3. POSTOPERATIVE CARE/REHABILITATION COMPLICATIONS PROSTHESIS
SITUATION IN OUR SUBREGION CONCLUSION
4. INTRODUCTION Amputation is the surgical removal of a limb or
part of a limb by cutting through the shaft of the bone. It is the
most ancient surgical procedures. Early surgical amputation was a
crude procedure by which a limb was rapidly severed from an
unanaesthesized patient,the open stump was crushed or dipped in
boiling oil to obtain haemostasis.
5. Hippocrates 1st to use ligature which was lost during the
dark ages. 1529:Pare reintroduced it & artery forceps.
1674:Morel introduced tourniquet. With the introduction of general
anaesthesia & antiseptic technique in the late 19th century
surgeons could now fashion a functional stump.
6. EPIDEMIOLOGY More than 300,000 patients with amputations
live in the U S according to NCHS and about 65,000 amputations are
performed annually. >90% of amputations performed in western
world are secondary to PVDx. In younger patient trauma is the
leading cause followed by malignancy. 1965, AK : BK = 70 : 30
7. 1980, AK : BK = 30 : 70. In FMC Owerri,41 BKA were done in
the last 2years with M : F = 1.7 : 1. Diabetic foot gangrene 88%,
Trauma & TBS 5% each, others 2%
8. RELEVANT ANATOMY
9. CLASSIFICATION 1) Emergency or Elective. 2)Provisional or
Definitive. 3)End bearing or Non end bearing.
10. INDICATIONSColloquially 3 Ds Dead (or Dying) Dangerous limb
Gangrene Malignant tumours Peripheral Vascular disease Osteosarcoma
Atherosclerosis Marjolins ulcer Embolism Melanoma DM Potentially
lethal sepsis Crush Injury Damn Nuisance Severe Trauma Pain Burns
Gross malformation Frost bite Recurrent Sepsis Bone setters
gangrene Severe loss of function Madura foot Elephantiasis
11. LEVEL OF AMPUTATION Determined by : a) Disease process b)
Viability of tissues and c) Prosthesis available. Determination of
adequate blood flow: Clinical : i.) lowest palpable pulse ii.)skin
colour and temperature iii)bleeding at surgery Others : .Doppler
ultrasonography: Ankle : brachial index > 0.5.
12. Compression pressure at the calf >65mmHg. Transcutaneous
oxygen measurement >40mmHg. Skin perfusion pressure measurement
by infrared thermography or laser doppler flowmetry. Too short a
stump may tend to slip out of prosthesis. Too long a stump may
have
13. inadequate circulation & can become painful or
ulcerate.
14. PREOPERATIVE PREPARATION Assessment and resuscitation
Investigate & address co-morbid conditions in consultation with
physicians, Anaesthetists & Physiotherapist(multidisciplinary).
FBC, FBS, Se/u/c, urinalysis, chest x-ray, ECG, serum
albumin(>3.5g/dl). Informed consent pathology, inevitability of
amputation, complications, availability of prosthesis
15. Determine the level of amputation. Goal of the surgeon is
to: a)Find a place where healing is mostly to be complete. b)To
have an ideal stump for prosthesis fitting.
16. QUALITIES OF AN IDEAL STUMP 1)Should heal adequately.
2)Should have rounded, gently contour with adequate muscle padding.
3)Should have sufficient length to bear prosthesis. 4)Should have
thin scar which does not interfere with prosthetic function.
5)Should have adequate adjacent joint movt.
17. 6)Should have adequate blood supply.
18. INTRAOPERATIVE PROCEDURE ANAESTHESIA : GA/Spinal POSITION :
Supine PREINCISION : prophylactic antibiotics, exsanguinate,
tourniquet, skin prep & draping. PROCEDURE: .An incision to
outline a long posterior flap & a short anterior one ---
combined length 1 times the diameter of the leg at the level of
amputation.
19. Deepened to the bone. Periosteum raised. Section tibia at
level of incision, bevel anterior surface. Fibular 2-3cm
proximally. Smoothen round sharp margins. Vessels isolated and
double ligated,Nerves pulled down & cut with a sharp knife
& allowed to retract into the soft tissue. Irrigation with N/S,
Removal of tourniquet to meticulously secure haemostasis.
20. Myoplasty or Myodesis done over a drain after trimming the
muscle to size. Close skin with interrupted non absorbable sutures.
Wound dressing- soft or rigid.
21. POSTOP CARE/ REHABILITATION General care: Control of pain,
prevention oedema, prevention of infection, DVT prevention, care of
concurrent medical conditions., Suture removal. Physiotherapy:
Muscles exercised, joints kept mobile, patients taught how to use
crutches & prosthesis.
22. Stump dressing: .Soft dressing: gauze, cotton wool,
bandage. Teach patient or relative stump bandaging. .Rigid
dressing: POP cast can be used with stump socks & padding. A
jig could be applied that allows attachment and alignment for early
pylon use where limited weight bearing with BAC is possible.
23. Cast changed every 5-7 days for skin care. Within 3-4 wks
rigid dressing can be changed to a removable temporary prosthesis.
Benefits: a)prevention of oedema b)enhanced wound healing c)early
maturation of stump d)decreased post op pain e)allow early
ambulation f)position stump to avoid contracture
24. Rehabilitation of the patient is a multidisciplinary
approach. Aim is to bring the patient to an optimum of physical ,
mental, emotional, social, vocational, & economic
efficiency.
25. COMPLICATIONS Early Haemorrhage Haematoma Infection Late
depression Stump ulceration Flap necrosis Painful scar Phantom limb
Phantom pain Joint stiffness Osteomyelitis Osteoporosis &
tendency to fracture
26. PROSTHESIS Is the substitution of a part of the body to
achieve optimum function. Eg BKA prosthesis A)patellar tendon
bearing B)solid ankle cushion heel Advantages: i) Cosmesis
ii)Ambulation iii) Function of the part. Disadvantages: i)infection
ii)pressure ulcer iii) cost
27. SITUATION IN OUR SUBREGION Socio-cultural belief
a)re-incarnation b)Husband authority over wife c)Children never
have authority d)Males usually decides Traditional bone setters Few
prosthetic centers Poverty Few centers for microvascular
surgeries.
28. CONCLUSION Amputation should be done by surgeons who have
knowledge of amputation surgical principles,postop rehabilitation,
& prosthetic design. Improved prosthetic design does not
compensate for a poorly performed surgical procedure. Amputation
should not be viewed as a failure
29. of treatment but rather as the 1st step towards a
patientsreturn to a more comfortable & productive life.