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26

Amputations

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Topic updated on 07/10/16 7:59pm
Introduction
  • May be used to treat
    • trauma
    • infection
    • tumor
    • vascular disease
    • congenital anomalies
  • Prognosis
    • outcomes are improved with involvement of psychological counseling for coping mechanisms 
    • amputation vs. reconstruction 
      • LEAP study
        • impact on decision to amputation limb
          • severe soft tissue injury
            • highest impact on decision-making process
          • absence of plantar sensation
            • 2nd highest impact on surgeon's decision making process
            • not an absolute contraindication to reconstruction
            • plantar sensation can recover by long-term follow-up
        • outcome measure
          • SIP (sickness impact profile) and return to work not significantly different between amputation and reconstruction at 2 years in limb-threatening injuries
          • most important factor to determine patient-reported outcome is the ability to return to work 
  • Complications
    • wound healing
    • neuroma
    • phantom limb pain
      • mirror therapy is a noninvasive treatment modality 
Metabolic Demand
  • Metabolic cost of walking
    • increases with more proximal amputations  
      • perform amputations at lowest possible level to preserve function
      • exception
        • Syme amputation is more efficient than midfoot amputation
    • inversely proportional to length of remaining limb
  • Ranking of metabolic demand (% represents amount of increase compared to baseline)
    • Syme - 15%
    • transtibial
      • traumatic - 25% average
        • short BKA - 40%
        • long BKA - 10%
      • vascular - 40%
    • transfemoral
      • traumatic - 68%
      • vascular - 100%
    • thru-knee amputation
      • varies based on patient habitus but is somewhere between transtibial and transfemoral
      • most proximal amputation level available in children to maintain walking speeds without increased energy expenditure compared to normal children 
    • bilateral amputations
      • BKA + BKA - 40% 
      • AKA + BKA - 118%
      • AKA + AKA - >200%
Wound Healing
  • Dependent on
    • vascular supply
    • nutritional status
    • immune status
  • Improved with
    • albumin > 3.0 g/dL 
    • ischemic index > .5
      • measurement of doppler pressure at level being tested compared to brachial systolic pressure
    • transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg)
    • toe pressure > 40 mm Hg (will not heal if < 20 mm Hg)
    • ankle-brachial index (ABI) > 0.45
    • total lymphocyte count (TLC) > 1500/mm3
  • Hyperbaric oxygen therapy
    • contraindications include
      • chemo or radiation therapy
      • pressure-sensitive implanted medical device (automatic implantable cardiac defibrillator, pacemaker, dorsal column stimulator, insulin pump) 
      • undrained pneumothorax
Upper Extremity Amputation
  • Indications
    • irreparable loss of blood supply
    • severe soft tissue compromise
    • malignant tumors
    • smoldering infection
    • congenital anomalies
  • Levels of amputation
    • wrist disarticulation versus transradial amputation
      • wrist disarticulation advantages
        • improved pronation and supination
        • recommended in children for preservation of distal radial and ulnar physes
        • longer lever arm
      • transradial advantages
        • more aesthetically pleasing
        • easier to fit prosthesis
    • transhumeral versus elbow disarticulation
      • elbow disarticulation advantages
        • indicated in children to prevent bony overgrowth seen in transhumeral amputations
  • Techniques
    • transcarpal
      • transect finger flexor/extensor tendons
      • anchor wrist flexor/extensor tendons to carpus
    • wrist disarticulation
      • preserve radial styloid flare to improve prosthetic suspension
    • transradial amputation
      • middle third of forearm amputation maintains length and is ideal
    • transhumeral amputation
      • maintain as much length as possible
    • shoulder disarticulation
      • retain humeral head to maintain shoulder contour
Transfemoral Amputation
  • Maintain as much length as possible
    • however, ideal cut is 12 cm above knee joint to allow for prosthetic fitting
  • Technique
    • 5-10 degrees of adduction is ideal for improved prosthesis function
    • adductor myodesis   
      • improves clinical outcomes
      • creates dynamic muscle balance
      • provides soft tissue envelope that enhances prosthetic fitting
Through-Knee-Amputation 
  • Indications
    • ambulatory patients who cannot have a transtibial amputation
    • non-ambulatory patients
  • Technique
    • suture patellar tendon to cruciate ligaments in notch
    • use gastrocnemius muscles for padding at end of amputation
  • Outcomes (based on LEAP data)
    • slower self-selected walking speeds than BKA 
    • similar amounts of pain compared to AKA and BKA
    • worse performance on the Sickness Impact Profile (SIP) than BKA and AKA
    • physicians were less satisfied with the clinical, cosmetic, and functional recovery
    • require more dependence with patient transfers than BKA
Below-Knee-Amputation (BKA)
  • Long posterior flap  
    • 12-15 cm below knee joint is ideal
      • ensures adequate lever arm
    • need approximately 8-12 cm from ground to fit most modern high-impact prostheses
    • osteomyoplastic transtibial amputation (Ertl) technique
      • create a strut from the tibia to fibula from a piece of fibula or osteoperiosteal flap
    • "dog ears"
      • left in place to preserve blood supply to the flap 
  • Modified Ertl 
    • designed to enhance prosthetic end-bearing 
    • technique
      • the original Ertl amputation required a corticoperiosteal flap bridge 
      • the modified Ertl uses a fibular strut graft
        • requires longer operative and touniquet times than standard BKA transtibial amputation
        • fibula is fixed in place with cortical screws, fiberwire suture with end buttons, or heavy nonabsorbable sutures. 
Ankle/Foot Amputation
  • Syme amputation (ankle disarticulation)
    • patent tibialis posterior artery is required 
    • more energy efficient than midfoot even though it is more proximal
    • stable heel pad is most important factor 
    • used successfully to treat forefoot gangrene in diabetics 
  • Pirogoff amputation (hindfoot amputation)
    • removal of the forefoot and talus followed by calcaneotibial arthrodesis
    • calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal
    • allows patient to mobilize independently without use of prosthetic
  • Chopart amputation (hindfoot amputation)
    • a partial foot amputation through the talonavicular and calcaneocuboid joints
    • primary complication is equinus deformity  
      • avoid by lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck  
  • Lisfranc amputation
    •  equinovarus deformity is common 
      • caused by unopposed pull of tibialis posterior and gastroc/soleus
      • prevent by maintaining insertion of peroneus brevis 
  • Transmetatarsal amputation  
    • more appealing to patients who refuse transtibial amputations
    • almost all require achilles lengthening to prevent equinus
  • Great toe amputations
    • preserve 1cm at base of proximal phalanx
      • preserves insertion of plantar fascia, sesamoids, and flexor hallucis brevis
      • reduces amount of weight transfer to remaining toes
      • lessens risk of ulceration
Pediatric Amputation
  • Most common complication is bone overgrowth
    • prevent by performing disarticulation or using epihphyseal cap to cover medullary canal

 

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Qbank (27 Questions)

TAG
(OBQ13.63) A 34-year-old man is involved in a motor vehicle accident and sustains an open tibia fracture and is treated with intramedullary nailing. For the next 4 years, he continues to have pain and persistent discharge from a sinus over his shin. He ambulates with crutches and refrains from putting weight on the extremity. The clinical appearance and radiographs are seen in Figures A and B. Wound culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What is the next step in treatment? Topic Review Topic
FIGURES: A   B        

1. Retention of tibial nail, lifelong intravenous antibiotic suppression
2. Debridement and lavage, exchange nailing using a larger diameter nail, intravenous antibiotics for 6 weeks.
3. Debridement and lavage, excision of sinus tract, implant removal, intravenous antibiotics for 6 weeks.
4. Debridement and lavage, addition of ring fixator, intravenous antibiotics for 6 weeks.
5. Debridement and lavage, excision of sinus tract, exchange nailing using antibiotic impregnated-cement nail, intravenous antibiotics for 6 weeks.

PREFERRED RESPONSE ▶
TAG
(OBQ12.171) A 65-year-old diabetic male with forefoot gangrene is evaluated for possible amputation. When discussing the amputation levels with the patient, which of the following should be noted to require the greatest increase in energy expenditure for ambulation? Topic Review Topic

1. Syme amputation
2. Unilateral transtibial amputation
3. Transfemoral amputation
4. Bilateral transtibial amputations
5. Through the knee amputation

PREFERRED RESPONSE ▶
TAG
(OBQ12.219) What is the most proximal level of amputation that a child can undergo and still maintain a normal walking speed without significantly increasing their energy cost? Topic Review Topic

1. Girdlestone hip resection
2. Above-knee amputation
3. Through-knee amputation
4. Below-knee amputation
5. Chopart amputation

PREFERRED RESPONSE ▶
TAG
(OBQ10.2) A 34-year-old male sustains a traumatic injury to his foot following a motorcycle accident. The patient's neurovascular status necessitates the amputation demonstrated in figures A through C. One year following the amputation, the patient complains of difficulty with gait and deformity of the ankle. Which of the following statements best describes the forces resulting in this deformity? Topic Review Topic
FIGURES: A   B   C      

1. Tight posterior capsule tissues of the ankle
2. Neuropraxia of the deep peroneal nerve
3. Unopposed pull of gastrocnemius-soleus only
4. Unopposed pull of gastrocnemius-soleus, posterior tibialis, and peroneus brevis
5. Unopposed pull of gastrocnemius-soleus and posterior tibialis

PREFERRED RESPONSE ▶
TAG
(OBQ10.162) For an above knee amputation, each of the following is a benefit of adductor myodesis EXCEPT: Topic Review Topic

1. Allows preservation of greater femoral length
2. Provides a soft tissue cushion beneath the osseous amputation
3. Improves the position of the femur to allow more efficient ambulation
4. Creates dynamic balance of the amputated femur
5. Improves prosthetic fit

PREFERRED RESPONSE ▶
TAG
(OBQ09.13) A 66-year-old male sustains an open crush injury to his right lower leg with significant skin loss. His history is significant for COPD, diabetes controlled with an insulin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a small pneumothorax which is being observed and does not require a thoracostomy tube. Which of the following is not a contraindication to hyperbaric oxygen treatment for this patient? Topic Review Topic

1. Presence of an acute open fracture and crush injury
2. History of COPD
3. History of bleomycin treatment
4. Presence of a pneumothorax
5. Presence of an insulin pump

PREFERRED RESPONSE ▶
TAG
(OBQ09.201) A 33-year-old man requires a transfemoral amputation because of a mangling injury to his leg. Six months after the amputation he has persistent difficulty with ambulation because his distal femur moves into a subcutaneous position in his lateral thigh. It persists despite a well-fitted prosthesis. What technical error is the most likely cause of his dysfunction? Topic Review Topic

1. Inadequate posterior skin flap
2. Inadequate anterior skin flap
3. Failure to bevel the distal femur
4. Lack of abductor myodesis to femur
5. Lack of adductor myodesis to femur

PREFERRED RESPONSE ▶
TAG
(OBQ08.235) Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation? Topic Review Topic

1. Abductors
2. Adductors
3. Hip flexors
4. Hip extensors
5. Hip external rotators

PREFERRED RESPONSE ▶
TAG
(OBQ08.246) In addition to lengthening the Achilles, transfer of which tendon is most important for functional ambulation after performing a Chopart amputation of the foot? Topic Review Topic

1. Peroneus brevis
2. Peroneus longus
3. Tibialis anterior
4. Tibialis posterior
5. Flexor hallucis longus

PREFERRED RESPONSE ▶
TAG
(OBQ07.6) A 7-year-old male is struck by a motor vehicle while crossing the street and suffers an open tibia fracture with a crush injury of the ipsilateral foot. After multiple attempts at limb salvage, the family and treating surgeon elect to proceed with a knee disarticulation. What complication of pediatric amputations is avoided with a knee disarticulation as opposed to a transtibial amputation? Topic Review Topic

1. Neurogenic pain
2. Bone overgrowth
3. Hip flexion contracture
4. Hip adduction contracture
5. Leg length inequality

PREFERRED RESPONSE ▶
TAG
(OBQ06.36) Figure A shows a below the knee amputation performed in a diabetic patient with significant vascular disease. Removal of the "dog ears", indicated by the red arrows, could cause direct damage to what vasculature leading to flap necrosis? Topic Review Topic
FIGURES: A          

1. Anterior tibial artery
2. Saphenous and sural arteries
3. Posterior tibial artery
4. Peroneal artery
5. Lower popliteal artery

PREFERRED RESPONSE ▶
TAG
(OBQ06.53) Which of the following is most important to achieve a good outcome following a Syme amputation? Topic Review Topic

1. trimming any dog ears
2. a viable and stable heel pad
3. achilles tendon lengthening
4. preserving the malleoli
5. tenodesing the extensor digitorum longus to the tibial shaft

PREFERRED RESPONSE ▶
TAG
(OBQ06.145) A 70-year-old female with a history of poorly controlled diabetes mellitus presents with purulent ulcers along the plantar aspect of her right forefoot and exposed metatarsal bone. She elects to undergo an amputation. She is insensate to the midfoot bilaterally. Her ankle-brachial index (ABI) for her right posterior tibial artery is 0.4. Further preoperative evaluation demonstrates a transcutaneous oxygen pressure of 45 and an albumin of 3.4. Which of the following would be a contraindication to performing a Syme amputation (ankle disarticulation) in this patient? Topic Review Topic

1. Albumin of 3.4
2. Active osteomyelitis
3. ABI of 0.4 for the posterior tibial artery
4. Transcutaneous oxygen pressure of 45
5. Peripheral neuropathy

PREFERRED RESPONSE ▶
TAG
(OBQ06.218) Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting? Topic Review Topic

1. Above-knee-amputation (transfemoral)
2. Below-knee-amputation (transtibial)
3. Through Knee
4. Syme
5. Midfoot

PREFERRED RESPONSE ▶
TAG
(OBQ06.230) During a Lisfranc (tarsometatarsal) amputation of the foot, which of the following is crucial to prevent the patient from having a supinated foot during gait.
Topic Review Topic

1. Releasing the posterior tibialis tendon
2. Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base
3. Myodesis of the anterior tibialis to the medial and middle cuneiforms
4. Lengthening of the gastrocsoleus (achilles tendon)
5. Osteotomy through 1st metatarsal

PREFERRED RESPONSE ▶
TAG
(OBQ05.150) Which of the following is true of a knee disarticulation as compared to a transtibial amputation? Topic Review Topic

1. Faster self-selected walking speeds
2. Improved performance on the Sickness Impact Profile (SIP) questionnaire
3. Physicians were more satisfied with the cosmetic appearance
4. Decreased use of a prosthetic
5. Decreased dependence with patient transfers

PREFERRED RESPONSE ▶
TAG
(OBQ05.271) A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation? Topic Review Topic

1. Decreased rate of prosthesis adjustment
2. Less postoperative time to final prosthesis fitting
3. Decreased neuroma formation
4. Decreased rate of revision
5. Less energy expenditure with ambulation

PREFERRED RESPONSE ▶
TAG
(OBQ04.11) A 40-year-old male who sustained an open pilon fracture 2 weeks ago is scheduled for a below-the-knee amputation (BKA). What laboratory value is the best predictor for wound healing? Topic Review Topic

1. serum albumin level
2. total protein level
3. calcium levels
4. C-reactive protein
5. ESR

PREFERRED RESPONSE ▶
TAG
(OBQ04.227) A 45-year-old diabetic woman with a gangrenous foot undegoes a Chopart amputation without tendon transfer or lengthening. Which type of deformity is the most likely complication of this procedure? Topic Review Topic
FIGURES: A          

1. Valgus deformity
2. Varus deformity
3. Equinus deformity
4. Cavus deformity
5. Planus deformity

PREFERRED RESPONSE ▶
TAG
(OBQ04.235) A 25-year-old male presents to the emergency department with a mangled lower extremity that is not salvageable. He undergoes transfemoral amputation. Three months later the patient presents to the office with the limb sitting in an abducted position. What important step was forgotten during the amputation? Topic Review Topic

1. Beveling the distal femur
2. Saving the patella
3. Allowing the sciatic nerve to retract deep into the soft tissue
4. Myodesis of the adductors
5. Timely fitting of orthosis

PREFERRED RESPONSE ▶
TAG
(OBQ04.275) A 37-year-old man presents to the emergency room with the left lower extremity injury shown in Figure A. A radiograph is shown in Figure B. Which of the following has the most impact on the decision to attempt limb salvage versus amputation? Topic Review Topic
FIGURES: A   B        

1. Quality of initial fracture reduction
2. History of tobacco use
3. Insurance status
4. Extent of soft tissue injury
5. Operative debridement and irrigation within 1 hour of injury

PREFERRED RESPONSE ▶
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