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Principles of Amputations for Orthopaedic Exams
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Principles of Amputations for Orthopaedic Exams
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Language: EN.
Segment:0 .
And today, we're very lucky. We've got two of our mentors. As you're aware, Mr zavala, what is one of our senior mentors? He's going to finish the clinical examination part two that's coming on later on.
But first, we have a 20 to 30 minute presentation by Mahmoud Ali rahami, who's going to do principles of limb amputation presentation. As always, if you want to ask a question or if you want to make a comment, please do so through the chat or raise your hand. Participant group and we will need volunteers for the second session where we're going to practice the clinical examination like we did the history examination of the hip last week.
So if you don't, please raise your hand to make it known to me in the chat that you want to participate. It's my pleasure to introduce my daddy who's going to talk about principles of implementation. Good evening, everyone. Just talk about principal of limb amputation. The reason we talk about this topic because it was my first trauma survivor and the exam and also I believe every trauma orthopedic surgeon should have some knowledge about this topic.
So surgical amputation is one of the oldest surgical procedures. It can lead to high morbidity and mortality. The learning objective is also to understand the indication from the patient. How do you decide about the level of amputation? We touch on the surgical technique and goals of surgery, rehab process. And complications. OK this is your slide based on UK data.
Lower limb amputation present like the 1% of total amputations, the common skull is peripheral vascular disease. 52% 42 diabetes trauma, which is our topic today, 11% of the growth in numbers and tumor, about 6% coming from an organization with the prosthetic and NBC rehab centers is trans. Tibial is about 50% and about 35% in terms of causes for mutation or causes lead to amputation.
As you can see, it's a long list. But just so familiarize yourself about the causes and you have something to talk about if you face a scenario in the exam. So I will just focus on the trauma cause you can divide it or classify two acute, subacute or chronic in acute trauma situation. The time of amputation can be within hours as part of damage control to predict.
Or you have to wait a few days until you identify the zone of injury and zone of soft tissue injury and margin of the injury. So you can decide about the level in terms of the indications. There's three clear indications to consider amputation. First one is unreconstructed blood bone or soft tissue, repairable vascular injury and severe loss of plantar foot skin and soft tissue.
Initially absent sensation does not predict the poor functional outcome. As we know, there are some studies shows 50% of patient by 24 months from the initial injury, they managed to have full recovery. And this very simple score you can use to decide about it's not actually to decide actually to help you.
It doesn't work in isolation. You have to look to other things as well to consider when you decide about amputation. You like patient pre injury, level of activities, ability of the patient to learn new skills, limbs and trunk coordination, et cetera. But what I like about the scoring system, it's simple to remember the parameters is just only four, and they do make sense.
So if you look to the first parameter, they look to the mechanism of injury if it's high energy trauma or low energy trauma and the level of the injury in the soft tissue state. The second parameter is the patient hemodynamic state if the patient hemodynamic is stable before transition to hypotension or following prolonged hypotension. Also, the third parameter, which is the most important one to look to the ischemia.
And you can see those four categories, and if they see ischemia more than six hours, you might multiply the figure by 2. And the last parameter is the patient age. We know young patients. Also, children have high potential for healing. I think this is the most important piece of information. The stroke is about in energy consumption following amputation.
I'm sure all of you guys are aware of this piece of information, and I think it's very important for people doing the first part of the exam as simple as like, if more proximal amputation you do the industry, energy consumption will be higher if you compare long term stable amputation. The amount of energy consumed is 10% compared to average transfemoral 65% and bilateral transfemoral more than 300% So bear that in mind.
In terms of like, optimum level of amputation, this illustration of Commons levels of amputation, if you look to the transradial or forearm amputation, the ideal or the optimal level, it's the junction between the proximal tubule third and distal one third to similar at the middle. One third of the arm trans femur is the same as the transhumeral and the trans tibia.
You need to remember this equation. It's $0.08 per meter high from the medial joint line. For example, if the patient 180 centimeter height so you'll be thinking about 14.4 centimeters from the joint line. And there is a technique of this articulation is an option when you cannot achieve an adequate below knee stump. It has advantages and disadvantages. The advantages?
It's simple to do. You think you don't need to cut through the bone or the muscles physically put through the ligaments? And it's a quicker technique or an option to consider. Also, you don't need to worry too much about balancing the muscles of the thigh. And generally speaking, the stomach heals quicker. It's provided the patient with the local lever arm when you compare it to above knee amputation also provide a lower surface area for weight bearing and bulbous shape of the stump.
Assist to suspend the prosthesis also is a feasible option in children because it's overcome the issue of bone overgrowth if you consider osas tensile forces amputation. The disadvantages of this technique is you have limited options in terms of the prosthetic and also seem patient, slow walking and speed in comparison to Balwani amputation.
So the amputation itself, you can classify it to three phases amputation. The surgery itself and amputations. Like what? What we do when we plan for any surgery, for example, knee arthroplasty. You plan the surgery preoperative intraoperative and postoperative preoperative in trauma situation. It has to be to consult on decision.
You can not decide on your own about the amputation and this the most guidelines. And this is very important to remember in term when you are creating discussion. If you face such a scenario in the vyver and also it's advisable to get your opinion from a consultant in rehabilitation medicine specialized in the management of amputees. It can help you to decide about the level of amputation.
However, this option can be difficult to achieve in an emergency situation. Also, you have to consider a therapy program should be started with operatively to establish the basis of the post-operative rehab and what the patient needs following the surgery. MDT approach achieves the best outcome following the surgery and also preoperative pain control is essential, including including preoperative epidural anesthesia and surgical technique.
As we mentioned, do you think about the level of amputation? Also, you have to think about other things. You have to think about the skin incision. How are you going to design the skin incision so the scar to be away from the weight bearing area and also the scar should be mobile, doesn't lead to joint construction, et cetera. Also, you have to think about other structures like what are you going to do about the muscles?
What are you going to do about the nerves, the vessels, the bone and wound closure? And then we're going to talk about each one briefly in terms of the skin incision use the rule of one third and 2/3 method. Basically, you measured the length of the confrontation and you divide it by 2/3 and one third. The 2/3 use it for the anterior transverse part and one third for the posterior flap.
The posterior flap should be thick, musculocutaneous flap. If you have any doubt, you could go with the longer posterior SLAP. If there's adequate soft tissue at the end, you trim and adjust as required. Intrinsic muscles. There's a few options. One option is called myofascial closer. When you cut the muscle, you close the hatch of the muscle or you stitch it to surrounding tissue.
It doesn't provide stability or stability to the stomach, but this is something to think about. The second option is my last year. When you stitch a group of muscle to another group, for example, if you're doing the above knee amputation, you could stitch the anterior muscle group to the posterior compartment muscle through to create padding around the bone end and also bulk for the prosthesis socket to fit in.
The third option is my reduces when you stitch the muscle to the bone and should be performed with the proximal joint in full. Extension to avoid muscle. Sorry to avoid joint construction. For example, if you do an above knee amputation, you need to make sure the hip in full extension. Otherwise will. This will lead to fixed flexion deformity of the hip, and the fourth option is tenodesis use stitching the tendons to the bone.
So I like this illustration is quite nice illustration. So this adapters might use. This is commonly done for above knee amputation. And the idea here is to balance the abductors hip muscle force by stitching the doctors to the bone end. And also, as you can see, is provide the padding and cover to the bone and.
And Ted ulnar nerve should be cut clearly under construction. The idea is not to prevent the neuroma the neuroma will formation. Neuroma formation is inevitable, but the idea to keep the neuroma away from the stump and the weight bearing area otherwise would be very painful and the patient cannot tolerate to wait bare and stone. The vessels should be managed and meticulous, in which case is achieved for clear reasons to avoid infection and hematoma formation and the bone should be prevalent.
The closer you should close a layer by layer. Avoid using unobservable sutures because none of the sutures will cause irritation to the tissue and the skin. And this can be very painful, except you can use an absorbable sutures for the skin. This Ertel amputation is a technique well known, and the idea of this technique to create large weight bearing area or surface at the end of the stump is based on creation since ptosis between the fibula and the tibia.
This X-ray is slightly modified technique, but because they use the tightrope, the initial technique is based on medial tuberosity and fibula hinge, and you can affix it to the tibia by using stitch or wire. There's some studies comparing this technique to the normal technique without syndesmosis and shows there is no difference, but I believe there is some RTC going on to look to the difference.
Simon, amputation is commonly used amputation when you have to consider foot amputation. There is this articulation type of amputation is based on anchoring the heel with the fat to the tibia telephone and also to excise both medial lateral modules. The advantage is provide more extended lever arm. Again, it's back to basic science and biomechanics.
Longer level Ami have a better quadriceps muscle function and also you preserve energy consumption. Patients require less rehabilitation with this technique, as you put on the stump the frontal skin, which is designed for weight bearing. And now we're talking about the post amputation phase. You have to make sure the patient has adequate postoperative analgesia is essential to avoid the severe pain and also you have to consider using neuropathic painkillers.
Also, early involvement of the pain team is advisable. Well, amputees should have access to physiotherapy, occupational therapy and psychological support. The rehabilitation process aims to achieve maximum functional independence. Early fitting of the prosthesis within 60 days improve the function and speed return to work. And this list of people involved in or subspecialist involved in the prosthetic and amputee rehab center.
You see, this is a big theme consist of consultant rehab medicine, bas status, physiotherapist, podiatrist, nurse psychologists, rehabilitation engineer and an advisor. Instead of the complication of amputation, I'd like to divide it to local complication and systematic complications easy for me to remember. Local complications related to the stump itself. At the end of the day is surgery with the risk of think about infection.
Hematoma formation won't break down skin, ulceration, thalassitis and scar related complication. A heterotopic ossification is not uncommon. Complication is it can happen, and one of the reasons for some revision phantom sensation when the patient feel part or the whole limp still there and other possible complications. Phantom pain not fully understood, but it believes is related to neuroplasticity, painful neuroma and shock syndrome.
As they mentioned, painful neuroma is inevitable, but the only way it could help just to make sure the nerve ends away from the stump and there is some technique you could inject local anesthetic during surgery to make sure the pain under control and post-operative period. If the patient default painful neuroma when the no.1 technique, you can go and dissect the nerve more proximal lead to another neuroma away from the weight bearing area.
Shock syndrome is about when the veins around the stump get occluded due to an even pressure pressure, while patient load and the prosthetic and and this can lead to a wound. Sorry, skin breakdown and skin ulceration and terms systematic complication. I think about it the same way when I think about our tenodesis can lead to lower back pain and contralateral side leg pain and hip and knee pain, either a systematic complication as we psychological and mental health issues.
And despite the energy consumption with limb amputation, cardiovascular disease and weight gain happen due to reduced the level of activity. So it's advisable for this group of patients. They have long term follow up with cardiologists and they have regular motor for their blood pressure. This X-ray shows above knee amputation, as you can see, a patient developed a bone.
And so as I mentioned, it's one of the common reasons to revise the stump. In summary, plan the level of fragmentation carefully take into consideration patient needs and comorbidities. Collaboration with a plastic surgeon and the vascular surgeon is essential for a good outcome. Maintain joint function when possible. So when you think about the mutation, if you decide to go below knee amputation, you have to consider the state of the knee function.
If the patient already has got pre-existing fixed flexion deformity or severe arthritis in that joint, so that might change your decision, aim to achieve pain free residual. Able to function in this approach is essential for successful outcome. Thank you. Thank you very much.
Is there any questions, anyone? So one question from it is it says, why does the bone need to be beveled for amputation? And basically it's to avoid the sharp edges, which can lead to local irritation. And also it would be easier to get adequate soft tissue padding over the bone and. Questions so in the exam scenario, what are the key points to make sure that you mention buzzwords?
First of all, you have to mention it's MDT approach. You have to think about consider independent second consultant opinion. Ideally, should be from different specialty like plastic or vascular surgeon. You have to talk about level of amputation. And the reason for that. You have to talk about how you prepare a patient for surgery if trauma scenario and patient presented with mangled limb.
And also, you consider all the things we talked about in terms of scoring system. You don't need to remember the score in details, but you just at least you're asking these specific questions. What's the mechanism of injury? What's the age of the patient? Was the ischemic stage when the patient arrived to the hospital? What's is the patient in shock?
So these are all relevant questions to help you to start the divider and build up and the progress. Yeah also, we've been joined by chewton Dorji. He's one of our mentors as well. Other things I'd like to point out is this scenario can come in the mangled extremity trauma scenario, and it's very important not to focus straightaway on the mangled extremity and focus on ATVs.
Instead, patients tend to throw a picture of a mangled extremity. And you'll get excited about that and you'll forget to talk about at first. If the markings in the atvs, they'll let you continue. If the markings in the actual discussion of mangled extremity, they'll tell you this is an isolated injury or so. Don't worry about that decision making in those extreme scenarios.
There's a couple of things, and insensitive foot is not necessarily an indication to amputate in the early stage. It has been shown not to make any difference. So we're waiting for better to try and salvage if you can. Decision to salvage is made between two to three consultants, depending, so you need at least decision between you and the orthopedic and the vascular surgeons about viability of salvage limb versus amputation.
Any further comments about any of the mentors? Yeah, I totally agree with you. Like sometimes can be difficult decision and you don't want to take that decision on your own, so you have to talk with the other consultant from different specialty and also to show you understand the principles, the guidelines. You might ask about the rehab process, which we covered to some degree in terms like pain management approach, early physio input, occupational therapist input, et cetera.
But I totally agree with you. Like, if you present with the trauma scenario, you have to talk about the basics first. Like first, you want to save lives. And after that, you think about saving limb. If you cannot save the limb, you have to think about what the other options in terms of amputation versus reconstruction and you have to track your decision. But what you think is ideal or like appropriate.
For that scenario. Exactly and the importance of discussion in the elective scenario, in the emergency scenario and the approach of who's involved in care with that dropdown list that you had was very nice. I like that. Thank you very much.
Have a good evening. Bye
Segment:0 .
And today, we're very lucky. We've got two of our mentors. As you're aware, Mr zavala, what is one of our senior mentors? He's going to finish the clinical examination part two that's coming on later on.
But first, we have a 20 to 30 minute presentation by Mahmoud Ali rahami, who's going to do principles of limb amputation presentation. As always, if you want to ask a question or if you want to make a comment, please do so through the chat or raise your hand. Participant group and we will need volunteers for the second session where we're going to practice the clinical examination like we did the history examination of the hip last week.
So if you don't, please raise your hand to make it known to me in the chat that you want to participate. It's my pleasure to introduce my daddy who's going to talk about principles of implementation. Good evening, everyone. Just talk about principal of limb amputation. The reason we talk about this topic because it was my first trauma survivor and the exam and also I believe every trauma orthopedic surgeon should have some knowledge about this topic.
So surgical amputation is one of the oldest surgical procedures. It can lead to high morbidity and mortality. The learning objective is also to understand the indication from the patient. How do you decide about the level of amputation? We touch on the surgical technique and goals of surgery, rehab process. And complications. OK this is your slide based on UK data.
Lower limb amputation present like the 1% of total amputations, the common skull is peripheral vascular disease. 52% 42 diabetes trauma, which is our topic today, 11% of the growth in numbers and tumor, about 6% coming from an organization with the prosthetic and NBC rehab centers is trans. Tibial is about 50% and about 35% in terms of causes for mutation or causes lead to amputation.
As you can see, it's a long list. But just so familiarize yourself about the causes and you have something to talk about if you face a scenario in the exam. So I will just focus on the trauma cause you can divide it or classify two acute, subacute or chronic in acute trauma situation. The time of amputation can be within hours as part of damage control to predict.
Or you have to wait a few days until you identify the zone of injury and zone of soft tissue injury and margin of the injury. So you can decide about the level in terms of the indications. There's three clear indications to consider amputation. First one is unreconstructed blood bone or soft tissue, repairable vascular injury and severe loss of plantar foot skin and soft tissue.
Initially absent sensation does not predict the poor functional outcome. As we know, there are some studies shows 50% of patient by 24 months from the initial injury, they managed to have full recovery. And this very simple score you can use to decide about it's not actually to decide actually to help you.
It doesn't work in isolation. You have to look to other things as well to consider when you decide about amputation. You like patient pre injury, level of activities, ability of the patient to learn new skills, limbs and trunk coordination, et cetera. But what I like about the scoring system, it's simple to remember the parameters is just only four, and they do make sense.
So if you look to the first parameter, they look to the mechanism of injury if it's high energy trauma or low energy trauma and the level of the injury in the soft tissue state. The second parameter is the patient hemodynamic state if the patient hemodynamic is stable before transition to hypotension or following prolonged hypotension. Also, the third parameter, which is the most important one to look to the ischemia.
And you can see those four categories, and if they see ischemia more than six hours, you might multiply the figure by 2. And the last parameter is the patient age. We know young patients. Also, children have high potential for healing. I think this is the most important piece of information. The stroke is about in energy consumption following amputation.
I'm sure all of you guys are aware of this piece of information, and I think it's very important for people doing the first part of the exam as simple as like, if more proximal amputation you do the industry, energy consumption will be higher if you compare long term stable amputation. The amount of energy consumed is 10% compared to average transfemoral 65% and bilateral transfemoral more than 300% So bear that in mind.
In terms of like, optimum level of amputation, this illustration of Commons levels of amputation, if you look to the transradial or forearm amputation, the ideal or the optimal level, it's the junction between the proximal tubule third and distal one third to similar at the middle. One third of the arm trans femur is the same as the transhumeral and the trans tibia.
You need to remember this equation. It's $0.08 per meter high from the medial joint line. For example, if the patient 180 centimeter height so you'll be thinking about 14.4 centimeters from the joint line. And there is a technique of this articulation is an option when you cannot achieve an adequate below knee stump. It has advantages and disadvantages. The advantages?
It's simple to do. You think you don't need to cut through the bone or the muscles physically put through the ligaments? And it's a quicker technique or an option to consider. Also, you don't need to worry too much about balancing the muscles of the thigh. And generally speaking, the stomach heals quicker. It's provided the patient with the local lever arm when you compare it to above knee amputation also provide a lower surface area for weight bearing and bulbous shape of the stump.
Assist to suspend the prosthesis also is a feasible option in children because it's overcome the issue of bone overgrowth if you consider osas tensile forces amputation. The disadvantages of this technique is you have limited options in terms of the prosthetic and also seem patient, slow walking and speed in comparison to Balwani amputation.
So the amputation itself, you can classify it to three phases amputation. The surgery itself and amputations. Like what? What we do when we plan for any surgery, for example, knee arthroplasty. You plan the surgery preoperative intraoperative and postoperative preoperative in trauma situation. It has to be to consult on decision.
You can not decide on your own about the amputation and this the most guidelines. And this is very important to remember in term when you are creating discussion. If you face such a scenario in the vyver and also it's advisable to get your opinion from a consultant in rehabilitation medicine specialized in the management of amputees. It can help you to decide about the level of amputation.
However, this option can be difficult to achieve in an emergency situation. Also, you have to consider a therapy program should be started with operatively to establish the basis of the post-operative rehab and what the patient needs following the surgery. MDT approach achieves the best outcome following the surgery and also preoperative pain control is essential, including including preoperative epidural anesthesia and surgical technique.
As we mentioned, do you think about the level of amputation? Also, you have to think about other things. You have to think about the skin incision. How are you going to design the skin incision so the scar to be away from the weight bearing area and also the scar should be mobile, doesn't lead to joint construction, et cetera. Also, you have to think about other structures like what are you going to do about the muscles?
What are you going to do about the nerves, the vessels, the bone and wound closure? And then we're going to talk about each one briefly in terms of the skin incision use the rule of one third and 2/3 method. Basically, you measured the length of the confrontation and you divide it by 2/3 and one third. The 2/3 use it for the anterior transverse part and one third for the posterior flap.
The posterior flap should be thick, musculocutaneous flap. If you have any doubt, you could go with the longer posterior SLAP. If there's adequate soft tissue at the end, you trim and adjust as required. Intrinsic muscles. There's a few options. One option is called myofascial closer. When you cut the muscle, you close the hatch of the muscle or you stitch it to surrounding tissue.
It doesn't provide stability or stability to the stomach, but this is something to think about. The second option is my last year. When you stitch a group of muscle to another group, for example, if you're doing the above knee amputation, you could stitch the anterior muscle group to the posterior compartment muscle through to create padding around the bone end and also bulk for the prosthesis socket to fit in.
The third option is my reduces when you stitch the muscle to the bone and should be performed with the proximal joint in full. Extension to avoid muscle. Sorry to avoid joint construction. For example, if you do an above knee amputation, you need to make sure the hip in full extension. Otherwise will. This will lead to fixed flexion deformity of the hip, and the fourth option is tenodesis use stitching the tendons to the bone.
So I like this illustration is quite nice illustration. So this adapters might use. This is commonly done for above knee amputation. And the idea here is to balance the abductors hip muscle force by stitching the doctors to the bone end. And also, as you can see, is provide the padding and cover to the bone and.
And Ted ulnar nerve should be cut clearly under construction. The idea is not to prevent the neuroma the neuroma will formation. Neuroma formation is inevitable, but the idea to keep the neuroma away from the stump and the weight bearing area otherwise would be very painful and the patient cannot tolerate to wait bare and stone. The vessels should be managed and meticulous, in which case is achieved for clear reasons to avoid infection and hematoma formation and the bone should be prevalent.
The closer you should close a layer by layer. Avoid using unobservable sutures because none of the sutures will cause irritation to the tissue and the skin. And this can be very painful, except you can use an absorbable sutures for the skin. This Ertel amputation is a technique well known, and the idea of this technique to create large weight bearing area or surface at the end of the stump is based on creation since ptosis between the fibula and the tibia.
This X-ray is slightly modified technique, but because they use the tightrope, the initial technique is based on medial tuberosity and fibula hinge, and you can affix it to the tibia by using stitch or wire. There's some studies comparing this technique to the normal technique without syndesmosis and shows there is no difference, but I believe there is some RTC going on to look to the difference.
Simon, amputation is commonly used amputation when you have to consider foot amputation. There is this articulation type of amputation is based on anchoring the heel with the fat to the tibia telephone and also to excise both medial lateral modules. The advantage is provide more extended lever arm. Again, it's back to basic science and biomechanics.
Longer level Ami have a better quadriceps muscle function and also you preserve energy consumption. Patients require less rehabilitation with this technique, as you put on the stump the frontal skin, which is designed for weight bearing. And now we're talking about the post amputation phase. You have to make sure the patient has adequate postoperative analgesia is essential to avoid the severe pain and also you have to consider using neuropathic painkillers.
Also, early involvement of the pain team is advisable. Well, amputees should have access to physiotherapy, occupational therapy and psychological support. The rehabilitation process aims to achieve maximum functional independence. Early fitting of the prosthesis within 60 days improve the function and speed return to work. And this list of people involved in or subspecialist involved in the prosthetic and amputee rehab center.
You see, this is a big theme consist of consultant rehab medicine, bas status, physiotherapist, podiatrist, nurse psychologists, rehabilitation engineer and an advisor. Instead of the complication of amputation, I'd like to divide it to local complication and systematic complications easy for me to remember. Local complications related to the stump itself. At the end of the day is surgery with the risk of think about infection.
Hematoma formation won't break down skin, ulceration, thalassitis and scar related complication. A heterotopic ossification is not uncommon. Complication is it can happen, and one of the reasons for some revision phantom sensation when the patient feel part or the whole limp still there and other possible complications. Phantom pain not fully understood, but it believes is related to neuroplasticity, painful neuroma and shock syndrome.
As they mentioned, painful neuroma is inevitable, but the only way it could help just to make sure the nerve ends away from the stump and there is some technique you could inject local anesthetic during surgery to make sure the pain under control and post-operative period. If the patient default painful neuroma when the no.1 technique, you can go and dissect the nerve more proximal lead to another neuroma away from the weight bearing area.
Shock syndrome is about when the veins around the stump get occluded due to an even pressure pressure, while patient load and the prosthetic and and this can lead to a wound. Sorry, skin breakdown and skin ulceration and terms systematic complication. I think about it the same way when I think about our tenodesis can lead to lower back pain and contralateral side leg pain and hip and knee pain, either a systematic complication as we psychological and mental health issues.
And despite the energy consumption with limb amputation, cardiovascular disease and weight gain happen due to reduced the level of activity. So it's advisable for this group of patients. They have long term follow up with cardiologists and they have regular motor for their blood pressure. This X-ray shows above knee amputation, as you can see, a patient developed a bone.
And so as I mentioned, it's one of the common reasons to revise the stump. In summary, plan the level of fragmentation carefully take into consideration patient needs and comorbidities. Collaboration with a plastic surgeon and the vascular surgeon is essential for a good outcome. Maintain joint function when possible. So when you think about the mutation, if you decide to go below knee amputation, you have to consider the state of the knee function.
If the patient already has got pre-existing fixed flexion deformity or severe arthritis in that joint, so that might change your decision, aim to achieve pain free residual. Able to function in this approach is essential for successful outcome. Thank you. Thank you very much.
Is there any questions, anyone? So one question from it is it says, why does the bone need to be beveled for amputation? And basically it's to avoid the sharp edges, which can lead to local irritation. And also it would be easier to get adequate soft tissue padding over the bone and. Questions so in the exam scenario, what are the key points to make sure that you mention buzzwords?
First of all, you have to mention it's MDT approach. You have to think about consider independent second consultant opinion. Ideally, should be from different specialty like plastic or vascular surgeon. You have to talk about level of amputation. And the reason for that. You have to talk about how you prepare a patient for surgery if trauma scenario and patient presented with mangled limb.
And also, you consider all the things we talked about in terms of scoring system. You don't need to remember the score in details, but you just at least you're asking these specific questions. What's the mechanism of injury? What's the age of the patient? Was the ischemic stage when the patient arrived to the hospital? What's is the patient in shock?
So these are all relevant questions to help you to start the divider and build up and the progress. Yeah also, we've been joined by chewton Dorji. He's one of our mentors as well. Other things I'd like to point out is this scenario can come in the mangled extremity trauma scenario, and it's very important not to focus straightaway on the mangled extremity and focus on ATVs.
Instead, patients tend to throw a picture of a mangled extremity. And you'll get excited about that and you'll forget to talk about at first. If the markings in the atvs, they'll let you continue. If the markings in the actual discussion of mangled extremity, they'll tell you this is an isolated injury or so. Don't worry about that decision making in those extreme scenarios.
There's a couple of things, and insensitive foot is not necessarily an indication to amputate in the early stage. It has been shown not to make any difference. So we're waiting for better to try and salvage if you can. Decision to salvage is made between two to three consultants, depending, so you need at least decision between you and the orthopedic and the vascular surgeons about viability of salvage limb versus amputation.
Any further comments about any of the mentors? Yeah, I totally agree with you. Like sometimes can be difficult decision and you don't want to take that decision on your own, so you have to talk with the other consultant from different specialty and also to show you understand the principles, the guidelines. You might ask about the rehab process, which we covered to some degree in terms like pain management approach, early physio input, occupational therapist input, et cetera.
But I totally agree with you. Like, if you present with the trauma scenario, you have to talk about the basics first. Like first, you want to save lives. And after that, you think about saving limb. If you cannot save the limb, you have to think about what the other options in terms of amputation versus reconstruction and you have to track your decision. But what you think is ideal or like appropriate.
For that scenario. Exactly and the importance of discussion in the elective scenario, in the emergency scenario and the approach of who's involved in care with that dropdown list that you had was very nice. I like that. Thank you very much.
Have a good evening. Bye
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