Upper Extremity Amputation

1. 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

2. Amputation: Presentation Goals Etiology Techniques Prosthetics and Rehabilitation

3. Amputation: Etiology Trauma Burns Peripheral Vascular Disease Malignant Tumors Neurologic Conditions Infections Congenital Deformities

4. 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

5. Etiology: Trauma

6. Etiology: Tumor

7. Etiology: Infection

8. Etiology: Gangrene/Necrotizing Fasciitis

9. Etiology:Failed Forearm Vascular Repair after trauma

10. Etiology: Vascular Disease

11. Etiology: Crush

12. Etiology: Congenital

13. Etiology: Infarction associated with IV Drug Abuse

14. Etiology: Scleroderma

15. 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

16. 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

17. Replantation: Multiple Digits

18. 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)

19. 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

20. Amputation: Replantation

21. 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.

27. 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

28. 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

29. Major Limb Replantation

30. UE traumatic amputation may be associated with life threatening hemorrhage

31. Aggressive resuscitation and limb repair

32. 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

33. 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 cases Daoutix 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

34. Amputation: Technique Preservation of functional residual limb length balanced with Soft tissue reconstruction to provide a well-healed, nontender, physiologic residual limb

35. 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

36. Tumor

37. Necrotizing Fasciitis

38. Trauma

39. Failed Vascular Repair

40. 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

41. 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.

42. 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

43. 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

44. Techniques Nerve: Prevent neuroma formation Draw nerve distally, section it, allow it to retract proximally Skin: Opportunistic flaps Rotation flaps Tension free Skin grafts

45. Techniques Bone: Choose appropriate level Smooth edges of bone Narrow metaphyseal flare for some disarticulations Postoperative Dressing: Soft Rigid

46. Techniques Goals of Postoperative Management Prompt, uncomplicated wound healing Control of edema Control of Postoperative pain Prevention of joint contractures Rapid rehabilitation

47. Technique: Example

48. Technique: Example

49. Technique: Example

50. Technique: Example

51. Technique:Example

52. Rehabilitation and Prosthetics

53. 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

54. 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

55. Psychological Adaptation Up to 2/3 of amputees will manifest postoperative psychiatric symptoms Depression Anxiety Crying spells Insomnia Loss of appetite Suicidal ideation

56. 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

57. 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

58. Management of Amputee Preparation Good Surgical Technique Rehabilitation Early Prosthetic Fitting Team Approach Vocational and Activity Rehabilitation

59. Prosthetics Passive Cosmetic Body Powered Harnesses and cables Myoelectric Surface EMG Activation delay Neuroprosthetics Investigational at this time

60. 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

61. Acknowledgement

62. Review Articles for Reference 1: 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.

63. Review Articles for Reference 6: 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.