surgical considerations in upper limb amputation
TRANSCRIPT
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Surgical Considerations in Upper Limb Amputation
Jay T Bridgeman, MDAssistant Professor
University of Missouri
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Disclosures
• Institutional
– None
• Financial– None
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Objectives
• Identify the indications for upper extremity amputation
• Understand the principles and goals of upper extremity amputation
• Review specific levels of amputation and important considerations for each
• Review special considerations involving upper extremity reconstruction
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Upper Extremity:Purpose
• Prehensile– Grip
• Nonprehensile
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Prehensile
• Power Grip
– Ulnar hand
– Ring and little fingers
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Prehensile
• Precision Grip–Radial side
–Thumb, Index, Middle
–“3 jaw chuck”
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Nonprehensile
• Touching• Feeling• Pressing down• Lifting• Pushing
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How is the upper extremity different from the lower?
• Don’t walk on our hands
• Minimal sensation better than prosthesis
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Indications for Amputation
Trauma–90%
–20-40 y/o males
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Indications for Amputations
• Trauma–Acute–Chronic
• Burn
• Infection
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Indications for Amputations• Peripheral Vascular Disease
• Neurological disorders– Brachial plexopathy
• Congenital deformities
• Malignant tumors– Clear margin
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Goals of Amputation Surgery
• Preservation of Length
• Preservation of useful sensibility
• Prevention of symptomatic neuromas
• Minimize phantom limb pain
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Goals for Amputation Surgery
• Prevention of adjacent joint contractures
• Early prosthetic fitting
• Early return to function
• Malignant tumors—restore function while preserving life
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General Amputation Principles
• Skin• Muscle• Nerves• Blood Vessels• Bone
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Skin
• Painless, pliable, nonadherent scar
• Scar placement and prosthetic wear
Coverage:–Flap coverage–Skin graft
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Muscle
• Myofascial closure– Minimal muscle stabilization
• Myoplasty– Opposing muscle groups
• Myodesis– Attached to bone
• Tenodesis– Tendon attached to bone
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Nerves
Separate from vessels– Pain generator
Traction on nerve and sharply transect– Retracts to safety
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Blood Vessels
• Suture ligate major vessels
• Full-thickness skin flaps– Minimize wound necrosis
• Hemostasis prior to closure– Drains
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Bone
• Minimize sharp edges– Beveling/filing
• Narrow metaphyseal flare/condyles
• Cap intramedullary canal– Minimize bleeding
• Minimize periosteal stripping– Spurs
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Levels of Amputation
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Levels of Amputation
• Digit• Hand• Radiocarpal/Wrist disarticulation• Transradial• Elbow disarticulation• Transhumeral• Shoulder disarticulation• Scapulothoracic disarticulation
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Digit
Interphalangeal– Leave cartilage– Trim condyles
• Transect tendons and nerves– Do not sew tendons
together
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Digit
• DIP amputation– Lumbrical plus finger
• Amputation distal to FDS– Good function
• Proximal to FDS= PIP disarticulation
M 80
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Digit
Ray resection –Middle Finger–Ring Finger
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Partial Hand
Basic Hand–Thumb–At least one
finger–Weak pinch–Minimal grasp
M 100
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Partial Hand
Tripod pinch– Two ulnar fingers– Thumb– Improved grip– Grasp large
objects
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Partial Hand
Reconstruct
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Partial Hand
• Toe transplants
• Dominant hand– Index/middle finger
position– Fine pinching
• Non-dominant– Ring/little finger– Pulp to pulp pinch
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Partial Hand Problems
• Nail deformity– Ablate germinal matrix and skin graft
• Quadriga– FDP scar together– Limited excursion of unaffected fingers– Release adherence
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Radiocarpal/Wrist Disarticulation
• Maintains forearm pronation/supination• Longer lever arm
• Palmar : dorsal flaps– 2:1
• DRUJ maintained
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Radiocarpal/Wrist Disarticulation
• DRUJ not reconstructable, consider trans-radial amputation
• Shape radial and ulnar styloids
• Tendons transected and stabilized under physiologic tension
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Transradial
Preserve length– Supination/pronation– Stronger lever arm
• Myodesis deep compartments
• Myoplasty superficial compartments
• Maintain long head of biceps for elbow flexion
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Transradial
• Biceps removed– Resect radius– Attach to ulna to maintain elbow flexion
• 4-5cm ulna needed for prosthesis
• Unequal bone length– Maintain lever arm– Create “one bone” forearm
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Transradial
• ~1/3 require revision surgery
• Bulbous/flabby residual limbs– Revise
• Elbow contracture– Release– Fusion
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Case Example
41y/o smoker s/p MCC• Intubated for ~1 week• ORIF of BBFA• Woke up w/o sensation
or use of hand and wrist• Likely compartment
syndrome• Nonunion repair x2• c/o burning extremity
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Case ExamplePMH:• Depression• alcoholism
• Lack of sensation• Wrist and finger contractures• Active bicep function• Liability
Plan: – Hardware removal– Transradial amputation
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Elbow Disarticulation
Controversy– Vs. long trans-humeral
Prosthesis– Enhanced suspension and
rotational control– External hinge poor
cosmesis
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Elbow Disarticulation Technique
Longer posterior flap
Biceps and triceps attached at physiological length
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Transhumeral
• Preserve length• Preserve deltoid insertion
Short transhumeral functionally similar to shoulder disarticulation
– Better cosmesis– Better prosthetic suspension
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Transhumeral
Short transhumeral– Abduction contracture– Consider arthrodesis
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Transhumeral
Technique– Long posterior flap– Angular osteotomy considered for prosthetic wear– Triceps over bone– Myodese triceps and biceps– Surgical neck level = shoulder arthrodesis
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Case Example
• 59y/o s/p fall 1995• Nonop humeral shaft • 1997 nonunion repaired
with IM nail proximal locking bolts only
• 1998 nonunion repair with distal locking bolts and bone graft
• s/p fall May 2009 with new fracture
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Case Example
• Morbid Obesity BMI 47.2 s/p gastric bypass
• NIDDM• COPD, on home O2• CAD s/p CABG• Depression
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Case Example
• Nonunion repair
• Shortening
• Plating & BMP
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6 Weeks Postop
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Options
– Revision nonunion repairvs.
– Transhumeral amputation through nonunion
– Considerations• Co-morbidities• Failed previous nonunion repair• Limited function
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Transhumeral Amputation
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Transhumeral Amputation
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Transhumeral Amputation
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Transhumeral Amputation
Follow-up– Joplin, MO– Working with prosthetist and local physician
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Shoulder Disarticulation
• Ultrashort transhumeral = modified disarticulation– Deltoid myofasciocutaneous flap– Surgical neck osteotomy– Latissimus dorsi and pectoralis major reattached
• Avoid brachial plexus entrapment
• Consider arthrodesis
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Shoulder Disarticulation
• Deltoid myofasciocutaneous flap
• Remove proximal humerus
• Avoid brachial plexus entrapment with vessels
• Glenoid fossa filling– Rotator cuff muscles– Pec major– Latissimus dorsi
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Scapulothoracic Disarticulation
Indications– Necrotizing fasciitis– Malignant tumors– Severe trauma
• Remove upper extremity, scapula, majority of clavicle
• Significant cosmetic deformity
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Scapulothoracic Disarticulation
• Anterior or posterior approach
• Determines approach to subclavian vessels
• Posterior approach potentially less blood loss
• Primary closure unlikely– Staged management– Soft tissue coverage
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Complications
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Amputation Site Breakdown
Early–Delayed wound healing
• Immunocompromised• Malnourished• Infection
–Marginal necrosis• Appropriate surgical technique
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Amputation Site Breakdown
Late–Deep infection
• Usually associated with PVD, DM–Adherent skin–Poor prosthetic fit
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Infection
• Debridement• Antibiotics• Local wound care• Secondary healing
–Prolonged wound healing
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Amputation Site Prominence
• Overgrowth• Bone spur• Muscle atrophy• Failed myoplasty/myodesis• Skin hypertrophy• Bursitis • Bulbous/floppy residual limb
– Poor surgical technique
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Amputation Site Prominence
Indications for Revision Amputation–Poor prosthetic fit–Limited function–Pain–Skin at risk
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Neurological Complications
• Neuroma
• Phantom limb pain
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Neuroma
• All nerve transections form neuromas
• Painful – Positive Tinel’s
Causes– Poor surgical technique– Scar formation– High pressure area
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Neuroma
• Avoid– Nerve stump retracts into soft tissue away from
scar and prominent areas
• Management– Prosthetic adjustment– Injection– Scar massage– Surgical resection
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Phantom Limb Pain
• May be nonpainful
• Painful–Up to 85% in LE–~40-69% in UE
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Phantom Limb Pain
• Surgical– Dehydrogenated alcohol and marcaine into
epineureum
• Non-surgical– Neurontin
• Shown effective
– Vitamin C?– Regional anesthetics perioperatively?
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Joint Contracture
• Usually related to short lever arm– Transhumeral– Transradial
• Quadriga
• Avoid with early therapy• Contracture release and tenolysis may be
required if fixed deformity
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Heterotopic Ossification/Bone Spur
Associated with:– Severe trauma– Excessive manipulation of periosteum– Residual bone after osteotomy
• May require surgical resection if problematic– Recurrence of HO
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Special Considerations
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Krukenberg Procedure
• 1916 Hermann Krukenberg– World War 1– Soldiers and civilians
• Sierra Leone civil war• Transradial amputees
– Radial and ulnar rays
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Indications
• Bilateral transradial amputee and blind
• Unilateral or bilateral – Highly motivated
• No access to prosthesis
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Contraindications
• < 2y/o• Elderly dependent• Unable to accept
appearance• Elbow contracture• Residual limb <10cm
in adult– Poor pincer
function
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Technique
• Ulnar and radial muscles divided• Interosseus membrane released 12cm from the
proposed bone ends• 18-20 cm distal to elbow crease
– Radius and ulna equal lengths• Myodesis radius and ulna• STSG preferred over muscle debulking
• Postop web management crucial
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Krukenberg Procedure
• Create a pincer• Allows independent function• Doesn’t preclude prosthetic use
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Replantation
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Indications
Children–Any level
Adults–Above wrist level
• Significant metabolic risk
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Indications for Digits
– Multiple– Through palm– Near wrist– Thumb– Children– Single digit distal to FDS insertion– Single digit in professional
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Contraindications
• Associated life-threatening disease• Medical co-morbidities—PVD• Severe crush or avulsion injury• Gross contamination• Multiple level injury• Excessive delay in treatment
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Outcomes for Digits
• 80-90% survival all levels• Major factors
– Age of patient– Experience of surgeon
• Early reoperation– Vascular occlusion up to 40%– Up to almost 50% survive
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Outcomes
• Postoperative hemorrhage– Up to 50%
• Sensation– Nearly all have protective sensation– Cold intolerance
• Nonunion and malunion– <5%
• Secondary surgery– Joint contracture release/tenolysis
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Replantation
Above digit level–Adults–<25% regain functional use–Sensation present and some residual
function = better than prosthesis
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Composite Tissue Allograft Transplantation
Hand Transplant– 59 successful (41 patients)– Composite tissue (vrs. Solid organ)– Kidney tansplant protocol– Direct Visualization/Biopsy– Morbidity/Ethics
• Infection/Malignancy/DM/CAD/HTN/Renal– Bone Marrow Cell Chimerism
• Tolerance• Low dose Immunosuppression
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Summary
• Upper extremity amputations above the digit are rare
• Trauma accounts for 90% of all UE amputations
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Summary
• Restoring function is important– Reconstruction– Prosthesis
• Preserve length and joint motion
• Avoid complications
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Final Thoughts
• Sensation is key
• Be careful when using a table saw
• No matter how fun it seems, don’t hold a lit firework
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Questions?
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References1. Smith DG, Michael JW, Bowker JH, American Academy of
Orthopaedic Surgeons. Atlas of amputations and limb deficiencies : surgical, prosthetic, and rehabilitation principles. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004.
2. Atroshi I, Rosberg HE. Epidemiology of amputations and severe injuries of the hand. Hand Clin. Aug 2001;17(3):343-350, vii.
3. del Pinal F. Severe mutilating injuries to the hand: guidelines for organizing the chaos. J Plast Reconstr Aesthet Surg. 2007;60(7):816-827.
4. Leit ME, Tomaino MM. Principles of limb salvage surgery of the upper extremity. Hand Clin. May 2004;20(2):v, 167-179.
5. Tamurian RM, Gutow AP. Amputations of the hand and upper extremity in the management of malignant tumors. Hand Clin. May 2004;20(2):vi, 213-220.