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% 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
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