R.

Richard Coughlin MD, MSc Director of Institute for Global Orthopaedics and Traumatology (IGOT) San Francisco General Hospital/OTI University of California, San Francisco

Introduction

What is the Global Burden of Amputation?

Introduction
Strictly speaking:

We dont know

What we do know
In

US, there are over 80,000 Amputations/yr Globally, estimate of over 1,000,000 Amputations/yr

Care of the Amputee

Surrogate marker for the adequacy of a Health System

Amputation Surgery is Reconstructive Surgery

E.Burgess

Introduction/Goals
Review of the history of amputations Review of lower extremity amputations Review of basic principles Discuss controversies/key points

History of Amputations
1800BC Indian Warrior Queen Vishpla, leg amputated after a battle Fitted with an Iron Prosthesis, returned to lead troops

History of Amputations
Judicial amputations of criminals sanctioned by both Babylonian Code of Hammurabi and Mosaic law.

History of Amputations
Hippocrates war is the only proper school for surgeons Recommended cutting through the insensate gangrene

History of Amputations

25-50 BC Celsus Trans-osseus at level of viable and necrotic tissue

Ligation of vessels/cautery last resort

History of Amputation
Middle Ages-Leprosy and Ergotism St. Anthonys Fire-ingestion bread made of fungus infected rye flour bread. Arterial vasoconstriction + burning sensation hands/feet

History of Amputation

Renaissance-Ambroise Pare reintroduced Celsus

Amputation through viable tissue Using ligatures for hemostasis

Abandoned boiling oil

Napoleonic Era
Dominique-Jean Larrey

Flying ambulances

American Civil War

Union Army
Experience with 20,500 amputations 35.7% Mortality Rate

Joseph Lister Using principles of antisepsis

Handwashing/clean instruments/carbolic acid spray

- Reduced mortality to 15%

World War II

Introduction of Sulfonimides/Penicillin
Marked the beginning of antibiotic era

Burgess Technique

Ernest M. Burgess, MD, PhD (1911-2000)

Tripler Hospital, Honolulu, 1944
1968: Popularized the long posterior flap Skin over the posterior leg has better blood supply that of anterior/lateral leg.

Kendrick, 1956
The posterior flap is made twice as long as the anterior, because gangrene in our experience has affected only the anterior flap.2

2Kendrick

RR. Below-knee amputation in arteriosclerotic gangrene. British J of Surgery. 1956;44:13-17.

Burgess Technique

Source: Burgess EM, et al. Amputations below the knee. p.9-10.

Burgess Technique
Paradigm shift:
Amputation must be considered plastic and reconstructive in nature. The need to create a dynamic and sensory motor end-organ should be foremost in the surgeons mind.The atrophic, wasted, boney, below-knee stump so commonly encountered in years past is no longer acceptable. -EM Burgess, 1969

Burgess Technique

Source: Skinner HB: Current Diagnosis & Treatment in Orthopedics, 4th Ed. http: //www.accessmedicine.com.

History of Amputation

Burgess technique: gold-standard for soft tissue coverage in transtibial amputation.

Cushioned, dynamic stump, well-suited for

prostheses.

With improvements in prostheses, it has revolutionized amputation surgery:

amputation surgery = reconstructive surgery. first step in a rehabilitation process that allows

patients to return to a fully active life.

Burgess: Disadvantages

Requires intraoperative assessment of muscular viability.

if overestimated in patients with vascular

disease (i.e. amputation is too distal) wound healing problems, necrosis, and infection revision Bruckner modification.

Source: Stahel PF, et al. Concepts of transtibial amputation. p.943.

Burgess: Disadvantages

Incision is directly over the anterior aspect of the distal part of the residual tibia:
potential for adherent scarring of skin to tibia Local discomfort, blistering or tissue breakdown from pistoning

between the residual limb and the prosthetic socket during walking. An extended posterior flap provides improved cushioning and comfort.

Source: Pinzur MS et al. Controversies in lower-extremity amputation. p.1125.

Ertl Procedure

1920s Professor Janos Ertl Sr. MD, of Hungary

Osteointegration
Bone anchored vs traditional socket

Lower Limb Levels

1. Foot - Hallux amputation - Lesser toes - Ray - Transmetatarsal - Hinfoot Chopart, Boyd, Pirogoff 2. Ankle - Syme 3. Leg BKA 4. Knee disarticulation 5. Transfemoral AKA 6. Hip disarticulation

Partial Foot Amputations/Foot Salvage

Lower Limb Levels

Surgeons goals
Removal

of diseased, damaged, and dysfunctional part Reconstruction of residual limb

Must Establish
Reasonable functional goal Disease process Unique needs of the patient

Considerations

Limb salvage vs amputation

Which has better outcomes
Leap Study (569 consecutive mutilating

injuries)

Realistic expectations Costs of care Risks

Considerations
Optimal length Reasonably functional proximal joint Durable soft tissue envelope (avoid adherence) Protective sensation (STSG?) Disarticulation vs Transosseous

To Ertl vs not to Ertl

Bone bridge Enhanced surface area for load transfer Proponents vs detractors Young and active

Considerations

Good Scar
Painless, pliable, non adherent, placement

Bad Scar
Tender, adherent, thin, non durable

Considerations

Good stump
Cylindrical, muscle padding

Bad stump
Boney, atrophied, tapered

Indications
Peripheral Vascular disease Trauma Tumors Burns Frostbite Infection

Peripheral Vascular Disease

PVD most common indication for amputation Diabetes 50% Age 50-75 Medical consult for concomitant disease processes Most significant predictor of amputation in diabetics is peripheral neuropathy

Trauma

Trauma is the leading cause of amputation in younger patients Absolute indication for primary amputation is an irreparable vascular injury in an ischemic limb The mangled extremity severity score is the most useful and grades the injury on the basis of the energy causing the injury, limb ischemia, shock, and the patient's age

Tumors

Limb salvage increasingly popular Consider: 1. Would treatment choice affect survival 2. Short and long-term morbidity 3. Function of limb salvage versus a prosthesis 4. Psychosocial consequences

Burns

Thermal and electrical injury produces tissue damage Early debridement and possible fasciotomy Early amputation for unsalvageable limb

Frostbite

Freezing of tissue -direct tissue injury with formation of ice crystals in the ECF and ischemic injury from damage to vascular endothelium, clot formation and increased sympathetic tone Amputation should be delayed for 2-6 months due to long period of time for clear demarcation of viable tissue

Infection
Acute or chronic infection unresponsive to debridement or antibiotics Gas forming organisms are most worrisome in acute setting Anaerobic cellulitis, clostridial myonecrosis, streptococcal myonecrosis

Goals for Amputation

Removal of diseased, injured, or nonfunctioning limb Restore function Preserve length and strength Muscular balance to provide stable residual limb

Preoperative Assessment

Check skin integrity, soft tissues, motor and sensory exam, and joint mobility Vascular status Nutrition and immune competence Psychological preparation

Psychological preparation
amputation as a step for recovery early prosthetic fitting counseling for patient amputee support group

Vascular status

Doppler with ABI: > .45 correlates with 90% healing Toe systolic pressure: min 55mm Hg Transcutaneous oxygen tension: PO2 > 35 for healing Skin blood flow measurement: Xenon 133 Arteriography: patency of vessels

Nutrition and immune competence

Total lymphocyte count > 1500/ml Serum albumin > 3g/dL 86% healing rate in Symes amputations in patients with serum albumin > 3.5 g/dL and total lymphocyte count > 1500/ml

Technical Aspects
Skin and muscle flaps Hemostasis Nerves Bone

Technical Aspects
Skin and Muscle Flaps Scar location Flaps should be thick Avoid adherent skin to bone Myodesis/myoplasty if possible

Technical Aspects
Hemostasis

Tourniquet (except ischemic limb) Exsanguination with Esmarch (not with infection/tumors) Major vessels identified and ligated Tourniquet deflated prior to closure Drain

Technical Aspects
Nerves

Neuromas=Pain=Frequent cause of Failure

Must identify nerves

-gentle traction and sharp division

Neuroma resection can be Gratifying

Technical Aspects
Bone
Avoid excessive periosteal stripping - ring sequestra - bony overgrowth Resect bony prominences Heterotopic Ossification

Post Op Care
1. Multi-disciplinary team approach 2. Conventional soft dressing > rigid dressing Plaster of Paris cast applied immediately, change weekly 3. Drains removed at 48 hours 4. Avoid dependency 5. PT to mobilize joints, prevent contractures, ambulate 6. Early weight bearing - Suitable in some cases - prosthetic cast should be applied

Complications
Hematoma
Delayed wound healing Meticulous hemostasis Drain Rigid dressing

Complications
Infection
More common in PVD patients with DM Antibiotics Surgical debridement

Complications
Wound necrosis
Consider pre-operative selection of amputation level Transcutaneous oxygen level Nutritional assessment Nutritional supplements promote healing Smoking cessation Small areas of necrosis < 1 cm treated with wound management

Complications
Contractures
Proper positioning Gentle passive stretching Exercises to strengthen muscles controlling joint Ambulation

Complications
Pain
Accurate diagnosis Mechanical LBP more common in amputees Phantom limb pain vs. residual limb pain Poorly fitting prosthesis Neuroma Phantom limb sensation very common Phantom limb pain < 10% Many treatment options

Complications
Dermatological problems
Contact dermatitis/ Bacterial folliculitis Epidermoid cysts at socket brim Verrucous hyperplasia wartlike overgrowth at end of stump Prevention of skin problems by properly fitted prosthesis Prevention of skin problems with good stump hygiene daily

Conclusion
Amputation

is Reconstruction Surgical Planning is paramount Surgical Technique is essential It takes a Team Approach

Thanks for your attention!

References

Arangio, GA and Trepman, E Instructional Course Lectures Foot and Ankle, 7179,AAOS Burgess EM and Zettl JH. Amputations below the knee. Artificial Limbs. 1969;13:7-12. Burgess EM, et al. Amputations of the leg for peripheral vascular insufficiency. J Bone Joint Surg Am. 1971;53:874-890. Carnesale PG. Ch. 11: Amputations of the Lower Extremity. From Campbells Operative Orthopaedics, 10th ed, edited by S. Terry Canale. Mosby: 2003; 575-579. Pinzur MS, et al. Controversies in lower-extremity amputation. J Bone Joint Surg Am. 2007;89:1118-1126. Smith, DG Atlas of Amputations and Limb Deficiencies AAOS Third Edition Stahel PF, et al. Concepts of transtibial amputation: Burgess technique versus modified bruckner procedure. ANZ J Surg. 2006;76:942-946. Tisi PV and Callam MJ. Type of incision for below knee amputation. Cochrane Database of Systematic Reviews 2004; Issue 1, Art. No.:CD003749.