reply 1
Amputation of the lower extremities is classified as below the knee (BTK) or above the knee (ATK) amputations. Amputation can be the result of significant trauma and damage to the soft tissues or can be a result of poor perfusion status secondary to infection or diabetes.
Diabetes Mellitus (DM) results in high glucose levels in the vascular system contributing to peripheral artery disease (PAD). PAD resulting in hypoxic conditions of soft tissues can lead to ulcer formation and promote bacterial growth. Frequently DM can result in diabetic neuropathy resulting in decreased sensory functions in the lower extremities. Factors promoting bacterial growth and potential for gangrene development include potential decreased awareness from neuropathy in conjunction with the possibility of the decreased awareness of the development of PAD. Sepsis or septicemia also can induce hypoxia in the soft tissues from chronic hypocatabolism and inflammatory response. Traumatic injuries to the bones or joints that result in damage to neurovascular bundles result in pulseless extremities that require immediate interventions.
Typically primary preventive measures include inserting peripheral arterial stents into the limbs, fluid resuscitation, anti-biotics regimen, and assessments of functional use in the case of poor perfusion from PAD, DM, sepsis, and trauma. Measurements for consideration include doppler studies of the peripheral limbs. When the decision to amputate has been made, the decision between ATK or BTK has to be considered. Studies show that ATK amputations are performed when inadequate perfusion status has reached the ankle. Subsequent studies also find that initial BTK amputations, that did not involve the ankle have higher risks for repeat ulcer formation, electrolyte imbalances from metabolic insufficiencies, and the need for repeat surgery.
ATK amputations involve the application of a tourniquet to prevent exsanguination from dissection. Skin flaps are considered for the closure of the wounds during their initial incision. The fascia is resected to expose the underlying muscles and tissues. The muscle must be assessed and transected in a length longer than the bone removed. Upon exposing the vasculature underneath the muscles, the femoral artery and femoral vein are identified, dissected, and ligated. Large branches of the vasculature may need to be addressed as needed but must still perfuse the distal tissues. After having addressed the vasculature, the sciatic and saphenous nerves are addressed and transected. Moving to the femur, the amount of bone needed for removal is dependent on the pathology of injury and the quality of insertion of tendons into the bone to anchor the distal structures. Layers of fascia are then attached.
Complications from ATK amputations consist of muscle atrophy, post-operation infections, and subsequent wounds from external stability devices. Some reports document fewer major amputations over the last several years secondary to increased proactive interventions in revascularization and endovascular intervention, but not all have PAD considered. Failed attempts at revascularization indicate causative factors for extremity amputation. Research also finds that increased rehabilitation rate in BTK vs ATK with prostheses was found to have post-operative mortalities that are significantly lower in BTK amputations.
1. Aulivola, B., 2004. Major Lower Extremity Amputation. Archives of Surgery, 139(4), p.395.
2. Berridge, D., Slack, R., Hopkinson, B. and Makin, G., 1989. A bacteriological survey of amputation wound sepsis. Journal of Hospital Infection, 13(2), pp.167-172.
3. Bild, D., Selby, J., Sinnock, P., Browner, W., Braveman, P. and Showstack, J., 1989. Lower-Extremity Amputation in People With Diabetes: Epidemiology and Prevention. Diabetes Care, 12(1), pp.24-31.
4. Gotts, J. and Matthay, M., 2016. Sepsis: pathophysiology and clinical management. BMJ, p.i1585.
5. Gutacker, N., Neumann, A., Santosa, F., Moysidis, T. and Kröger, K., 2009. Amputations in PAD patients: Data from the German Federal Statistical Office. Vascular Medicine, 15(1), pp.9-14.
6. Roessler, M., 1991. The Mangled Extremity. Archives of Surgery, 126(10), p.1243.
7. Myers M, Chauvin BJ. Above the Knee Amputations. [Updated 2021 Jun 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan
Reply 2:
Inguinal hernias can be classified into two types: indirect and direct. Indirect hernias are due to congenital defects in the muscles of the abdominal wall which creates a space for the small intestine to protrude. The Processus Vaginalis is a temporary abdominal opening in embryonic development that facilitates the descent of the testes in males. Upon maturation it forms the inguinal canal, which carries the ilioinguinal nerve and the spermatic cord in males and the ilioinguinal nerve and uterine ligaments. Incomplete closures can allow the small intestines to herniate through the inguinal canal from birth. Indirect inguinal hernias affect mostly males but can be found in women as well.
Direct inguinal hernias are acquired through weakening and degeneration of abdominal muscles. Increases in intraabdominal pressure due to exertion, straining while defecating, urinating, or coughing, and lifestyle conditions such as obesity and emphysema can contribute to weakening of the muscles. Men are also the most likely to present with this type of inguinal hernia due to the increased size of the inguinal canal to facilitate the spermatic cord. Therefore, the deep inguinal ring is the most common site of herniation through the transversalis fascia.
Patient presentation can vary in severity from person to person. Some smaller hernias can be found incidentally during routine physical examination and have no presenting symptoms. Others can be more obvious, with a noticeable bulge in the groin that can be accompanied by discomfort or pressure that worsens while standing or with strenuous activity. More acute cases will present severe pain, lack of bowel movements, and a pronounced bulge. These can be life-threatening as there is a higher risk of bowel ischemia and necrosis if left untreated.
Treatment of inguinal hernias consists of surgical repair to remove the intestine from the herniated area. Not all hernias, however, require immediate surgery. Asymptomatic hernias can be monitored and managed via pressure belts to keep the hernia reduced. This is not a permanent solution though, as the hernias present a risk of worsening and becoming incarcerated, meaning trapped outside of the abdominal wall. This leads to a strangulated hernia where there is a lack of blood flow to the protruding section of organ which leads to tissue death. Symptomatic inguinal hernias can be accessed surgically via an open or laparoscopic method and can be repaired via a mesh or suture only.
Suture inguinal hernia repairs involve reduction of the hernia back into the abdominal cavity followed by closure of the opening via suturing. This method leaves just enough room for the structures of the inguinal canal to pass through while having a low chance of repeat herniation. Due to size constraints, suture only repairs are typically only performed for strangulated or small inguinal hernias. The other option for hernia repair involves the use of surgical mesh. Surgical meshes can be either synthetic or organic and are placed over the hernia after reduction. The mesh is then sewn into the surrounding tissues to close the opening. Mesh plugs are also used for hernia repair, which involves a bundle of mesh filling the opening before being sewn into the surrounding tissue. Surgical mesh repairs allow for greater surface areas to be repaired and are often used for large inguinal herniations but do have a slightly higher rate of recurrence.
The post reply 1 Amputation of the lower extremities is classified as below the appeared first on PapersSpot.
