Amputation Types in Surgery
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Questions and Answers

What percentage of amputees die within 5 years?

  • 50-75% (correct)
  • 75-90%
  • 25-50%
  • 90-100%

    • What is the second leading cause of lower extremity amputation?

  • Diabetes
  • Infection
  • Trauma (correct)
  • PVD

    • What type of amputation is above the ankle?

  • Minor amputation
  • Toe amputation
  • Major amputation (correct)
  • Transmetatarsal amputation

    • What is the key principle in deciding whether to amputate an ischaemic limb?

    <p>Revascularization first</p> Signup and view all the answers

    What type of amputation involves a two-stage procedure?

    <p>Staged amputation</p> Signup and view all the answers

    What is the advantage of staged amputations in diabetics?

    <p>Improved healing</p> Signup and view all the answers

    What is the disadvantage of single operation amputations?

    <p>Up to 30% require revision amputation</p> Signup and view all the answers

    What is the term for amputation of the toe?

    <p>Toe amputation</p> Signup and view all the answers

    What is the main principle of amputation?

    <p>Remove all infected tissue and preserve length</p> Signup and view all the answers

    What type of amputation involves division of the phalynx or disarticulation of the metatarsal-phalangeal joint?

    <p>Toe amputation</p> Signup and view all the answers

    What is the advantage of mid and hindfoot amputations such as Lis Franc and Chopart?

    <p>Preservation of length and epiphyseal plate in children</p> Signup and view all the answers

    What is the goal of toe amputation techniques?

    <p>To conserve function and as much tissue as possible</p> Signup and view all the answers

    Why is the hallux important in toe amputation?

    <p>It is important for balance and walking</p> Signup and view all the answers

    What is the ideal length of a below knee amputation stump?

    <p>1/3 the length of the tibia</p> Signup and view all the answers

    What is the main predictor of wound healing in amputation?

    <p>TcPO2</p> Signup and view all the answers

    What is the energy expenditure of a short transtibial amputation?

    <p>40%</p> Signup and view all the answers

    What is the complication of mid and hindfoot amputations such as Lis Franc and Chopart?

    <p>All of the above</p> Signup and view all the answers

    What is the importance of preserving the head of the 1st metatarsal (hallux) in toe amputation?

    <p>It is important for balance and walking</p> Signup and view all the answers

    What type of antibiotic cover is recommended for prophylactic antibiotics in amputation?

    <p>Broad spectrum aerobic cover</p> Signup and view all the answers

    What is a complication of amputation that can be avoided by cutting the nerve sharply?

    <p>Neuroma</p> Signup and view all the answers

    What is the primary goal of Phase 1 of rehabilitation after amputation?

    <p>To avoid contractures</p> Signup and view all the answers

    What is an advantage of using soft dressings in amputation?

    <p>Ease of application</p> Signup and view all the answers

    What is a key consideration when selecting the appropriate level of amputation?

    <p>Co-morbidities of the patient</p> Signup and view all the answers

    What is a crucial aspect of rehabilitation after amputation?

    <p>Team approach</p> Signup and view all the answers

    What percentage of patients require revision amputation after a single operation?

    <p>Up to 30%</p> Signup and view all the answers

    In what percentage of patients does peripheral arterial disease with diabetes account for more than 50% of lower extremity amputations?

    <p>50%</p> Signup and view all the answers

    What is the primary indication for an emergency amputation?

    <p>Trauma</p> Signup and view all the answers

    What is the type of amputation that involves division of the phalynx or disarticulation of the metatarsal-phalangeal joint?

    <p>Toe amputation</p> Signup and view all the answers

    What is the key principle in deciding whether to amputate an ischaemic limb?

    <p>Revascularization should be attempted first</p> Signup and view all the answers

    What is the term for amputation of the midfoot?

    <p>Lis Franc amputation</p> Signup and view all the answers

    What is the advantage of staged amputations in diabetics?

    <p>Improved wound healing</p> Signup and view all the answers

    What type of amputation is considered a definitive treatment option?

    <p>Major amputation</p> Signup and view all the answers

    What is the primary goal of using prophylactic antibiotics in amputation?

    <p>To achieve a significant decrease in infection rate</p> Signup and view all the answers

    What is a disadvantage of using soft dressings in amputation?

    <p>Decreased mobility</p> Signup and view all the answers

    What is a complication of amputation that can be avoided by cutting the nerve sharply?

    <p>Neuroma</p> Signup and view all the answers

    What is the primary focus of Phase 1 of rehabilitation after amputation?

    <p>Avoiding contractures</p> Signup and view all the answers

    What is a key consideration when selecting the appropriate level of amputation?

    <p>Co-morbidities of the patient</p> Signup and view all the answers

    What type of antibiotic cover is recommended for prophylactic antibiotics in amputation?

    <p>Broad spectrum aerobic cover</p> Signup and view all the answers

    What is the primary principle in toe amputation technique?

    <p>Preserving the tendon attachments at the base of the phalynx</p> Signup and view all the answers

    What is the main advantage of mid and hindfoot amputations such as Lis Franc and Chopart?

    <p>Preservation of the epiphyseal plate in children</p> Signup and view all the answers

    What is the primary reason for the importance of the hallux in toe amputation?

    <p>It is responsible for push-off during gait</p> Signup and view all the answers

    What is the ideal location for cutting the fibula in a below knee amputation?

    <p>Higher than the tibia</p> Signup and view all the answers

    What is the primary predictor of wound healing in amputation?

    <p>TcPO2</p> Signup and view all the answers

    What is the primary complication of mid and hindfoot amputations such as Lis Franc and Chopart?

    <p>Equinous deformity</p> Signup and view all the answers

    What is the primary goal of toe amputation technique?

    <p>Conserve function and as much tissue as possible</p> Signup and view all the answers

    What is the primary consideration in selecting the appropriate level of amputation?

    <p>Assessing blood flow at the level of amputation</p> Signup and view all the answers

    What is the primary reason for avoiding repeated amputations?

    <p>To avoid 'funny feet'</p> Signup and view all the answers

    What is the primary advantage of using TcPO2 in amputation?

    <p>All of the above</p> Signup and view all the answers

    Study Notes

    Definitions

    • Toe amputation involves division of the phalynx or disarticulation of the metatarsal-phalangeal joint.
    • Ray amputation involves removal of the corresponding metatarsal.
    • Transmetatarsal amputation involves partial foot amputation through the metatarsals.

    Principles

    • Remove all infected, gangrenous, ischaemic tissue.
    • Preserve length and wound that heals successfully, leaving a functional limb.
    • Avoid repeated amputations, "funny feet", and non-healing operative sites.
    • Technical principles include fashioning adequate flaps, dividing bone proximal to muscle, beveling bone, performing myoplasty, achieving hemostasis, and using atraumatic skin approximation.

    Toe Amputation Principles

    • Conserve function and as much tissue as possible.
    • Partial amputation of a toe keeps the adjacent toes in normal alignment.
    • The head of the 1st metatarsal (hallux) is important in weight-bearing and should be spared.
    • Amputation through a phalange is better than disarticulation, preserving tendon attachments at the base of the phalynx.

    Toe Amputation

    • The hallux is important for balance and walking because it provides push-off.
    • The 2nd toe acts as a lateral support for the hallux, and its amputation may lead to hallux valgus.
    • The transverse arch gets affected with any toe amputation.

    Post-Operative Care

    • Weight-bearing is prohibited if a formal amputation is performed until wound healing has been achieved.

    Mid and Hindfoot Amputations

    • Types include Lis Franc, Chopart, and Symes.
    • Advantages include preservation of length and epiphyseal plate in children.
    • Disadvantages include wound breakdown and cosmesis.
    • Complications include equinus deformity due to imbalance in gastroc-soleus and dorsiflexion.

    Below Knee Amputation

    • The ideal BKA stump should be 1/3 the length of the tibia, with the fibula cut higher to avoid diastasis and erosion through the skin.
    • There should be no flexion contractures, and the nerves should be divided under tension to avoid neuroma in scar tissue.

    Energy Expenditure

    • Amputation level and energy expenditure above baseline (%) are related: long transtibial (BKA) 10%, average transtibial (BKA) 25%, short transtibial 40%, bilateral transtibial 41%, and transfemoral (AKA) 65%.

    Wound Healing

    • Failure to heal amputation is multifactorial, with causes including ischaemia, infection, haematoma, and trauma.
    • Predictors of wound healing include assessing blood flow at the level of amputation, with TcPO2 demonstrated to be the most accurate predictor.

    Introduction

    • Despite advances in revascularization, lower extremity amputation remains a common procedure in modern vascular practice.
    • Peripheral vascular disease (PVD) alone or with diabetes accounts for >50% of amputations, with an incidence of 12-50 per 100,000/year according to the TASC II working group.

    Basic Anatomy

    • Forefoot: 5 toes + metatarsals.
    • Midfoot: arches of the foot (tarsal bones).
    • Hindfoot: heel + ankle.

    Indications

    • Elective indications include peripheral arterial disease, complications of diabetes mellitus, failed limb salvage, and failed minor amputation.
    • Emergency indications include trauma and life-saving decisions.

    Classification

    • Minor amputations are below the ankle (toe, transmetatarsal).
    • Major amputations are above the ankle (below knee, through knee, above knee, hip disarticulation).

    Types of Amputation

    • Guillotine and formal amputations are two types of amputation.

    Staged Amputations

    • Local study: important for diabetics, with advantages including improved healing and disadvantages including 2 operations in high-risk patients.

    Antibiotics

    • Prophylactic antibiotics are used to cover broad-spectrum aerobic, perineal, and Gram-positive organisms (Staph).

    Soft Dressings

    • Advantages include ease of application, low cost, and wound accessibility.
    • Disadvantages include decreased skin perfusion, knee contracture, poor pain control, and decreased mobility.

    Complications

    • Neuroma can be avoided by cutting nerve sharply under tension.

    Rehabilitation

    • Phase 1 includes avoiding contractures, physiotherapy (passive movements and isometric exercises), and exercises.
    • Phase 2 includes standing and balancing exercises, parallel bars, and inflatable prosthetics, as well as endurance exercises if needed.

    Amputations

    Indications

    • Lower extremity amputation remains a common procedure in modern vascular practice
    • PVD alone or with Diabetes account for >50% of amputations
    • Trauma is the 2nd leading cause
    • Amputation is a definitive treatment option, despite being viewed as a failure of treatment
    • 50-75% of amputees die within 5 years

    Basic Anatomy

    • Forefoot: 5 toes + metatarsals
    • Midfoot: arches of the foot (tarsal bones)
    • Hind foot: heel + ankle

    Classification

    • Minor (below the ankle): toe, transmetatarsal
    • Major (above the ankle): below knee amputation (BKA), through knee amputation (TKA), above knee amputation (AKA), hip disarticulation

    Types of Amputation

    • Guillotine
    • Formal

    Staged Amputations

    • Important for diabetics
    • Advantage: healing improved
    • Disadvantage: 2 operations in high-risk patients

    Definitions

    • Toe amputation: involves division of the phalynx or disarticulation of the metatarsal-phalangeal joint
    • Ray amputation: removal of the corresponding metatarsal
    • Transmetatarsal amputation: partial foot amputation through the metatarsals

    Principles

    • GENERAL:
      • Remove all infected, gangrenous, ischaemic tissue
      • Preserve length
      • Wound that heals successfully - leaving a functional limb
      • Avoid repeated amputations, “funny feet”, and non-healing operative sites
    • TECHNICAL:
      • Fashion adequate flaps
      • Bone divided proximal to muscle
      • Bevel bone
      • Myoplasty
      • Haemostasis
      • Atraumatic skin approximation

    Toe Amputation

    • Conserve function and as much tissue as possible
    • Partial amputation of a toe keeps the adjacent toes in normal alignment
    • The head of the 1st metatarsal (hallux) is important in weight-bearing and should be spared
    • Amputation through a phalange is better than disarticulation

    Mid and Hindfoot Amputations

    • Lis Franc, Chopart, Symes
    • Advantage: preservation of length and epiphyseal plate in children
    • Disadvantages: wound breakdown, cosmesis
    • Complications: equinous deformity due to imbalance in gastroc-soleus and dorsiflexion

    Below Knee Amputation

    • Should be scar-free
    • Ideal BKA stump:
      • 1/3 the length of the tibia
      • The fibula should be cut higher as it is prone to diastasis and erosion through the skin
      • No flexion contractures
      • Nerves should be divided under tension to avoid neuroma in scar tissue

    Energy Expenditure

    • Amputation level affects energy expenditure
    • Long transtibial (BKA): 10%
    • Average transtibial (BKA): 25%
    • Short transtibial (BKA): 40%
    • Bilateral transtibial (BKA): 41%
    • Transfemoral (AKA): 65%
    • Wheelchair: 0-8%

    Wound Healing

    • Failure to heal amputation is multifactorial
    • Causes: ischaemia, infection, haematoma, trauma
    • Predictors of wound healing:
      • Emphasis on assessing blood flow at level of amputation
      • TcPO2 demonstrated to be most accurate predictor of wound healing
    • Antibiotics: prophylactic antibiotics are important for wound healing

    Complications

    • Neuroma: avoid by cutting nerve sharply and under tension

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    Description

    This quiz covers the definitions and principles of toe amputation, ray amputation, and transmetatarsal amputation. It includes the removal of infected tissue and preservation of limb length.

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