overview 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 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 trauma most common reason for an upper extremity amputation infection tumor vascular disease most common reason for a lower extremity amputation congenital anomalies 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 use 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 "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 cast 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 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 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 higher rates of return to vigorous activity in the amputation group
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Midfoot Amputation Orthobullets Team Trauma - Amputations Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Below Knee Amputation Orthobullets Team Trauma - Amputations Technique Guide CPT Codes: 33875, Descending thoracic aorta graft, with or without bypass 47370 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Above Knee Amputation Orthobullets Team Trauma - Amputations
QUESTIONS 1 of 45 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ20TR.15) Figure A is the clinical radiograph of a 36-year-old male who presents to the trauma bay following a motor vehicle collision. The corresponding radiograph is seen in Figure B. When considering amputation versus limb salvage, which of the following is true? QID: 215791 FIGURES: A B Type & Select Correct Answer 1 Ability to return to work is the strongest factor to predict outcomes following amputation 58% (384/662) 2 Amputation results in better Sickness Impact Profile at 2 years 9% (60/662) 3 The absence of plantar sensation has the highest impact on surgeon assessment of the need for amputation 10% (68/662) 4 Limb salvage results in worse functional outcomes at 2 years 11% (70/662) 5 Psychological distress is the strongest factor to predict outcomes following limb salvage 12% (77/662) L 4 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18FA.66) A 37-year-old diabetic man undergoes the amputation depicted in Figure A. Intraoperatively a tendon transfer is performed in order to prevent a postoperative equinus deformity. What nerve innervates the tendon that was transferred? QID: 211825 FIGURES: A Type & Select Correct Answer 1 Lateral plantar nerve 0% (4/1245) 2 Medial plantar nerve 1% (7/1245) 3 Tibial nerve 43% (534/1245) 4 Superficial peroneal nerve 6% (76/1245) 5 Deep peroneal nerve 50% (619/1245) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ18.255) Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation? QID: 213151 Type & Select Correct Answer 1 Syme 9% (148/1653) 2 Traumatic transtibial 28% (463/1653) 3 Vascular transtibial 38% (622/1653) 4 Traumatic transfemoral 17% (287/1653) 5 Vascular transfemoral 7% (114/1653) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ18.31) Regarding Syme amputations, which of the following is true? QID: 212927 Type & Select Correct Answer 1 It does not require a patent tibialis posterior artery 2% (33/1954) 2 It is dependent on a stable heel pad 78% (1515/1954) 3 It is less energy efficient than a midfoot amputation 9% (179/1954) 4 The primary complication is an equinus deformity 7% (138/1954) 5 It is also known as a hindfoot amputation 4% (74/1954) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.81) Which of the following deformities is most common after the amputation shown in Figure A? QID: 4716 FIGURES: A Type & Select Correct Answer 1 Pes cavus 3% (132/4638) 2 Pes planus 3% (134/4638) 3 Hindfoot valgus 4% (163/4638) 4 Equinovarus 87% (4047/4638) 5 Calcaneovalgus 3% (137/4638) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4531 Type & Select Correct Answer 1 Syme amputation 3% (165/4749) 2 Unilateral transtibial amputation 2% (96/4749) 3 Transfemoral amputation 74% (3522/4749) 4 Bilateral transtibial amputations 15% (716/4749) 5 Through the knee amputation 5% (216/4749) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 4579 Type & Select Correct Answer 1 Girdlestone hip resection 1% (19/3190) 2 Above-knee amputation 3% (95/3190) 3 Through-knee amputation 37% (1195/3190) 4 Below-knee amputation 34% (1082/3190) 5 Chopart amputation 25% (784/3190) L 5 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.145) A 34-year-old male is an inpatient at a rehabilitation hospital after sustaining severe lower extremity injuries in a motor vehicle collision. As a result, his energy expenditure while ambulating is 40% above baseline after being fitted with an appropriate prosthetic prescription. What is this patient's most likely lower extremity amputation level? QID: 3233 Type & Select Correct Answer 1 Unilateral long transtibial 3% (113/3286) 2 Unilateral average transtibial 26% (841/3286) 3 Bilateral transtibial 47% (1560/3286) 4 Unilateral transfemoral 22% (719/3286) 5 Bilateral transfemoral 1% (37/3286) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3090 FIGURES: A B C Type & Select Correct Answer 1 Tight posterior capsule tissues of the ankle 1% (13/1569) 2 Neuropraxia of the deep peroneal nerve 1% (14/1569) 3 Unopposed pull of gastrocnemius-soleus only 12% (191/1569) 4 Unopposed pull of gastrocnemius-soleus, posterior tibialis, and peroneus brevis 14% (215/1569) 5 Unopposed pull of gastrocnemius-soleus and posterior tibialis 71% (1121/1569) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ10.162) For an above knee amputation, each of the following is a benefit of adductor myodesis EXCEPT: QID: 3255 Type & Select Correct Answer 1 Allows preservation of greater femoral length 84% (2665/3190) 2 Provides a soft tissue cushion beneath the osseous amputation 5% (162/3190) 3 Improves the position of the femur to allow more efficient ambulation 3% (95/3190) 4 Creates dynamic balance of the amputated femur 3% (88/3190) 5 Improves prosthetic fit 5% (164/3190) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3014 Type & Select Correct Answer 1 Inadequate posterior skin flap 2% (26/1465) 2 Inadequate anterior skin flap 1% (13/1465) 3 Failure to bevel the distal femur 1% (21/1465) 4 Lack of abductor myodesis to femur 5% (68/1465) 5 Lack of adductor myodesis to femur 91% (1331/1465) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 2826 Type & Select Correct Answer 1 Presence of an acute open fracture and crush injury 45% (667/1491) 2 History of COPD 7% (105/1491) 3 History of bleomycin treatment 9% (141/1491) 4 Presence of a pneumothorax 8% (124/1491) 5 Presence of an insulin pump 30% (442/1491) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE08OS.13) Which one of the following lower extremity amputations requires a soft-tissue balancing procedure to prevent deformity following amputation? QID: 6375 Type & Select Correct Answer 1 Gritti-Stokes 13% (89/665) 2 Transtibial 8% (53/665) 3 Transmetatarsal 13% (88/665) 4 Knee disarticulation 15% (103/665) 5 Lisfranc 49% (329/665) L 5 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 632 Type & Select Correct Answer 1 Peroneus brevis 4% (102/2306) 2 Peroneus longus 6% (140/2306) 3 Tibialis anterior 69% (1588/2306) 4 Tibialis posterior 15% (350/2306) 5 Flexor hallucis longus 5% (114/2306) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ08.235) Myodesis of which muscle group is most important for optimal outcome after transfemoral amputation? QID: 621 Type & Select Correct Answer 1 Abductors 3% (52/1561) 2 Adductors 90% (1400/1561) 3 Hip flexors 4% (64/1561) 4 Hip extensors 2% (34/1561) 5 Hip external rotators 0% (6/1561) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 667 Type & Select Correct Answer 1 Neurogenic pain 1% (14/1286) 2 Bone overgrowth 89% (1144/1286) 3 Hip flexion contracture 3% (42/1286) 4 Hip adduction contracture 2% (21/1286) 5 Leg length inequality 5% (63/1286) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 331 Type & Select Correct Answer 1 Albumin of 3.4 4% (52/1372) 2 Active osteomyelitis 7% (90/1372) 3 ABI of 0.4 for the posterior tibial artery 77% (1053/1372) 4 Transcutaneous oxygen pressure of 45 6% (84/1372) 5 Peripheral neuropathy 7% (90/1372) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ06.218) Which of the following amputations will lead to the greatest oxygen requirement per meter walked following prosthesis fitting? QID: 229 Type & Select Correct Answer 1 Above-knee-amputation (transfemoral) 90% (1669/1860) 2 Below-knee-amputation (transtibial) 1% (26/1860) 3 Through Knee 7% (123/1860) 4 Syme 1% (15/1860) 5 Midfoot 1% (17/1860) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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. QID: 241 Type & Select Correct Answer 1 Releasing the posterior tibialis tendon 16% (284/1751) 2 Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base 45% (788/1751) 3 Myodesis of the anterior tibialis to the medial and middle cuneiforms 33% (572/1751) 4 Lengthening of the gastrocsoleus (achilles tendon) 5% (79/1751) 5 Osteotomy through 1st metatarsal 1% (16/1751) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 147 FIGURES: A Type & Select Correct Answer 1 Anterior tibial artery 3% (27/822) 2 Saphenous and sural arteries 72% (593/822) 3 Posterior tibial artery 15% (127/822) 4 Peroneal artery 6% (51/822) 5 Lower popliteal artery 2% (18/822) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ06.53) Which of the following is most important to achieve a good outcome following a Syme amputation? QID: 164 Type & Select Correct Answer 1 trimming any dog ears 1% (9/1593) 2 a viable and stable heel pad 87% (1378/1593) 3 achilles tendon lengthening 8% (124/1593) 4 preserving the malleoli 2% (38/1593) 5 tenodesing the extensor digitorum longus to the tibial shaft 2% (29/1593) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ05.271) A through-knee disarticulation has been shown to have what advantage over a traditional above-knee (transfemoral) amputation? QID: 1157 Type & Select Correct Answer 1 Decreased rate of prosthesis adjustment 4% (61/1547) 2 Less postoperative time to final prosthesis fitting 7% (101/1547) 3 Decreased neuroma formation 3% (51/1547) 4 Decreased rate of revision 4% (69/1547) 5 Less energy expenditure with ambulation 81% (1257/1547) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ05.150) Which of the following is true of a knee disarticulation as compared to a transtibial amputation? QID: 1036 Type & Select Correct Answer 1 Faster self-selected walking speeds 9% (75/871) 2 Improved performance on the Sickness Impact Profile (SIP) questionnaire 8% (70/871) 3 Physicians were more satisfied with the cosmetic appearance 17% (151/871) 4 Decreased use of a prosthetic 57% (495/871) 5 Decreased dependence with patient transfers 9% (77/871) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 1332 FIGURES: A Type & Select Correct Answer 1 Valgus deformity 2% (33/1657) 2 Varus deformity 7% (121/1657) 3 Equinus deformity 85% (1402/1657) 4 Cavus deformity 3% (53/1657) 5 Planus deformity 2% (29/1657) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 1380 FIGURES: A B Type & Select Correct Answer 1 Quality of initial fracture reduction 0% (4/931) 2 History of tobacco use 1% (10/931) 3 Insurance status 1% (5/931) 4 Extent of soft tissue injury 95% (885/931) 5 Operative debridement and irrigation within 1 hour of injury 2% (20/931) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 1340 Type & Select Correct Answer 1 Beveling the distal femur 0% (7/1492) 2 Saving the patella 0% (2/1492) 3 Allowing the sciatic nerve to retract deep into the soft tissue 1% (9/1492) 4 Myodesis of the adductors 98% (1455/1492) 5 Timely fitting of orthosis 1% (10/1492) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 122 Type & Select Correct Answer 1 serum albumin level 89% (1392/1565) 2 total protein level 7% (117/1565) 3 calcium levels 1% (8/1565) 4 C-reactive protein 2% (30/1565) 5 ESR 0% (5/1565) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
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