Lecture 31 parekh amputations
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This document provides an overview of various amputation levels of the foot and ankle, including: - Distal, great toe, lesser toe, and ray amputations to remove individual toes or parts of the foot. - Transmetatarsal, Chopart's, and Syme's amputations, which remove increasing portions of the foot and ankle. - Considerations for each procedure like bone removal, tendon management, wound closure, and prosthetics. - Causes of amputation like diabetes, PVD, trauma, and infection. The goal is to remove diseased tissue while preserving maximum function.
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Lecture 31 parekh amputations
- 1. Amputations of the Foot & Ankle Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 2. Overview • Introduction/General considerations • Distal Syme’s amputation • Great toe amputation • Lesser toe amputation • Ray resection/partial foot amputation • Transmetatarsal amputation • Chopart’s amputation • Syme’s amputation • Below knee amputation
- 3. Amputation • Admission of failure • Surgical defeat
- 4. Amputation • Positive procedure • First step on road to rehabilitation
- 5. Amputation • Save a marginally viable foot • “Win the battle. Lose the war”
- 6. Amputation • Challenges • Selection of proper level • Maximize function • Surgical technique • Post-operative management • Footwear modifications & prostheses
- 7. Causes 1. Diabetes 2. PVD 3. Trauma 4. Chronic infection 5. Tumors 6. Congenital abnormalities
- 8. Limb Salvage • Change in paradigm • Complete amputation • Partial amputation
- 9. General Considerations • Plantigrade painless foot w/ stable healing wounds
- 10. General Considerations • Preservation of greater portion of limb • Must be able to heal w/ stable soft tissue envelope • More proximal amputation better if it yields more functional result
- 11. Wound Closure • Balance between length of preserved bone & available soft tissue • Immediate or delayed primary closure • Minimize trauma to wound edges • Palpate stump through flap (no rough edges) • Leave sutures in longer • Drain
- 12. Vascular Reconstruction • Consultation • Bypass • Angioplasty
- 13. Determination of Level • Arterial doppler ultrasound • Best initial screen • Toe pressures • Most reliable for predicting healing • Normal >40 mmHg • Transcutaneous oxygen measurements • Cumbersome, time consuming
- 14. Nutritional Status • Predictive of wound healing • Total lymphocyte count > 1500/ul • Serum albumin > 3.5 g/dl • Total protein > 6.2 g/dl • Hgb > 11 g/dl
- 16. Terminal Syme Amputation • Terminal amputation of toe & nail • Indications • Nail deformity • Infection • Remove enough bone to close s/ tension (1/3-1/2 distal phalanx) • Remove nail plate • Include all proximal eponychial fold
- 17. Terminal Syme Amputation • Terminal amputation of toe & nail • Indications • Nail deformity • Infection • Remove enough bone to close s/ tension (1/3-1/2 distal phalanx) • Remove nail plate • Include all proximal eponychial fold
- 18. Great Toe Amputation • Save base of proximal phalanx (1cm) • Preserve PF & FHB • Preserve WB function of 1st ray • Minimize transfer lesion
- 19. • Avoid sesamoid resection, if possible • Complications • Dehiscence • Varus/claw deformity 2nd toe Great Toe Amputation
- 20. Great Toe Amputation • Custom molded filler in shoe • Prevents sliding of foot inside shoe
- 21. • MTP disarticulation • Partial amputation • Residual partial toe maintains space • Blocks migration of adjacent toes Lesser Toe Amputation
- 22. • Do not leave 1 or 2 remaining toes • Develop ulceration • Transmetatarsal amputation Lesser Toe Amputation
- 23. Lesser Toe Amputation • Toe separators to avoid drift • Complications • Dehiscence • Toe drift • DF of the stump
- 24. Ray & Partial Foot Amputations • More common • Durable • Easy to fit in shoes w/ minor modifications • Narrowing of foot • Increased forefoot pressure • Treat w/ molded insole • Preservation of foot length
- 25. Border Ray Resection • 1st & 5th easiest • Straight incisions • Loop around digit • Longer plantar flap
- 26. Border Ray Resection • 1st ray resection • Controversial • Transmet???
- 27. Central Ray Resection • Flaps not as mobile; gap may not close • Preserve soft tissue • Avoid disarticulation @ base of MT • Midfoot instability • Further breakdown
- 28. Partial Forefoot Amputation • 2 (or 3) medial or lateral ray resection • ≥3 rays transmet • Lateral ray resection tolerated better • Creative flaps often necessary
- 29. Partial Forefoot Amputation • Aftercare • Extra depth shoes • Accommodates remaining posture & deformities • E.g. claw toes • Accommodates molded insoles • Shoe filler • Prevents windshield wiper motion • Rocker-bottom sole
- 30. Partial Forefoot Amputation • Complications • Delayed/poor wound healing • Unstable foot • Charcot • Ulceration
- 31. Transmetatarsal Amputation • Technically easy • Tibialis anterior preserved • Active DF • Counteracts equinus contracture • Rule out equinus deformity • TAL may be necessary
- 32. Transmetatarsal Amputation • Incision based on viable margins • Full thickness flap dorsally • Long plantar flap • Tendons cut under tension • Cascade metatarsals • Each successive MT ≥2mm shorter
- 33. Transmetatarsal Amputation • Bevel metatarsals • 15-20° dorsal distal to plantar proximal • 5th beveled in 2 planes (plantar & lateral) • Prevents sharp plantar edge & ulceration
- 34. Transmetatarsal Amputation • Preserve length, if possible • Shorter healed stump better than longer, incompletely healed • Preserve MT bases
- 35. Transmetatarsal Amputation • Toe-filler, lace-up shoe • Rigid & rocker-bottom sole • +/- MAFO
- 36. Transmetatarsal Amputation • Complications • Recurrent/recalcitrant ulceration • Most often equinus contracture • TAL • Prominent bone • Resect
- 37. Chopart’s Amputation • Through transverse tarsal (TN & CC) joint or “Chopart’s joint”
- 38. Chopart’s Amputation • Advantages • Easier than Syme’s • Allows use of a shoe w/ AFO rather than prosthesis • Less limb shortening • Preserves tough weight bearing skin of heel • Poor choice for an active person
- 39. Chopart’s Amputation • Dorsal and plantar flaps • Leave sufficient soft tissue to accommodate for width of foot • Extensor tendons resected • Tibialis anterior & peroneal brevis tendons preserved
- 40. Chopart’s Amputation • TT joint released • Achilles tenectomy • Simple TAL leads to recurrent equinus • TA transferred to neck of talus • PB transferred to anterior process of calcaneus
- 41. Prosthetic Considerations • Since minimal distance from floor, leaves little/no room for prosthesis • Poor amputation level for active patients
- 42. Prosthetic Considerations • AFO w/ built-in molded insole • Plastizote lining to protect & cushion the limb • Rigid prosthesis extending to tibial tubercle • Carbon fiber plate • Posterior opening door
- 43. James Syme, 1799-1870 • Clinical professor @ U. of Edinburgh • Never earned MD • Joseph Lister • Son-in-law • Invented modern raincoat • 1843 • Ankle disarticulation in 16 yo boy w/ TB talus & calcaneus
- 44. Syme’s Amputation • Ankle disarticulation • Advantages • Longer limb • Specialized skin & pad of heel • Room available for self- suspending prosthesis w/ artificial foot
- 45. Syme’s Amputation • Contraindicated if patient lacks viable heel pad
- 46. Syme’s Amputation • Incisions connect points 1.5cm anterior/inferior to malleoli • Plantar incision down to calcaneus • Dorsal incision to dome of talus • Anterior tendons resected • Anterior tibial artery ligated
- 47. Syme’s Amputation • Release ligamentous attachments to talus • Preserve medial neurovascular bundle • Common cause for wound breakdown
- 48. Syme’s Amputation • Protect subcutaneous attachment of Achilles • Subperiosteal dissection calcaneus • Technically difficult • Avoid penetrating skin @ this level
- 49. Syme’s Amputation • Cut malleoli flush w/ plafond • Preserve medial & lateral aspects • Important to aid in prosthesis suspension • Heel pad sutured to bone • Otherwise becomes hypermobile & problematic
- 50. Syme’s Amputation • Plantar fascia sutured to deep fascia on anterior aspect of leg • Do not resect dog ears (can lead to failure) • Can be done in 2 stages for infection
- 51. Syme’s Amputation • Advantages over BKA • Full lower leg segment allows for greater quad leverage • Minimal prosthetic training • Lower energy cost • Higher velocity • Greater stride length
- 52. Syme’s Amputation • Success rate 50-90% • Early failure • Dysvascular heel pad most common • Late failure • Progressive PVD • Distal bony prominences • Hypermobility of stump • Neuroma formation • Heel pain
- 53. Prosthetic Considerations • Door or window allows donning & doffing prosthesis in presence of bulbous distal stump
- 54. Pirogoff’s Amputation • Variation of Syme’s • Portion of calcaneus preserved & internally fixed • Advantages • Longer soft tissue flaps • Less shortening • Disadvantages • Symptomatic non-union
- 55. Boyd’s Amputation • Neither Pirogoff’s nor Boyd’s amputations performed very often • Increased surgical time • Few advantages • Should only be performed if patient is low demand & will not use prosthesis
- 56. BKA • Necessary when foot salvage fails • Tibial resection 9-12cm below joint line • Fibular resection 1cm proximal to tibia • Long posterior flap • 12-15cm
- 57. Energy Expenditure Amputation Level Energy, Above Baseline (%) Speed (m/min) Oxygen Cost (mL/kg/m) Long BKA 10 70 0.17 BKA 25 60 0.20 Bilat BKA 40 50 0.20 AKA 65 40 0.20 Wheelchair 0-8 70 0.16