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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 don’t 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. Anthony’s 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 surgeon’s 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
Surgeon’s 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
Scar location
Flaps should be thick
Avoid adherent skin to bone
Myodesis/myoplasty if possible
Skin and Muscle Flaps
Technical Aspects
Tourniquet (except ischemic limb)
Exsanguination with Esmarch (not with infection/tumors)
Major vessels identified and ligated
Tourniquet deflated prior to closure
Drain
Hemostasis
Technical Aspects
Neuromas=Pain=Frequent cause of Failure Must identify nerves
-gentle traction and sharp division
Neuroma resection can be
Gratifying
Nerves
Technical Aspects
Avoid excessive periosteal stripping
- ring sequestra
- bony overgrowth
Resect bony prominences
Heterotopic Ossification
Bone
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
Delayed wound healing
Meticulous hemostasis
Drain
Rigid dressing
Hematoma
Complications
- More common in PVD patients with DM
- Antibiotics
- Surgical debridement
Infection
Complications
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
Wound necrosis
Complications
Proper positioning
Gentle passive stretching
Exercises to strengthen muscles controlling joint
Ambulation
Contractures
Complications
- 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
Pain
Complications
- 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
Dermatological problems
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”, 71-
79,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
Campbell’s 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.