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 Extremity Amputations

Roger T. Gregory, M.D., G. Patrick Clagett, M.D., H. Fabio Giron , M.D.

Includes:

  • Determination of Amputation Level
  • Additional Important/Non-Core Cirriculum Topics:
  • Post-Amputation Care
  • Prosthetic Management
  • Rehabilitation
  • Phantom Pain Symptoms

I. Anatomy and Pathophysiology

1. To learn the normal anatomy of the extremities including all muscles, nerves, vessels, and bones.

2. To understand the various pathophysiologic conditions which leads to the need for an extremity amputation.

II. Diagnostic Evaluation

Clinical Indications for Amputation

1. To understand when acute ischemia is irretrievable.

2. To understand when chronic ischemia is unacceptable.

3. To define when amputation offers improved quality of life.

4. To be able to recognize when an ischemic limb is a threat to survival.

5. To understand when diabetic foot infections may necessitate amputation despite adequate circulation - the concept of “life threatening infection.”

6. To define the role of osteomyelitis in determining the need and type of amputation.

Determining the Level of Amputation

1. To understand the importance of proper amputation level selection.

2. To define the methods of determining amputation level by clinical criteria.

3. To define methods of determining amputation level by noninvasive methods.

4. To understand the limits of angiography.

III . Treatment

Lower Extremity Amputation Techniques

1. To understand the basic techniques for toe amputation, ray amputation, transmetatarsal amputation, below knee amputation, above knee amputation and upper extremity amputation.

2. To understand situations when “unusual” amputations may be appropriate, such as Choparts , Lisfranc , Symes , through-knee, hip disarticulation, hemipelvectomy , and, even, hemicorporectomy .

3. To understand the causes of stump failure, including technical problems, inadequate skin and muscle perfusion, hematoma , inadequate flaps, pressure necrosis from transected bone, and infection.

Postamputation Care, Prosthetic Management and Rehabilitation

1. To define the differences offered by soft versus rigid dressings.

2. To understand the importance of early mobilization.

3. To achieve a basic understanding of lower extremity prosthetic devices, specifically the pros and cons of immediate versus delayed prosthesis.

4. To understand how amputation technique can impact upon prosthetic application and subsequent rehabilitation.

5. To define goals of rehabilitation with individual capabilities.

6. To understand the importance of communication and participation of a multiple disciplined team approach to the amputee and the special problems presented.

7. To understand the consequences of flexion contracture following amputation.

8. To be able to recognize and manage phantom pain syndromes.

References (*excellent references)

Texts

1. Current Therapy in Vascular Surgery, 2nd edition. Ed. Ernst C & Stanley J. Section on Amputation. Philadelphia, BC Decker Inc. 1991. Pp. 690 - 712.

2. * Vascular Surgery, 4th edition. Ed. Rutherford RB. Philadelphia, WB Saunders Co. Section XIX. Extremity Amputation for Vascular Disease. 1995 ; Pp . 1951-2033.

3. Tooms RE. Amputation of the Lower Extremity. In Crenshaw AH ( ed ). Campbell 's Operative Orthopaedics . 7th ed. St. Louis , CV Mosby , 1987, vol. 1 Pp. 607-627.

4. * Malone JM. Lower Extremity Amputation. In Vascular Surgery, 4th ed . Philadelphia, WB Saunders Co. 1993 ; Pp . 809-853.

Journal Articles

1. Couch NP , David JK, Tilney NL, et al. Natural History of the Leg Amputee. Am J. Surg . 1977; 133:469.

2. Eneroth M, Persson BM. Risk Factors for Failed Healing in Amputation for Vascular Disease. A Prospective, Consecutive Study of 177 Cases. Acta Orthop Scand . 1993; 369.

3. Fisher, DF, Clagett P, Fry RE, Humble TH, Fry WJ. One-Stage versus Two-Stage Amputation for Wet Gangrene of the Lower Extremity: A Randomized Study . J Vasc Surg . 1988; 8:428.

4. Gibbons G. The Diabetic Foot: Amputations and Drainage of Infection. J Vasc Surg . 1987. 5:791.

5. * Keagy BA, Schwartz JA, Kotb M, Burnham SJ, Johnson G. Lower Extremity Amputation: The Control Series. J Vasc Surg . 1986; 4:321.

6. Malone JM, Moore WS, Goldstone J, Malone SJ. Therapeutic and Economic Impact of a Modern Amputation Program. Ann Surg . 1979; 189:798.

7. Malone JM, Moore W, Leal JM, Childers SJ. Rehabilitation for Lower Extremity Amputation. Arch Surg . 1981. 116:93.

8. * Malone JM, Anderson CG, Robertson CL, et al. Prospective Comparison of Noninvasive Techniques for Amputation Level Selection. Am J Surg . 1987; 154:179.

9. McIntyre KE. Control of Infection in the Diabetic Foot: The Role of Microbiology, Immunopathology , Antibiotics and Guillotine Amputation. J Vasc Surg . 1987; 5:787.

10. * Pinzur MS, Gogttschalk F, Smith, Shanfield S et al. Functional Outcome of Below-Knee Amputation in Peripheral Vascular Insufficiency. A Multicenter Review. Clin Orthop . 1993; 286:247.

11. Porter JM, Baur GM, Taylor LM. Lower Extremity Amputations for Ischemia. Arch Surg . 1981; 116:89.

12. * Roon AJ, Moore WS, Goldstone J. Below-Knee Amputation: A Modern Approach . Am J Surg . 1977; 138:52.

13. Sherman RA. Stump and Phantom Limb Pain. Neurol Clin . 1989; 7:249.

14. Schina MJ, Atnip RG, Healy, Thiele BL. Relative Risks of Limb Revascularization and Amputation in the Modern Era. Cardiovasc Surg . 1994; 6:754.

15. Tunis SR, Bass EB, Steinberg EP. The Use of Angioplasty, Bypass Surgery, and Amputation in the Management of Peripheral Vascular Disease. N Engl J Med. 1991; 325:556.

Posted June 2010