upper extremity amputation original author: andrew h. schmidt, md; march 2004 revised by: david...
TRANSCRIPT
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Upper Extremity Amputation
Original Author: Andrew H. Schmidt, MD; March 2004
Revised by: David Fuller, MD; June 2006
Revised by: David Ring, MD PhD; February 2011
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Amputation: Presentation Goals
• Etiology
• Techniques
• Prosthetics and Rehabilitation
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Amputation: Etiology
• Trauma
• Burns
• Peripheral Vascular Disease
• Malignant Tumors
• Neurologic Conditions
• Infections
• Congenital Deformities
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Etiology: Trauma
• 90% of Upper Extremity Amputation• Male:Female = 4:1• Most Amputations at level of Digit• Major Limb Amputations less common• Revascularization sometimes possible for
incomplete amputation• Replantation sometimes possible for
complete amputation
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Etiology: Trauma
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Etiology: Tumor
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Etiology: Infection
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Etiology: Gangrene/Necrotizing Fasciitis
Radiograph: Subcutaneous air throughout arm
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Etiology:Failed Forearm Vascular Repair after trauma
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Etiology: Vascular Disease
Ischemia after AV Fistula Procedure
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Etiology: Crush
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Etiology: Congenital
polydactyly
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Etiology: Infarction associated with IV Drug Abuse
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Etiology: Scleroderma
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Amputation: Trauma and Replantation
• Candidates for Replantation after Trauma– 1. Thumb– 2. Multiple Digits– 3. Partial Hand– 4. Wrist or Forearm– 5. Above Elbow– 6. Isolated Digit Distal to FDS insertion– 7. Almost any part in child
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Amputation: Trauma and Replantation
• Candidates for Replantation after Trauma– Clean cut– Limited crush– Limited contamination– Acceptable ischemia time
• 6 hours with muscle• 24 hours with digit
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Replantation: Multiple Digits
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Surgical Technique: Digit Replantation
• 1. Identify Vessels and Nerves• 2. Debride• 3. Shorten and fix bone• 4. Repair Extensor Tendon• 5. Repair Flexor Tendon• 6. Repair Arteries• 7. Repair Nerves• 8. Repair Veins• 9. Skin Closure (skin graft if necessary)
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Amputation: Replantation
• Poor Candidates for Replantation– 1. Severely crushed or mangled parts– 2. Multiple levels– 3. Other serious injuries or diseases– 4. Atherosclerotic vessels– 5. Mentally unstable – 6. > 6 hours ischemic time– 7. Severe contamination
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Amputation: Replantation
Mangled and Crushed – Poor Candidate
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Ectopic “banking” of amputated parts
Ectopic “banking” of amputated parts
Indicated for extensive injuries with adequate amputated part in setting of contaminated or absent support structures.
Recipient sites described- anterior thorax, contralateral arm/leg, groin. High complication rate.
Largest and original series described by Marko Godina 1986.
Indicated for extensive injuries with adequate amputated part in setting of contaminated or absent support structures.
Recipient sites described- anterior thorax, contralateral arm/leg, groin. High complication rate.
Largest and original series described by Marko Godina 1986.
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Courtesy: J. Higgins
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Grip strength 80 # (unaffected side 100#)Injured right hand has remained dominant
hand
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Surgical Technique: Major Limb Replantation
• Myonecrosis is greater concern than in digit replant• Immediate shunting to obtain arterial inflow may be
necessary• High Potassium levels (>6.5 mmol/l ) in venous
outflow from amputated part negative prognostic factor
• Sequence of repair similar to digit– Identify structures, Debride, Rapid bone stabilization,
Vascular repair (artery then veins), Tendons and Nerves
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Upper vs Lower Limb
• Upper extremity nonweightbearing– Less durable skin acceptable– Decreased sensation better tolerated– Joint deformity better tolerated– Late amputations rare– Transplants now being performed
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Major Limb Replantation
Include Surgical Prep of Legsfor vascular and nerve grafts
Rapid Bone StabilizationReady for Anastomosis
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UE traumatic amputation may be associated with life threatening
hemorrhage
Courtesy of T. Higgins, M. Dietch
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Aggressive resuscitation and limb repair
Courtesy of T. Higgins, M. Dietch
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Amputation: Major Limb Replantation Outcomes
• >2/3 survival rate
• Can be a life threatening undertaking
• Multiple Surgeries often required– Late Nerve, Bone, Tendon Surgeries
• Function of major upper extremity replantations even though poor can be superior to prosthetic function
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Outcomes: Major Limb Replantation
• Comparison of functional results of replantation versus prosthesis in a patient with bilateral arm amputation
Peacock, Tsai, CORR, 1987• Major amputation of the UE: Functional Results after
replantation/revascularization in 47 casesDaoutix et al, Acta Orthop Scand, 1995
• Major Replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcome study
Graham et al, J Hand Surg, 1998
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Amputation: Technique
• Preservation of functional residual limb length
balanced with
• Soft tissue reconstruction to provide a well-healed, nontender, physiologic residual limb
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Technique: Determination of Level
• Zone of Injury (trauma)
• Adequate margins (tumor)
• Adequate circulation (vascular disease)
• Soft tissue envelope
• Bone and joint condition
• Control of infection
• Nutritional status
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Tumor
Forequarter Amputation
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Necrotizing Fasciitis
Emergent Open Shoulder Disarticulation
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Trauma
High TranshumeralNerves Avulsed
from High in Plexus
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Failed Vascular Repair
Transradial
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Levels of Amputation
• Wrist Disarticulation vs. Transradial– Disarticulation offers potential of better active
pronation and suppination of forearm– Transradial often difficult to transmit rotation through
prosthesis– Disarticulation poor aesthetically– Disarticulation more difficult to fit prosthetic– Transradial needs to be done 2 cm or more proximal to
joint to allow prosthetic fitting– Transradial usually favored
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Levels of Amputation
• Transhumeral vs. Elbow Disarticulation– Adults: Elbow disarticulation allows enhanced
suspension and rotation control of prosthesis however retention of full length precludes use of prosthetic elbow. Long transhumeral favored
– Pediatrics: Transhumeral amputation results in high incidence of bony overgrowth. Elbow disarticulation is level of choice. Humeral growth slowed after trauma.
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Levels of Amputation
• Preservation of Elbow function is a priority– Consider replantation/salvage of parts to
maintain elbow function– 4-5 cm of proximal ulna necessary for elbow
function– For very proximal amputations, it may be
necessary to attach bicep tendon to ulna
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Techniques
• Debridement of all Nonviable tissue and foreign material
• Several debridements may be required• Primary wound closure often contraindicated• High voltage, electrical burn injuries require
careful evaluation because necrosis of deep muscle may be present while superficial muscles can remain viable
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Techniques
• Nerve: Prevent neuroma formation– Draw nerve distally, section it, allow it to
retract proximally
• Skin: – Opportunistic flaps– Rotation flaps– Tension free– Skin grafts
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Techniques
• Bone:– Choose appropriate level– Smooth edges of bone– Narrow metaphyseal flare for some
disarticulations
Postoperative Dressing:– Soft– Rigid
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Techniques
• Goals of Postoperative Management– Prompt, uncomplicated wound healing– Control of edema– Control of Postoperative pain– Prevention of joint contractures– Rapid rehabilitation
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Technique: Example
30 yo male, assault
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Technique: Example
Be sure to identify all injuries and treat
ray amputation
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Technique: Example
1 year postop
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Technique: Example
debridement and preservation of viable structure
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Technique:Example
Late reconstruction after initial amputation surgery
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Rehabilitation and Prosthetics
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Rehabilitation
• 1. Residual Limb Shrinkage and Shaping
• 2. Limb Desensitization
• 3. Maintain joint range of motion
• 4. Strengthen residual limb
• 5. Maximize Self reliance
• 6. Patient education: Future goals and prosthetic options
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Psychological Adaptation
• Amputation represents loss of function, sensation and body image
• Psychological response is determined by many variables– Psychosocial/Age– Personality– Coping Strategies– Economic/Vocational– Health– Reason for amputation
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Psychological Adaptation
• Up to 2/3 of amputees will manifest postoperative psychiatric symptoms– Depression– Anxiety– Crying spells– Insomnia– Loss of appetite– Suicidal ideation
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Psychological Adaptation: Stages
• 1. Preoperative– Tumor, Vascular Disease, Chronic Infection– Support Groups
• 2. Immediate Postoperative– Hours to days– Safety, Pain, Disfigurement
• 3. In-Hospital Rehabilitation• 4. At-Home Rehabilitation
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In-Hospital Rehabilitation
• Initial: concerns about safety, pain, disfigurement• Later: emphasis shifts to social reintegration and
vocational adjustments
• Grief Response:– 1. “numbness” or denial– 2. yearning for what is lost– 3. Disorganization: all hope is lost for recovery of lost
part– 4. Reorganization
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Management of Amputee
• Preparation
• Good Surgical Technique
• Rehabilitation
• Early Prosthetic Fitting
• Team Approach
• Vocational and Activity Rehabilitation
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Prosthetics• Passive
– Cosmetic
• Body Powered– Harnesses and cables
• Myoelectric– Surface EMG– Activation delay
• Neuroprosthetics– Investigational at this time
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Rehabilitation
Suggested timeline for transradial amputation
• 1-14 days: immediate postop prosthesis
• 2-4 weeks: training body powered prosthesis
• 6-12 weeks: definitive body powered prosthesis
• 6-12 weeks: training electronic prosthesis
• 4-6 months: definitive electronic prosthesis
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Acknowledgement
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Review Articles for Reference1: Tintle SM, Baechler MF, Nanos GP 3rd, Forsberg JA, Potter BK. Traumatic and
trauma-related amputations: Part II: Upper extremity and future directions. J
Bone Joint Surg Am. 2010 Dec 15;92(18):2934-45. Review. PubMed PMID: 21159994.
2: Muilenburg TB. Prosthetics for pediatric and adolescent amputees. Cancer Treat
Res. 2009;152:395-420. Review. PubMed PMID: 20213404.
3: Jones NF, Schneeberger S. Arm transplantation: prospects and visions.
Transplant Proc. 2009 Mar;41(2):476-80. Review. PubMed PMID: 19328907.
4: Buncke GM, Buncke HJ, Lee CK. Great toe-to-thumb microvascular transplantation
after traumatic amputation. Hand Clin. 2007 Feb;23(1):105-15. Review. PubMed
PMID: 17478257.
5: Hanel DP, Chin SH. Wrist level and proximal-upper extremity replantation. Hand
Clin. 2007 Feb;23(1):13-21. Review. PubMed PMID: 17478249.
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Review Articles for Reference6: Tamurian RM, Gutow AP. Amputations of the hand and upper extremity in the
management of malignant tumors. Hand Clin. 2004 May;20(2):vi, 213-20. Review.
PubMed PMID: 15201025.
7: Moran SL, Berger RA. Biomechanics and hand trauma: what you need. Hand Clin.
2003 Feb;19(1):17-31. Review. PubMed PMID: 12683443.
8: Breidenbach WC 3rd, Tobin GR 2nd, Gorantla VS, Gonzalez RN, Granger DK. A
position statement in support of hand transplantation. J Hand Surg Am. 2002
Sep;27(5):760-70. Review. PubMed PMID: 12239664.
9: Shatford RA, King DH. The treatment of major devascularizing injuries of the
upper extremity. Hand Clin. 2001 Aug;17(3):371-93. Review. PubMed PMID: 11599207.
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