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)
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: PVD -Failed revascularisation -Extensive tissue loss -Unreconstructable -Excess surgical risk
Indications for amputation: Diabetes -Overwhelming sepsis -Extensive tissue loss -Excess surgical risk
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? 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: 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: Major amputation: above tarso metatarsal joint. Levels - BKA - Through knee - AKA - Hip disarticulation
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: 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 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.