Amputations

Amputation and disarticulation should be viewed as reconstructive procedures and not a failure of treatment.

• In this manner, one realizes that it is the initial step in getting patients back to their previous functional status.

Indications for amputation include ischemia, trauma, infection, tumor, and painful dysfunction of the foot and ankle not amenable to further conservative management.

The goal is to create a modified limb that has a comfortable interface with a prosthesis and offers the most efficient energy-conserving gait as possible.

A team effort, with a team composed of different medical specialists, is the best way to ensure a good result and restore patients to their optimal level of function.

It is important to be aware of the psychosocial recovery of the patient with an amputation.

Functional outcome is generally worse in patients with diabetes or end-stage renal disease.

Team assessment

Atraumatic soft tissue handling

Adequate skin flaps

Myodesis or myoplasty whenever possible

Nerve transection sharp and at level well above amputation

Artery and vein dissected free and double ligated

Closure without tension

No "dog ear" resection

Accept delayed primary closure if there is tension

Peripheral vascular disease (PVD) is the most common reason for amputation.

• Affects mainly geriatric patients and those with diabetes mellitus.

Up to 20% of patients with diabetes mellitus will suffer from PVD.

• Patients are prone to develop foot ulcers leading to lower extremity amputation.

Peripheral neuropathy increases risk of complications.

• Loss of protective sensation compromises the likelihood of healing ulcers.

Prior to considering amputation, vascular studies are useful to determine the following:

• Possibility of revascularization

• Level of amputation

25% of diabetics who undergo amputation will require an amputation on the contralateral limb within the following 3 years.

Because of the medical complexity of these patients, optimal management is multidisciplinary with a team composed of a primary care physician, internist, surgeon, physiatrist, physical therapist, prosthetist, and social worker.

• The input of an infectious diseases specialist may also be required.

PVD accounts for 90% of amputations with 97% of dysvascular amputations performed on the lower limb.

African American males are at greatest risk for dysvascular amputation.

• They are 2-4x more likely to lose a limb than white persons of similar age and gender.

In amputees with PVD, the 5-year survival rate is between 70-90% with heart disease as the leading cause of death (51%).

• This is possibly because the coronary heart vessels are subject to the same occlusions as the peripheral arteries.

Approximately 50% of dysvascular amputees are diabetic.

Several well-established scoring systems have been developed to help in arriving at a decision to perform an immediate amputation following lower extremity trauma.

A commonly used scoring system is the Mangled Extremity Severity Score, which consists of 4 categories: Skeletal/soft tissue injury, limb ischemia, shock, and age.

• A lower number of points indicates a less severe injury.

• A total score of 7 or below is almost always compatible with limb salvage.

It is felt by some that soft tissue injury severity has the greatest impact on decision-making regarding limb salvage vs. amputation.

There are several other proposed limb salvage scoring systems.

While they may provide guidance for a treating surgeon, none of the scoring systems are considered very reliable in predicting need for amputation.

In cases of severe limb damage, primary amputation at first surgery may be best for the patient’s physical and psychologic well-being.

In other cases, it may be better to plan an initial attempt at limb salvage and observe.

• Prolonged attempts at limb salvage lead to severe psychologic and economic burdens on the patient and the family.

If it is thought that amputation is inevitable, it should be performed as a delayed primary amputation within the first 10-14 days after injury.

Almost 70% of trauma-related amputations are upper limb amputation.

The most common causes of lower extremity trauma requiring amputation are lawn mower injuries and motorcycle accidents.

Traumatic amputees have a better functional prognosis than dysvascular amputees.

The changing nature of military conflicts over the past few decades has lead to an increasing number of blast injuries.

• A mangled extremity is a common combat injury.

While advances have been made in limb salvage of complex injuries, amputation sometimes offers the best outcome.

In several studies of wounded soldiers, immediate and delayed lower extremity amputation patients generally have better functional outcomes compared to limb salvage, both physically and psychologically.

• This is not true for every patient but rather represents a trend for the groups as a whole.

• Individual decisions are made based on the extent of injury, the experience of the surgeon, and the capabilities of the health care system.

• Immediate amputation may be necessary for a critically ill patient in a combat zone, whereas the same injury in a stable patient at a tertiary center may be offered limb salvage.