Amputations

Author: Mark Karadsheh

Topic updated on 05/08/13 7:21am

Introduction

May be used to treat
- trauma
- infection
- tumor
- vascular disease
- infection
- congenital anomalies
Prognosis
- 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

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 suppination
    - 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 amputaiton
- 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)

Technique
- 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

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
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 (19 Questions)

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(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

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 ▶

DISCUSSION: The clinical photograph and radiograph demonstrate a Lisfranc amputation. The loss of the peroneus longus, EHL, EDL, and peroneus tertius insertions result in an equinovarus deformity due to the pull of the gastrosoleus complex, posterior tibialis, and anterior tibialis. The gastrocsoleus complex and posterior tibialis are primarily innervated by the S1 nerve root.

The referenced article by Early reviews the indications and complications involved with Lisfranc and Chopart amputations of the midfoot.

REFERENCES:

1. Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract)

2. Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, 2nd ed. Philadelphia, PA: JB Lippincott; 1983:218-247.

Question Authors:

John Badylak MD, Patrick McCulloch MD, Michael Hughes MD,

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(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 insluin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a pneumothorax which is treated with 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 thoracostomy tube
5. Presence of an insulin pump

PREFERRED RESPONSE ▶

DISCUSSION: The presence of a crush injury to an extremity is an indication for hyperbaric oxygen (HBO) therapy. The remainder of the options listed are contraindications to hyperbaric oxygen treatment.

Hyperbaric oxygen therapy potentially can provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma. The idea behind HBO is to provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma.

Greensmith et al provide a review of HBO therapy and discuss the relative and absolute contraindications and indications for this treatment. They report in patients with crush injury or early compartment syndrome, hyperbaric oxygen therapy may reduce the penumbra of cells at risk for delayed necrosis and secondary ischemia. They report that both animal studies and prospective human clinical trials suggest the benefits of such therapy.

Buettner et al found that based on clinical evidence and cost analysis, medical institutions that treat open fractures and crush injuries are justified in incorporating HBO theray as a standard of care.

Illustration A shows an example of a hyperbaric oxygen(HBO) chamber.

Incorrect Answers:
Answer 2: COPD is a contraindications to hyperbaric oxygen treatment.
Answer 3: History of bleomycin treatment is a contraindications to hyperbaric oxygen treatment.
Answer 4: Presence of a thoracostomy tube is a contraindications to hyperbaric oxygen treatment. It should be noted that the presence of a pneumothorax not treated with a thoracostomy tube is a contraindication to HBO treatment.
Answer 5: Presence of an insulin pump is a contraindications to hyperbaric oxygen treatment.

Illustrations: A

REFERENCES:

1. Greensmith JE: Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg 2004;12:376-384 PMID:15615503 (Link to Abstract)

2. Kindwall EP: Contraindications and side effects to hyperbaric oxygen treatment, in Kindwall EP, Whelan HT (eds): Hyperbaric medicine practice, ed 2. Flagstaff, AZ, Best Publishing Company, 1999, pp 83-98

3. Buettner MF, Wolkenhauer D: Hyperbaric oxygen therapy in the treatment of open fractures and crush injuries. Emerg Med Clin North Am 2007;25:177-188 PMID:17400080 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Derek Moore, Ben Taylor MD,

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(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 femur bone 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 disfunction? 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 ▶

DISCUSSION: Pinzur et al highlight the fact that amputations are reconstructive procedures and should leave the patient with a functional residual limb. Adductor myodesis is a critical part of a transfemoral amputation. If it is not performed, then the abductors and hip flexors can cause the femur to abduct, leading to severe problems with gait. The gait disturbance persists despite proper prosthetic fitting. A transfemoral amputation is usually performed with equal anterior and posterior flaps.

REFERENCES:

1. Pinzur MS, Gottschalk F, Pinto MA, et al: Controversies in lower extremity amputation. Instr Course Lect 2008;57:663-672 PMID:18399614 (Link to Abstract)

2. Pinzur MS, Bowker JH, Smith DG, et al: Amputation surgery in peripheral vascular disease. Instr Course Lect 1999;48:687-691 PMID:10098097 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

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(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 ▶

DISCUSSION: Adductor myodesis is critical for optimal outcome after transfemoral amputation. Pinzur et al. emphasize that when the adductors are not anchored to bone, the hip abductors are able to act unopposed, producing a dynamic flexion-abduction deformity. This deformity prepositions the femur in an orientation that is not conducive to efficient walking. The retracted adductor muscles lead to a poorly cushioning soft-tissue envelope, further complicating prosthetic fitting. Preservation of a functional adductor magnus helps to maintain the muscle balance between the adductors and abductors by allowing the adductor magnus to maintain its power and retain the mechanical advantage for positioning the femur. Preservation is best accomplished with a myodesis.

REFERENCES:

1. Pinzur MS: Amputations in trauma, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, Saunders, 2003, pp 2613-2626

2. Pinzur MS, Gottschalk FA, Pinto MA, et al: Controversies in lower-extremity amputation. J Bone Joint Surg Am 2007;89:1118-1127 PMID:18399614 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

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(OBQ08.246) In addition to lengthening the achilles, transfer of which tendon is 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 ▶

DISCUSSION: The partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. The Chopart amputation may result in significant equinovarus deformity with anterior weight bearing through the scar line, predisposing to skin breakdown over time. Therefore, lengthening of the Achilles tendon and transfer of the tibialis anterior to the talar neck should also be performed in conjunction with this disarticulation. The tib ant transfer results in dorsiflexion and distributes the weight-bearing portion more centrally and the lengthening of the Achilles tendon is necessary to accommodate this posteriorly. Transfer of the tibialis anterior or posterior tibialis to the calcaneous would exacerbate the equinovarus deformity. Shortening of the Achilles tendon would also exacerbate the anterior loading of the scar.

REFERENCES:

1. Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 970-1006

2. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL American Academy of Orthopaedic Surgeons, 2005, pp 645-654

Question Authors:

Greg Galano MD,

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(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 ▶

DISCUSSION: Bone overgrowth is a poorly understood phenomenon in which the bone end undergoes disorganized appositional growth following amputation in a skeletally immature patient. Overgrowth is the most common complication following transosseous amputation in pediatric patients.

Krajbich reviews the management of pediatric patients with lower-limb deficiences and amputations. He advocates disarticulation as opposed to transosseous amputation when possible as bone overgrowth has not been observed in bone ends covered by articular cartilage.

O'neal et al retrospectively reviewed their rates of surgical revision for bone overgrowth in pediatric and adolescent amputees. The highest rates of revision were seen with metaphyseal-level amputations (50%) and with traumatic amputations (43%).

Benevenia et al reviewed their rates of overgrowth in skeletally immature transosseous amputees using an autogenous epiphyseal transplant from the amputated limb to cap the medullary canal. They found that only 1 of 10 patients undergoing amputation with this technique had complications due to bone overgrowth, compared with 6 of 7 patients undergoing traditional transosseous amputation.

Illustration A is a clinical photo of bone overgrowth eroding through the soft tissue in a transhumeral amputee. Illustration B demonstrates the radiographic appearance of bone overgrowth in a transtibial amputation.

Incorrect Answers:
Answer 1. Neurogenic pain is a concern for adults, but rarely occurs in children.
Answer 3. Flexion contracture is not a common complication following amputation in pediatric patients.
Answer 4. Adduction contracture is not a common complication following amputation in this patient population.
Answer 5. The proximal tibial physis, important for longitudinal growth of the limb, would be sacrificed with a knee disarticulation, meaning the residual limb will be shorter than if the patient had a transtibial amputation.

Illustrations: A

REFERENCES:

1. Krajbich JI. Lower-limb deficiencies and amputations in children. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):358-67. PMID:9826419 (Link to Abstract)

2. O'Neal ML, Bahner R, Ganey TM, Ogden JA. Osseous overgrowth after amputation in adolescents and children. J Pediatr Orthop. 1996 Jan-Feb;16(1):78-84 PMID:8747360 (Link to Abstract)

3. Benevenia J, Makley JT, Leeson MC, Benevenia K. Primary epiphyseal transplants and bone overgrowth in childhood amputations. J Pediatr Orthop. 1992 Nov-Dec;12(6):746-50. PMID:1452744 (Link to Abstract)

Question Authors:

Brian Weatherford MD, Ben Taylor MD, John Badylak MD,

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(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 ▶

DISCUSSION: "Dog ears" at the edge of a long posterior flap BKA incision are typically left intact because removal risks posterior flap blood supply.

Gray et al conducted an anatomic study to examine the BKA vascular anatomy and specifically the blood supply contribution of the soleus muscle. In their article, they describe the saphenous and sural arteries as being the main blood supply to the proximal posterior aspect of the calf. These arteries lie on the medial and lateral border of a long posterior flap, and can be at risk for transection when excising "dog ears". These arteries are particularly important in patients with severe vascular disease, as the popliteal artery and its immediate branches may be occluded, while the collateral smaller vessels (ie. saphenous and sural arteries) remain patent. Of note, the authors did conclude that the soleus muscle does not contribute blood supply to a long posterior flap, and it should be entirely excised.

Faltie-Jensen et al compared the rate of complications with long posterior flaps vs. equal sagittal flaps in diabetic and non-diabetic patients. They found that in diabetic patients, there was a higher incidence of infection and failure of wound healing in patients with the long posterior flap.

Manoli argues against the use of equal coronal flap, "fish mouth" incisions for below the knee amputations in patients with diabetes and peripheral vascular disease because of the increased risk of anterior flap necrosis.

REFERENCES:

1. Gray DW, Ng RL. Anatomical aspects of the blood supply to the skin of the posterior calf: technique of below-knee amputation. Br J Surg. 1990 Jun;77(6):662-4. PMID:2383735 (Link to Abstract)

2. Falstie-Jensen N, Christensen KS, Brøchner-Mortensen J. Long posterior flap versus equal sagittal flaps in below-knee amputation for ischaemia. J Bone Joint Surg Br. 1989 Jan;71(1):102-4. PMID:2914977 (Link to Abstract)

3. Manoli A 2nd. A long posterior flap in below-knee amputations for peripheral vascular disease: rationale and technique. Foot Ankle Int. 1998 Feb;19(2):110-2. PMID:9498584 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Ben Taylor MD,

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(OBQ06.53) Which of the following is most important to acheive 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 ▶

DISCUSSION: A Syme amputation is effectively a tibiotalar disarticulation, which provides an end-bearing stump that could potentially allow ambulation without a prosthesis over short distances. It works better for tumor and trauma, but the heel pad must be viable. The two most common problems are 1) skin sloughing from compromised vascular supply and 2) migration of the heel pad due to instability. A hypermobile heel pad can cause difficulty with prosthesis wear and damage to the soft tissues which can eventually lead to failure. Both malleoli are usually removed in the procedure, except in children or during the first stage procedure of a diabetic or infection case. The tibialis anterior is usually tenodesed to the anterior heel pad along with the EDL tendon to avoid posterior migration of the heel pad.

REFERENCES:

1. Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 970-1006.

2. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 305-314.

Question Authors:

Greg Galano MD, Derek Moore, Patrick McCulloch MD,

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(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 ▶

DISCUSSION: A Syme amputation (ankle disarticulation) is a function-preserving amputation option that allows for terminal weight bearing, however strict criteria must be met for a patient to undergo successful Syme amputation. An ankle-brachial index (ABI) less than 0.5 for the posterior tibial artery in a patient with diabetes would be a contraindication for this procedure as success is dependent on the vascular supply of posterior tibial artery to the plantar flap and heel pad.

Pinzur et al retrospectively reviewed their results when performing a single-stage Syme ankle disarticulation in patients with diabetes either for peripheral neuropathy or infection. Patients with ABIs less than 0.5 for the posterior tibial artery had significantly decreased healing rates and smokers had a three-fold increased risk of postoperative infection.

Incorrect Answers:
Answer 1: Albumin of 3.4 indicates adequate preoperative nutrition. Albumin of 2.0 or less would be concerning for increased wound healing risk.
Answer 2: Osteomyelitis was the indication for amputation in a number of diabetic patients in the referenced study, and should not preclude Syme amputation unless the hindfoot and/or distal tibia is involved
Answer 4: Transcutaneous 02 pressure of 45 signifies adequate oxygenation and vascularity. Less than 30 is generally considered a cutoff for adequate vascularity.
Answer 5: Peripheral neuropathy with recurrent ulceration was an indication for amputation in the referenced study.

REFERENCES:

1. Brodsky JW. Amputations and prostheses of the foot and ankle. Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, 7th ed. St. Louis, MO: Mosby, 1999: 970-1006.

2. Mizel MS, Miller RA, Scioli MW, (eds). Orthopaedic Knowledge Update: Foot and Ankle 2. American Academy of Orthopaedic Surgeons, Rosemont, IL: 1998

3. Chapman’s Orthopaedic Surgery, Ch. 120: Amputations of the Lower Extremity.

4. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am. 2003 Sep;85-A(9):1667-72 PMID:12954823 (Link to Abstract)

Question Authors:

Brian Weatherford MD, John Badylak MD,

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(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 ▶

DISCUSSION: The general trend is increasing energy requirement for more proximal amputations. Amputation should be performed at the lowest possible level in order to preserve the most function. Pinzur compared 5 patients with amputations at midfoot, Syme’s, BKA, through knee, and AKA with five controls. Walking speed and cadence decreased while oxygen consumption per meter walked increased with each more proximal amputation. The only exception is the Syme which was the most energy efficient even though it is more proximal to the midfoot amputation.

REFERENCES:

1. Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992Sep;15(9):1033-6; discussion 1036-7. PMID:1437862 (Link to Abstract)

2. Rheinstein J, Yanke J, Marzano R: Developing an effective prescription for a lower-extremity prosthesis. Foot Ankle Clin 1999;4:113-138

Question Authors:

Derek Moore, Patrick McCulloch MD,

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(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 ▶

DISCUSSION: A Lisfranc amputation is through the tarsometatarsal joints, except the 2nd metatarsal, which is osteotomized to preserve the stability of the medial cuneiform. To prevent the patient from supinating the foot following this amputation, the evertors on the foot must be maintained. The principal evertors are the peroneus brevis and longus (Illustration A). Therefore, the function of the peroneus brevis must be preserved. Technically this is done preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base.

Illustration B depicts the level of a Lisfranc amputation of the foot.

Incorrect Answers:
1-The posterior tibialis is the primary supinator of the foot, and releasing it would lead to an eversion deformity. The tibialis posterior tendon attachment to the bases of the second and third metatarsals will actually be released with this amputation, but the main attachment to the navicular preserved.
3-The anterior tibialis dorsiflexes and inverts the foot, but transferring it to the medial and middle cuneiforms would mimick its native function to dorsiflex and invert the foot.
4-A lengthened Achilles would lead to increased dorsiflexion, not supination.
5-Osteotomy of 2nd MT is crucial to preserve the medial cuneiform and midfoot stable.

Illustrations: A

REFERENCES:

1. Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract)

Question Authors:

Dan Prince MD, Derek Moore, Michael Hughes MD,

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(OBQ05.150) With comparison to a below the knee amputation, each of the following are disadvantages of a through the knee amputation EXCEPT: Topic

Review Topic

1. Slower self-selected walking speeds
2. Worse performance on the Sickness Impact Profile (SIP)
3. Physicians were less satisfied with the cosmetic recovery
4. More severe pain at amputation site
5. Require more dependence with patient transfers

PREFERRED RESPONSE ▶

DISCUSSION: Through-the-knee amputation level is associated with the worst functional result 2 years after injury (compared to transmetatarsal, Symes, AKA, or BKA)

The cohort study by MacKenzie et al prospectively followed 161 patients that were part of the Lower Extremity Assessment Project (LEAP). These patients underwent an above-the-ankle amputation at a trauma center within 3 months following the injury and followed for 2 years. This study revealed that through-the-knee amputations had significantly worse scores for the objective performance measures of self-selected walking speed, independence in transfers, walking, and stair-climbing. Through-the-knee amputees also had worse SIP scores than AKA and BKA patients. Physicians were also less satisfied with both the clinical and the cosmetic recovery of the patients with a through-the-knee amputation. It should be noted that patients with a BKA had a faster walking speed than those with an AKA. Despite the worse SIP scores for through-the-knee amputations, patients actually reported less pain than those with an AKA or BKA, though this wasn't statistically significant.

REFERENCES:

1. MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, Burgess AR, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, Travison TG, McCarthy ML. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am. 2004 Aug;86-A(8):1636-45. Erratum in: J Bone Joint Surg Am. 2004 Nov;86-A(11):2503. PMID:15292410 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

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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 ▶

DISCUSSION: A through-knee disarticulation has been shown to have decreased energy expenditure with ambulation, improved limb proprioception, improved sitting capabilities, decreased hip joint flexion contracture incidence, and improved lever arm for mobilization. Knee disarticulation is also recommended in children to prevent overgrowth of the distal femur which may be seen in transfemoral amputations (if the physis remains open). No difference in prosthesis fitting has been shown between transfemoral amputation and through-knee disarticulation. The referenced paper by Pinzur et al is a excellent review of knee disarticulation, from technique to outcomes.

REFERENCES:

1. Pinzur MS, Bowker JH. Knee disarticulation. Clin Orthop Relat Res. 1999 Apr;(361):23-8. PMID:10212592 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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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 ▶

DISCUSSION: Albumin is the best measure of nutrition that is vital for wound healing. Total protein is a valuable measure as well, however it is not as sensitive as albumin levels. Calcium levels and ESR/C-reactive protein levels play no role.

REFERENCES:

1. Kay SP, Moreland JR, Schmitter E. Nutritional status and wound healing in lower extremity amputations. Clin Orthop Relat Res. 1987 Apr;(217):253-6. PMID:3829507 (Link to Abstract)

Question Authors:

Paul D. Kim MD, Derek Moore, Patrick McCulloch MD,

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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

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

PREFERRED RESPONSE ▶

DISCUSSION: The Chopart amputation is an amputation of the foot at the level of the calcaneocuboid and talonavicular level. Historically, its use has been criticized because an amputation at this level results in a muscular imbalance with flexor predominance and equinus deformity that eventually leads to stump breakdown. To prevent this complication it should be coupled with Achilles tenotomy (vs. lengthening) as well as transfer of the tibialis anterior insertion to the talar neck.

Advantages of the Chopart amputation include increased limb length and maintenance of heel proprioception that cannot be preserved with more proximal amputations.

Lieberman et al argue in patients with peripheral vascular disease, it is important to preserve as much tissue as possible to preserve maximum function. They recommend that with appropriate care, an amputation at the Chopart (calcaneocuboid-talonavicular) level can give a good functional result.

REFERENCES:

1. Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): Aurgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 970-1006

2. Lieberman JR, Jacobs RL, Goldstock L, Durham J, Fuchs MD: Chopart amputation with percutaneous heel cord lengthening. Clinical Orthopaedics and Related Research 1993;296:86-91 PMID:8222456 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, John Badylak MD,

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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 ▶

DISCUSSION: Prior to the late 80’s, techniques for transfemoral amputation sacrificed the hip adductor muscles resulting in unopposed abductor forces. Amputation with an abducted femur leads to an increase in side lurch and higher energy consumption. Gottschalk in ’99 showed that myodesis of the adductor magnus through drill holes in the lateral femur preserved maximum muscle force and provided a mechanical advantage for the adductors of the thigh. This resulted in maintenance of the normal anatomic alignment of the femur and a balance between the abductor and adductor mechanisms of the hip, thus providing patients with improved control and easier prosthesis fit.

REFERENCES:

1. Gottschalk F. Transfemoral amputation. Biomechanics and surgery. Clin Orthop Relat Res. 1999 Apr;(361):15-22. PMID:10212591 (Link to Abstract)

Question Authors:

Sam Cho MD, Patrick McCulloch MD, Derek Moore,

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Average 4.0 of 5 Ratings

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

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 ▶

DISCUSSION: Extent of soft tissue injury has been shown in Level 2 evidence as having the highest impact on the decision to undergo limb salvage or amputation.

The referenced study by MacKenzie et al looked at 527 of the 601 patients initially enrolled in the Lower Extremity Assessment Project (LEAP) and looked at several variables which are thought to be predictors of amputation. Severe muscle injury had the highest impact on the decision to amputate the limb, likely related to the surgeon’s assessment that the salvaged limb would function poorly because of the risk of infection, nonunion, and poor function. The absence of plantar sensation had the next most significant impact on surgical decision making. Factors that would influence proceeding with an amputation include an nonviable limb, irreparable vascular injury, warm ischemia time of more than 8 hours, or a severe crush injury with minimal remaining viable tissue. Amputation should also be considered when attempts at limb salvage leave the limb so severely damaged that function will be less satisfactory than that afforded by a prosthetic replacement, are a threat to the patient’s life, or would demand multiple surgical procedures and prolonged reconstruction time that is incompatible with the personal, sociologic, and economic consequences the patient is willing to undergo.

REFERENCES:

1. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA; LEAP Study Group. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002 Apr;52(4):641-9. Erratum in: J Trauma 2002 Jul;53(1):48. PMID:11956376 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

Please Rate Educational Value!

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Average 4.0 of 7 Ratings

Cases

http://upload.orthobullets.com/cases/1268/calcanectomy.jpg

calcanectomy (C1268)

Trauma - Treatment Consult - Amputations

HPI - Machete wound to heel, 2 day referral to teaching hospital with calcanectomy.

treatment

9/11/2012

7 responses

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ABOS II: Amputations

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

MacKenzie EJ, Bosse MJ, Castillo RC, Smith DG, Webb LX, Kellam JF, Burgess AR, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, Travison TG, McCarthy ML. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg Am. 2004 Aug;86-A(8):1636-45. Erratum in: J Bone Joint Surg Am. 2004 Nov;86-A(11):2503. PMID:15292410 (Link to Abstract)

Level of Evidence 2 (Prospective Cohort Study)

Jeans KA, Browne RH, Karol LA. Effect of amputation level on energy expenditure during overground walking by children with an amputation. J Bone Joint Surg Am. 2011 Jan 5;93(1):49-56. PMID:21209268 (Link to Abstract)
Herbert LM, Engsberg JR, Tedford KG, Grimston SK. A comparison of oxygen consumption during walking between children with and without below-knee amputations. Phys Ther. 1994 Oct;74(10):943-50. PMID:8090845 (Link to Abstract)
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA; LEAP Study Group. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002 Apr;52(4):641-9. Erratum in: J Trauma 2002 Jul;53(1):48. PMID:11956376 (Link to Abstract)

Level of Evidence 4 (Case Series)

O'Neal ML, Bahner R, Ganey TM, Ogden JA. Osseous overgrowth after amputation in adolescents and children. J Pediatr Orthop. 1996 Jan-Feb;16(1):78-84 PMID:8747360 (Link to Abstract)
Benevenia J, Makley JT, Leeson MC, Benevenia K. Primary epiphyseal transplants and bone overgrowth in childhood amputations. J Pediatr Orthop. 1992 Nov-Dec;12(6):746-50. PMID:1452744 (Link to Abstract)
Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am. 2003 Sep;85-A(9):1667-72 PMID:12954823 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract)
Greensmith JE: Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg 2004;12:376-384 PMID:15615503 (Link to Abstract)
Buettner MF, Wolkenhauer D: Hyperbaric oxygen therapy in the treatment of open fractures and crush injuries. Emerg Med Clin North Am 2007;25:177-188 PMID:17400080 (Link to Abstract)
Krajbich JI. Lower-limb deficiencies and amputations in children. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):358-67. PMID:9826419 (Link to Abstract)
Early JS. Transmetatarsal and midfoot amputations. Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID:10212600 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Sarrafian SK. Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, 2nd ed. Philadelphia, PA: JB Lippincott; 1983:218-247.
Brodsky JW. Amputations and prostheses of the foot and ankle. Coughlin MJ, Mann RA, eds. Surgery of the Foot and Ankle, 7th ed. St. Louis, MO: Mosby, 1999: 970-1006.
Mizel MS, Miller RA, Scioli MW, (eds). Orthopaedic Knowledge Update: Foot and Ankle 2. American Academy of Orthopaedic Surgeons, Rosemont, IL: 1998
Chapman’s Orthopaedic Surgery, Ch. 120: Amputations of the Lower Extremity.

Undefined

Kindwall EP: Contraindications and side effects to hyperbaric oxygen treatment, in Kindwall EP, Whelan HT (eds): Hyperbaric medicine practice, ed 2. Flagstaff, AZ, Best Publishing Company, 1999, pp 83-98
Pinzur MS, Gottschalk F, Pinto MA, et al: Controversies in lower extremity amputation. Instr Course Lect 2008;57:663-672 PMID:18399614 (Link to Abstract)
Pinzur MS, Bowker JH, Smith DG, et al: Amputation surgery in peripheral vascular disease. Instr Course Lect 1999;48:687-691 PMID:10098097 (Link to Abstract)
Pinzur MS: Amputations in trauma, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, Saunders, 2003, pp 2613-2626
Pinzur MS, Gottschalk FA, Pinto MA, et al: Controversies in lower-extremity amputation. J Bone Joint Surg Am 2007;89:1118-1127 PMID:18399614 (Link to Abstract)
Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St. Louis, MO, Mosby, 1999, pp 970-1006
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL American Academy of Orthopaedic Surgeons, 2005, pp 645-654
Gray DW, Ng RL. Anatomical aspects of the blood supply to the skin of the posterior calf: technique of below-knee amputation. Br J Surg. 1990 Jun;77(6):662-4. PMID:2383735 (Link to Abstract)
Falstie-Jensen N, Christensen KS, Brøchner-Mortensen J. Long posterior flap versus equal sagittal flaps in below-knee amputation for ischaemia. J Bone Joint Surg Br. 1989 Jan;71(1):102-4. PMID:2914977 (Link to Abstract)
Manoli A 2nd. A long posterior flap in below-knee amputations for peripheral vascular disease: rationale and technique. Foot Ankle Int. 1998 Feb;19(2):110-2. PMID:9498584 (Link to Abstract)
Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 970-1006.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 305-314.
Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992Sep;15(9):1033-6; discussion 1036-7. PMID:1437862 (Link to Abstract)
Rheinstein J, Yanke J, Marzano R: Developing an effective prescription for a lower-extremity prosthesis. Foot Ankle Clin 1999;4:113-138
Pinzur MS, Bowker JH. Knee disarticulation. Clin Orthop Relat Res. 1999 Apr;(361):23-8. PMID:10212592 (Link to Abstract)
Kay SP, Moreland JR, Schmitter E. Nutritional status and wound healing in lower extremity amputations. Clin Orthop Relat Res. 1987 Apr;(217):253-6. PMID:3829507 (Link to Abstract)
Brodsky JW: Amputations and prostheses of the foot and ankle, in Coughlin MJ, Mann RA (eds): Aurgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 970-1006
Lieberman JR, Jacobs RL, Goldstock L, Durham J, Fuchs MD: Chopart amputation with percutaneous heel cord lengthening. Clinical Orthopaedics and Related Research 1993;296:86-91 PMID:8222456 (Link to Abstract)
Gottschalk F. Transfemoral amputation. Biomechanics and surgery. Clin Orthop Relat Res. 1999 Apr;(361):15-22. PMID:10212591 (Link to Abstract)

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