24 amputations.pdf

Amputations of the Lower Extremity John D. Bennett DPM, FACFAS College of Podiatric Medicine and Surgery Des Moines University Indications for Lower Extremity Amputations Acute infection Chronic infection Ischemic limb Gangrene Charcot deformity Trauma Tumors Congenital Abnormalities Reasons for Dis...

Amputations of the Lower Extremity John D. Bennett DPM, FACFAS College of Podiatric Medicine and Surgery Des Moines University Indications for Lower Extremity Amputations Acute infection Chronic infection Ischemic limb Gangrene Charcot deformity Trauma Tumors Congenital Abnormalities Reasons for Distal Limb Salvage Superior Function Better Cosmesis Enhance Lifestyle Lower Energy Consumption Increased Sensory Input Better Weight-bearing Surface Less Distortion of Body Image Considerations for successful limb salvage 1. Ensure good blood flow 2. Control infection 3. Aim for good biomechanical result 4. Create a stable soft tissue envelope Attinger and Brown, Diabetes/Metabolism Research and Reviews 2012; 28(Supple 1) 93-96. Successful Amputations 1. “Remove all necrotic, painful, or infected tissue.” 2. “Must be able to fit amputation stump with a functional and easily applied prosthesis.” 3. “Blood supply at the level of the proposed amputation must be sufficient to allow primary skin healing.” Malone, J. et al, Chapter 64, Vascular Diagnosis, 4th edition, Mosby, 1993, page568 Major Factors to Consider for Amputation Level ¨Vascular Status ¡ Determining the level of adequate blood flow can help predict success of healing ¡ Not meeting criteria is not always considered a contraindication to performing amputation at a certain level Prediction of Healing Based on Vascular Status ¨ Still speculative and work continues ¡ “I have cut many things that have bled poorly and healed well, and I have cut many thing that have bled well and healed poorly.” ¨ ¨ ¨ ¨ ¨ ¨ ¨ Doppler Ultrasound Segmental Blood Pressure Ankle Brachial Index Toe Blood Pressure Plethysmography Transcutaneous Oxygen Pressure Spy technology – intra operative evaluation with dye and imaging. ¨ Emerging technology Timing of Surgery after Vascular Intervention Various schools of thought – Attinger et al 4 to 10 days after a bypass 10 to 30 days after an angioplasty – My experience with local vascular surgeons and interventionalists Definitive procedure as quickly as possible. Typically can keep patients vascular medications : Plavix, etc. Attinger and Brown, Diabetes/Metabolism Research and Reviews 2012; 28(Supple 1) 93-96. The concept of angiosomes to predict healing potential Angiosomes: composite vascular territories providing blood supply to skin, nerves, muscle, tendon, and bone The angiosome concept was derived from plastic surgery to evaluate healing potential of flaps. Entire body is divided into 40 angiosomes. The foot is divided into 6 angiosomes Posterior tibial artery feeds 3 angiosomes The anterior tibial artery feeds one angiosome The peroneal artery feeds two angiosomes The posterior tibial artery gives rise to a calcaneal branch, which supplies the medial ankle and lateral plantar heel, a medial branch that feeds the medial plantar instep, and a lateral branch that supplies the lateral forefoot, plantar midfoot, and entire plantar forefoot The anterior tibial artery continues on to the dorsum of the foot, as the dorsalis pedis The peroneal artery supplies the lateral ankle and plantar heel via the calcaneal branch and the anterior upper ankle via an anterior branch Major Factors to Consider for Amputation Level ¨ Rehabilitation Potential ¡ ¡ ¡ ¡ Ambulatory Status at time of presentation Motivation Family /Social Support Other comorbidities – cardiac, pulmonary, neurological, musculoskeletal Major Factors to Consider for Amputation Level Ambulatory Status – If not ambulatory, BKA or AKA may be better level – Even if patient is not ambulatory, maintaining limb can be advantageous for transfers Medical Considerations ASA classification 1. In planning appropriate consultation for perioperative medical care, the podiatric surgeon should be aware of the evaluation of physical status completed by the anesthesiologist before surgery. A. Class 1 patients have no medical problems, other than the pathologic condition associated with the surgery, no diabetic patient will fit this category. B. Class 2 patients have a stable, chronic medical problem that is well controlled such as stable diabetes. C. Class 3 patients are more seriously ill, with unstable medical problems, and are more likely to need intensive, or at least close, medical supervision in the perioperative period. D. Class 4 patients are very seriously ill, perhaps at risk for septic shock, or other major cardiovascular complications and definitely require intensive perioperative care. E. Class 5 patients are not expected to survive surgery or the perioperative period. F. The surgeon should ensure that appropriate medical consultation, clearance, and follow-up have been obtained to provide for the perioperative medical care of a diabetic patient who will undergo surgery for an infected foot. Rehabilitation Team Model Malone et al, “Rehabilitation for Lower Extremity Amputation,” Archives of Surgery, Vol 116, Jan 1981, p 93 Amputation Levels Toes – Partial – Complete Partial Rays – 1st ray – Middle rays – 5th ray Transmetatarsal Lisfranc’s Hindfoot – Choparts – Boyd’s and Pirogoff – Symes Calcanectomy Below Knee (BKA) Above Knee (AKA) Toe Amputation 1. Toe amputation is frequently performed through the base of the proximal phalanx. 2. This is left in place to maintain intrinsic muscle stability around the metatarsal phalangeal joint. 3. resection at the proximal metaphysis allows for closure over raw cancellous bone, which is an area that is better vascularized than the cartilage of the metatarsal head. 4. Skin incisions are made with medial and lateral flaps fashioned around the base of the digit. Ray Resections 1. Ray section is defined as amputation of a digit and most, or all, of its associated metatarsal. 2. This is an excellent procedure for drainage of an acute infection. 3. It is usually performed in the presence of either abscess or osteomyelitis of a toe and its metatarsalphalangeal joint. 4. Extensive necrosis of skin, soft tissue, or bone in the involved digit may necessitate ray resection to obtain adequate viable skin for closure. 63 year old male s/p partial ray resection of the left 2nd. PMH: -DM with neuropathy -HTN -High cholesterol -PVD S/p 2nd toe amputation secondary to abscess/osteomyelitis. S/P angiogram w/ stent Required additionally a hallux amputation and partial ray resection of the 3rd Additionally, a wound vac was needed. 59 year old male with a history of psoriasis, and s/p kidney transplant Developed a verruca of the 4th digit. The toe was amputated, but patient retained the verruca Due to the verruca having an un-characteristic presentation. The decision was made to biopsy the lesion. Biopsy came back consistent with verruca carcinoma. Treatment required wide excision, which resulted in partial ray resections of 3,4 and 5. Transmetatarsal Amputations 1. Indications for transmetatarsal amputation: A. Gangrene of one or more toes including the metatarsals, provided the gangrene has stabilized and does not involve the dorsal or plantar aspect of the foot B. Stabilized infection or open wound of the distal portion of the foot C. An open infected lesion in a neuropathic foot D. Extension of an infectious process to the web space or plantar aspect of the foot is an indication for an open transmetatarsal amputation. (This may be closed at a later time or allowed to heal by second intention.) E. This amputation maybe e performed at any level of the metatarsals, provided the insertion of the tibialis anterior tendon is preserved. F. Preservation of the tendon cannot be overemphasized as loss of function will result in an equinus deformity. Transmetatarsal Amputation Transmetatarsal Amputation Transmetatarsal Amputation LisFranc’s Disarticulation Hindfoot Amputations Choparts ¨ Disarticulation at Talonavicular and calcaneal cuboid joint Boyd – tibial – calcaneal fusion – Modified Boyd’s – utilize talus as interposition bone graft if viable Pirogoff – tibial – calcaneal fusion – Calcaneus is positioned vertical to help alleviate limb length discrepancy Symes – Full ankle disarticulation Surgical Considerations Check Hemaglobin and Hematocrit Many patients have had a LE bypass or stent General consensus is not to utilize tourniquet Expect blood loss Take your time Have at least 2 units of blood available at time of surgery Ducic et al, “Use of the tourniquet in reconstructive surgery in patients with previous ipsilateral lower extremity revascularization : Is it safe? a survey”, Journal of reconstructive microsurgery, 2006 Surgical Considerations Need to stabilize hindfoot fusions in most cases for long term success – – – – Steinman pin or K-wires Screws External fixation IM nail Choparts Amputation Diabetes Mellitus, Peripheral Neuropathy, multiple amputations Left foot Chronic ulcers, osteomyelitis Remained Stable for 10 years 3 years later Boyd and Pirogoff amputation Boyd, H. R., Amputation of the Foot, with Calcaneotibial Arthrodesis. JBJS. 21: 997 – 1000, October 1939. q Developed the amputation for the patient who cannot afford an artificial leg, or for the laborer to give an excellent weight-bearing stump and relieve the patient of having to use an artificial limb q Advantages qA natural, painless stump is provided qOperation is more advantageous from an anatomical and physiological standpoint over other amputations through the region of the ankle or tarsus q Recognized problems in other amputations Modified Boyd’s Kornah, 1996 Utilize talus as graft to help fill defect at fusion site Graft insert 55 year old diabetic male ESRD – kidney transplant PVD – Right LE bypass Left below knee amputation Retinopathy Case contributed by Dr. Pehde Charcot arthropathy 5th ray amputation Neuropathic lateral ankle ulcer Unstable, unbraceable ankle varus deformity 3 Weeks Following Amputation Syme’s Amputation ¨ Disarticulation at ankle ¨ Advocated for alternative to BKA ¡ Full length extremity that can be used in emergency ambulation ¡ Boyd Amputation ú Symes with tibialcalcaneal fusion ­ Allows for more length of limb ¨ Single Stage procedure ¨ Double Stage procedure ¡ 2nd stage is to remove malleoli and to remodel stump for prosthesis ¨ Controversy surrounds the stability of the amputation and difficulty related to prosthetic construction Calcanectomy Partial or complete removal of calcaneus Advantageous for large heel ulcers with calcaneal osteomyelitis and a stable midfoot and forefoot Patients are typically able to ambulate well with or without an assistive device (ankle foot orthosis –AFO) Good alternative to BKA or AKA Partial Calcanectomy 65 year old female presents with a necrotic wound of the left heal. Patient states of 2 ½ weeks duration. PMH: IDDM, Venous stasis, lymph edema 1 month s/p debridement of bone and soft tissue, with wound vac assisted closure 9/19/06 4 month s/p procedure wound is healed. Patient currently ambulates with an AFO and a walker