AND THE STANDARD TYPES OF AMPUTATION IN THE LOWER LIMBS BY DR. OKPALACHUKWU, I
MODERATOR: DR. G.O. EYICHUKWU,
CHIEF CONSULTANT ORTHOPAEDIC SURGEON NOHE. OUTLINE: -INTRODUCTION -HISTORY -EPIDEMIOLOGY -PROBLEMS IN THE SUB REGION -INDICATIONS (GENERAL) -CLASSIFICATION -ANATOMICAL LEVELS -ELECTION OF LEVEL OF AMPUTATION -SPECIFIC INDICATIONS FOR EACH LEVEL -PRINCIPLES OF AMPUTATION IN LOWER LIMB -QUALITIES OF A GOOD STUMP E.G. B/K -COMPLICATION -CONCLUSION -REFERENCES INTRODUCTION: Amputation is the removal of a part or whole of an appendage or limb. It may be definitive or provisional, emergency or elective. It is the oldest surgical procedure, the meanest, yet the greatest life saving operation. The increasing incidence of trauma and peripheral vascular disease as leading indications for amputation and activities of traditional bone setters have made amputation yet more important than ever. With the invention of modern prosthetic devices, the level may not be necessarily important in election of the site of amputation, however, the stump must be of adequate length to fit into prosthesis. HISTORY: 1700BC Babylonian code of Hammurabi is the earliest literature discussing amputation. 460-375BC Hippocrates documented earliest description of therapeutic amputation. 1588 William Cloves did 1st successful A/K amputation. 1870 Stokes modified Grittis procedure. World War II- government funding into research in amputation. EPIDEMIOLOGY: .In USA, about 65000 amputations are performed yearly. .>90% due to peripheral vascular dz., DM accounting for 20%. .Trauma is commoner in the young. .Male preponderance. .In 1965, A/K : B/K =70:30 .In 1980, A/K : B/K =30:70 EPIDEMIOLOGY CONT.D -In our subregion M:F= 2-5:1 -Trauma is the leading cause -Age incidence 30-40yrs (trauma) -Peripheral ischaemic vascular dz (DM) is becoming very common, age incidence =50-70yrs. -More lower extremity amputation -B/K is commoner -Mishaps from TBS is an avoidable cause. PROBLEMS IN THE SUB REGION -Avoidable indications like bone setters gangrene. -Increasing influence of trauma- commercial motor cyclist. -Difficulty accepting amputation as a life saving measure- cultural bias, economic hardship, scarcity and cost of prosthesis. -Preference to begging than accepting prosthesis. INDICATIONS (GENERAL) -Colloquially, the 3Ds. 1.Dead/dying limb-gas gangrene -traumatic gangrene -peripheral vascular dz -ergotism -crushed devitalised limb -TBS gangrene -lethal sepsis -burns -frost bite INDICATIONS CONTD. 2.Dangerous limb- osteosarcoma -marjolin ulcer -malignant melanoma -crushed limb 3.Damn nuisance- persistent pain -gross malformation -recurrent sepsis -gross severe deformity ( elephantoid limb, neurofibromatosis, A-V fistulas) CLASSIFICATIONS -Emergency or Elective -Definitive /classical/closed or provisional guillotine/open (circular open/open amputation with inverted skin flaps) -End bearing or Non end bearing -Weight bearing or Non weight bearing. ANATOMICAL LEVELS: -Toe amputation meta tarsophalangeal joint -Trans metatarsal amputation
-Ray amputation- Tarso metatarsal joint
(single toe) -Lisfrancs amputation Tarso metatarsal joint of all five toes -Choparts amputation-mid tarsal joint -Pirogoffs amputation sub talar joint -Symes amputation (end bearing) just above the two malleoli. -Wagner amputation two stage symes -Boyds amputation ANATOMICAL LEVEL CONT.D -B/K(Transtibial) amputation, 14cm from knee joint line -Knee disarticulation (children) -Gritti-Stokes amputation -A/K (Transfemoral) amputation, 12cm from knee joint line -Disarticulation of hip -Hemipelvectomy ELECTION OF LEVELS OF AMPUTATION: -HX (Cause - trauma, DM, peripheral vascular dz. Congenital, tumours- extent of metastasis ), pre morbid dz- HBP, Asthma , epilepsy, occupation -Clinical examination pallor, jaundice, cardiac and respiratory impairments, palpable peripheral pulses, skip lesions- colour, warmth, extent of functional disability , patients expectation. ELECTION OF SITE CONT.D -INVESTIGATIONS: ( To confirm diagnosis of tumour, extent of metastasis, and stage:- -X-RAY of the limb AP/LATERAL -CXR-PA -CTscan -MRI -BIOPSY INVESTIGATIONS- To ascertain whether the stump will heal:- -Doppler U/S measurement of segmental blood pressure -Xenon-133 clearance test -Transcutaneous O2 tension measurement -Fluorescence studies -Arteriography -Nutrition & immunocompetence studies INVESTIGATIONS to optimise the patient for surgery:- -FBC+ESR -SEUC -FBS -GRP X-MATCH BLOOD -Lipid profile -Urinalysis -Clinical photography -Informed consent SPECIFIC INDICATION FOR EACH LEVEL -Toe amputation- crush injury to the toe -Trans metatarsal amputation- crush injury to the toe. -Ray amputation subungeal melanoma, toe deformity, commonly done. -Lisfranc amputation- forefoot crush injury. -Chopart amputation- forefoot cush injury -Pirogoffs amputation- no longer done. -Symes amputation- uses heel as end bearing. May have problem of blood supply, forefoot tumours, fore foot crush injury. SPECIFIC INDICATIONS CONT.D -B/K-Amputation , 14cm from knee joint line, most commonly done, has advantage of knee joint mechanism, better balance, cheaper and better fitting prosthesis, psychological advantage. Done for peripheral vascular dz., fore foot gangrene, diabetic foot, crush injury to the foot. -A/K-amputation, 12cm from the knee joint line. Done for indications as in B/K, Preferable when vascular status is in question, lethal sepsis in the foot/leg, osteosarcoma of tibia. SPECIFIC INDICATION CONT.D -Knee disarticulation preferable in children. -Gritti- Stokes amputation end bearing. -Hip disarticulation- extra compartmental spread of osteosarcoma of tibia. -Hemipelvectomy rarely done, extra compartmental osteosarcoma of tibia or distal femur. PRINCIPLES OF AMPUTATION IN THE LOWER LIMB, E.G. B/K 1.Thorough clinical assessment + indication. 2.Election of site. -3.Anaesthesia, tourniquet?, exsanguination? 3.Informed consent. 4.Skin incision, anterior + posterior or (medial + posterior ) skin flaps. May be step lather particularly peripheral vascular insufficiency. PRINCIPLES CONT.D 5.Muscles cut distal to bone, nerve proximal to bone, fibula 3cm proximal to tibia, anterior border of tibia shelved to make better contour. 6.Major vessels doubly ligated (separate) with silk. 7.Tourniquet off, haemostasis 8.Myoplasty / myodesis 9.Active drain 10.Firm stump bandaging to mould a conical stump. PRINCIPLES CONT.D 11. Adequate analgesia, adequate antibiotic, adequate fluid and electrolyte therapy, T.T prophylaxis, DVT prophylaxis. 12. Physiotherapy to prevent joint stiffness 13.Prosthesis 14. Occupational advice? QUALITIES OF A GOOD STUMP e.g. A/K -Good blood supply -Stable scar, not terminal in end bearing, but anterior/ posterior -Adequate soft tissue padding -Adequate length for prosthesis fitting -No phantom limb pain COMPLICATIONS: .EARLY-Flap necrosis -Haematoma -Gas gangrene .LATE-skin eczema/ ulceration -Stump ulceration -Nerve neuroma -phantom limb -painful phantom limb -Insecure fitting prosthesis -Joint stiffness -Bone spur /osteoporosis CONCLUSION Amputation despite its frightening implication, continues to be the only life saving option to some patients. With the increasing violent world and modernity, amputation continues to assume important role in surgical practice. With new prosthetic designs the level of amputation is no longer important. -Adequate stump length for prosthesis fitting is still very important. THANK YOU. REFERENCES: -1.A.H. CRENSHAW, Campbells operative orthopaedics vol.1,7th ed., pp597-626. -2.LOUIS SOLOMON et al, Apleys System of Orthopaedics and fractures, 8th ed., pp267- 271. -3.JOHN EBNEZAR, Textbook of Orthopaedics, 3rd ed., pp593-595. -4.PART I UPDATE, WACS 2008, P.H.
Metallurgical and Materials Transactions A Volume 40 Issue 13 2009 (Doi 10.1007/s11661-009-0055-3) K.D. Carlson C. Beckermann - Authors' Reply To Discussion of "Prediction of Shrinkage Pore Volume