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Lower Limb Amputations – Level Selection Arvind Lee Vascular Fellow Nepean Hospital.

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Presentation on theme: "Lower Limb Amputations – Level Selection Arvind Lee Vascular Fellow Nepean Hospital."— Presentation transcript:

1 Lower Limb Amputations – Level Selection Arvind Lee Vascular Fellow Nepean Hospital

2 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)

3 Overview Australian data – diabetes related lower limb amputations per year - 2:1 male: female ratio - majority in the year age group - Highest incidence in SA and NT (MJA 2000)

4 Indications for amputation: PVD -Failed revascularisation -Extensive tissue loss -Unreconstructable -Excess surgical risk

5 Indications for amputation: Diabetes -Overwhelming sepsis -Extensive tissue loss -Excess surgical risk

6 Indications for amputation: Trauma -Crush -Nerve injuries Others -Spina bifida -Contractures -Neuropathy -Bed bound

7 Goals of amputation: Get rid of all infected, necrotic and painful tissue Attain successful wound healing Have an adequate stump for a prosthetic

8 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

9 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 % were mobile at home. (BJS 1992)

10 Amputation levels and significance: Major amputation: above tarso metatarsal joint. Levels - BKA - Through knee - AKA - Hip disarticulation

11 Amputation levels and significance: BKA – maximal rehabilitation potential % increase in energy expenditure % of all BKAs go onto an AKA in 3 years (5% periop mortality) AKA – less rehab potential % extra energy expenditure - Better rates of healing

12 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.

13 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.

14 Level Selection: Objective tests: -Non invasive 1.Doppler pressures – maybe unreliable in diabetics; ankle pressures >60mm – >50% chance of BKA healing.

15 Level Selection Non invasive 2. Skin perfusion pressures -Radio isotope washout -Laser doppler velocimetry -<20mm Hg – 89% failure of healing

16 Level Selection Non Invasive 3. Transcutaneous oximetry -Tested under local hyperthermia -Correlates with true PaO2 -Threshold value – 30mm

17 Level Selection: Invasive – Angiographic scoring Poor correlation

18 Level Selection

19 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

20 Case 1 93 yr old from NH Bed bound after stroke Painful heel ulcer on stroke affected side Palpable popliteal pulse

21 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


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