Shawn M. Gage, PA C Department of Surgery Section of Vascular Surgery Duke University Medical Center

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1 Shawn M. Gage, PA C Department of Surgery Section of Vascular Surgery Duke University Medical Center

2 Amputare = History Amb (about), putare (to prune) French extirper / desmembrer 45,000 year old amputee 1 st prosthesis, Rig Veda Sanskrit poem B.C. Surgical/trauma c. 460 B.C. Surgical/disease 16 th cen

3

4 Modern Surgical Advances Hippocrates & Celsus ligature c. 460 B.C. (reintroduced by) Ambroise Pare 1529 Tourniquet 1674 Screw Tourniquet Jean Louis Petit 1718 Anesthesia (chloroform, ether) 1840 s Lord Lister antiseptic technique (iodine, chloride) History.html">Amputation History coalition.org/related_articles

5 Amputation Stats Approx. 1.7 million people with limb loss in US (Est. 1/200) 3 Nearly 135,000 amputations per year in US 3 Dysvascular population accounts for largest percentage ~ 82% 1 A.A. male has greatest incidence 1 Male at greatest risk for traumatic amputation 1 ratio of upper limb to lower limb amputation ~ 1:4 2 Mortality rate at 3 & 5 years ~ 41.5% & 55.5% resp. 4 Likely hood of contralateral limb amputation at 5 years ~ 50% 5 1.http://www.amputee coalition.org/fact_sheets/amp_stats_cause.html Patricia F. Adams, et al, Current Estimates from the National Health Interview Survey, 1996, Vital and Health Statistics 10:200 (1999). 4. Jennifer A. Mayfield, MD, MPH; et al, Journal of Rehabilitation Research and Development, Vol. 38 No. 3, May/June 2001, Survival following lower limb amputation in a veteran population 5.

6 Mortality Rates in LE Amputees VA study Mortality rates in LE amputees of dysvascular origin in ~ 5100 amputees 99% male, 43% age 65 74, 64% white, 61% DM, 57% PVD Mortality rate for all levels of LE amp at 3 & 5 years 41.5% & 55.5%. ~ 20% of all primary TTA died before discharge Jennifer A. Mayfield, MD, MPH; et al, Journal of Rehabilitation Research and Development, Vol. 38 No. 3, May/June 2001, Survival following lower limb amputation in a veteran population

7 Amputation Statistics by cause United States, Amputee Coalition of America, coalition.org/fact_sheets/amp_stats_cause.html Limb Amputation and Limb Deficiency: Epidemiology and Recent Trends in the United States DILLINGHAM, TIMOTHY R.; PEZZIN, LILIANA E.; MACKENZIE, ELLEN J. Southern Medical Journal. 95(8): , August 2002.

8 Duke Vs. National Data Duke 5 Year Data 1996 National Data Patricia F. Adams, et al, Current Estimates from the National Health Interview Survey, 1996, Vital and Health Statistics 10:200 (1999).

9 Duke University 5 Year Data Major amputation including : TMA, TTA, TFA, and HDA Vascular, PSU, Ortho, and CTS Average 233/yr over 5 year period

10 Duke University Data Duke 5 Year Data Duke Amputation per year

11 Duke University 5 Year Data Distribution Primary Vs Revision

12 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

13 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

14 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

15 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

16 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

17 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

18 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

19 Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy

20 Digit Deletion interphalangeal joint amputation metatarsal phalangeal joint (MTP) amp Ray amputaion

21 MTP joint disarticulation Distal phalangy necrosis

22 Ray amputation May de stabilize gait

23 Transmetatarsal Amputation

24 Midfoot amputations Lisfranc Bona Jaeger Chopart Lisfranc Chopart

25 Chopart Amputation

26 Midfoot Amputations Pirogoff spares a portion of the calcaneous Syme disarticulaton at the talo crural joint (ankle disarticulation

27 Transtibial (BKA) Burgess (long posterior flap) Skew Sagittal 5 nerves saphenous, D&S peroneal, tibial, sural

28 Trans knee (Knee disarticulation) Gait difficulty if patient has contralateral knee joint End weight bearing

29 Transfemoral (AKA) Transcondyloidal Low/mid/high transfemoral High energy expenditure with prosthesis 1 or 3 nerves (sciatic or tibial, sural, peroneal)

30 Hip disarticulation Lack of viable tissue on the thigh

31 Van Ness Rotationplasty Proximal Focal Femoral Deficiency (PFFD) Osteosarcoma or Synovialsarcoma

32 Van Ness Rotationplasty

33 Considerations in LE Amputation Urgent or elective? Options for revascularization? Patient and family education Goals / Expectations What level?

34 Urgent or Elective? Bothersome chronic non healing wound. No options for revasc Osteosarcoma Intractable pain Patient choice Infection/sepsis

35 Urgent or Elective? Bothersome chronic non healing wound. No options for revasc Osteosarcoma Intractable pain Patient choice Infection/sepsis

36 Options for revascularization?

37 Patient / Family Education Do they understand their options? Do they understand what you are going to do? Family / friend support? Are they ready? Misconceptions Hospital resources

38 Goals & Expectations Current level of activity Walking Transfers

39 Physical exam skin temp. most distal pulse/tone Non invasive testing What Level? TC O2 monitoring Imaging

40 What Level?

41 What Level? Practicality Non viable tissue

42 Post operative care Apply appropriate dressing Silver Vs. Xeroform Gauze, stump sock, cast padding, bias wrap +/ casting or knee immobilizer Negative pressure

43 Appropriate Orders

44 Post operative complications Incorrect dressing / immobilizer application Trauma

45 Post operative complications Neglect Ischemia

46 Post operative Complications Phantom limb sensation Neuropathic pain Neuroleptic agents Neurontin, Lyrica, Trileptal

47 Preventative care Edema control RRD Stump shrinker diuretics

48 Diligent wound management

49 Diligent wound management

50 Multidisciplinary Approach Surgical / wound Social support / nursing OT / PT Prosthetic / orthotic

51 The Future of Amputee Care

52 Success

53 Resources coalition.org Nancy Payne, RN

54 Thanks

Heikki Uustal, MD Prosthetic/Orthotic Team JFK Johnson Rehab Institute Edison, NJ

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