Cohn’s Conference - Chadwick.pptx

8/14/2019 Cohns Conference - Chadwick.pptx

1/20

A B O V E T H E K N E E A M P U A T I O N

( A K A )

Cohns Conference


2/20

HPI

CC: 46 YO M airlifted to ILH s/p fell from the back ofa garbage truck and was run over by car followinggarbage truck. He suffered from an open fracture

and dislocation of the right ankle.Airway- protecting, speaking

Breathing- equal bilaterally

Circulation- 2+ pulses B radial, 2+ B DP pulse

GCS = 15

No other significant acute injuries


3/20

JamesBarrios


4/20


5/20


6/20

Imaging Results- Ankle AP, Lat, and Obl

Comminuted fracture of the distal fibula commondislocation of the tibia and abnormal relationship ofthe calcaneus to the cuboid and cuneiforms


7/20

Imaging Results - CT Angio Lower Extremity

The right posterior tibial artery dissipates at the levelof the fracture of the tibia above the ankle.


8/20

Course of Care

Pt was admitted on 10/15/13

10/15/2013 I&D, CRPP Chopart

POD - Open bimalleolar ankle fracture dislocation chopart

dislocation, heel pad avulsion 10/17/13 I&D, ORIF of bimalleolar fx, wound vac

placement

10/20/13 I&D

10/22/13 I&D

10/27/13 BKA


9/20


10/20

Preparation

Medical Risk - MI, Atelectasis, PNE, Renal failure

Psych Evaluation Depression and PTSD

Level of amputationThe level of theamputation is dictated by the extent of the disease,healing potential of the stump, and rehabilitationpotential of the patient. Although preservation oflimb length is desirable, removal of all nonviable andinfected tissue is a higher priority. The surgeon must

be satisfied that sufficient arterial perfusion ispresent at the proposed amputation level to sustainhealing.


11/20

Preparation

Antibiotics

Intravenous prophylactic antibiotics appropriate for skin floraare adequate for amputation that is not complicated by lowerextremity soft tissue wound infection or gangrene. If any of

these conditions are present, broad spectrum perioperativeantibiotics should be administered. Anaerobic coverage shouldbe considered for diabetics.

Antibiotics are continued in the postoperative period inpatients undergoing staged debriding amputation for infectionor gangrene. Broad spectrum antibiotics are selected inaccordance with the local antibiogram and adjusted inresponse to wound culture and sensitivities


12/20

Preparation

Thromboprophylaxis

Thromboprophylaxis is administered prior to amputationdepending upon individual patient risk, amputation level andexpected level of activity following amputation.

Patients undergoing major lower extremity amputation are athigh risk for thromboembolism due to the nature of thesurgery as they will have weight-bearing restrictions and willbe immobilized postoperatively.

Complications stump hematoma, infection, need for repeat amputation,

phantom limb syndrome and flexion contracture.


13/20

Techniques

Staged amputation first a debriding amputation in the form of an open guillotine

amputation (transfemoral, transtibial), through-the-jointamputation, or less commonly, cryoamputation, followed bydefinitive revision and wound closure after infection has beencontrolled.

A debriding amputation is a rapid and effective method for removinginfected or necrotic tissue that is a source of sepsis. Non-stagedamputations should be avoided in patients with severe lowerextremity infections, particularly patients with diabetes with severeforefoot infections.

Once the infected limb is removed, the patient is treated with

antibiotics and open dressing changes for three to five days. If thewhite blood cell count is trending downward and the stump is clean,the second stage can be performed. At the second stage, the stump isdebrided and closed. A drain is usually left in place.


14/20

Techniques

Cryoamputation bedside technique that uses dry ice to hard freeze the extremity,

resulting in a physiologic amputation. Cryoamputation controls localinfection by quarantining metabolic waste products within the frozenlimb.

Patients with indications for amputation but who have severemedical comorbidities that preclude safe anesthesia, cryoamputationcan be used as a temporizing measure to avoid surgery until thepatient can be stabilized medically

rarely needed where modern surgical and anesthetic techniques areavailable.

main complication associated with cryoamputation is migration ofthe frost line above the intended level of amputation. The need foramputation stump revision may also be greater.


15/20

Techniques - BKA

techniques for below-knee amputation are named for theorigin of the flap used to cover the tibia.

The posterior flap is the most commonly used techniquefor below-knee amputation and can be used for anyindication. The advantage of this technique is theplacement of the incision, and resultant scar, on a surfacethat is not weight-bearing. A disadvantage is thepotential for ischemia in the posterior flap.

Four other BKA techniques are described using sagittal,skew, medial, and fish-mouth flaps, each of which may

be more useful when one flap may be better vascularizedthan another. Amputations performed to resect tumorsare dictated by the location of the tumor and the need foradequate margins.


16/20

Techniques - BKA


17/20

Techniques

Draping

A mechanical barrier (impervious plastic sleeves, iodinatedadhesive skin drape) should be used to isolate infected areasprior to undertaking amputation.

Tourniquets shown to reduce intraoperative blood loss and decrease the

need for postoperative blood transfusion in above-knee andbelow-knee amputations. However, tourniquets are probably

of little benefit in patients undergoing amputation forextremity ischemia.


18/20

Procedure Details

The tourniquet was raised to 300 mmHg and left up for about45 minutes.

Amputation was done just above the level of the prior wound.

The tibia was divided about 13 cm below the knee and the

fibula was divided just above that level. There was extensive muscle necrosis in the posterior deep and

superficial compartments which was debrided. No gross puswas noted. Muscle at the level of the amputation was sent forculture. We irrigated out the wound extensively.

Once convinced all necrotic muscle was debrided, a drain wasplaced, the wound was closed with vicryl for the fascia and 2-0Nylon for the skin.


19/20

Procedure Details

An incisional wound vac was placed because of thepotential space in the superficial posteriorcompartment.

Hemostasis was good. A dressing was applied. A

knee immobilizer was placed. Wound will be monitored and debrided additionally

if necessary. If further debridement is needed, mayneed plastics assistance to preserve length.

Drain was removed on 10/30 Abx: 10/15-21 Gent and Ancef; 10/21-pres Vanc,

Zosyn, and Clindamycin


20/20

Sources

Medscapehttp://emedicine.medscape.com/article/1232102-overview#a0101

Uptodatehttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_

result&search=amputation&selectedTitle=1~150&provider=noProvider
http://emedicine.medscape.com/article/1232102-overviewhttp://emedicine.medscape.com/article/1232102-overviewhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://www.uptodate.com/contents/lower-extremity-amputation?detectedLanguage=en&source=search_result&search=amputation&selectedTitle=1~150&provider=noProviderhttp://emedicine.medscape.com/article/1232102-overviewhttp://emedicine.medscape.com/article/1232102-overviewhttp://emedicine.medscape.com/article/1232102-overview

Documents

Cohn’s Conference - Chadwick.pptx