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Atlas of Limb Prosthetics > Chapter 2- Amputation/Limb Salvage Surgeries and techniques > Flashcards

Chapter 2- Amputation/Limb Salvage Surgeries and techniques Flashcards

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1
Q

What specialists should be sought out before amputation is performed?

A

Vascular surgeon
Diabetologist
Infectious disease specialist
Surgical oncologist

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2
Q

What methods can be used to prevent amputation due to trauma?

A

Improved methods of fracture fixation
Vessel and Nerve repair
Vascularized distant muscle and skin flaps

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3
Q

What methods can be used to prevent amputation due to vascular problems?

A

Recanalization

Reconstruction of vessels

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4
Q

What method can be used to prevent amputation for infection?

A

Kritter method

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5
Q

What method can be used to prevent amputation for tumors?

A

Ablation of the tumor

Reconcstruction using allograft, endoprosthesis, or a combination

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6
Q

In 1832, what was the mortality rate for amputations?

A

52% for major amputations overall

62% for thigh amputations

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7
Q

What was the mortality rate for open fractures during the war?

A

50% transtibial

66% transfemoral

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8
Q

When did germ theory occur?

A

World War I

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9
Q

When did vascular reconstruction develop?

A

Korean War

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10
Q

How are wounds classified?

A

Based on Wound size

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11
Q

What levels of trauma should cause surgeons to consider opting for amputations?

A

Open IIIB and IIIC fractures

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12
Q

What variables can be used as basis for amputation?

A

Extent of soft tissue damage
The duration and severity of ischemia
The presence of shock
The age of Patient

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13
Q

Which variable, to determine amputation, is the most important?

A

Soft tissue grading

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14
Q

What is the index called to determine the likelihood of amputation?

A

Mangled Extremity Severity Index (MESI)

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15
Q

What score on the MESI scale indicates amputation?

A

7 or greater

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16
Q

Why does open fracture type IIIB have greater limb salvage success?

A

Vascular injury requiring repair is not present.

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17
Q

What is the most preponderant problem of type IIIB open fractures?

A

Infection

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18
Q

What is the most important treatment to prevent infection?

A

Debridement

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19
Q

What injuries should be met with an amputation of the limb?

A

Much muscle damage

Bone loss of more than 6cm

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20
Q

For patient’s facing end stage vascular problems, what percent of patient die after 2 years of amputation?

A

40 %

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21
Q

What percent of patient’s with end stage vascular problems will require a second amputation?

A

30%

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22
Q

What variables should be considered when deciding on an amputation for end stage vascular disease patients?

A

Quality of life
Ethics
Financial considerations
Informed consent

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23
Q

What four broad groups may lead to amputation?

A
  1. Peripheral vascular disease and diabetes
  2. Trauma
  3. Infection
  4. Tumor
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24
Q

What percent of patients requiring amputation are a direct or indirect consequence of CLI?

A

90%

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25
What are three risk factors for PVD?
Smoking Diabetes Hypertension
26
What are the management options for PVD?
Nonsurgical management Interventional radiology Sympathectomy Vascular reconstruction
27
What are nonsurgical management options for PVD?
Medications
28
What are the level of priorities for trauma in patients with vascular insuffiency?
1. Vessels 2. Nerves 3. Bones 4. Soft Tissue
29
What is Dry gangrene?
A result of reduced arterial inflow or stasis in the circulation of the limb or digit.
30
What is wet gangrene?
A consequence of both arterial and venous obstruction
31
What measurements should be done to determine the amputation level of the patient?
``` Clinical assessment Angiography Segmental systolic pressure measurements Skin fluorescence Skin blood flow measurements Transcutaneous oxygen measurements ```
32
Where do the majority of limb-threatening infections occur?
In the foot
33
What is the greatest risk factor for infection?
Sensory neuropathy
34
What are other causes of infection?
Calf abscess | Chronic osteomyelitis
35
What scale is used to grade foot lesion severity?
Meggitt-wagner foot lesion grading system
36
What are grades one and two of the meggitt-Wagner foot lesion system?
Ulcers that have not involved bone and joint
37
What are grade 3 lesions in the Meggitt-Wagner foot lesion system?
Ulcers penetrating bone and joint
38
What can be used to determine the bone exposure in an ulcer?
Plain Radiographs are okay | MRI are the best
39
What is the best bedside test to determine blood flow in the distal part of the foot?
The Doppler Ultrasonic Evaluation
40
What is the Doppler ultrasonic evaluation?
Take the blood pressure just above the malleoli, then move the cuff down to the metatarsal necks and take the blood pressure again. If the ischemic index is 0.5 or more the foot is salvageable, if not then they should be sent to a vascular surgeon.
41
How long can an open wound take to heal?
3-6 months
42
How long should a patient be non-weight bearing when healing an open wound?
5-6 weeks
43
What does success of patient wounds depend on?
Timely presentation of the patient Control of infection Hyperglycemia by a combination of early and complete bridegment
44
What should happen if gangrene and poor healing is based on Vascular occlusion?
Consultation with a vascular surgeon for vessel reconstruction
45
How can a patient prevent wounds from occurring?
Proper footwear Tight control of diabetes Education in foot care Emphasis on assumption of responsibility for self care
46
When dealing with Tumors, what is the definition of limb salvage?
Removing a bone or soft-tissue tumor while preserving the limb with a satisfactory functional and cosmetic result.
47
How do you determine the surgical stage of a tumor?
It is based on its histogenic type as well as on its local extent and any existing metastasis
48
How do you determine the histogenic type of a tumor?
biopsy
49
How do you determine the metastasis of a tumor?
``` Radiologic studies like radiographs Bone scan CT MRI ```
50
What are the problems of a poor biopsy performed on a patient with a tumor?
Can prevent some limb saving procedures.
51
In which direction should the biopsy incision be taken?
Longitudinally
52
What should the deep dissections avoid during a biopsy?
Intermuscular planes | major neurovascular structures
53
What are the three categories of benign tumors?
Stage 1- latent Stage 2- Active Stage 3- aggressive
54
What are the three categories of malignant tumors?
Stage 1- low-grade malignancy without metastasis (intracompartmental/extracompartmental) Stage 2- High-grade malignancy without metastasis (intracompartmental/extracompartmental) Stage 3- Any grade with reginal or distant metastasis
55
What is the ultimate goals of determining between amputation and limb salvage with a tumor?
Patient's survival Minimize risk of metastasis Local recurrence
56
What are other factors involved in deciding on amputation and limb salvage for a patient with a tumor?
Psychological impact | Function of limb
57
What are the indications for limb saving procedure for patients with tumors?
A sound wide or radical resection of the tumor can be achieved Limb reconstruction is feasible The prognosis is not compromised The cosmetic and functional results are better than amputation
58
What types of tumors lend to limb saving?
``` Malignant tumor (stage 1 and 2) Recurrent aggressive benign tumors (stage 3) ```
59
What is radical resection for bone?
Removing the entire bone from joint to joint
60
What is wide resection of bone?
Removing the tumor with a wide margin of normal bone around it
61
What is radical resection of soft tissue?
Removing the entire muscle compartment from origin to insertion
62
What is wide resection of soft tissue?
Removing the tumor with a wide surrounding cuff of normal soft tissue in all dimensions
63
Lately, what do most oncologist do when removing tumors
Wide resection with chemotherapy and radiotherapy
64
For a wide resection, how much further should they cut around the tumor?
3-5cm beyond the tumor limit
65
Which bones can be resected without need for reconstruction after tumor removal?
``` Scapula (not glenoid portion) Clavicle Rib Proximal radius Distal ulna Metacarpal Phalanx Ischium Pubis Patella Fibula (not distal end) Metatarsal bone ```
66
What is reconstruction after tumor removal determined by?
``` Location of tumor Size of resected bone Patient's lifestyle Surgeon's preference Expertise ```
67
What are the three major skeletal reconstruction methods?
Intercalary (segmental) reconstruction Arthrodesis Arthroplasty
68
What skeletal substitutes are used for skeletal reconstruction?
Autografts Allografts Metallic prostheses
69
When is intercalary reconstruction needed?
diaphyseal resection
70
What does intercalary reconstruction use for materials?
allografts Autografts Rarely metallic prostheses
71
When is arthrodesis used?
After extra-articular resection of a joint such as the knee, shoulder, or wrist
72
What materials does arthrodesis use?
Allografts Autografts Rarely metallic prostheses
73
When is arthroplasty used?
When replacing a resected hemijoint or whole joint with an articulating joint such as knee, hip, shoulder, elbow, or wrist.
74
What materials are used with an arthroplasty?
Allografts Customized metallic prostheses Allograft prosthesis composites
75
Which material is the best bone substitutes?
Autografts
76
What can autografts not be used for?
large bone segments | joints
77
which materials can make large bone segments and joints?
Allografts | Prostheses
78
What are the problems with surgical prostheses
Later, it might loosen or fatigue and frature
79
What are the advantages of surgical prostheses?
Simple operation procedure Quick recovery Easy rehabilitation
80
What is used for children needing reconstruction after tumor removal?
Expandable metallic prostheses
81
What are the four types of allografting procedures?
Massive osteoarticular allografts Allograft-prosthesis composites intercalary allografts Intercalary allograft-arthrodesis
82
How do you determine which of the four types of allografting procedures you are going to perform?
Skeletal location and extent of tumor resection
83
Which of the four allograft procedures is the most commonly used?
osteoarticular allografts
84
What technical aspects of allografting must be heeded to achieve optimal results?
Size matching of the graft to the resected segment Rigid fixation of the graft-host junction Congruent joint fit Reconstruction of ligaments, tendons, and joint capsule Adequite skin and soft-tissue coverage Local muscle trasfer Skin grafts Free flaps
85
How long do patients have to take antibiotics after reconstruction surgery?
3 months due to risk of infection
86
What brace should be used for patients who received a proximal femur allograft-prosthesis?
Abduction hip brace and crutches for 2-3 months | Followed by a cane
87
What braces should be used for patients who received allografts in the knee?
Plaster cast for 8 weeks Knee ankle foot orthosis (locked then slow ROM). Worn till radiologic evidence of union at the allograft-host junction. Crutches
88
What braces should be used for allografts of the humerus?
Shoulder abduction splint for 6 weeks | Then sling
89
What braces are used for distal radius allografts?
Short arm plaster cast | Then volar splint

Atlas of Limb Prosthetics (7 decks)

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