Lower Limb Amputations – Level SelectionJajang badrudjaman. S.KedNur alifah. S.KedNur laila zuhria.S.KedPinky kinasih. S.Ked

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.

Overview•Indonesian data – - 2629 diabetes related lower limb

amputations per year - 2:1 male: female ratio - majority in the 65-79 year age group

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

Indications for amputation:• Trauma- Crush- Nerve injuries

• Others- Spina bifida- Contractures- Neuropathy

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.

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.

Level Selection:•Objective tests:- Non invasive1.Doppler pressures – maybe unreliable in

diabetics; ankle pressures >60mm – >50% chance of BKA healing.

Level Selection•Non invasive2. Skin perfusion

pressures- Radio isotope

washout- Laser doppler

velocimetry- <20mm Hg – 89%

failure of healing

Level Selection•Non Invasive3. Transcutaneous

oximetry- Tested under local

hyperthermia- Correlates with

true PaO2- Threshold value –

30mm

Level Selection:•Invasive –

Angiographic scoring

•Poor correlation

Level Selection

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