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Lower Limb Amputations – Level Selection. Arvind Lee Vascular Fellow Nepean Hospital. Overview. Integral part of any surgical practice. The global lower extremity amputation study group - wide variations in amputation rates worldwide - similarities in age and sex distribution

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lower limb amputations level selection

Lower Limb Amputations – Level Selection

Arvind Lee

Vascular Fellow

Nepean Hospital

overview
Overview
  • Integral part of any surgical practice.
  • The global lower extremity amputation study group

- wide variations in amputation rates worldwide

- similarities in age and sex distribution

- very high correlation with diabetes (BJS 2000)

overview1
Overview
  • Australian data –

- 2629 diabetes related lower limb amputations per year

- 2:1 male: female ratio

- majority in the 65-79 year age group

- Highest incidence in SA and NT (MJA 2000)

indications for amputation
Indications for amputation:
  • PVD
  • Failed revascularisation
  • Extensive tissue loss
  • Unreconstructable
  • Excess surgical risk
indications for amputation1
Indications for amputation:
  • Diabetes
  • Overwhelming sepsis
  • Extensive tissue loss
  • Excess surgical risk
indications for amputation2
Indications for amputation:
  • Trauma
  • Crush
  • Nerve injuries
  • Others
  • Spina bifida
  • Contractures
  • Neuropathy
  • Bed bound
goals of amputation
Goals of amputation:
  • Get rid of all infected, necrotic and painful tissue
  • Attain successful wound healing
  • Have an adequate stump for a prosthetic
attempt limb salvage or primary amputation
Attempt limb salvage or primary amputation?
  • Extent of tissue loss in foot
  • Anatomy of reconstruction
  • Associated comorbidities
  • ESRD with heel gangrene – maybe best treated with primary amputation
natural history of major amputation
Natural history of major amputation:
  • 10% perioperative mortality
  • 3 year survival after BKA – 57%; after AKA – 39%
  • Of 440 major amputations – 75 died in hospital, 113 deemed unsuitable for prosthesis. Of 57% referred for prosthesis – at 3years follow up a further 54 died, only 10-15% were mobile at home. (BJS 1992)
amputation levels and significance
Amputation levels and significance:
  • Major amputation: above tarso metatarsal joint.
  • Levels

- BKA

- Through knee

- AKA

- Hip disarticulation

amputation levels and significance1
Amputation levels and significance:
  • BKA – maximal rehabilitation potential

- 10-40% increase in energy expenditure

- 15-20% of all BKAs go onto an AKA in 3 years (5% periop mortality)

  • AKA – less rehab potential

- 50-70% extra energy expenditure

- Better rates of healing

level selection
Level Selection:
  • Subjective:
  • Clinical exam – skin quality, extent of ischemia/ infection
  • Pulses – presence of a pulse immedietly above the level of amputation – almost 100% chance of healing
  • “Clinical judgment” alone 80% accurate in predicting healing with BKA and 90% in AKA.
level selection1
Level Selection:
  • Wagner et al (J vasc surgery 1988): clinical judgment superior to objective assessments. More distal amputations can be achieved with clinical measures over objective studies.
  • Clinical judgment is central to amputation level selection.
level selection2
Level Selection:
  • Objective tests:
  • Non invasive
  • Doppler pressures – maybe unreliable in diabetics; ankle pressures >60mm – >50% chance of BKA healing.
level selection3
Level Selection
  • Non invasive

2. Skin perfusion pressures

  • Radio isotope washout
  • Laser doppler velocimetry
  • <20mm Hg – 89% failure of healing
level selection4
Level Selection
  • Non Invasive

3. Transcutaneous oximetry

  • Tested under local hyperthermia
  • Correlates with true PaO2
  • Threshold value – 30mm
level selection5
Level Selection:
  • Invasive – Angiographic scoring
  • Poor correlation
conclusions
Conclusions:
  • Amputation is traumatic enough…poor level selection can make it worse.
  • Clinical judgement central to proper level selection
  • Patient factors are more important than objective testing
case 1
Case 1
  • 93 yr old from NH

Bed bound after stroke

Painful heel ulcer on stroke affected side

Palpable popliteal pulse

case 2
Case 2
  • 68 yr old male

CRF on hemodialysis

Post surgery for #NOF – bilateral heel ulcers

Painful, non healing despite multiple debridements

Palpable popliteal pulses