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https://upload.orthobullets.com/topic/1052/images/amputation.jpg
https://upload.orthobullets.com/topic/1052/images/wrist disarticulation.jpg
https://upload.orthobullets.com/topic/1052/images/transradial.jpg
https://upload.orthobullets.com/topic/1052/images/shoulder disarticulation.jpg
https://upload.orthobullets.com/topic/1052/images/adductor myodesis.jpg
Introduction
  • Overview
    • amputations are done urgently and electively to reduce pain, provide independence, and restore function
    • the goals of amputation are
      • preserve functional length
      • preservation of useful sensibility
      • prevention of symptomatic neuromas 
      • prevention of adjacent joint contractures 
      • early prosthetic fitting 
      • early return of patient to work and recreation
  • Epidemiology 
    • 1.7 million individuals in the United States with an amputation 
    • 80% of amputations are performed for vascular insufficiency 
  • Pathophysiology 
    • Amputations may be indicated in the following
      • trauma
        • most common reason for an upper extremity amputation
      • infection
      • tumor
      • vascular disease
        • most common reason for a lower extremity amputation
      • congenital anomalies
  • Prognosis
    • outcomes are improved with the involvement of psychological counseling for coping mechanisms 
      • Involves a close working relationship between rehab physicians, prosthetists, physical therapists, as well as psychiatrists and social workers 
    • amputation vs. reconstruction 
      • LEAP study
        • impact on decision to amputate 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
          • 25% infection rate
          • Mangled foot and ankle injuries requiring free tissue transfer have a worse SIP than BKA
          • most important factor to determine patient-reported outcome is the ability to return to work 
            • About 50% of patients are able to return to work 
      • METALS study
        • study focused on military population in response to LEAP study 
        • slightly better results in regard to patient-reported outcomes for the amputation group with a lower risk of PTSD
          • more severe limbs were going into salvage pathway
          • military population with better access to prostheses
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
  • Amputation versus limb salvage and replantation
    • mangled upper extremity has a far greater impact on overall function than does a lower extremity amputation
      • upper extremity prostheses have much more difficulty replicating native dexterity and sensory feedback provided by the native limb  
    • results of nerve repair and reconstruction are more successful in upper extremity than lower extremity 
    • superior functional outcomes can be expected in replanted limbs compared with upper extremity amputations
      • diminishing outcomes from replantation are expected the more proximal the level, especially about the elbow
  • Levels of amputation
    • wrist disarticulation or transcarpal versus transradial amputation
      • wrist disarticulation advantages
        • improved pronation and supination
        • recommended in children for preservation of distal radial and ulnar physes
        • longer lever arm
      • Disadvantage
        • can be difficult to with highly functional prosthesis compared to transradial
          • Although, this may be changing with advancing technology 
      • transradial advantages
        • more aesthetically pleasing
        • easier to fit prosthesis (myoelectric prostheses)
    • transhumeral versus elbow disarticulation
      • elbow disarticulation advantages
        • indicated in children to prevent bony overgrowth seen in transhumeral amputations
  • Techniques
    • general
      • All named motor and sensory branches within operative field should be identified and preserved 
        • can result in improved muscle mass and preserve the ability to create myoelectric signal for targeted reinnervation 
        • myodesis, the process of attaching the muscle-tendon unit directly to bone is recommended 
    • transcarpal
      • transect finger flexor/extensor tendons
      • anchor wrist flexor/extensor tendons to carpus
    • wrist disarticulation
      • preserve radial styloid flare to improve prosthetic suspension
      • requires healthy and intact DRUJ
    • transradial amputation
      • middle third of forearm amputation maintains length and is ideal
      • residual 5cm of ulna is required for elbow motion, but at this level will have limited pronation/supination
    • transhumeral amputation
      • maintain as much length as possible
      • ideal level is 4-5cm proximal to elbow joint 
      • if more proximal amputation is required:
        • At least 5-7cm of residual length is needed for glenohumeral mechanics 
    • shoulder disarticulation
      • retain humeral head to maintain shoulder contour
  • Targeted Muscle Reinnervation
    • designed to improve control of myeolectric prostheses used for amputation 
    • general
      • transfer amputated large peripheral nerves to reinnervated functionally expendable remaining muscles to create a new discrete muscle signal for the myoelectric prosthesis control 
      • secondary benefit of alleviating symptomatic neuroma pain 
Transfemoral Amputation
  • Maintain as much length as possible
    • however, ideal cut is 12 cm (10-15cm) 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 (otherwise have unopposed abductors)
      • provides soft tissue envelope that enhances prosthetic fitting
  • Gritti-Stokes amputation
    • amputation through the femur near level of adductor tubercle
    • synovium is excised to prevent postoperative effusion
    • patella is arthrodesed to the end of femur for improved end bearing
    • prepatellar soft tissue is maintained without iatrogenic injury
    • improved outcomes as compared to transfemoral amputation
Through-Knee-Amputation 
  • Indications
    • ambulatory patients who cannot have a transtibial amputation
    • 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
      • Consequence of poor soft tissue envelope from loss of gastrocnemius padding 
    • require more dependence with patient transfers than BKA
Below-Knee-Amputation (BKA)
  • Long posterior flap  
    • 12-15 cm below knee joint is ideal (10-16cm of residual tibia bone)
      • ensures adequate lever arm
      • longer than this gets into the achilles tendon which has a suboptimal blood supply and ability for soft tissue cushioning 
    • 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" 
      • preventable with well-designed incision lines
      • if present, left in place to preserve blood supply to the posterior flap
  • Modified Ertl 
    • designed to enhance prosthetic end-bearing
      • argument is that the bone bridge will enhance weight bearing through the fibula and increase total surface area for load transfer 
    • increased reoperation rates have been reported  
    • technique
      • the original Ertl amputation required a corticoperiosteal flap bridge 
      • the modified Ertl uses a fibular strut graft
        • requires longer operative and tourniquet times than standard BKA transtibial amputation
        • fibula is fixed in place with cortical screws, fiberwire suture with end buttons, or heavy nonabsorbable sutures
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 
    • used successfully to treat forefoot gangrene in diabetics 
    • technique
      • medial and lateral malleoli are removed flush with distal tibia articular surface 
      • the medial and lateral flares of the tibia and fibula are beveled to enhance heel pad adherence 
      • heel pad is secured to anterior tibia  
  • Pirogoff amputation (hindfoot amputation)
    • removal of the forefoot and talus followed by calcaneotibial arthrodesis
    • calcaneus is osteotomized and rotated 50-90 degrees to keep posterior aspect of calcaneus distal
    • allows patient to mobilize independently without use of prosthetic
  • Chopart or Boyd 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  
      • leads to apropulsive gait pattern because the amputation is unable to support modern dynamic elastic response prosthetic feet 
  • Lisfranc amputation (midfoot amputation) 
    •  equinovarus deformity is common 
      • caused by unopposed pull of tibialis posterior and gastroc/soleus
      • prevent by maintaining insertion of peroneus brevis and performing achilles lengthening  
      • a walking casst is generally used for 4 week to prevent late equinus contracture 
    • Energy cost of walking similar to that of BKA
  • 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
Complications
  • Wound healing
  • Contractures
    • adjacent joint contractures are common 
    • prevent with early aggressive mobilization and position changes 
  • Heterotopic ossification
    • more common in trauma-related setting 
  • Infection
    • trauma-related amputation have an infection rate of around 34%
  • Postamputation Neuroma 
    • occurs in 20-30% of amputees 
    • prevent with proper nerve handling at the time of procedure 
    • treatment
      • targeted muscle reinnervation 
        • a method of guiding neuronal regeneration to prevent or treat post-amputation neuroma pain and improve patient use of myoelectric prostheses
  • Phantom limb pain
    • occurs in 53-100% of traumatic amputations 
      • mirror therapy is a noninvasive treatment modality 
  • Bone overgrowth
    • most common complication with pediatric amputations 
      • treatment
        • prevent by performing disarticulation or using epihphyseal cap to cover medullary canal
 
 

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Technique Guides (3)
Questions (37)
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(SAE08OS.13) Which one of the following lower extremity amputations requires a soft-tissue balancing procedure to prevent deformity following amputation? Review Topic

QID: 6375
1

Gritti-Stokes

11%

(11/103)

2

Transtibial

9%

(9/103)

3

Transmetatarsal

18%

(19/103)

4

Knee disarticulation

22%

(23/103)

5

Lisfranc

40%

(41/103)

ML 5

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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? Review Topic

QID: 3090
FIGURES:
1

Tight posterior capsule tissues of the ankle

1%

(6/1159)

2

Neuropraxia of the deep peroneal nerve

1%

(9/1159)

3

Unopposed pull of gastrocnemius-soleus only

13%

(145/1159)

4

Unopposed pull of gastrocnemius-soleus, posterior tibialis, and peroneus brevis

13%

(149/1159)

5

Unopposed pull of gastrocnemius-soleus and posterior tibialis

72%

(835/1159)

ML 2

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PREFERRED RESPONSE 5
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(OBQ05.271) A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation? Review Topic

QID: 1157
1

Decreased rate of prosthesis adjustment

3%

(38/1117)

2

Less postoperative time to final prosthesis fitting

7%

(74/1117)

3

Decreased neuroma formation

3%

(33/1117)

4

Decreased rate of revision

5%

(57/1117)

5

Less energy expenditure with ambulation

81%

(908/1117)

ML 2

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PREFERRED RESPONSE 5

(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? Review Topic

QID: 331
1

Albumin of 3.4

5%

(29/563)

2

Active osteomyelitis

7%

(42/563)

3

ABI of 0.4 for the posterior tibial artery

76%

(427/563)

4

Transcutaneous oxygen pressure of 45

5%

(29/563)

5

Peripheral neuropathy

6%

(35/563)

ML 2

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PREFERRED RESPONSE 3

(OBQ08.246) In addition to lengthening the Achilles, transfer of which tendon is most important for functional ambulation after performing a Chopart amputation of the foot? Review Topic

QID: 632
1

Peroneus brevis

4%

(80/1872)

2

Peroneus longus

6%

(113/1872)

3

Tibialis anterior

70%

(1313/1872)

4

Tibialis posterior

15%

(278/1872)

5

Flexor hallucis longus

4%

(77/1872)

ML 2

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PREFERRED RESPONSE 3

(OBQ06.218) Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting? Review Topic

QID: 229
1

Above-knee-amputation (transfemoral)

90%

(1276/1410)

2

Below-knee-amputation (transtibial)

1%

(15/1410)

3

Through Knee

7%

(92/1410)

4

Syme

1%

(9/1410)

5

Midfoot

1%

(8/1410)

ML 1

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PREFERRED RESPONSE 1

(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 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? Review Topic

QID: 3014
1

Inadequate posterior skin flap

1%

(10/886)

2

Inadequate anterior skin flap

1%

(8/886)

3

Failure to bevel the distal femur

1%

(5/886)

4

Lack of abductor myodesis to femur

4%

(34/886)

5

Lack of adductor myodesis to femur

93%

(825/886)

ML 1

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PREFERRED RESPONSE 5

(OBQ12.171) 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? Review Topic

QID: 4531
1

Syme amputation

3%

(143/4152)

2

Unilateral transtibial amputation

2%

(84/4152)

3

Transfemoral amputation

74%

(3089/4152)

4

Bilateral transtibial amputations

15%

(627/4152)

5

Through the knee amputation

4%

(179/4152)

ML 3

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PREFERRED RESPONSE 3

(OBQ13.81) Which of the following deformities is most common after the amputation shown in Figure A? Review Topic

QID: 4716
FIGURES:
1

Pes cavus

3%

(100/3792)

2

Pes planus

3%

(107/3792)

3

Hindfoot valgus

3%

(130/3792)

4

Equinovarus

88%

(3329/3792)

5

Calcaneovalgus

3%

(111/3792)

ML 2

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PREFERRED RESPONSE 4

(OBQ05.150) Which of the following is true of a knee disarticulation as compared to a transtibial amputation? Review Topic

QID: 1036
1

Faster self-selected walking speeds

6%

(27/439)

2

Improved performance on the Sickness Impact Profile (SIP) questionnaire

7%

(31/439)

3

Physicians were more satisfied with the cosmetic appearance

21%

(90/439)

4

Decreased use of a prosthetic

57%

(249/439)

5

Decreased dependence with patient transfers

9%

(40/439)

ML 4

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PREFERRED RESPONSE 4

(OBQ08.235) Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation? Review Topic

QID: 621
1

Abductors

3%

(36/1136)

2

Adductors

90%

(1020/1136)

3

Hip flexors

4%

(51/1136)

4

Hip extensors

2%

(22/1136)

5

Hip external rotators

0%

(4/1136)

ML 1

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PREFERRED RESPONSE 2

(OBQ10.162) For an above knee amputation, each of the following is a benefit of adductor myodesis EXCEPT: Review Topic

QID: 3255
1

Allows preservation of greater femoral length

85%

(2122/2500)

2

Provides a soft tissue cushion beneath the osseous amputation

5%

(120/2500)

3

Improves the position of the femur to allow more efficient ambulation

3%

(65/2500)

4

Creates dynamic balance of the amputated femur

2%

(62/2500)

5

Improves prosthetic fit

5%

(118/2500)

ML 1

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PREFERRED RESPONSE 1

(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.
Review Topic

QID: 241
1

Releasing the posterior tibialis tendon

17%

(204/1195)

2

Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base

43%

(518/1195)

3

Myodesis of the anterior tibialis to the medial and middle cuneiforms

34%

(408/1195)

4

Lengthening of the gastrocsoleus (achilles tendon)

4%

(46/1195)

5

Osteotomy through 1st metatarsal

1%

(9/1195)

ML 4

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PREFERRED RESPONSE 2

(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 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? Review Topic

QID: 2826
1

Presence of an acute open fracture and crush injury

42%

(411/982)

2

History of COPD

8%

(76/982)

3

History of bleomycin treatment

8%

(81/982)

4

Presence of a pneumothorax

6%

(62/982)

5

Presence of an insulin pump

35%

(347/982)

ML 4

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PREFERRED RESPONSE 1

(OBQ12.219) 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? Review Topic

QID: 4579
1

Girdlestone hip resection

0%

(12/2630)

2

Above-knee amputation

3%

(73/2630)

3

Through-knee amputation

36%

(951/2630)

4

Below-knee amputation

34%

(895/2630)

5

Chopart amputation

26%

(686/2630)

ML 5

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 1332
FIGURES:
1

Valgus deformity

2%

(20/1193)

2

Varus deformity

8%

(96/1193)

3

Equinus deformity

85%

(1012/1193)

4

Cavus deformity

3%

(36/1193)

5

Planus deformity

1%

(16/1193)

ML 2

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 147
FIGURES:
1

Anterior tibial artery

3%

(15/461)

2

Saphenous and sural arteries

70%

(325/461)

3

Posterior tibial artery

15%

(67/461)

4

Peroneal artery

8%

(38/461)

5

Lower popliteal artery

3%

(12/461)

ML 2

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 667
1

Neurogenic pain

1%

(5/884)

2

Bone overgrowth

92%

(812/884)

3

Hip flexion contracture

2%

(19/884)

4

Hip adduction contracture

1%

(13/884)

5

Leg length inequality

4%

(34/884)

ML 1

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 1380
FIGURES:
1

Quality of initial fracture reduction

0%

(2/454)

2

History of tobacco use

1%

(5/454)

3

Insurance status

0%

(2/454)

4

Extent of soft tissue injury

97%

(439/454)

5

Operative debridement and irrigation within 1 hour of injury

1%

(4/454)

ML 1

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PREFERRED RESPONSE 4

(OBQ06.53) Which of the following is most important to achieve a good outcome following a Syme amputation? Review Topic

QID: 164
1

trimming any dog ears

1%

(6/1195)

2

a viable and stable heel pad

87%

(1034/1195)

3

achilles tendon lengthening

8%

(101/1195)

4

preserving the malleoli

2%

(27/1195)

5

tenodesing the extensor digitorum longus to the tibial shaft

1%

(17/1195)

ML 1

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PREFERRED RESPONSE 2

(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? Review Topic

QID: 1340
1

Beveling the distal femur

0%

(5/1091)

2

Saving the patella

0%

(2/1091)

3

Allowing the sciatic nerve to retract deep into the soft tissue

0%

(5/1091)

4

Myodesis of the adductors

98%

(1068/1091)

5

Timely fitting of orthosis

1%

(6/1091)

ML 1

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 122
1

serum albumin level

89%

(1014/1140)

2

total protein level

7%

(85/1140)

3

calcium levels

0%

(5/1140)

4

C-reactive protein

2%

(21/1140)

5

ESR

0%

(1/1140)

ML 1

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PREFERRED RESPONSE 1
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