Complications in amputees

Transcription

1 Complications in amputees Poster No.: C-2255 Congress: ECR 2014 Type: Authors: Keywords: DOI: Educational Exhibit I. Ferreira, J. Araújo, S. Magalhães, M. Certo, J. Pires; Porto/PT Musculoskeletal system, CT, Plain radiographic studies, MR, Treatment effects, Infection, Metabolic disorders /ecr2014/C-2255 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 16

2 Learning objectives - Review common surgical techniques in amputations - Describe the most frequent complications associated with amputations - Illustrate imaging findings of amputees complications Images for this section: Fig. 1: Coverpage Page 2 of 16

3 Background Amputation of extremities is one of the oldest surgical procedures; Amputations are frequently "life-saving". However, the burden of disability they cause is a very high price for some patients; Common causes include peripheral artery disease, trauma, tumors and infection. Besides phantom limb pain, for which imaging has no role, other complications such as infection and tumour recurrence, among others, can easily be accessed with different imaging techniques. Findings and procedure details 1 - Surgical considerations Lower extremity amputation Fingers/Phalanges: more frequently performed in patients with diabetic foot. Functional consequences are usually on the hindfoot due to overload. Transmetatarsal amputation: relatively frequent; bigger functional sequel. Lisfranc amputation: disarticulation of the metatarsals with the cuboid and cuneiform. Chopard amputation: disarticulation of the navicular and cuboid with the talus and calcaneus. Transtibial amputation: it preserves the greatest possible length of the leg (note that at transtibial amputation, it should be done at least at 8cm above the tibiotarsic joint and the fibula should have 4cm less than the tibia). Transfemoral amputation: it is preserved the longest length of the thigh. Page 3 of 16

4 1.2 - Upper extremity amputation They are much less frequent than the lower limb amputations. Hand/Partial-Hand Amputations: level is variable according to the pathology. Traumatic lesions are the most frequent cause. Wrist Disarticulation: Limb is amputated at the level of the wrist. Transradial: The level depends on the affected area, with amputation occurring in the forearm, from the elbow to the wrist. Transhumeral: Amputation occurring in the upper arm from the elbow to the shoulder. Shoulder Disarticulation: Performed at the level of the shoulder, with the shoulder blade remaining. 2 - Amputees complications Phantom limb pain: It refers to the pain felt in the area of an amputated limb. It should be differentiated from the phantom limb sensation that refers to any sensation of the limb except pain. Phantom limb pain usually decreases over the time. Imaging studies have no role in this condition Aggressive Bone Edge: The angle of Farabeuf (35 o ) is the angle that should be respected in the transversal section of the diaphysis to avoid a bone-skin conflict. Radiography, with weight bearing preferably, is usually enough to the diagnosis. Fig. 2 on page Osteopenia and fractures: Patients with lower limb amputation have lower bone mineral density, although current bibliographic data doesn't establish a direct relation between bone mineral density and limb fractures. Fig. 3 on page 7 Fig. 4 on page 8 Fig. 5 on page 9 Page 4 of 16

5 2.4 - Infection: Soft tissues infection can occur at any time after amputation, although it is more frequent in the immediate post-surgery. Osteomyelitis might occur by direct spread from a contiguous soft tissue infection, haematogenous dissemination or in a previous quiescent septic focus. Conventional radiography can be enough to stablish the diagnosis, but MRI and radionuclide bone scintigraphy are the best examinations to confirm the diagnosis and to evaluate the extent of bone affection, while CT can detect sequestra that otherwise could be missed. Fig. 6 on page Neuroma: It results from the nerve trauma and can be of two types: terminal neuroma which originates at the end of the nerve, being the pattern of nerve healing, often asymptomatic; and the spindle neuroma which is far from the nerve extremity resulting from microtrauma due to stretching or compression by the localized scar tissue. MRI is the preferable examination to its detection. Usually it has low signal intensity on T1- weighted images and intermediate to high signal intensity on T2-weighted images. Fig. 7 on page Heterotopic ossification: Heterotopic ossification is a common finding at the stump end. It can cause pain and ulceration. Radiography is usually enough to establish the diagnosis. Fig. 8 on page Tumor recurrence: Tumors are still an important cause of amputation, particularly in younger patients. These patients are under follow-up for about 5 years, but tumor recurrence can occur many years after the surgery. Angiosarcoma is a rare complication of limb amputation. Fig. 9 on page 13 Images for this section: Page 5 of 16

6 Fig. 1: Coverpage Page 6 of 16

7 Fig. 2: Lateral and anteroposterior radiographs: Below knee amputation with irregular bone edge as a cause of pain. Note the soft tissue ulceration. Page 7 of 16

8 Fig. 3: CT scan images (coronal and axial planes): Red arrows point to areas of lower bone density in the femoral condyles of left leg in a patient with transtibial amputation. Fibula was also removed. Page 8 of 16

9 Fig. 4: CT scan (axial, sagital and coronal planes): Red arrows point to areas of lower bone density in the femoral condyles and the green ones in the tibia. Page 9 of 16

10 Fig. 5: Anteroposterior radiography of transtibial amputation, with a pseudoarthrosis (red arrows) also evaluated with MRI (T1 and PD fat sat sequences). Page 10 of 16

11 Fig. 6: CT scans (axial and coronal planes): The red arrows point to a soft tissue abscess and the green ones show the edema and thickening of subcutaneous tissue. Page 11 of 16

12 Fig. 7: Radiography of a below elbow amputation. T2 and T2 FAT SAT weighted MRI images (axial plane): orange arrows point to a terminal neuroma of median nerve (2cm below the bone); yellow arrows point to a spindle neuroma of radial nerve (10cm above the bone). Page 12 of 16

13 Fig. 8: Lateral and anteroposterior radiograph: heterotopic ossification of the fibula (red arrows). Page 13 of 16

14 Fig. 9: T2 FAT SAT and PD weighting MRI images: Coronal plan show a popliteal mass also seen at coronal plan, that was a recurrence of a leg rhabdomyosarcoma. Page 14 of 16

15 Conclusion Diabetes, renal insufficiency and several other entities can lead to major arterial disease, which end of line treatment is amputation. Younger patients are also submited to this treatment after severe traumatic injury or to make a tumor ressection. Considering all possible complications, radiographs are frequently enough to determine the cause of patients complaints and should be the first exam to perform. Nevertheless, when further workup is needed, MRI and CT play an important role. Surgery techniques and complications of these surgeries need to be known by the radiologist, so that he can help these patients, who are already debilitated. Personal information References Henrot P, Stines J, Walter F, Martinet N, Paysant J, Blum A. Imaging of the painful lower limb stump. Radiographics Oct;20 Spec No:S Boutin RD, Pathria MN, Resnick D. Disorders in the stumps of amputee patients: MR imaging. AJR Am J Roentgenol 1998; 171: Barouti H; Agnello M; Volckmann P. Amputaciones del miembro superior. Enciclopedia Médico-Quirúrgica A-10, Menager D. Amputaciones y prótesis del miembro inferior. Enciclopedia Médico- Quirúrgica E B-15, Matielo MF et al. Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease. J Vasc Surg Dec;48(6): Smith E, Comiskey C, and Carroll A. A study of bone mineral density in lower limb amputees and a national prosthetics center. J Prosthet Orthot. 2011: Page 15 of 16

16 Gailey R, Allen K, Castles J, Kucharik J, Roeder M. Review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. J Rehabil Res Dev. 2008;45(1): Page 16 of 16