How To Determine The Appropriate Level Of Amputation

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Continuing Education Course #127 January 2005

I am pleased to introduce the latest article, “How To Determine The Appropriate Level Of Amputation,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
As Kathleen Satterfield, DPM, points out in her article, several studies have shown that the rate of revisional amputations ranges from 10 to 50 percent. While there are many factors that may lead to repetitive amputations, Dr. Satterfield says “poor planning is at the top of the list.” With this in mind, Dr. Satterfield describes the key factors that one must consider in order to determine the appropriate level for an amputation.
At the end of this article, you’ll find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 60 and successfully answering the questions on pg. 66. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond electronically.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by the NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Satterfield has disclosed that she has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of her presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: January 2005.
EXPIRATION DATE: January 31, 2006.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss key diagnostic signs of infection one should look for when assessing tissue viability;
• explain how ulcerations can impact one’s planning for amputations;
• compare the various methods of assessing circulation prior to surgery;
• describe possible biomechanical issues that may arise after a lower-extremity amputation; and
• discuss how the patient’s cardiac demand and energy expenditure can affect post-op results.

Sponsored by the North American Center for Continuing Medical Education.

Leaving an isolated digit predisposes the foot to other ulcerations due to the biomechanically unstable deformity.
By leaving the base of the proximal phalanx of the hallux, there will be minimal medial drift of the second digit.
The reverse buckling of the hallux creates a pressure point that ulcerates. The patient would benefit from a transmetatarsal amputation.
The proximal amputation may initially heal but the equino-varus deformity will break down with time unless it is corrected.
Transcutaneous oxygen pressure monitoring (TCPO2 ) will give an accurate indication of perfusion in the area of a wound.
With amputation of a third ray, the other digits remain fairly rectus because they are limited in their motion by opposing digits.
66
Author(s): 
By Kathleen Satterfield, DPM

   One should not view an amputation as a failure but as an opportunity to give a patient a chance to improve his or her quality of life.1-3 If the amputation is a definitive procedure, it may allow the patient freedom from the continuing wound care that chronic ulcerations tend to require. While the amputation is often thought of as a simple procedure, one should only perform this procedure after careful consideration of factors that will lead to a successful long-term outcome for each patient.

   Selecting an inappropriate level of amputation can doom a procedure to failure from the start, even if the surgeon has performed the technical aspects of the surgery flawlessly. The pre-planning of a successful procedure should, in fact, comprise the majority of effort in a well-performed amputation.4

   Surgeons must weigh many considerations in order to successfully plan the appropriate level of amputation. These factors include: tissue viability (the presence of ulcerations, skin anomalies, tissue deficits); micro- and macro-vascular circulation; anatomy and biomechanical function (residual deformities); cardiac demand and energy expenditure; and rehabilitation potential.

Tissue Viability: Why It Is Essential To Evaluate For Possible Infection

   While it is of paramount importance to leave only viable tissue when performing an amputation, it is not always an easy call to make. The decision to leave “marginal” tissue has been the cause of many failed surgeries. Infection, ulcerations, necrosis and fibrotic tissue or dysvascular tissue can all predispose the surgery to fail. A failed amputation can mean the need for revision and exposing the compromised patient to further risk of anesthesia.2

   There is an inherent desire on the part of the surgeon, and indeed the patient, to leave as much length as possible during an amputation. However, leaving even any question of potentially infected tissue within the wound is inadvisable and foolhardy. That said, identifying affected tissue can be difficult in cases that are marginal.5-7

   There are some important signs to consider when evaluating patients. Strep infections, which are most destructive to tissue of all origins, cause hemorrhagic changes that are clearly visible as dark red, maroon and/or black color changes to connective tissues, blood vessels and muscle tissue.

   Staph infections may be more commonly represented by purulence. While the adjacent tissue may not have become compromised, it is necessary in this case to perform an atraumatic exploration of all potential spaces for further presence of infection. This is a learned skill that requires considerable caution and care. By exploring adjacent spaces, the surgeon may inadvertently spread infection. It is important to not only have an ingress into a compartment, but also to have an egress to allow for drainage of potentially infected materials.8-10

   It is imperative to visualize all tissue that may have been contiguous with known areas of infection. Under pressure, infectious fluids will extrude from one compartment to the next along anatomic lines.11, 12

   Van Baal states in Clinics of Infectious Disease that “Proper debridement and drainage of the infection requires a sound knowledge of foot anatomy. The usual routes of progression of the infection along anatomic pathways must be understood.”13 Reviewing the compartments of the foot will aid both novice and experienced surgeons in ensuring a knowledgeable exploration of potential areas of infection progression.

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