Chapter 112 - Lower extremity amputation operation

Question 1

The first use of tourniquet for amputation

Answer 1

1674 Morell (France) in battle of Besancon

Question 2

Use of antiseptic for amputation

Answer 2

1867 Lister prior to this 50% died from infection

Question 3

General principles of amputation surgery

Answer 3

1) atraumatic tissue handling 2) excise all nonviable/infected tissue 3) tourniquet for blood loss 4) eliminate sharp bone edge/fragments 5) minimize number of cuts 6) sharp transect nerve allow retraction 7) minimize cautery 8) tension free closure 9) myodesis/myoplasty to stabilize antagonistic muscle group 10) drain to reduce dead space

Question 4

Myoplasty in amputation

Answer 4

Suture fixation of antagonistic muscle group

Question 5

Myodesis in amputation

Answer 5

Direct suturing of musculotendinous unit to bone

Question 6

Ring sequestra

Answer 6

Devitalized area of bone from excessive periosteal stripping

Question 7

bones of the ankle

Answer 7

1) 7 tarsal bone 2) 5 metatarsal bone 3) D1 has two phalanges 4) others have 3 5) medial + lateral sesamoid bone in flexor of D1 provides stability 6) joint capsules are around interphalangeal and metatarsophalangeal hinge joints 7) ligamentous and tendinous attachment work with planta fascia for integrity

Question 8

Bone anatomy of the foot and ankle

Answer 8

FIGURE 112.1

Question 9

Ray amputation

Answer 9

digit amputation + metatarsal head amputation

Question 10

Risk of ulceration in D1 ray amputation

Answer 10

60%

Question 11

Lisfranc joint

Answer 11

Tarsometatarsal joint joins the midfoot and forefoot

Question 12

Stability of metatarsal maintained by

Answer 12

1) deep transverse metatarsal ligament distally 2) plantar ligament distally 3) plantar metatarsal ligaments proximally 4) articulate with 3 cuneiform bones (D1-3) and cuboid laterally (D4-5)

Question 13

TMA key points

Answer 13

1) metatarsal cut each 3mm shorter than the last from D1 to D5 2) 30-45 degree plantar bevel helps with ambulation 3) Achilles tendon lengthening or transection? - avoid risk of recurrent ulceration

Question 14

Proximal/hind foot amputations

Answer 14

Lisfrank tarsometatarsal Chopart midfoot Syme Boyd Pirogoff

Question 15

Talocrural joint

Answer 15

Talus with tibia and fibula Supported by 1) deltoid ligament 2) anterior and posterior talofibular ligament 3) calcaneofibular ligament

Question 16

Subtalar joint

Answer 16

talus with calcaneus Supported by 1) medial and lateral talocalcaneal ligament 2) cervical ligament

Question 17

Talocalcaneonavicular joint

Answer 17

multiaxial joint supported by 1) talonavicular ligament 2) plantar calcaneonavicular ligament

Question 18

Supination of ankle

Answer 18

Inversion Produced by tibialis anterior and posterior

Question 19

Pronation of ankle

Answer 19

eversion Produced by peroneus longus and brevis

Question 20

Lisfranc amputation first described in

Answer 20

1815 Lisfranc

Question 21

Lisfranc steps

Answer 21

1) release tendon and synovial sheaths at level of skin incision 2) 1, 3, 4, 5 tarsometatarsal joints disarticulated 3) 2nd metatarsal dividied 1-2 cm distal to medial cuneiform 4) modified* preserve base of 5th metatarsal for peroneus brevis insertion 5) Achilles tendon release transection/Z-plasty 6) plantar fascia approximated to dorsal periosteum

Question 22

Chopart amputation first described in

Answer 22

1814 Chopart

Question 23

Chopart steps

Answer 23

1) incision through talocalcaneonavicular joint and calcaneocuboid joint 2) achilles tenectomy 3) extensor hallucis longus and tibialis anterior tendon reattached to talar neck 4) extensor digitorum longus attached to calcaneus

Question 24

Post op key points for lisfranc and chopart amputation

Answer 24

1) short leg plaster cast molded to ensure talus dorsiflexed in relation to tibia 2) ensure calcaneal tuberosity is parallel to long axis of tibia 3) weight bearing in 6 weeks 4) lisfrank will need toe filler 5) chopart will need custom ankle-foot orthosis and filler

Question 25

Syme amputation first described in

Answer 25

1843 Syme

Question 26

Syme steps

Answer 26

1) anterior incision across ankle distal to top of malleoli 2) posterio incision extends from malleoli vertically down and across sole of foot 3) extensor tendon divided at level of skin 4) dorsalis pedis artery ligated and divided 5) ankle joint capsule incised while plantar flexing the foot before dividing medial and lateral ankle ligaments 6) transect posterior tibialis and flexor hallucis longus 7) avoid injury to posterior tibial nerve 8) heel fat pat dissected carefully but stay close to calcaneus to avoid buttonhole 9) disarticulate ankle 10) malleoli divided at level of articular surface of tibia and reduce width 11) drill holes in medial, anterior and lateral part of distal tibia and fibula to secure heel pad under tibia

Question 27

Two stage syme difference

Answer 27

1) wound closed by suturing heel flap to dorsal fascia 2) 6 weeks later malleoli removed through separate vertical incision

Question 28

Syme amputation key considerations

Answer 28

1) preserve limb length 2) leg-length discrepancy 3) cosmetically not as appearling

Question 29

Anterior compartment contents

Answer 29

1) tibialis anterior 2) extensor hallucis longus 3) extensor digitorum longus 4) anterior tibial artery 5) anterior tibial vein 6) deep peroneal nerve

Question 30

Lateral compartment contents

Answer 30

1) peroneus longus 2) peroneus brevis 3) superficial peroneal nerve

Question 31

Superficial posterior compartment contents

Answer 31

1) soleus 2) gastrocnemius 3) plantaris muscle

Question 32

Deep posterior compartment

Answer 32

1) flexor digitorum longus 2) tibialis posterior 3) flexor hallucis longus 4) popliteus muscle 5) posterior tibial artery 6) posterior tibial vein 7) peroneal artery 8) peroneal vein 9) tibial nerve

Question 33

Perforator arteries that supply the posterior flap

Answer 33

Musculocutaneous perforator from sural artery

Question 34

Source of sural artery

Answer 34

popliteal artery

Question 35

Types of BKA flaps

Answer 35

1) posterior flap 2) skew flap 3) sagittal flap 4) medial flap

Question 36

Posterior flap BKA first description

Answer 36

Burgess

Question 37

Posterior flap BKA steps

Answer 37

1) divide tibial 12-15 cm (4 finger breadth) distal to tibial tuberosity 2) 2/3-1/3 technique: anterior incision encompass 2/3 of the circumference 3) posterior flap length 1/3 of circumference 4) fibula divided 1-2 cm proximal to tibia 5) soleus can be cut, gastroc and fascia must be preserved 6) sural nerve transect 5 cm proximal to skin edge to prevent neuroma

Question 38

Myodesis of gastrocnemius

Answer 38

1) two holes drilled into anterior surface of tibia 2) gastrocnemius fixted to tibia with nonabsorbable suture

Question 39

Sagittal flap to BKA steps

Answer 39

1) Equal length medial and lateral myocutaneous flap 2) myoplasty to cover tibia by suturing anterior and lateral compartment muscles to medial component of gastroc and soleus

Question 40

Skew flap to BKA steps

Answer 40

1) equal anteromedial and posterolateral fasciocutaneous flap 2) posterior flap is same as usual posterior flap 3) each flap is 1/4 circumference long

Question 41

Fish-mouth flap for BKA

Answer 41

Not used anymore because of vulnerability of anterior flap to ischemia

Question 42

Medial flap for BKA

Answer 42

Long medial flap short lateral flap

Question 43

Evidence 2014 Cochrane on superior method of BKA

Answer 43

no difference

Question 44

Ertl procedure

Answer 44

Tibiofibular bone bridging leaving 2-4 cm of tibia length at first then cutting it flush but leaving blood supply attach parallel and screw in place no clear evidence

Question 45

Rate of BKA healing at 100 days and 200 days

Answer 45

55% and 83%

Question 46

Rate of BKA that needs conversion to higher level

Answer 46

9.4-19.6%

Question 47

Through knee amputation steps

Answer 47

1) fish mouth incision with corners at level of mid condyles of femur 2) anterior flap extended to tibial tuberosity 3) posterior flap to same length 4) medial and lateral collateral ligaments divided 5) patellar ligament divided from attachment to tibial tuberosity 6) skin and deep fasia dissected off knee capsule 7) excise knee capsule and divide cruciate ligament 8) ligate popliteal vascularture and nerves 9) popliteus and gastroc divided 10) lateral 1/3 of condyle and medial 1/2 of condyl trimmed 11) hamstring approximated to patellar ligament incorporating cruciate ligaments

Question 48

Mazet vs Gritti-Stokes TKA

Answer 48

Mazet: distal femur preserved and condyles trimmed Gritti-Stokes: transect articular head of femur; preserve patella as end-cap

Question 49

Thigh compartments

Answer 49

Anterior Medial Posterior

Question 50

Anterior thigh compartment muscles

Answer 50

1) quadricep femoris 2) sartorius 3) tensor fascia latae

Question 51

Medial thigh compartment muscles

Answer 51

1) adductor longus 2) adductor brevis 3) adductor magnus 4) gracilis 5) pectineus

Question 52

Posterior thigh compartment muscles

Answer 52

Hamstrings 1) biceps femoris (long and short heads) 2) semitendinosus 3) semimembranosus

Question 53

Linea aspera

Answer 53

Adductor inserts into the posterolateral femur along this

Question 54

Adductor tubercle

Answer 54

Adductor magnus inserts into this = bony prominence on medial epicondyle of femur

Question 55

AKA technique

Answer 55

1) 12 cm proximal to femoral condyles or junction of middle and distal 1/3 of femur 2) fishmouth incision 3) SFA and FV divided 4) transect femur 5) sciatic nerve cut

Question 56

Natural tendency of the AKA stump to deviate and myodesis involved to prevent his

Answer 56

Hip flexor to abduct and flex thigh 1) Quatriceps detached proximal to patella leaving some tendon 2) vastus medialis reflected laterally off intermuscular septum to expose adductor magnus 3) adductor magnus divide at its attachment to adductor tubercle on medial epicondyle 4) vessels in Hunter canal ligated 5) remaining muscles divided 1-2cm distal to femur transection 6) drill holes into lateral cortex of femur and posterior cortex 1-2 cm from end adductor magnus wrapped over end of bone and femur held in max adduction before anchoring no clear studies

Question 57

Ligament of the head of the femur

Answer 57

1) iliofemoral 2) ischiofemoral 3) pubofemoral 4) transverse acetabular ligaments

Question 58

Muscles anterior to hip joint

Answer 58

1) rectus femoris 2) iliopsoas 3) pectineus muscle 4) tensor fascia lata 5) sartorius

Question 59

Muscles posterior to the joint

Answer 59

1) piriformis muscle 2) obturator internus 3) obturator externus 4) superior gemelli 5) inferior gemelli 6) quadratus femoris

Question 60

Hip disarticulation steps

Answer 60

1) semilateral position of patient 2) anterior racket incision 2.5 cm medial to ASIS towards pubic tubercle 3) continue posteriorly distal to ischial tuberosity and gluteal crease 4) continue incision anterioly, medial to greater trochanter and anterior inferior iliac spine then join back 5) cut down to external oblique and deep fascia of thigh 6) femoral vessels suture ligated and femoral nerve transected 7) divide sartorius at origin and iliopsoas at insertion site 8) pectineus divide at origin from superior pubic ramus 9) gracilis and 3x adductor divided at origin on pubic rami 10) obturator neurovascular bundle divided 11) obturator externus divided at insertion to trochanteric fossa 12) hamstring transected at ischial tuberosity 13) divide tensor fasciae latae, gluteus maximus, rectus femoris 14) divide remaining muscles on greater trochanter 15) divide all ligament to hip joint capsule 16) transect sciatic nerve 17) posterior quadratus femoris sutured to anterior iliopsoas 18) lateral gluteus medius sutered to medial obturator externus

Question 61

Operative mortality of major amputation

Answer 61

6-13%

Question 62

Operative mortality of minor amputations

Answer 62

2-4%

Question 63

Guillotine amputation mortality compared to other types

Answer 63

double 14.3 vs 7.8%

Question 64

5 year mortality after major amputation

Answer 64

44.4% AKA 60% BKA

Question 65

1 year survival after BKA vs AKA

Answer 65

BKA 64.5-80.4% AKA 49.6-64.6%

Question 66

K-level

Answer 66

Classification system by US center for medicare and medicaid Stratify potential functional ability in amputee TABLE 112.2

Question 67

Rate of foot/ankle amp conversion to higher amp in 1 year

Answer 67

35%

Question 68

Risk factors for amputation related problems

Answer 68

1) diabetes 2) ESRD 3) index BKA

Question 69

Complication of major amputation

Answer 69

1) Bleeding 3-8% 2) Infection 13-40% 3) Contracture 3-5% 4) CHF 4.2% 5) MI 3.4% 6) arrhythmia 2.6% 7) pulmonary 8) DVT 10% 9) renal failure 0.6-2.6% 10) stroke 0.28-1.4% 11) PTSD 5% 12) suicidal ideation 16% 13) chronic pain 95% 14) phantom pain 5-85%

Question 70

Boney anatomy of foot

Answer 70

FIGURE 112.1