Please rate topic.
Average 4.3 of 73 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 65-year-old diabetic male with forefoot gangrene is evaluated for possible amputation. When discussing the amputation levels with the patient, which of the following should be noted to require the greatest increase in energy expenditure for ambulation?
Unilateral transtibial amputation
Bilateral transtibial amputations
Through the knee amputation
Select Answer to see Preferred Response
A transfemoral level amputation requires the greatest increase in energy expenditure of the amputation levels given, and a Syme amputation the least.
Biologic joints are energy couples. When performing amputation surgery, more proximal amputations, accompanied by the removal of more joints, decreases the ability of patients to walk and live independently. Therefore a Syme amputation would require only a small increase in energy needed for ambulation. Bilateral transtibial amputee patients have an energy expenditure that is 40% above baseline levels. According to Miller's Review text, unilateral transfemoral amputee's require a 65% increase in energy expenditure.
Pinzur et al. retrospectively studied 97 adult patients with diabetes mellitus who underwent Syme ankle disarticulation because of a neuropathic foot with an infection or gangrene, or both, during an 11 year period. They found that overall 84.5% of the patients achieved wound healing. Their data support the value of Syme ankle disarticulation in diabetic patients with infection or gangrene.
Laughlin et al. retrospectively reviewed the surgical results and functional outcome of 52 patients treated with Syme amputations for forefoot gangrene. Wound healing was correlated with the preoperative status of the posterior tibial artery and follow-up averaged 27 months. The authors found that that posterior tibial artery Doppler examination is predictive of healing in the Syme amputation performed on diabetics, and that furthermore, diabetics can attain a functional level of ambulation with a Syme amputation.
Illustration A shows a clinical photo of a standard Syme amputation with a healthy heel pad which can allow for limited weight bearing in the absence of a prosthesis.
1,2,4,5: All of these amputation levels have lower energy expenditure increases than a transfemoral amputation.
Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z.
J Bone Joint Surg Am. 2003 Sep;85-A(9):1667-72. PMID: 12954823 (Link to Abstract)
Pinzur, JBJS 2003
Laughlin RT, Chambers RB.
Foot Ankle. 1993 Feb;14(2):65-70. PMID: 8454236 (Link to Abstract)
Please rate question.
Average 3.0 of 15 Ratings
What is the most proximal level of amputation that a child can undergo and still maintain a normal walking speed without significantly increasing their energy cost?
Girdlestone hip resection
A through-knee amputation, or knee disarticulation, is the most proximal level of amputation a child can undergo and still maintain a self-selected walking speed without significantly increasing their energy expenditure.
Jeans et al. conducted a study of 73 children. They found that children with Above-knee amputations (AKA) and hip disarticulation amputations had significantly reduced walking speed and increased oxygen consumption. They also determined that children with a Syme's amputation, transtibial amputation, or knee disarticulation ambulated with approximately the same speed and oxygen consumption as did normal children in the same age group.
Herbert et al. performed a study of 10 children with below knee amputations (BKA's)compared to 14 children without amputations. They found that that children with BKAs did not choose speeds different from their peers without amputations, regardless of residual limb length of the BKA.
Illustration V is a video showing a through-knee amputation.
Answer 1: Girdlestone hip resection removes the entire proximal femur and commonly is done through a lateral approach.
Answer 2: Above-knee amputation is performed through the femur and attention is needed for adductor myodesis to prevent abduction deformity.
Answer 4: Below-knee amputation is performed commonly 12-15cm inferior to the knee joint line.
Answer 5: Chopart amputation is performed through the transverse tarsal joints and leaves the talus and calcaneus intact.
Jeans KA, Browne RH, Karol LA
J Bone Joint Surg Am. 2011 Jan;93(1):49-56. PMID: 21209268 (Link to Abstract)
Jeans, JBJS 2011
Herbert LM, Engsberg JR, Tedford KG, Grimston SK.
Phys Ther. 1994 Oct;74(10):943-50. PMID: 8090845 (Link to Abstract)
Average 2.0 of 26 Ratings
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?
Tight posterior capsule tissues of the ankle
Neuropraxia of the deep peroneal nerve
Unopposed pull of gastrocnemius-soleus only
Unopposed pull of gastrocnemius-soleus, posterior tibialis, and peroneus brevis
Unopposed pull of gastrocnemius-soleus and posterior tibialis
The clinical photograph and radiograph demonstrate a modified Lisfranc amputation. The loss of the peroneus longus, peroneus brevis, EHL, EDL, and peroneus tertius insertions result in an equinovarus deformity due to the pull of the gastroc-soleus complex, posterior tibialis, and anterior tibialis.
Several surgical techniques have been described to address or prevent equinovarus deformities after Lisfranc amputation. Open or percutaneous achilles tendon lengthening, open gastrocnemius recession, or endoscopic gastrocnemius recession have shown to address the equinus deformity. Split tibialis anterior tendon transfer (STATT), 4th and 5th digit flexor-to-extensor tendons tenodesis, as well as peroneus brevis (PB) to peroneus longus (PL) tendon transfers have shown to address the varus deformity.
Early et al. state the Lisfranc amputation should be considered when there is inadequate soft tissue coverage for transmetatarsal amputation or instability at the LisFranc joint. In addition, they comment that the deforming forces, the gastroc-soleus complex and posterior tibialis, are primarily innervated by the S1 nerve root.
Figures A through C show clinical and radiographic images of a modified Lisfranc amputation. The classic Lisfranc amputation describes transaction of the first, third, fourth, and fifth tarsometatarsal joints. The second TMT is usually left in place, as it provides stability for the middle cuneiform. These radiographs show a midfoot amputation carried out more transversely across the bones of the midfoot.
Answers 1-4: The equinus deformity occurs after the elimination of extensor digitorum longus and extensor hallucis longus muscles, which cause an imbalance between the posterior compartment and the anterior compartment muscles that across the ankle. The varus deformity occurs when tibialis anterior and posterior compartment muscles overpower the eversion strength of the peroneus brevis muscle.
Clin Orthop Relat Res. 1999 Apr;(361):85-90. PMID: 10212600 (Link to Abstract)
Early, CORR 1999
Average 4.0 of 31 Ratings
For an above knee amputation, each of the following is a benefit of adductor myodesis EXCEPT:
Allows preservation of greater femoral length
Provides a soft tissue cushion beneath the osseous amputation
Improves the position of the femur to allow more efficient ambulation
Creates dynamic balance of the amputated femur
Improves prosthetic fit
Adductor myodesis enhances clinical function following an above knee amputation. An example is provided in illustration A. Adductor myodesis balances the pull of the hip abductors and flexors that insert proximally This prevents an abducted and flexed deformity that encumbers ambulation. It also creates a soft tissue envelope that pads the distal bony amputation and enhances suction fitting of the prosthesis. Performing the myodesis does not preserve femoral length. A little extra distal femur is actually resected to facilitate the myodesis insertion.
In an instructional course lecture, Pinzur et al review the goals and techniques of lower extremity amputations. To achieve a successful amputation, the surgeon must establish reasonable goals with the patient, manage the soft tissue envelope, create an osseous platform for weight-bearing, and facilitate physical rehabilitation.
Pinzur MS, Gottschalk F, Pinto MA, Smith DG.
Instr Course Lect. 2008;57:663-72. PMID: 18399614 (Link to Abstract)
Average 3.0 of 25 Ratings
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 insulin pump, and testicular cancer treated with bleomycin twenty years ago. A radiograph of the chest shows a small pneumothorax which is being observed and does not require a thoracostomy tube. Which of the following is not a contraindication to hyperbaric oxygen treatment for this patient?
Presence of an acute open fracture and crush injury
History of COPD
History of bleomycin treatment
Presence of a pneumothorax
Presence of an insulin pump
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.
Answer 2: COPD is a contraindication to hyperbaric oxygen treatment due to the possible presence of air trapping or bleb formation, which could place the patient at risk of pneumothorax.
Answer 3: History of bleomycin treatment is a contraindication to hyperbaric oxygen treatment because supplemental oxygen may cause life threatening pneumonitis.
Answer 4: Presence of a pneumothorax is a contraindication as hyperbaric oxygen treatment may cause a gas embolism, tension pneumothorax, or pneumomediastinum.
Answer 5: Presence of an insulin pump is a contraindication to hyperbaric oxygen treatment because malfunction or deformation of the device may occur under pressure.
J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):376-84. PMID: 15615503 (Link to Abstract)
Greensmith, JAAOS 2004
Buettner MF, Wolkenhauer D.
Emerg Med Clin North Am. 2007 Feb;25(1):177-88. PMID: 17400080 (Link to Abstract)
Average 2.0 of 55 Ratings
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 distal femur 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 dysfunction?
Inadequate posterior skin flap
Inadequate anterior skin flap
Failure to bevel the distal femur
Lack of abductor myodesis to femur
Lack of adductor myodesis to femur
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.
Pinzur et al highlight the fact that amputations are reconstructive procedures and should leave the patient with a functional residual limb.
Pinzur MS, Bowker JH, Smith DG, Gottschalk F.
Instr Course Lect. 1999;48:687-91. PMID: 10098097 (Link to Abstract)
Average 4.0 of 20 Ratings
Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation?
Hip external rotators
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.
Average 4.0 of 22 Ratings
In addition to lengthening the Achilles, transfer of which tendon is most important for functional ambulation after performing a Chopart amputation of the foot?
Flexor hallucis longus
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 tibialis anterior 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 calcaneus would exacerbate the equinovarus deformity. Shortening of the Achilles tendon would also exacerbate the anterior loading of the scar.
Average 3.0 of 28 Ratings
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?
Hip flexion contracture
Hip adduction contracture
Leg length inequality
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.
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.
J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):358-67. PMID: 9826419 (Link to Abstract)
Krajbich, JAAOS 1998
O'Neal ML, Bahner R, Ganey TM, Ogden JA.
J Pediatr Orthop. 1996 Jan-Feb;16(1):78-84. PMID: 8747360 (Link to Abstract)
O'Neal, JPO 1996
Benevenia J, Makley JT, Leeson MC, Benevenia K.
J Pediatr Orthop. 1992 Nov-Dec;12(6):746-50. PMID: 1452744 (Link to Abstract)
Benevenia, JPO 1992
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?
Anterior tibial artery
Saphenous and sural arteries
Posterior tibial artery
Lower popliteal artery
"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.
Gray DW, Ng RL.
Br J Surg. 1990 Jun;77(6):662-4. PMID: 2383735 (Link to Abstract)
Falstie-Jensen N, Christensen KS, Brøchner-Mortensen J.
J Bone Joint Surg Br. 1989 Jan;71(1):102-4. PMID: 2914977 (Link to Abstract)
Falstie-Jensen, BJJ 1989
Manoli A 2nd.
Foot Ankle Int. 1998 Feb;19(2):110-2. PMID: 9498584 (Link to Abstract)
Manoli, FAI 1998
Average 3.0 of 27 Ratings
Which of the following is most important to achieve a good outcome following a Syme amputation?
trimming any dog ears
a viable and stable heel pad
achilles tendon lengthening
preserving the malleoli
tenodesing the extensor digitorum longus to the tibial shaft
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.
Average 4.0 of 25 Ratings
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?
Albumin of 3.4
ABI of 0.4 for the posterior tibial artery
Transcutaneous oxygen pressure of 45
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.
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.
Average 3.0 of 20 Ratings
Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting?
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.
Pinzur MS, Gold J, Schwartz D, Gross N.
Orthopedics. 1992 Sep;15(9):1033-6; discussion 1036-7. PMID: 1437862 (Link to Abstract)
Pinzur, ORTHO 1992
Average 4.0 of 19 Ratings
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.
Releasing the posterior tibialis tendon
Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base
Myodesis of the anterior tibialis to the medial and middle cuneiforms
Lengthening of the gastrocsoleus (achilles tendon)
Osteotomy through 1st metatarsal
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.
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.
Average 4.0 of 23 Ratings
Which of the following is true of a knee disarticulation as compared to a transtibial amputation?
Faster self-selected walking speeds
Improved performance on the Sickness Impact Profile (SIP) questionnaire
Physicians were more satisfied with the cosmetic appearance
Decreased use of a prosthetic
Decreased dependence with patient transfers
Knee disarticulation level is associated with the worst functional result 2 years after injury (compared to transmetatarsal, Symes, AKA, or BKA). The prosthetic use is decreased with a knee disarticulation as compared to a transtibial amputation.
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.
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
J Bone Joint Surg Am. 2004 Aug;86-A(8):1636-45. PMID: 15292410 (Link to Abstract)
MacKenzie, JBJS 2004
Average 1.0 of 110 Ratings
A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation?
Decreased rate of prosthesis adjustment
Less postoperative time to final prosthesis fitting
Decreased neuroma formation
Decreased rate of revision
Less energy expenditure with ambulation
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.
Pinzur MS, Bowker JH.
Clin Orthop Relat Res. 1999 Apr;(361):23-8. PMID: 10212592 (Link to Abstract)
Pinzur, CORR 1999
Average 3.0 of 10 Ratings
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?
serum albumin level
total protein level
Based on the choices above, the most important predictor of wound healing is the serum albumin level.
Wound healing is based on several factors, which include the vascular status, the immune status, and the nutritional status of the patient. Some important clinical findings include an ankle brachial index (ABI) > 0.45, a total lymphocyte count > 1500/mm3 and a serum albumin > 3.0 g/dL.
Kay et al. discuss the importance of the nutritional status in wound healing after lower extremity amputation procedures. They found eleven of 25 patients who were malnourished sustained either local or systemic complications postoperatively. They recommend that patients should undergo nutritional screening prior to elective lower extremity amputations, to help optimize their wound healing.
Answer 2: While total protein is a marker of nutritional status, it is not as sensitive as the serum albumin for wound healing potential.
Answers 3, 4, 5: Calcium levels, C-reactive protein and ESR are not markers of wound healing
Kay SP, Moreland JR, Schmitter E.
Clin Orthop Relat Res. 1987 Apr;(217):253-6. PMID: 3829507 (Link to Abstract)
Kay, CORR 1987
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?
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.
Figure A shows a lateral radiograph of a Chopart amputation, while Illustration A is a diagram showing this amputation.
Lieberman JR, Jacobs RL, Goldstock L, Durham J, Fuchs MD.
Clin Orthop Relat Res. 1993 Nov;(296):86-91. PMID: 8222456 (Link to Abstract)
Lieberman, CORR 1993
Average 3.0 of 18 Ratings
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?
Beveling the distal femur
Saving the patella
Allowing the sciatic nerve to retract deep into the soft tissue
Myodesis of the adductors
Timely fitting of orthosis
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.
Clin Orthop Relat Res. 1999 Apr;(361):15-22. PMID: 10212591 (Link to Abstract)
Gottschalk, CORR 1999
Average 4.0 of 21 Ratings
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?
Quality of initial fracture reduction
History of tobacco use
Extent of soft tissue injury
Operative debridement and irrigation within 1 hour of injury
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.
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA.
J Trauma. 2002 Apr;52(4):641-9. PMID: 11956376 (Link to Abstract)
MacKenzie, JTACS 2002
the video shows how to plan a prosthesis for hip disarticulation. In addition, i...
Above Knee Amputation
Example of a below knee amputation
HPI - known above knee amputation rt. femur since 26 years, he fell down at home 2 days ago on the stump, complaining of pain by movements rt. thigh and hip.
How would you treat this fracture?
HPI - Run over by a 4 wheeler on 27.12.15. Isolated injury to left leg. Clinical and xrays attached to show the extent of the wound.
How would you treat this acutely following the initial debridement and exploration?
HPI - 48-year-old male s/p ORIF calcaneus and subsequent flap coverage approximately 3 years ago at outside hospital. Infection developed and he underwent a Burgess-type transtibial amputation at the same facility.
He has continued pain in his limb which limits his activity. He notes instability between his tibia and fibula when he wears his prosthetic (chopsticking). Of note, he is employed by a prosthetist as a tester of new equipment and prosthetics.
What would you do for this patient?
HPI - Machete wound to heel, 2 day referral to teaching hospital with calcanectomy.