Lower Limb Amputations Level Selection

Arvind Lee Vascular Fellow Nepean Hospital

Overview
Integral part of any surgical practice. The global lower extremity amputation study group - wide variations in amputation rates worldwide - similarities in age and sex distribution - very high correlation with diabetes (BJS 2000)

Overview
Australian data - 2629 diabetes related lower limb amputations per year - 2:1 male: female ratio - majority in the 65-79 year age group - Highest incidence in SA and NT (MJA 2000)

Indications for amputation:

PVD Failed revascularisation Extensive tissue loss Unreconstructable Excess surgical risk

Indications for amputation:

Diabetes Overwhelming sepsis Extensive tissue loss Excess surgical risk

Indications for amputation:

Trauma - Crush - Nerve injuries

Others Spina bifida Contractures Neuropathy Bed bound

Goals of amputation:
Get rid of all infected, necrotic and painful tissue Attain successful wound healing Have an adequate stump for a prosthetic

Attempt limb salvage or primary amputation?

Extent of tissue loss in foot Anatomy of reconstruction Associated comorbidities ESRD with heel gangrene maybe best treated with primary amputation

Natural history of major amputation:

10% perioperative mortality 3 year survival after BKA 57%; after AKA 39% Of 440 major amputations 75 died in hospital, 113 deemed unsuitable for prosthesis. Of 57% referred for prosthesis at 3years follow up a further 54 died, only 1015% were mobile at home. (BJS 1992)

Amputation levels and significance:

Major amputation: above tarso metatarsal joint. Levels - BKA - Through knee - AKA - Hip disarticulation

Amputation levels and significance:

BKA maximal rehabilitation potential - 10-40% increase in energy expenditure - 15-20% of all BKAs go onto an AKA in 3 years (5% periop mortality) AKA less rehab potential - 50-70% extra energy expenditure - Better rates of healing

Level Selection:
Subjective: - Clinical exam skin quality, extent of ischemia/ infection - Pulses presence of a pulse immedietly above the level of amputation almost 100% chance of healing - Clinical judgment alone 80% accurate in predicting healing with BKA and 90% in AKA.

Level Selection:
Wagner et al (J vasc surgery 1988): clinical judgment superior to objective assessments. More distal amputations can be achieved with clinical measures over objective studies. Clinical judgment is central to amputation level selection.

Level Selection:
Objective tests: - Non invasive 1. Doppler pressures maybe unreliable in diabetics; ankle pressures >60mm >50% chance of BKA healing.

Level Selection
Non invasive 2. Skin perfusion pressures - Radio isotope washout - Laser doppler velocimetry - <20mm Hg 89% failure of healing

Level Selection
Non Invasive 3. Transcutaneous oximetry - Tested under local hyperthermia - Correlates with true PaO2 - Threshold value 30mm

Level Selection:
Invasive Angiographic scoring Poor correlation

Level Selection

Conclusions:
Amputation is traumatic enoughpoor level selection can make it worse. Clinical judgement central to proper level selection Patient factors are more important than objective testing

Case 1
93 yr old from NH Bed bound after stroke Painful heel ulcer on stroke affected side Palpable popliteal pulse

Case 2
68 yr old male CRF on hemodialysis Post surgery for #NOF bilateral heel ulcers Painful, non healing despite multiple debridements Palpable popliteal pulses