overview Overview amputations are done urgently and electively to reduce pain, provide independence, and restore function the goals of amputation are login to view 6 more bullets Epidemiology Incidence 1.7 million individuals in the United States with an amputation Risk factors 80% of amputations are performed for vascular insufficiency Etiology Pathophysiology Amputations may be indicated in the following login to view 7 more bullets Metabolic Demand Metabolic cost of walking increases with more proximal amputations login to view 3 more bullets inversely proportional to length of remaining limb Ranking of metabolic demand (% represents amount of increase compared to baseline) Syme - 15% transtibial login to view 4 more bullets transfemoral login to view 2 more bullets thru-knee amputation login to view 2 more bullets bilateral amputations login to view 3 more bullets Wound Healing Dependent on vascular supply nutritional status immune status Improved with albumin > 3.0 g/dL ischemic index > .5 login to view 1 more bullet 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 login to view 3 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet Levels of amputation wrist disarticulation or transcarpal versus transradial amputation login to view 10 more bullets transhumeral versus elbow disarticulation login to view 2 more bullets Techniques general login to view 3 more bullets transcarpal login to view 2 more bullets wrist disarticulation login to view 2 more bullets transradial amputation login to view 2 more bullets transhumeral amputation login to view 4 more bullets shoulder disarticulation login to view 1 more bullet Targeted Muscle Reinnervation designed to improve control of myeolectric prostheses used for amputation general login to view 2 more bullets 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 login to view 3 more bullets Osseointegration metal implant is directly anchored to the residual bone, which is then attached to a prosthetic limb using a transcutaneous connector through a stoma reported increased prosthesis wear, improved mobility, quality of life, and extremity proprioception compared to those with socket prostheses most common complication is low-grade infection that can be managed without antibiotics 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 login to view 1 more bullet 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) login to view 2 more bullets need approximately 8-12 cm from ground to fit most modern high-impact prostheses "dog ears" login to view 2 more bullets Modified Ertl designed to enhance prosthetic end-bearing login to view 1 more bullet increased reoperation rates have been reported technique login to view 4 more bullets 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 login to view 3 more bullets 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 login to view 2 more bullets Lisfranc amputation (midfoot amputation) equinovarus deformity is common login to view 3 more bullets 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 login to view 3 more bullets 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 login to view 2 more bullets Phantom limb pain occurs in 53-100% of traumatic amputations login to view 1 more bullet Bone overgrowth most common complication with pediatric amputations login to view 2 more bullets 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 High rate of late amputation in patients with high-energy foot trauma 1st metatarsal fracture fracture involving all five metatarsals Amputation vs. reconstruction LEAP study login to view 13 more bullets METALS study login to view 5 more bullets