Lower Extremity Amputations PDF

Amputations of the Lower Extremity John D. Bennett DPM, FACFAS College of Podiatric Medicine and Surgery Des Moines University objectives Demonstrate knowledge of determining the appropriate level of Amputation involving the lower extremity/foot Recognize what needs to be considered for a successful...

Amputations of the Lower Extremity John D. Bennett DPM, FACFAS College of Podiatric Medicine and Surgery Des Moines University objectives Demonstrate knowledge of determining the appropriate level of Amputation involving the lower extremity/foot Recognize what needs to be considered for a successful amputation Identify indications, procedures, post-op care and complications of digital, foot and leg amputations 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 Plastic and Reconstructive Surgery: June 2006 - Volume 117 - Issue 7S - p 261S-293S Posterior tibial artery feeds 3 angiosomes The anterior tibial artery feeds one angiosome The peroneal artery feeds two angiosomes Volume 117, Number 7S Angiosomes of the Foot and Ankle 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 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. ASA Physical Status: Class 1: patients have no medical problems, other than the pathologic condition associated with the surgery, no diabetic patient will fit this category. Class 2: patients have a stable, chronic medical problem that is well controlled such as stable diabetes. 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. Class 4: patients are very seriously ill, perhaps at risk for septic shock, or other major cardiovascular complications and definitely require intensive perioperative care. Class 5: patients are not expected to survive surgery or the perioperative period. 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) B. 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. C. 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. S/P angiogram w/ stent Recent hallux amputation additional partial 3rd ray resection 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 2 months s/p biopsy and surgical treatment D. Transmetatarsal Amputations Indications for metatarsal amputation: A. Gangrene of one or more toes and associated metatarsal, 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. 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.) D. This amputation maybe e performed at any level of the metatarsals, provided the insertion of the tibial and peroneal tendons are preserved. E. Preservation of the tendon cannot be overemphasized as loss of function will result in an equinus deformity. TAL or gastric recession is adjunct procedure. Transmetatarsal Amputation Transmetatarsal Amputation Transmetatarsal Amputation Transmetatarsal case #2 LisFranc’s Disarticulation What are the indications for performing a lisFranc’s disarticulation? Patient with a failed transmetatarsal amputation: -recurrent infection at distal stump 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 Rod Choparts Amputation Diabetes Mellitus, Peripheral Neuropathy, multiple amputations Left foot Chronic ulcers, osteomyelitis Indications for insertion of antibioti -contaminated tissue -osteomyelitis (acute or chronic) -Charcot arthropathy -Open fractures -infected arthroplasty -infected non-unions JP-7 drain Remained Stable for 10 years Choparts amp case #2 Fusing the ankle and subtalar joint is essential for stability and function 3 years later 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 weightbearing 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 55 year old diabetic male ESRD – kidney transplant PVD – Right LE bypass Left below knee amputation Retinopathy 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 Deep Venous Thrombosis and Pulmonary Embolism April 2022 Ashley M. Dikis, DPM, FACFAS OBJECTIVES 01 Recognize the pathogenesis of deep venous thrombosis (DVT) and pulmonary embolism (PE) 02 Recognize the evaluation and workup of a patient with a suspected DVT or PE 03 Identify the patient at risk for DVT and select the appropriate pre-operative prophylaxis and treatment DEFINITIONS Thrombus A blood clot formed in situ within the vascular system of the body and impeding blood flow Thrombophelbitis Presence of thrombus within a vein accompanied by inflammation Superficial Venous Thrombosis Thrombus in superficial vein Occurs in both inherited and acquired thrombophilic states and may progress to DVT and/or pulmonary embolism (PE) Deep Venous Thrombosis (DVT) Thrombus in deep vein network More likely to migrate proximally Pulmonary Embolism (PE) Thrombus in pulmonary artery Can be fatal Venous thromboembolism (VTE) Blood clot within a vein Introduction DVT secondary to foot and ankle injury/surgery is an uncommon but potentially devastating complication Pulmonary embolism Potentially fatal Recurrent DVT 1/3 will see recurrence within 10 years Postphlebitic Syndrome Edema, pain, induration, pigment change, ulceration DVT following F&A surgery: 0.5-3.5%* 900,000 Annual incidence of DVT/PE in the US PE following F&A surgery: 0.15% Pathogenesis Most common presentations of VTE DVT of the lower extremity Pulmonary embolism Two main categories for etiology Hereditary Acquired f o y r o t s i H T V D s u o i prev Copyrights apply Virchow’s Triad Alterations in the constituents of the blood (i.e. inherited or acquired hypercoaguable state) Status Alterations in blood flow Stasis Vascular endothelial injury Injury Pathogenesis Unprovoked DVT No known underlying cause Provoked DVT Risk factor known Proximal DVT Popliteal, femoral, or iliac veins Distal DVT No proximal component Located below the knee Confined to the calf veins (peroneal, posterior, anterior tibial, and muscular veins) Pathogenesis Thigh DVT generally more severe than calf DVT 50% of thigh DVT will propagate to PE if left untreated 20-30% of calf DVT will propagate to thigh Pathogenesis Blood passes from superficial to deep veins through perforators Valves keep blood from retrograding (Thrombus usually forms at valves) Vena cava to right side of heart, then proceeds into the pulmonary arteries and lungs OBJECTIVES 01 Recognize the pathogenesis of deep venous thrombosis (DVT) and pulmonary embolism (PE) 02 Recognize the evaluation and workup of a patient with a suspected DVT or PE 03 Identify the patient at risk for DVT and select the appropriate pre-operative prophylaxis and treatment Clinical Presentation High index of suspicion necessary Symptoms include: Pain Swelling Warmth Erythema along the affected extremity Normal post-op / post-injury? Work-Up Note on Homan sign: A positive Homan sign—calf pain with the ankle dorsiflexed and the knee flexed—is neither particularly sensitive nor specific and can be positive in up to half of patients with or without a DVT Differential Diagnosis Postoperative edema/pain Ruptured Baker’s cyst Muscle or bone pathology PVD Hematoma Lymphedema CHF Timing → Data regarding timing of DVT postoperatively: ◆ 7 days (Zixuan et al) ◆ Initial peak around day 4, with second peak around day 14 (Forsh et al) ◆ Bell curve, with increased incidence around week 2 and 3 following inpatient shoulder replacement (Sweetland et al) ◆ Within first 6 weeks postop (MacDonald et al) ◆ Timing to the diagnosis of VTE was 33.1 days on average (range 7–47) (Saragas et al)** Work-Up: Testing Noninvasive duplex ultrasound Reported sensitivity and specificity of more than 90% in diagnosing DVT Ordered ASAP in patients with suspected DVT Work-Up: Testing Most common presenting symptom for PE is dyspnea followed by chest pain and cough Referral to ED Chest xray Normal or near normal Computed tomography pulmonary angiogram (CTPA) Work-Up: Testing Ventilation perfusion scan Nuclear medicine scan that uses radioactive material (radiopharmaceutical) to examine airflow (ventilation) and blood flow (perfusion) in the lungs V/Q scanning is mostly reserved for patients in whom CTPA is contraindicated or inconclusive, or when additional testing is needed. Most patients have indeterminate scans OBJECTIVES 01 Recognize the pathogenesis of deep venous thrombosis (DVT) and pulmonary embolism (PE) 02 Recognize the evaluation and workup of a patient with a suspected DVT or PE 03 Identify the patient at risk for DVT and select the appropriate pre-operative prophylaxis and treatment The Journal of Foot & Ankle Surgery 54 (2015) 497–507 “Routine chemical prophylaxis is not warranted in foot/ankle surgery or injuries requiring immobilization. Rather foot and ankle surgeons should attempt to stratify patients and develop a prophylaxis plan for those at high risk of VTED.” —ACFAS Clinical Consensus Panel Peri-operative Prophylaxis Fundamental reason for preventing postoperative deep vein thrombosis (DVT) is to avoid clinically significant chronic venous stasis, phlebitis, and, most importantly, potentially fatal pulmonary embolism Numerous specialty society guidelines underscore the importance of postoperative venous thromboembolism prophylaxis after hip or knee arthroplasty or in the setting of hip fracture, for which there is robust literature supporting the use of such preventive measures Peri-operative Prophylaxis But what about foot and ankle surgery? Recommendations currently in use after hip and knee arthroplasty may not be safely extrapolated to foot and ankle surgery patients Wide variability in procedure type and severity Differences in postoperative immobilization protocols Peri-Operative Risk Stratification At the population level, the overall risk of VTE for patients without risk factors undergoing foot and ankle surgery is approximately 3:1000 (overall population rate of 1:1000) Risk of VTE increases to more than 4% in the presence of previous VTE history and 2 or more of the following risk factors: Obesity with a body mass index (BMI) greater than 30 kg/m2 Age greater than 40 Medical comorbidities Use of a contraceptive pill Immobilization Peri-Operative Risk Stratification May consider Hematology referral if concern for underlying coagulopathy Peri-Operative Risk Stratification A generalized, overall incidence remains difficult to determine given the wide range of host factors and foot and ankle disorders and procedures Procedures thought to carry increased risk: Trauma Achilles rupture TAR Peri-Operative Risk Stratification Literature Available evidence frequently of low quality and often contradictory in its conclusions Higher-powered level I data will be necessary to definitively answer questions related to VTE prophylaxis and develop consensus for the foot and ankle population Numerous scales to assist with risk prediction exist, though accuracy is questionable, and many have not been properly validated University of California (UC) San Diego model “3 bucket model” Caprini score Padua VTE RAM Peri-operative Prophylaxis Several different prophylactic strategies exist to prevent VTE in the foot and ankle patient, ranging from mechanical prophylaxis to chemoprophylaxis Full anticoagulation is generally reserved once the patient has developed a DVT or PE “Full” meaning full dose with goal of therapeutic as opposed to prophylactic degree of anticoagulation Aspirin MOA: Inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, ultimately leading to inhibition of platelet aggregation Evidence: Currently insufficient to support the use of aspirin after foot and ankle surgery Hip and knee arthroplasty Limited evidence exists specifically for the foot and ankle population Aspirin Dosage: 81mg BID – 325mg BID Mixed results in literature for low vs high dose Cardiology literature has demonstrated an equivalent cardioprotective effect of lower dose (81 mg) vs higher dose (325 mg) Notably, as compared with other blood thinners, it may have a lower rate of adverse events, such as bleeding or wound complications postoperatively Low Molecular Weight Heparin (LMWH) MOA: Indirect inhibition of factor Xa Evidence: Mixed regarding the use of LMWH after lower leg injury or surgery The AOFAS consensus panel recommends that if considering LMWH following a foot or ankle surgery, therapy should begin when immobilization is initiated and continued for the duration of immobilization, with non–weight-bearing status recognized as a modifiable risk factor, but without specific recommendation for starting chemoprophylaxis Low Molecular Weight Heparin (LMWH) Dosage: Lovenox 40mg subcutaneous injection once daily Lovenox 30mg subcutaneous injection twice daily Risk of developing heparin-induced thrombocytopenia (HIT), a potentially fatal complication from an immunologic process Carries less risk than unfractionated heparin Presenting symptoms include hemodynamic instability with fevers, tachycardia, hypertension, diaphoresis, chills, dyspnea, and chest and abdominal pain Unfractionated Heparin (UFH) MOA: Binds to antithrombin III which potentiates the inhibition of thrombin (II) and Xa, IXa, XIa, XIIa Inactivates thrombin by cofactor II which acts independently of ATIII Dosage: 5000 U subcutaneous TID Short half-life Can be reversed with protamine sulfate Unfractionated Heparin (UFH) Benefits of LMWH over UFH: Administered subQ bid/daily Much less bleeding and virtually no thrombocytopenia No lab monitoring More predictable pharmacodynamics Coumadin Has been almost completed replaced by other agents Requires bridge therapy Peak effect 24-72 hours Requires routine INR Many drug and food interactions Other chemoprophylaxis Per AOFAS panel, when subcutaneous injections such as LMWH are not an option in the outpatient setting (eg, patient intolerance or nonadherence) and chemical prophylaxis is desired, warfarin with a targeted international normalized ratio (INR) 2.5 (acceptable range 2.0–3.0) or newer oral agents such as apixaban, dabigatran, or rivaroxaban that do not require INR monitoring are viable options Apixaban = Eliquis Dabigatran = Pradaxa Rivaroxaban = Xarelto IVC Filter Greenfield filter May be considered when contraindications to chemical prophylaxis exist, such as head injury or severe hemodynamic instability There is no specific evidence in the use of IVC filters for foot and ankle surgery, and the IVC filter efficacy for patients without a prior history of DVT is not well established So you’ve diagnosed a DVT… …now what? Decision for inpatient or outpatient management Most can be managed outpatient, except: Massive DVT (eg, iliofemoral DVT) Concurrent symptomatic pulmonary embolism (PE) High risk of bleeding on anticoagulant therapy Comorbid conditions or other factors that warrant in-hospital care DVT management In most situations, some form of treatment will be indicated: Oral chemoprophylaxis Eliquis Xarelto LMWH or heparin Coumadin with heparin bridge The American College of Chest Physicians (ACCP) 2012 guidelines suggest for acute isolated distal DVT without severe symptoms or risk factors to perform serial imaging of the deep veins for 2 weeks. Only if patients have severe symptoms or risk factors, then anticoagulation should be initiated. DVT management Thrombolytics rarely indicated Does not seem to decrease incidence of PE Preserve venous values Decrease risk of developing postphlebitic syndrome Thrombectomy seldom performed Summary Although the risk in aggregate of VTE in the foot and ankle population remains lower than the overall risk identified in the hip and knee population, it has yet to be properly defined Additional large-scale, prospective studies are needed Studies exist recommending against the use of prophylaxis, yet majority of providers continue to prescribe routinely If considering the use of chemical prophylaxis, LMWH is effective at reducing the rate of clinically significant VTED and appears to be the most studied agent in current literature Summary Risk factors for development of VTE Clinical presentation Work-up for suspected DVT or PE Perioperative prophylaxis Who What Treatment for DVT Remember—there aren’t any easy answers to these questions. You ultimately have to use your best judgement and available information Clinical Takeaways: Identify risk factors: I always ask about previous DVT and family history of DVT or bleeding disorder Discuss plans for anticoagulation based on risk factors and type of surgery being performed Often decision is made based on need for NWB postoperatively in addition to presence of risk factors Common choices include Lovenox 40mg subq once daily Xarelto 10mg PO once daily Eliquis 2.5 PO BID Aspirin? Consider renal status and risk factors for bleeding event Duration of treatment will vary based on risks and NWB status Reach out to PCP or Hematology for additional guidance as needed REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Chien et al. Venous Thromboembolism Disease Prophylaxis in Foot and Ankle Surgery. Orthop Clin N Am 49 (2018) 265–276. Fleischer et al. American College of Foot and Ankle Surgeons’ Clinical Consensus Statement: Risk, Prevention, and Diagnosis of Venous Thromboembolism Disease in Foot and Ankle Surgery and Injuries Requiring Immobilization. J Foot Ank Surg 54 (2015) 497– 507. Weisman et al. Venous Thromboembolic Prophylaxis in Foot and Ankle Surgery: A Review of Current Literature and Practice. Foot Ankle Spec 2017 Aug;10(4):343-351. Uptodate – “Overview of the treatment of lower extremity deep vein thrombosis (DVT)” and “Overview of the causes of venous thrombosis” Deep vein thrombosis and pulmonary embolism [PowerPoint 2021] Courtesy of Erin Nelson, DPM. Saragas et al. The impact of risk assessment on the implementation of venousthromboembolism prophylaxis in foot and ankle surgery. Foot Ank Surg 2014; 20: 85-89. Forsh et al. Deep Venous Thrombosis Prophylaxis in Orthopedic Surgery, 2021. Sweetland et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ 2009. THANKS! This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. Please keep this slide for attribution CREDITS: This presentation template was created by Slidesgo, including icons by Flaticon and infographics & images by Freepik Post-Operative Fever Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Identify malignant hyperthermia, risk factors and treatment. Demonstrate knowledge of the evaluation, diagnosis and treatment of febrile patients in the post-operative period. Malignant Hyperthermia: Definition A pharmacogenetic disorder which presents as hypermetabolic response to inhalation agents, muscle relaxants, or rarely, exercise and heat Emergency situation Can be fatal if not recognized and treated Proposed Mechanism Exposure to halogenated anesthetic agent Release of Ca+2 from skeletal muscle sarcoplasmic reticulum leads to increased muscle contraction Leads to depletion of ATP which increases O2 consumption, CO2 production and heat Membrane failure, leakage of K+, creatinine kinase, and myoglobin https://www.jcvaonline.com/article/S1053-0770(18)30221-0/fulltext MH Risk Factors Numerous triggers have been described in the literature Most common: Inhalation anesthetic agents Halothane, Desflurane, Enflurane, Ether, Isoflurane, and Sevoflurane All except nitrous oxide have been found to cause MH Muscle relaxant Succinylcholine https://www.shutterstock.com/video/clip-1006893628-pov-eyes-patient-male-anesthesiologist-scrubs-putting Safer Anesthetics Propofol Ketamine Catecholamines Nondepolarizing muscle relaxants Digitalis Local anesthetics Benzodiazepines Barbiturates Opioids https://in.pinterest.com/pin/206813807861586829/ Clinical Features Tachycardia (early sign) Unexplained elevation of expired carbon dioxide, despite increased minute ventilation Muscle rigidity (Masseter Muscle Rigidity) Hyperthermia Acidosis Hyperkalemia Cardiac dysrhythmias Rhabdomyolysis (late) Treatment Immediate discontinuation of possible causative agent May need to change any source connection to patient (change tubing) Increase minute ventilation to lower ETCO2 Cool the patient Treat arrhythmias as needed Labs: Blood gases Electrolyte Creatine kinase Blood and urine for myoglobin Dantrolene 2.5 mg/kg initial dose, continue with same dose as needed pending symptoms up to maximum cumulative dose of 10 mg/kg total Post-Operative Fever Fever which occurs in the postoperative state Normal: 36.1 °- 37.2°C (97.7 ° 99.5° F) Temperature greater than 100.4° F or 38° C https://www.mountsinai.org/health-library/symptoms/fever 5 W’s of Post-Operative Fever Wind POD 1-2 Pneumonia/atelectasis Water POD 2-3 Urinary tract infection Wound POD 3-7 Infection/hematoma Walk POD 5-7 DVT/PE Wonder Drug POD > 7 https://teachmesurgery.com/perioperative/on-the-wards/post-operative-fever/ Post-Operative Fever 0-2 Days Pneumonia/atelectasis Aspiration pneumonia Atelectasis: condition in which the alveoli in the lung collapse or do not expand appropriately Pneumonia: infection which causes inflammation of one or both lungs May be viral or bacterial Symptoms: Cough, tachycardia, shortness of breath, inability to cough Preventative: Incentive spirometry Treatment (pneumonia): Amoxicillin, plus macrolide (outpt) Azithromycin plus ceftriaxone (inpt) https://radiopaedia.org/cases/normal-frontal-chest-x-ray?lang=us Normal vs Atelectasis Normal vs Pneumonia Post-Operative Fever 2-3 Days Urinary Tract Infection Symptoms: Diagnosis: History Physical exam Urinalysis Urine culture Dysuria Increased urinary frequency Malodor Treatment: Suprapubic pain Nitrofurantoin Fever TMP-SMX Flank pain Ciprofloxacin Hematuria *Do not need to treat asymptomatic Altered mental status urine culture* hypotension Post-Operative Fever 3-7 Days Wound Infection Symptoms: Fever Chills Erythema Pain Drainage Dehiscence Management: Local wound care Culture Antibiotics Incision and drainage https://monib-health.com/en/post/96-postoperativeinfection Post-Operative Fever 5-7 Days Deep Venous Thrombosis/Pulmonary Embolism Blood clot which forms in the deep veins, usually the lower extremity, but can occur in the upper extremity Symptoms: Pain Erythema Edema Shortness of breath Chest pain Sudden death https://trombo.info/venous-thromboembolism/tromboinfo-deep-vein-thrombosis/?lang=en Post-Operative Fever 5-7 Days Diagnosis: DVT: Well’s Score D-Dimer Venous duplex PE: Chest X-ray Chest Tomographic Angiography VQ scan Management: Coagulopathy studies Anticoagulants https://www.researchgate.net/figure/Wells-score-original-and-simplified_tbl1_563487 Post-Operative Fever 7 Days Wonder Drugs Drug fever Transfusion Emergent Etiology of Ealy-Post Operative Fever Necrotizing soft tissue infections/myonecrosis Pulmonary embolism Alcohol withdrawal Adrenal insufficiency Malignant hyperthermia Sources Schneiderbanger, Daniel et al. “Management of malignant hyperthermia: diagnosis and treatment.” Therapeutics and clinical risk management vol. 10 355-62. 14 May. 2014, doi:10.2147/TCRM.S47632 Narayan M, Medinilla SP. Fever in the postoperative patient. Emerg Med Clin North Am. 2013 Nov;31(4):1045-58. doi: 10.1016/j.emc.2013.07.011. PMID: 24176478. Modified from Dr. Bennett lecture “Post Op Fever and Complications” Post-Op Management Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Demonstrate knowledge on the various types of post-operative dressings, splints, cast, boots, and post-op shoes Demonstrate knowledge of discharging and admitting of the postoperative patient Recognize and treatment of acute post-operative complications and patient concerns Outline: Post-Operative Dressings and Splints Dressings Materials and indications Incisional Wound Vac Jones compressive dressing Posterior splint Sugar tong splint Cast CAM boot Flat surgical shoe Post-Operative Dressing Materials: Incision Site Non-adhesives for incisions: Xeroform- fine mesh material impregnated with petrolatum and Bismuth Tribromophenate Inhibits bacterial growth Prevents adhesion to incision Adaptic- knitted cellulose acetate impregnated with petrolatum Prevents dressing from adhering to incision Cover with gauze and remainder of indicated dressing May only be gauze and ACE bandage May be full splint/cast https://www.exmed.net/What-is-Xeroform-Sterile-Petrolatum-Gauze-Dressing https://medicalmonks.com/product/adaptic-non-adhering-dressing/ Incisional Wound Vacs Multiple models available Apply wound vac directly to incision site Draws moisture away from incisions Uses negative pressure to hold incision site flaps together Removes infectious materials from drainage in incisions if present https://thewoundvaccompany.com/blog/2019/6/7/negative-pressure-wound-therapy-for-closed-surgical-incisions Post-Operative Compression Jones Compressive Dressing Multi-layer compressive wrap Alternating layers of cast padding and ACE bandages Used to help control edema in post-operative or trauma patients “Soft cast” https://www.researchgate.net/figure/A-Two-layers-of-multipurpose-underpadding-bandage-are-placed-over-the-tubular-gauze_fig3_262071982 Posterior Splint Main goal is to immobilize the foot and ankle following injury or surgery Primary indications: High-grade ankle sprain Ankle fracture Ankle dislocation (following reduction) Post-operative stabilization Foot fracture https://readysplints.com/products/ankle-splint-kit Posterior-Splint Application & Management Commonly used over soft dressing such as jones compressive dressing or surgery dressing Ensure that prominent areas are padded well Malleoli Metatarsal heads Calcaneus Fibular head/neck (common peroneal N.) Splint should extend from metatarsal heads to fibular head/neck Check digits for possible rubbing Secure splint with ACE bandages Check neurovascular status after application Ankle should be at 90 degrees Patient should remain non-weight bearing in the splint Keep pillow under lower leg to keep the heel off the bed Monitor for pressure ulcerations Sugar-Tong Splint (Stirrup/U-Splint) Rigid splint which maintains stability and immobilization of the ankle U-shaped splint Usually has posterior splint as well Indications: Ankle sprain Stable fibular fractures Ankle dislocations (reduced) Posterior heel surgery (w/wo posterior splint) https://www.ebay.com/itm/143767350822 Post-Operative Cast Allow for complete immobilization following injury or surgery Patient unable to remove them Can uni- or bi-valve them to relieve compression and allow for swelling Many modifications exist depending on needs of the cast Do have to be changed if become wet or if significant incision/wound drainage DVT risk Post-Operative Cast 2 main materials options: Fiberglass Lighter Dry quickly Allow for weight bearing sooner Easier to radiograph More expensive Plaster Heavier Slower to dry Can be molded in more custom fashion Less clear radiographs More cost effective https://www.pixelsquid.com/png/blue-fiberglass-leg-cast-1226885963746121502 https://jamesmazurdpm.com/blog/item/440-possible-treatments-options-for-a-broken-ankle.html Controlled Ankle Motion (CAM) Boot Removable boot used to control foot and ankle motion Tall and short options Contralateral hip and knee concerns Indications: Stress fractures Post-operative immobilization Ankle sprains Traumatic foot injuries (fractures/dislocations) Tendonous/ligamentous injuries (tendon tear, Lisfranc) Stable ankle fractures https://www.shhc.com.au/cam-boots Post-Operative Shoe Used to stabilize structures of the foot following injury or surgery Stiff soled shoed that prevents excessive motion of the foot Does not provide control of the ankle or lower leg muscles Can lead to contralateral hip and knee pain, should wear supportive shoe on contralateral foot when ambulating https://www.amazon.com/ProCare-Squared-Post-Op-Shoe-Medium/dp/B006IUU95W Post-Operative Admission Checklist of post-operative admission New H & P Admission order Pain control DVT prophylaxis Antibiotics? Weight bearing status Diet Consults Imaging Labs Medication reconciliation Post-Operative Discharge (Inpatient) Discharge order Discharge summary Brief description of why the patient was in the hospital, overview of their care including procedure and lab/imaging results as well as pending results and follow up appointments Prescriptions Pain Antibiotics Home medications Durable Medical Equipment (DME) Referrals Follow up appointments Discharge instructions Post-Operative Discharge (Outpatient) Discharge order Prescriptions Pain Antibiotics Home medications Durable Medical Equipment (DME) Referrals Follow up appointments Discharge instructions Discharge Instructions Should include very specific details on what you wish the patient to do post-operatively Medication management Pain management Follow up appointments Signs and symptoms of infection (and what to do if these occur) Signs and symptoms of DVT (and what to do if these occur) Outline: Post-Operative Complications Dressings Bleeding Drainage Pain Infection Hardware https://www.pinterest.com/pin/205195326759178572/ Post-Operative Dressings Bleeding in dressing (“strike-through”) Common reason to hear about/from patient How much blood? Reinforce dressing if minimal bleeding Ideally, want to keep surgical dressing intact for 1-7 days post-operative If necessary, take dressing down in clean environment Check for arterial bleed if significant blood volume Address as needed Post-Operative Dressings Drainage What type? How much? Color? Odor? Saturation Rain Bathing May be able to reinforce, may have to remove and re-apply https://stock.adobe.com/search?k=%22trauma+shears%22 Post-Operative Pain How much pain? What does it feel like? Loosen dressings R.I.C.E Opioids NSAIDs Neurological agents Acetaminophen Rule out: Surgical Infection DVT Compartment syndrome Post-Operative Infection Identify infection Labs Imaging Clinical findings PO antibiotics Local wound care Admission with IV antibiotics Incision and Drainage Amputation https://www.hmpgloballearningnetwork.com/site/podiatry/article/2787 Post-Operative Hardware Concerns Pain Hardware backing out Breakage Loosening Removal Revision https://www.huffingtonpost.co.uk/2015/08/10/man-with-screw-coming-out-of-foot_n_7964576.html https://eor.bioscientifica.com/view/journals/eor/7/1/EOR-21-0025.xml Questions? Post-Operative Infection I & II Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Identify patterns of soft tissue and bone infections in the foot and ankle Demonstrate knowledge of SIRS criteria and sepsis associated with lower extremity infections Identify the types of foot and ankle soft tissue, joint and bone infections requiring surgery Demonstrate knowledge of the surgical techniques and goals for foot and ankle soft tissue, joint and bone infections Demonstrate knowledge of the diagnosis and surgical management of diabetic foot infections Outline Define clinical parameters of common lower extremity infections Soft tissue Bone Joint SIRS criteria Sepsis criteria Medical and surgical management of common infections Workup Treatment Expected Outcomes Infection Defined “Infection can be defined as the pathological presence of bacteria in a site or wound. This pathogenesis is evidenced by the body’s response through the presence of inflammation and white blood cells.” -Warren Joseph, DPM Handbook of Lower Extremity Infections, 3rd Edition Soft Tissue Infection- Cellulitis A bacterial skin and soft tissue infection which occurs when the physical skin barrier, the immune system and/or the circulatory system are impaired Common symptoms: Erythema Edema Warmth Tenderness https://healthjade.net/cellulitis/ Cellulitis Recurrence is high after initial episode (22-49%) Rarely, if ever, bilateral Traumatic injuries Multiple other diseases present similarly Venous insufficiency/stasis Gout DVT Charcot neuroarthropathy https://drashchiheart.com/venous-insufficiency-understanding-venous-disease/ Cellulitis Pathogens: Streptococci and S. aureus are the most commonly identified organisms Atypical organisms may be found https://www.njmonline.nl/getpdf.php?id=1907 Cellulitis Treatment Difficulty to culture Outpatient PO antibiotics covering most likely organism (Gram +) Admission may be necessary if fail outpatient antibiotics Inpatient IV antibiotics covering most likely organism (Gram +) Passive elevation Compressive dressing after resolution of symptoms Reduction in recurrence Abscess A localized collection of purulent material encapsulated by inflammation and granulation in response to an infectious source Most commonly associated with S. aureus or streptococcal species Occur frequently in areas of skin with increased friction or minor trauma https://podiatry.com/ezine/iframe/1197 Abscess Clinical symptoms: Erythema Warmth Edema Pain Concentrated area of fluctuance Diagnosis: Clinical exam Ultrasound X-ray CT MRI Abscess Treatment Small abscess ( 50,000 and 90% neutrophils predominance Crystal analysis Culture and sensitivity Identification of organism in synovial fluid confirms diagnosis Septic Arthritis Risk Factors Advanced age Recent joint surgery or injection Pre-existing erosive joint disease Skin or soft tissue infection IV drug abuse Long-term indwelling catheters Immunocompromised patients Septic Arthritis Treatment: IDSA Guidelines Septic Arthritis Treatment Joint drainage Arthrotomy Arthroscopy Daily needle aspiration Empiric antibiotic administration (after joint aspiration) Removal of prosthetic joint if present Based on IDSA guidelines SIRS and Sepsis Systemic Inflammatory Response Syndrome (SIRS) Clinical syndrome characterized as dysregulated response to inflammation Not only caused by infectious organism Burns, surgery, pancreatitis, autoimmune disorders SIRS Criteria Need 2 or more for confirmation: Fever > 38.0° C or < 36 ° C Tachycardia > 90 beats/min Tachypnea > 20 breaths/min Leukocytosis > 12,000 or leukopenia < 4,000 Sepsis Life-threatening organ dysfunction caused by dysregulated host response to infection Can result in single or multi-organ failure Prior to 2000, mortality was 50% in severe sepsis patients Mortality between 20-25% currently 1 in 3 patients who die in the hospital results from sepsis SIRS plus source of infection Sepsis Multiple objective means to diagnose sepsis: Sequential (sepsis-related) Organ Failure Assessment Score (qSOFA) Respirator rate ≥22/min Altered mental status Systolic BP 6 mm, little callus is seen to form 26 Diamond Concept Risk Factors for Nonunion 28 Diamond Concept Patient Work-Up History Physical Open versus closed Surgery (Type, Fixation) Smoker Diabetes Vascular disease Vitamin D NSAIDs Steroids Pain Sinus tracts Drainage Movement 30 30 Nicotine Use Decreases peripheral oxygen tension Dampens peripheral blood flow Well documented difficulties in wound healing in patients who smoke Increased risk of NONUNION Overall 15% higher 4x Greater Risk 31 31 Nonunion should be considered infected until proven otherwise Dramatic association between deep infection and nonunion Debridement, debridement, debridement Infection Multiple cultures. Identify the bacteria Infectious disease consult is helpful Infected bone requires stability to resolve infection May achieve union in the presence of infection with appropriate treatment 32 Patient Work-Up Lab Work Up Rule-Out Infection Radiographs WBC with Diff ESR CRP CMP Vit D Levels Callus Formation Fixation CT Scan?? 33 33 Communication Treatment Non-operative Operative 34 Non-Operative Treatment Electrical stimulation Ultrasound Extracorporeal shock wave therapy Immoblization 35 Electrical Stimulation Applied mechanical stress on bone generates electrical potentials Compression = electronegative potentials = bone formation Tension = electropositive potentials = bone resorption Basic science suggests e-stim upregulates TGF-β and BMP’s suggesting osteoinduction 36 Contraindications for Electrical Stimulation Synovial pseudoarthrosis Electric stimulation does not addressassociated problems of angulation, malrotation and shortening – deformity!! 37 Ultrasound Piezoelectric transducer generates an acoustic pressure wave Some evidence to show faster healing in fresh fractures Evidence is moderate to poor in quality with conflicting results 38 Extracorporeal Shock Wave Therapy (ESWT) Single impulse acoustic wave with a high amplitude and short wavelength Microtrauma induced in bone thought to stimulate neovascularization and cell differentiation 39 Operative Treatment Debridement and hardware removal Plate osteosynthesis Intramedullary nailing External fixation Autogenous bone graft Bone marrow aspirate Allograft bone Demineralized bone matrix BMP’s Platelet concentrates 40 Autologous Bone Graft Considered the “gold standard” Osteoinductive - proteins and other factors promoting vascular ingrowth and healing Osteogenic – contains viable osteoblasts, progenitor cells, mesenchymal stem cells Osteoconductive - contains a scaffolding for which new bone growth can occur 41 Operative Strategy Define nonunion type Hyper-, oligo-, atrophic, or pseudarthrosis Nonunion location – diaphysis vs metaphysis Infected vs Aseptic Deformity? Patient/host factors Goals and expectations 42 Non-union Crescentic 62 y/o smoker s/p crescentic 2 Month p/o admitted for cellulitis and edema at osteotomy site MRI showed fluid collection Needle aspiration cultured Staph a. (s) IV Abx resolved infection Bone stim at 5 months 43 6 months S/P Crescentic 44 Orthobiologics 52 53 54 55 56 57 58 59 Thank You 60