Shawn M. Gage, PA C Department of Surgery Section of Vascular Surgery Duke University Medical Center
Amputare = History Amb (about), putare (to prune) French extirper / desmembrer 45,000 year old amputee 1 st prosthesis, Rig Veda Sanskrit poem 3500 1800 B.C. Surgical/trauma c. 460 B.C. Surgical/disease 16 th cen www.amputee-coalition.org/related_articles
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) 1867 http://science.jrank.org/pages/313/amputation History.html">Amputation History www.amputee coalition.org/related_articles
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 2. Http://www.aapmr.org/zdocs/assembly/handouts/M116.pdf 3. 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. http://www.rcep7.org/projects/handbook/amputation.pdf
Mortality Rates in LE Amputees VA study Mortality rates in LE amputees of dysvascular origin in 1992. ~ 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
Amputation Statistics by cause United States, 1988 1996 Amputee Coalition of America, http://www.amputee 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):875 883, August 2002.
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).
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
Duke University Data Duke 5 Year Data Duke Amputation per year
Duke University 5 Year Data Distribution Primary Vs Revision
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Types of Lower Extremity Amputation Digit deletion Forefoot amputation Transtarsal Below the Knee At the Knee Above the knee Hip disarticulation Hemicorpectomy
Digit Deletion interphalangeal joint amputation metatarsal phalangeal joint (MTP) amp Ray amputaion
MTP joint disarticulation Distal phalangy necrosis
Ray amputation May de stabilize gait
Transmetatarsal Amputation
Midfoot amputations Lisfranc Bona Jaeger Chopart Lisfranc Chopart
Chopart Amputation
Midfoot Amputations Pirogoff spares a portion of the calcaneous Syme disarticulaton at the talo crural joint (ankle disarticulation
Transtibial (BKA) Burgess (long posterior flap) Skew Sagittal 5 nerves saphenous, D&S peroneal, tibial, sural
Trans knee (Knee disarticulation) Gait difficulty if patient has contralateral knee joint End weight bearing
Transfemoral (AKA) Transcondyloidal Low/mid/high transfemoral High energy expenditure with prosthesis 1 or 3 nerves (sciatic or tibial, sural, peroneal)
Hip disarticulation Lack of viable tissue on the thigh
Van Ness Rotationplasty Proximal Focal Femoral Deficiency (PFFD) Osteosarcoma or Synovialsarcoma
Van Ness Rotationplasty
Considerations in LE Amputation Urgent or elective? Options for revascularization? Patient and family education Goals / Expectations What level?
Urgent or Elective? Bothersome chronic non healing wound. No options for revasc Osteosarcoma Intractable pain Patient choice Infection/sepsis
Urgent or Elective? Bothersome chronic non healing wound. No options for revasc Osteosarcoma Intractable pain Patient choice Infection/sepsis
Options for revascularization?
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
Goals & Expectations Current level of activity Walking Transfers
Physical exam skin temp. most distal pulse/tone Non invasive testing What Level? TC O2 monitoring http://www.pmsinstruments.co.uk/toe_pressure.htm Imaging
What Level?
What Level? Practicality Non viable tissue
Post operative care Apply appropriate dressing Silver Vs. Xeroform Gauze, stump sock, cast padding, bias wrap +/ casting or knee immobilizer Negative pressure
Appropriate Orders
Post operative complications Incorrect dressing / immobilizer application Trauma
Post operative complications Neglect Ischemia
Post operative Complications Phantom limb sensation Neuropathic pain Neuroleptic agents Neurontin, Lyrica, Trileptal
Preventative care Edema control RRD Stump shrinker diuretics
Diligent wound management
Diligent wound management
Multidisciplinary Approach Surgical / wound Social support / nursing OT / PT Prosthetic / orthotic
The Future of Amputee Care
Success
Resources www.ampsurg.org www.amputee coalition.org www.wheelessonline.com Nancy Payne, RN
Thanks