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SurgicalConsiderationsinLowerExtremityAmputation
TinaDreger,MDOrthopaedic TraumaFellow
UniversityofMissouri
Disclosures
–None–OriginalpresentationbyBrettCrist,MD
Objectives
• Understandtheindicationsforlowerextremityamputation
• Understandtheprinciplesandgoalsoflowerextremityamputation
• Reviewspecificlevelsofamputationandimportantconsiderationsforeach
• Reviewspecialconsiderationsinvolvinglowerextremityreconstruction
LowerExtremity:Purpose
• Ambulation/locomotion
IndicationsforAmputations
• Trauma–Acute
–Chronic
• MedicalCo-morbidities
AmputationDuetoTrauma
• Trauma–20-40y/omales–16%ofamputations–45%ofamputees
IndicationsforAmputation
• LEAP–569patientsfollowedprospectively–Ampvs.limbsalvage–2and7yeardata–Hospitalization–Whitecollar–=?
Bosseetal.NEJM2002;JBJS2005
IndicationsforAmputation
• Lackofplantarsensation– Notequalautomaticamputation
– >50%ofsalvageswithinitiallackofplantarsensationrecoveredby2years
Bosseetal.JBJSAm2005
IndicationsforAmputation
• Military–Pushingtheenvelope–ExtremityWarInjuriesSymposia
AmputationsAmongMilitary
• Increasednumberof3and4extremityamputees
• IED’s=infection• Soldierswithtourniquets
• Significantpsychologicalandsocietalimplications
IndicationsforAmputations
• Infection– 2⁰todiabetes
• PeripheralVascularDisease– 2⁰todiabetes(71%)– 80%oflowerextremityamputees
IndicationsforAmputations
• Neurologicaldisorders– Peripheralneuropathy2⁰todiabetes– Lackofprotectivesensation
• Burn
• Congenitaldeformities
• Malignanttumors– Clearmargin
SuccessfulAmputation
• Removalofdysfunctional/devitalizedtissue– easy
• Reconstructionofadurableresiduallimb– challenging
GoalsofAmputationSurgery• PreservationofLength
– Preventionofadjacentjointcontractures
• Preservationoffunction– Minimizeenergyexpenditure
• Earlyreturntofunction– Earlyprostheticfittingwhenpossible
• Painlessresiduallimb– Preventionofsymptomaticneuromas– Minimizephantomlimbpain
• PreservationofLife
EnergyExpenditure• Normalenergyexpenditure–Walking–O2consumption
• Levelofamputation–Higher=moreenergy
Gottschalk,Frank;Rehabilitation:Gait,Amputations,Prostheses,Orthoses,andNeurologicInjury,Chpt.10.
GeneralAmputationPrinciples
• Skin• Muscle• Nerves• BloodVessels• Bone
Skin
• Painless,pliable,nonadherentscar
• Scarplacementandprostheticwear– Viablelevel
• Coverage:–Flapcoverage–Skingraft
Muscle
• Myofascialclosure– Providesminimalmusclestabilization
• Myoplasty– Balancesopposingmusclegroups
• Myodesis– Attachmuscletobone
• Tenodesis– Attachtendontobone
Nerves
• Avoidingpainfulneuromas1. Separatenervefromvessels
2. Tractionnerveandsharplytransect-Retractstosafety
3. Nervepreparation-Injectionofalcohol
BloodVessels
• Sutureligatemajorvessels
• Full-thicknessskinflaps–Minimizewoundnecrosis
• Hemostasispriortoclosure–Drains
Bone• Minimizesharpedges– Beveling/filing
• Narrowmetaphysealflare/condyles
• Capintramedullarycanal–Minimizebleeding
• Minimizeperiostealstripping– Exostosis
LevelsofAmputation
LevelsofAmputation• Toe
• Rayresection
• Partialforefoot
• Transmetatarsal
• Symes
• ModifiedSymes
• BKA
• Throughknee
• AKA
• HipDisarticulation
• Hemipelvectomy
Toe
• Interphalangeal– Leavecartilage– Trimcondyles
• Transecttendonsandnerves– Donotsewtendonstogether
• Greattoe– Leave1cm– Footbalanceandfunction
RayResectionandPartialFoot
• Includestoeandpartofmetatarsal
• Preserve1st MTlength–Orthosis–Footbalance
• Avoidsharpbonyprominences
• Multiplelateralrays
Transmetatarsal
• Considered– 2ormoremedialrays– Morethanonecentralray
• Preservelength• Maintainarchandmetatarsalcascade
• AvoidAchillescontracture– Achilleslengthening
Transmetatarsal
Ngetal.JAAOS2010
NegativesforTransmetatarsal
–Footbalance–Prostheticfit–Woundhealing•33%primarywoundclosure•56%mayrequirerevisiontohigherlevel
Symes
• Ankledisarticulation
• Required–Viableheelpad
• Modifications–Malleoliexcision– Incision
Symes
Benefits– Longerlimb/lessenergy–Highlevelwalkers– Endbearingforobesepatients–Ambulatewithoutprosthesis
Negatives–Woundhealing–Compliance–Heelpadinstability
Symes
• Mustpreserveposteriortibialarterialsupply
Ngetal.JAAOS2010
BelowKneeAmputation
• Mostcommon
• Longerisbetter– Always?– Softtissue
• MinimumtoutilizeBKAprosthesis– 2.5cmper30cmptheight– 5cmdistaltothetubercle
BelowKneeAmputation:Techniques
• Longposteriormyocutaneousflap
• Modifyskinflapsbaseduponavailableskin
• IDneurovascularstructures
• Isolatefibulaandtransect1.5cmabovetibia
• Tibialcut
• Bevelbonecuts
• Ligatevesselsandtransectnerves
• Myodesisvs.myoplasty
BelowKneeAmputation
Staged– Traumaticorinfection
– Guillotine• Allowssofttissuesandbonetodeclare
ErtlProcedure
• Tibiofibularsynostosis
• Indication– Young– Proximaltib/fibinstability– Highactivitylevel
• Outcomes– Functionalscores=nobenefit(Ngetal.JAAOS2010)
Technique
– Fibulacutatsamelevel– Leavemedialperiostealhinge–Connecttotibia•Metal• Suture
Ngetal.JAAOS2010
CaseExample
• 45y/os/pMCC• Policeofficer• Rightopenfemurfx• Rightopentib/fibwithvascularinsufficiency
• Ex-fix• Multipledebridements• Progressivenecrosis
CaseExample
CaseExample
CaseExample
CaseExample
• Femurinfected– ABXbeads– IVabx– debridements
• 2STSG• Sutureremoval
• 11mo
Afterprosthesis
• c/okneepainandcrepitance
BKAatallcosts
• Improvedenergyexpenditure
• Softtissuereconstructiontomaintainlengthandkneefunction– Skingraftorsubstitute–Muscleflap
• Morefunctionalprosthesis
CaseExample
• 40y/omales/pBKAduetomangledlowerextremityaftergo-cartaccident
• Within2weeksofBKAandDPC– Infected–Necroticskin
Options
• RevisiontoAKA
• Reconstructsofttissueweight-bearingsurface
CaseExample
• Multipledebridements
• Negativepressurewoundtherapy(NPWT)
CaseExample
• STSGlowprobability
• Muscleflaprequired–Gracillisrotationflap
CaseExample
• Gracilliscoveringtibia
• STSGovermuscle
ThroughKneeAmputation/KneeDisarticulation
• Prosthetists– Thumbsupordown
• Endbearingresiduallimb
• Softtissuecoverage– Improvedwithposteriorflaptechnique
Indications
• Trauma
• Infection
• Dysvascular
• Nonambulatory
– *RiskofkneecontractureswithBKA
ThroughKneeAmputation/KneeDisarticulation
Benefits– Endbearingsurface– Sittingcomfort– Longerleverarm–Balancedthighmuscles–Prostheticsuspension(femoralcondyles)
Negatives–Kneeheight– Softtissuecoverage
Technique• Suturepatellartendontocruciates
• Patellanotdistaltofemur
DougSmith,MD
ThroughKneeAmputation/KneeDisarticulation
• LEAPstudy– Slowestwalkingspeed– Leastsatisfaction
–12/18nogastroc coverage->poorprosthetictolerance
Mackenzieetal.JBJS2004
AboveKneeAmputation
• Maintainlength
• Energyexpenditure
• Recurrentinfectedtotalkneearthroplasty–Alternativetokneefusion
Technique
• Fishmouthincision-Modifytopreventweightbearingonincision
• Myodeseadductors
• Myodesequadandhamstrings
• Nomyodesis=poorfunctionandpain– Femurmoveswithinmuscularsleeve
AboveKneeAmputation
CaseExample:Maintainlengthatallcost
• 32y/os/pMCC• Leftopentibialshaftfx• Leftopenbicondylartibialplateaufx
• Leftopenfemoralshaftfx
• Leftfemoralneckfx• Leftclaviclefx• Leftulnafx
CaseExample
CaseExample
CaseExample
• Rideshorses
• Noresidualpain
HipDisarticulation
Indications– Preservationoflife– Co-morbidptwithinfectionandsepsis– Necrotizingfasciitis– Non-ambulators(paraplegics)– Advancedischemicdisease– Tumor
HipDisarticulation
• Problems–Woundmanagement– Sittingbalance–Noprosthesis?•Maychoosenottowear• Usecrutchesanyway
Technique• Lateralposition
• Medialandlateralskinflaps
• Usemusclestofilldeadspace
• Woundcomplications
Hemipelvectomy
• Indications– Sameashipdisarticulation– Tumormorecommon–Morecommoninmilitaryrecently
• Procedureoflastresort• Poorfunctionaloutcome
Technique
• Semi-lateralposition
• Largeposteriorflap
• Keepasmuchofthehemipelvisaspossibleforsittingbalance
Complications
AmputationSiteBreakdownEarly• Delayedwoundhealing– Immunocompromised–Malnourished– Infection
• Marginalnecrosis–Appropriatesurgicaltechnique
AmputationSiteBreakdown
Late• Deepinfection–UsuallyassociatedwithPVD/DM/amputationforinfectedhardware
• Adherentskin
• Poorprostheticfit
Infection
• Debridement• Antibiotics• Localwoundcare• Secondaryhealing–Prolongedwoundhealing
• Revisionamputation
AmputationSiteProminence
• Overgrowth• Bonespur• Muscleatrophy• Failedmyoplasty/myodesis• Skinhypertrophy• Bursitis• Bulbous/floppyresiduallimb– Poorsurgicaltechnique
IndicationsforRevisionAmputation
• Tissueprominence–Poorprostheticfit–Limitedfunction–Pain–Skinatrisk
HeterotopicOssification/BoneSpur
• Associatedwith:– Severetrauma– Excessivemanipulationofperiosteum
– Residualboneafterosteotomy
• Mayrequiresurgicalresectionifproblematic– RecurrenceofHO
IndicationsforRevisionAmputation
• NeurologicComplications– Neuroma– Phantomlimbsensation
Neuroma• Allnervetransectionsformneuromas
• Painful–PositiveTinel’s
• Causes–Poorsurgicaltechnique–Highpressurearea–Crushinjury
PhantomLimbPain
• Maybenonpainful
• Painful–Upto85%inLE–~40-69%inUE
PhantomLimbPain
• Surgical– Dehydrogenatedalcoholandmarcaineintoepineureum
• Non-surgical– Neurontin• Showneffective
– VitaminC?– Regionalanestheticsperioperatively?
JointContracture
• Usuallyrelatedtoshortleverarm
• Contracturereleaseandtenolysismayberequirediffixeddeformity
Summary
• Lowerextremityamputationsaremuchmorecommonthanupperextremity
• Restoringfunctionisimportant– Reconstruction– Prosthesis
• Preservelengthandjointmotion• Avoidcomplications• Patientcounseling/support
Questions?
ThankYou
Email:[email protected]
References
1. SmithDG,MichaelJW,BowkerJH,AmericanAcademyofOrthopaedicSurgeons.Atlasofamputationsandlimbdeficiencies:surgical,prosthetic,andrehabilitationprinciples.3rded.Rosemont,IL:AmericanAcademyofOrthopaedicSurgeons;2004.
2. Scottetal.TraumaticandTrauma-relatedAmputationsIandII.JBJSAmDec2010
3. NgandBerlet.EvolvingTechniquesinFootandankleAmputations.JAAOSApril2010