primarily (84%)
7 Major Dehiscence revised to Transfemoral (9%)
22 of 27 who walked Pre-op Successfully
Used a Prosthesis and Walked Post-op
Technique Provided a Comfortable, Well Padded,
End-Bearing Residual Limb
Bowker JH, San Giovanni TP, Pinzur MS
J Bone Joint Surg Am 2000 Nov;82-A(11)
77. Sagittal Flap
Technique:
38 of 46 (83%) Healed Overall
30 of 34 (88%) Healed in Non-ambulators
felt to have the potential to heal a BKA
8 of 12 (67%) Healed in Ambulators
felt not to have the potential to
heal a BKA
Pinzur, Smith, Daluga, Osterman
JBJS Vol. 70-A, 1988
79. BKA TKA AKA
(n=24) (n=17) (n=18)
Don and Doff Prosthesis 100% 70% 56%
Daily Use of Prosthesis 96% 76% 50%
> 9 Hours / Day 54% 41% 22%
6- 9 Hours / Day 17% 11% 6%
3-6 Hours / Day 16% 24% 22%
< 3 Hours / Day 13% 24% 28%
No Use for Prosthesis 4% 12% 39%
Function after Through-Knee Compared
with Below-Knee and Above-Knee Amputation
Hagberg E, Berlin OK, Renstrom P. -- University of Gothenburg, Sweden.
Prosthet Orthot Int 1992 Dec;16(3):168-73
80. LEAP
Study:
With Outcome Tools Used: (SIP)
No Difference Between Salvage, BKA and AKA
Knee Disarticulation (n=18) Scored Worse
- Case Review Could Not Find Why
Looked at Patallectomy, Condylar Trimming, Muscle Coverage
- There are several unique patients circumstances that
makes analysis tricky.
- Small numbers make definitive conclusions difficult.
81. Knee Disarticulation versus
the Supracondylar
Amputation
Knee Disarticulation With Good Soft Tissue Envelope:
Longer Lever Arm
Balance Thigh Muscles
End Bearing
Suspension of the Prosthesis on the Femoral Condyles
BUT: If the Flap Is Traumatized, Likely to Be Scarred, Painful, or
Adherent …
Then a Supracondylar Amputation Is Much Better
82. Transfemoral (Above Knee) Amputation
Muscle Stabilization is Extremely Important
Deforming Force into
Flexion (Iliopsoas) and Abduction (Abductors)
Myodesis with Post / Medial Muscle (Adductors)
Stronger Limb
Femur Centered in Muscle Mass
Less Adductor Roll
83. Transfemoral - with No Muscle Stabilization - Ouch!
Transfemoral - with Good Muscle Stabilization !
84.
85.
86. Intra-Op Ace Wrap Spica
Up Around Waist
At Day 3-5 Post-op
Shrinker with Waist Belt
Simple Wrap
Rolls Down
Hard To Re-Wrap b/o Pain
“Extra Turn at the Top -
To keep it in Place”
Tourniquet Effect
88. Extraordinary Measures to
Save the Hip
19 y.o. Female, Victim of Shark Attack
Transferred - South Pacific - Panama - Seattle
89. Occasionally Use Traction
Techniques in Amputations
Skin Traction
Dates Back Over 100 years
Used Over Open Wounds to Save Length
Elastomeric Sleeves Can be Used Instead of Glued Stockinette
Home Set-up Possible
Start at 2 lbs, Slowly Work Up Towards 5 lbs
Decrease Weight if Skin Blisters
90. Traction facilitated closure and preservation of length.
Revision performed after 18 months because of scar irritation.
91. Hip Disarticulation and
Transpelvic Amputations
(Hemi-Pelvectomy)
Tumor or Severe Trauma
Last Resort in Vascular Disease
Prosthesis is Heavy and Difficult
Many Patients Still Require
Crutches or Walker
Many Choose Not to Use
Prosthesis
95. Post-Operative Amputation
Dressings
Partial Foot, Syme, Transtibial, and Knee Disarticulation:
Rigid Dressing - Avoids Knee Contractures, Protects the End of the
Amputation, Documented Less Pain, Ability to Facilitate Rehabilitation
Soft Dressings - Pain Response is for the Patient to Hold the Leg With
Knee and Hip Flexion, This Can Cause Contractures. If ACE Bandages
Are Applied Poorly, They Can Cause Congestion, Edema, and Wound
Problems
Removable Splints - Very Useful for Open Wounds, STSG, Post-operative
Amputation Infections. The Splint Needs to Hold the Knee in Extension,
and Protect the Distal End of the Amputation
96. Post-Operative Amputation
Dressings
Transfemoral and Hip Disarticulation Levels
Rigid Dressing Techniques Are Available and While They Facilitate
Standing and Walking They Can Make Sitting, Transfers and Toilet
Activity Very Difficult
Shrinker Socks With Waistband or Spica ACE Wrap Work Well
Avoid the Middle of the Night, Isolated AKA Wrap That
Puts “An Extra Turn at the Top to Keep It On”
97. Active Young Trauma Victim
Early Weight Bearing
In Immediate Post-Operative
Prosthetic Cast
and Foot Attachment
98. Amputee Rehabilitation
Traumatic Amputation Above The Zone Of Injury:
Casting and Early Weight Bearing Protocols
Traumatic Amputation Involving the Zone Of Injury:
Commonly These Amputations have some Marginal Tissue or Recent Skin
Grafts
A Rigid Dressing of Cast or Splints Is Used to Prevent Knee Flexion
Contractures, and Protect the Limb From Outside Injury
If Open Wound Care is Required, a Thermoplastic Posterior Amputation
Splint can be Fabricated to Allow Wound Care but Provide the Benefits of
Contracture Prevention and Pain Relief
102. Many Amputees Prefer Non-Impact
Sports and Activities
Although Running and Impact Sports
Are Possible
Many Choose Other
Activities because of the Discomfort
and Sores that Can Result from
Repeated Impact
103. Employment, Sports,
and Recreational
Activities
The Concept of "Good Days and Bad Days"
Makes Defining Work Conditions Difficult.
What Will the Amputee Do on the 2 to 4 Days a
Month When They Have a Skin Sore, Soreness
From Overexertion, or Cannot Wear their
Prosthesis.
104. Dr Burgess Understood
The Ancient Philosophers
----------
The Purpose of Life
Is To
Create Enthusiasm
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Lower Extremity
Index
