jurnal presentasi amputasi ok
DESCRIPTION
Jurnal Presentasi Amputasi Ok.TRANSCRIPT
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