amputation .2003dr. mohammad q. abu ain

8/7/2019 Amputation .2003dr. Mohammad q. Abu Ain

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BY

DR. ABU AIN M.

(CONSULTANT ORTHOPAEDIC SURGEON)



y Amputation is the most ancient of surgicalprocedures.

y

Early surgical amputation was a crudeprocedure by which a limb was rapidly severed from an unanesthetized patient.The open stump was then crushed or dipped

in boiling oil to obtain hemostasis.y Hippocrates was the first to use ligatures;



y This technique was lost during the DarkAges but was reintroduced in 1529 by Ambroise Paré, a French military surgeon,who introduced the "artery forceps

y In 1674 Morel's introduced the tourniquet

y In1867 Lord Lister's introduced the

antiseptic technique.



yMeticulous attention to detail andgentle handling of soft tissues are

important for creating a well-healedand highly functional amputationstump.

y

The tissues often are poorly vascularized or traumatized, and therisk for complications is high.



Skin and Muscle Flaps:y Flaps should be kept thick.

y Unnecessary dissection should be avoided toprevent further devascularization of already compromised tissues.

y

Covering the end of the stump with a sturdy soft tissue envelope is of the mostimportance.



yW ith modern total-contact prostheticsockets, the location of the scar rarely

is important, but the scar should not beadherent to the underlying bone.(Anadherent scar makes prosthetic fitting

extremely difficult, and this type of scaroften breaks down after prolongedprosthetic use.)



y

Redundant soft tissues or large dog ears alsocreate problems in prosthetic fitting andmay prevent maximal function of anotherwise well-constructed stump.

y Muscles usually are divided at least 5 cmdistal to the intended bone resection. They may be stabilized by

y myodesis (suturing muscle or tendon tobone)

y myoplasty (suturing muscle to periosteum

or to fascia of opposing musculature).



H emostasis:y Except in severely ischemic limbs the use

of a tourniquet is highly desirable andmakes the amputation easier.

yMajor blood vessels should be isolated andindividually ligated. Larger vessels shouldbe doubly ligated.

yThe tourniquet should be deflated beforeclosure, and meticulous hemostasis shouldbe obtained.



y A drain should be used in all cases for 48 to72 hours.



Bone:y Excessive periosteal stripping is

contraindicated and may result in the

formation of ring sequestra or bony overgrowth.

y Bony prominences that will not be well paddedby soft tissue should always be resected, and

the remaining bone should be rasped to form asmooth contour.



yPAIN

yHEMATOMA

yINFECTION

yWOUND NECROSIS

y

CONTRACTURESyDERMATOLOGICAL PROBLEMS



yNueroma

yPhantom limb pain

yResidual limb painyMechanical low back pain: which

has been shown to be moreprevalent in amputees than in thegeneral population.



N ueroma:

yA neuroma always forms after

division of a nerve.yA painful neuroma occurs when the

nerve end is subjected to pressureor repeated irritation



yA painful neuroma usually can beprevented by gentle traction on the

nerve followed by sharp proximaldivision, allowing the nerve end toretract deep into the soft tissue.

y

Strong tension on the nerve should beavoided during this maneuver.Crushing also should be avoided.



y Treatment initially consists of socketmodification.

y If this fails to relieve symptoms, simpleneuroma excision or a more proximalneurectomy.



Phantom limb pain:y phantom limb pain is present in up to 80%

of amputees.

y truly bothersome phantom limb pain ismuch less common and is probably presentin less than 10% of amputees.

y Phantom limb sensations are so commonafter an amputation that they should beconsidered normal.



y The most important part of management issimply to educate the patient regardingthese sensations so that they will not besurprised by their presence.

y Some investigators claim that phantom limbpain can be prevented with the use of

epidural anesthesia beginning the day before surgery.



y Although no one specific method isuniversally beneficial, some patients may benefit from such diverse measures asmassage, ice, heat, increased prosthetic use,relaxation training, biofeedback,sympathetic blockade, local nerve blocks,

epidural blocks, ultrasound, transcutaneouselectrical nerve stimulation, and placementof a dorsal column stimulator.



Residual limb pain:y Residual limb pain often is caused by a

poorly fitting prosthesis.y The stump should be evaluated for areas of

abnormal pressure, especially over bony prominences.

y Ulceration or gangrene could result. Theseproblems can be avoided with socketmodifications.



y Other possible causes of residual limb painmay be unrelated to the amputation stump.(e.g : Osteoarthritis , Herniated lumbardisc,..)



y A hematoma can delay woundhealing and serve as a culturemedium for bacterial infection.

y Hematoma formation should beprevented

y If the hematoma is associated withdelayed wound healing with orwithout infection, it should beevacuated in the operating room.



y Infection is considerably more common inamputations for peripheral vascular disease,especially in diabetic patients, than in

amputations secondary to trauma or tumor

y Any deep wound infection should be treatedwith immediate debridement and irrigation

in the operating room and open woundmanagement

y Antibiotics should be tailored according to

the results of intraoperative cultures



y Smith and Burgessdescribed a method

whereby the central onethird of the wound isclosed while theremainder of the wound

is packed open .Thisallows for continuedopen woundmanagement while

maintaining adequateflaps for distal bonecoverage.



y The first step in evaluating significant woundnecrosis is to reevaluate the preoperative selectionof the amputation level.

y

If transcutaneous oxygen studies were notobtained preoperatively, they should be obtainedat this point to evaluate wound healing potential.

y A serum albumin level and a total lymphocytecount should be obtained. (more problems withwound healing in patients with serum albuminlevels less than 3.5 g/dl or total lymphocyte countsless than 1500 cells/m)



yPatients who smoke tobacco shouldquit immediately: Lind J, Kramhoft M,

Bodtker : The influence of smoking oncomplications after primary amputations of the lower extremity

showed that the risk of infection andreamputation was 2.5 times higher insmokers than in nonsmokers



y Necrosis of the skin edges less than 1 cm can betreated conservatively with open wound management

y Its better to discontinue prosthetic use until thewound has healed.

y In cases of severe necrosis, wedge resection may beindicated to salvage the initial amputation level



y Finally, hyperbaric oxygen therapy andtranscutaneous electrical nerve stimulationhave been shown in some studies to

promote wound healing.



y Mild or moderate contractures of the joints of anamputation stump should be prevented by

y Proper positioning of the stump

y Gentle passive stretching,y Having the patient engage in exercises to

strengthen the muscles controlling the joint

y In some patients, prosthetic modification may benecessary to adapt to the contracture.



y Rarely, severe fixed contractures may requiretreatment by wedging casts or by surgicalrelease of the contracted structures.



PLEASE KEEP IN MIND THATAMPUTATION IS ONE OF THEW

ORST SURGICAL PROCEDURES A PATIENT COULD GO THROUGH,,,,,AND A LITTLE EFFORT AND

KNOLEDGE FROM THE SURGEONCOULD SAVE THE PATIENT A LOTOF SUFFERING



DR. ABU AIN M. MD.(CONSULTANT ORTHOPAEDIC SURGEON)

DR. SHOUBAKI A. MD. MRCS(Ed)(ORTHOPAEDIC SURGEON)

http://medicsorg.tripod.com/drabuain/index.htm

amputation .2003dr. mohammad q. abu ain

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