Bhaskar Raj Pant, MD Orthopedic Surgeon

Transcription

1 Bhaskar Raj Pant, MD Orthopedic Surgeon SIGN Program Manager Board of Director Grande International Hospital [Nyaya Health Nepal] Dhapasi, NEPAL POSSIBLE

2 SIGN Conference 2015 Is amputation a FAILURE? Bhaskar Raj Pant, MD Department of Orthopedics & Trauma Grande International Hospital, Nepal

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4 Frost Bite

5 What to do? Case I: AK 3/F RTA - Bike

6 What to do? Case II: RM 23/M RTA - Bike

7 What to do? Case III: AS 36/M RTA - Bus

8 What to do? Case IV: SG 36/M RTA - Truck

9 What to do? Case V: PM 28/M RTA - Bike

10 What to do? Case VI: DP 52/M RTA - Bus

11 What to do? Case VII: MBS 32/M Saw

12 Amputation Removal of a body extremity trauma, prolonged constriction, or surgery To control pain or a disease process in affected limb(malignancy/gangrene) Preventative surgery Congenital amputation by constrictive bands

13 It is necessary that there is a method available not only to predict salvage but also to provide guidelines in treatment and prognosticate the clinical outcome. DECISION is MORE IMPORTANT than INCISION

14 Reincarnation?! Reincarnation is the religious or philosophical concept that the soul or spirit, after biological death, can begin a new life in a new body Transmigration, Rebirth If you die with absence of any body part, you will suffer in second life

15 TRUE Prognostication A true prognosticating score must evaluate each component of the limb separately and also collectively Gustilo's classification is biased on the size and nature of the wound. The damage to the functional structures and severity of bone injury are not provided equal emphasis making it a poor predictor of outcome The sequence of treatment and decision of salvage or amputation cannot be done in isolation on the severity of injury to the limb. It is also dependent on the age of the patient, presence of systemic illnesses, injury to other systems, delay in presentation to the hospital, and the presence of risk factors like uncontrolled diabetes and cardio-respiratory illness Such factors must be given due consideration in a score which hopes to provide prognostication of the outcome.

16 Tools for classification of the lower limb injury Mangled Extremity Syndrome Index (MESI) Mangled Extremity Severity Score (MESS) Predictive Salvage Index (PSI) Limb Salvage Index (LSI) Nerve injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA) The Ganga Hospital Injury Severity Score

17 Tscherne

18 Gustillo Classification Type IIIB open injuries of limbs are a major challenge in management being associated with a high incidence of nonunions, early & late infections, a prolonged period of treatment, a high number of secondary procedures, poor functional outcome & possibility of secondary amputations It includes a wide spectrum ranging from the easily manageable to almost unsalvageable Classification too generalized, all inclusive and therefore not specific or much use in prognostication Type IIIB injury involves injury to the covering tissues (skin and fascia), functional tissues (muscles, tendons and nerves), and skeleton (bones and joints) of the limb

19 MESS Score

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22 Outcomes of limb salvage and amputation Georgiadis et al. 11 Limb salvage patients following type III B and III C injuries felt more disabled than their counterparts who had undergone primary amputation Seekamp et al. 34 and Dagum et al. 6 In III B and C injuries primary amputation patients suffered more physical morbidity compared to those undergoing limb salvage Hertel et al. 17 Amputations are neither cost effective nor do they have a good functional outcome compared with limb salvage Mackenzie and Bosse 22 Outcomes of limb amputation versus reconstruction were not significantly different Bosse et al. 3 Outcomes of limb reconstruction did not differ significantly from those of amputation Hoogendoorn and van der Werken 18 Amputation is a serious treatment option in patients presenting with a fractured tibia with major soft tissue injury Dagum et al (1999) 6 Using SF-36, reported that patients in the amputation group had lower physical functional outcome scores than patients in the successful salvage group, while mental and pain outcome scores were similar in both groups Dougherty 7 and Gunawardena et al. 14 Compared the quality of life based on SF-36 scores with a reference population and highlighted the morbidity of amputees Pezzin et al. 28 Concluded that health profile of post-traumatic amputees is lower than the general population, with the deficit being more marked in terms of physical health status Smith et al. 37 Concluded that compared with controls the patients had significantly decreased scores in physical function, role play and body pain Smith et al. 37 Concluded that compared with controls the patients had significantly decreased scores in physical function, role play and body pain

23 Scoring systems outcome Helfet et al. 16 MESS score >7 has 100% predictive value for amputation Russell et al. 31 Used limb salvage index concluded that Scoring assessments cannot replace clinical judgement Poole et al. 29 Severity of injury of the soft tissues is closely associated with a high probability of amputation Moniz et al. 26 Concomitant vascular and orthopaedic injuries can be used as a good prediction tool for amputation Elsharawy 10 No correlation between MESS and MESI scores and the likelihood of an amputation Durham et al. 9 Scoring systems were able to identify the majority of patients who required amputation, but that prediction in individual patients was problematic and none of the scoring systems were able to predict functional outcome Bosse et al. 3 Questioned the clinical utility of any of the scores

24 FUNCTIONAL OUTCOME vs. RADIOLOGICAL UNION

25 What was done? Case I: AK 3/F RTA - Bike

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29 What was done? Case II: RM 23/M RTA - Bike

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32 What was done? Case III: AS 36/M RTA - Bus

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35 What was done? Case IV: SG 36/M RTA - Truck

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39 What was done? Case V: PM 28/M RTA - Bike

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41 What was done? Case VI: DP 52/M RTA - Bus

42 Multiple Debridements and Soft Tissue Procedures failed, Wound necrosed, Open BKA was done, Patient died of Septicemia after 6 days. All the effort done to save the limb was a wrong decision!!!

43 What was done? Case VII: MBS 32/M Saw

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46 Irony Saving a transected hand Amputating a good looking limb Informed Consent Prognosis / Final Functional Outcome

47 After Amputation: Stump care Pressure wound management Good prosthetic fitting Joint Function Muscle Strength Further Reconstructive Surgeries Etc. Psychotherapy/Counselling

48 Follow your patient and achieve/prove better functional result

49 Ulnar neuroma excised

50 Assessment tools for quality of life Prosthetic evaluation questionnaire scales (SIP) SF-36 Nottingham health profile Musculoskeletal function assessment scale General well being schedule Houghton scale Walk test Timed up and go test Groningen activity restriction scale

51 Conclusion Success of treatment in open injuries depend on not only severity of limb injury but also a variety of factors associated injuries & comorbid factors facilities available & expertise of treating team What is salvageable in an advanced center may not be so in another less-equipped center All should endeavor to identify particular score & threshold value, which is applicable to them

52 Trauma surgeon should not attempt to salvage a doomed or useless lower extremity Should permit early prosthetic rehabilitation to follow definitive primary amputation Amputation is not a failure

53 SIGN Conference 2015 Thank you!