Cohns Conference

ABOVE THE KNEE AMPUATION (AKA)

HPI
CC: 46 YO M airlifted to ILH s/p fell from the back of

a garbage truck and was run over by car following garbage truck. He suffered from an open fracture and dislocation of the right ankle. Airway- protecting, speaking Breathing- equal bilaterally Circulation- 2+ pulses B radial, 2+ B DP pulse GCS = 15 No other significant acute injuries

James Barrios

Imaging Results Tib Fib View

Comminuted fracture of the distal fibula common

dislocation of the tibia

Imaging Results Foot View

Comminuted fracture of the distal fibula common

dislocation of the tibia and abnormal relationship of the calcaneus to the cuboid and cuneiforms

Imaging Results- Ankle AP, Lat, and Obl

Comminuted fracture of the distal fibula common

dislocation of the tibia and abnormal relationship of the calcaneus to the cuboid and cuneiforms

Imaging Results - CT Angio Lower Extremity

The right posterior tibial artery dissipates at the level

of the fracture of the tibia above the ankle.

Course of Care
Pt was admitted on 10/15/13

10/15/2013 I&D, CRPP Chopart POD - Open bimalleolar ankle fracture dislocation chopart dislocation, heel pad avulsion
10/17/13 I&D, ORIF of bimalleolar fx, wound vac

placement 10/20/13 I&D 10/22/13 I&D 10/27/13 BKA

Lower Extremity Amputations Indications

An unsalvageable extremity due to critical limb ischemia in

patients with vascular disease. Peripheral artery disease, Acute arterial thrombosis, or thromboembolism Trauma resulting in a mangled extremity or failed attempt at limb salvage Severe infections with extensive soft tissue or bony destruction or osteomyelitis Locally unresectable malignant tumors of the musculoskeletal Frostbite-related gangrene Failed management of acute compartment syndrome Failed management of Charcots degenerative osteoarthropathy Debilitating extremity paralysis from infection or pressurerelated complications

Preparation
Medical Risk - MI, Atelectasis, PNE, Renal failure

Psych Evaluation Depression and PTSD

Level of amputation The level of the

amputation is dictated by the extent of the disease, healing potential of the stump, and rehabilitation potential of the patient. Although preservation of limb length is desirable, removal of all nonviable and infected tissue is a higher priority. The surgeon must be satisfied that sufficient arterial perfusion is present at the proposed amputation level to sustain healing.

Preparation
Antibiotics Intravenous prophylactic antibiotics appropriate for skin flora are adequate for amputation that is not complicated by lower extremity soft tissue wound infection or gangrene. If any of these conditions are present, broad spectrum perioperative antibiotics should be administered. Anaerobic coverage should be considered for diabetics. Antibiotics are continued in the postoperative period in patients undergoing staged debriding amputation for infection or gangrene. Broad spectrum antibiotics are selected in accordance with the local antibiogram and adjusted in response to wound culture and sensitivities

Preparation
Thromboprophylaxis Thromboprophylaxis is administered prior to amputation depending upon individual patient risk, amputation level and expected level of activity following amputation. Patients undergoing major lower extremity amputation are at high risk for thromboembolism due to the nature of the surgery as they will have weight-bearing restrictions and will be immobilized postoperatively. Complications stump hematoma, infection, need for repeat amputation, phantom limb syndrome and flexion contracture.

Techniques
Staged amputation

first a debriding amputation in the form of an open guillotine amputation (transfemoral, transtibial), through-the-joint amputation, or less commonly, cryoamputation, followed by definitive revision and wound closure after infection has been controlled. A debriding amputation is a rapid and effective method for removing infected or necrotic tissue that is a source of sepsis. Non-staged amputations should be avoided in patients with severe lower extremity infections, particularly patients with diabetes with severe forefoot infections. Once the infected limb is removed, the patient is treated with antibiotics and open dressing changes for three to five days. If the white blood cell count is trending downward and the stump is clean, the second stage can be performed. At the second stage, the stump is debrided and closed. A drain is usually left in place.

Techniques
Cryoamputation

bedside technique that uses dry ice to hard freeze the extremity, resulting in a physiologic amputation. Cryoamputation controls local infection by quarantining metabolic waste products within the frozen limb. Patients with indications for amputation but who have severe medical comorbidities that preclude safe anesthesia, cryoamputation can be used as a temporizing measure to avoid surgery until the patient can be stabilized medically rarely needed where modern surgical and anesthetic techniques are available. main complication associated with cryoamputation is migration of the frost line above the intended level of amputation. The need for amputation stump revision may also be greater.

Techniques - BKA
techniques for below-knee amputation are named for the

origin of the flap used to cover the tibia. The posterior flap is the most commonly used technique for below-knee amputation and can be used for any indication. The advantage of this technique is the placement of the incision, and resultant scar, on a surface that is not weight-bearing. A disadvantage is the potential for ischemia in the posterior flap. Four other BKA techniques are described using sagittal, skew, medial, and fish-mouth flaps, each of which may be more useful when one flap may be better vascularized than another. Amputations performed to resect tumors are dictated by the location of the tumor and the need for adequate margins.

Techniques - BKA

Techniques
Draping A mechanical barrier (impervious plastic sleeves, iodinated adhesive skin drape) should be used to isolate infected areas prior to undertaking amputation. Tourniquets shown to reduce intraoperative blood loss and decrease the need for postoperative blood transfusion in above-knee and below-knee amputations. However, tourniquets are probably of little benefit in patients undergoing amputation for extremity ischemia.

Procedure Details
The tourniquet was raised to 300 mmHg and left up for about

45 minutes. Amputation was done just above the level of the prior wound. The tibia was divided about 13 cm below the knee and the fibula was divided just above that level. There was extensive muscle necrosis in the posterior deep and superficial compartments which was debrided. No gross pus was noted. Muscle at the level of the amputation was sent for culture. We irrigated out the wound extensively. Once convinced all necrotic muscle was debrided, a drain was placed, the wound was closed with vicryl for the fascia and 2-0 Nylon for the skin.

Procedure Details
An incisional wound vac was placed because of the

potential space in the superficial posterior compartment. Hemostasis was good. A dressing was applied. A knee immobilizer was placed. Wound will be monitored and debrided additionally if necessary. If further debridement is needed, may need plastics assistance to preserve length. Drain was removed on 10/30 Abx: 10/15-21 Gent and Ancef; 10/21-pres Vanc, Zosyn, and Clindamycin

Sources
Medscape

http://emedicine.medscape.com/article/1232102overview#a0101 Uptodate http://www.uptodate.com/contents/lowerextremityamputation?detectedLanguage=en&source=search_ result&search=amputation&selectedTitle=1~150&pr ovider=noProvider