A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam evaluate vascular status if severe vascular dysfunction may require revascularization procedure prior to amputation check with nutrition labs to evaluate wound healing potential albumin prealbumin transferrin total lymphocyte count soft tissue injury severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases infection CRP, ESR neuropathy trauma vascular exam Doppler (ischemic index) ABI transcutaneous oxygen pressure toe pressures need to assess associated injuries and comorbidities (diabetes) documental baseline neurovascular exam check plantar sensation check dorsalis pedis and posterior tibial pulse 2 Appropriately interprets basic and advanced imaging studies radiographs weightbearing AP/Lat views of foot, ankle, and tibia/fibula CT scan bone sequestra cortical destruction MRI look for integrity of soft tissue infection extent of neoplastic process MRA and CT angiography identifies level of arterial occlusion and whether surgical correction of the occlusion is warranted 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound management remove sutures on week three nonweightbearing until wound is well healed once healed can ambulate in well molded prosthetic device diagnose and management of early complications<br /> B Advanced Evaluation and Management 1 Provides complex non-operative treatment multiple co-morbidities non-compliant C Preoperative H & P 1 Perform basic medical and orthopaedic history and physical check neurovascular status to determine level of amputation 2 Appropriately order basic imaging studies weightbearing images AP/Lat views of foot, ankle, and tibia/fibula 3 Perform operative consent describe complications of surgery including infection stump neuroma wound breakdown (worse in diabetics, smokers, vascular insufficiency) superficial and deep infections phantom limb pain skin ulceration muscle imbalance most common is equinovarus of the residual stump dyvascular stump bony exostoses
E Preoperative Plan 1 Radiographic templating 2 Execute surgical workthrough describes the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation basic major orthopedic set oscillating saw amputation knife silk free and stick ties suction drain 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning place patient supine place small bump under ipsilateral hip to internally rotate the leg place a thigh tourniquet G Superficial Dissection 1 Trace the dorsal and plantar skin flaps 2 Make the skin incision make a skin incision starting at the dorsomedial aspect of the foot at the midshaft level of the first metatarsal continue the incision in a transverse manner along the dorsal aspect of the foot along the midshafts of the 2nd,3rd and 4th metatarsals end the incision over the dorsolateral aspect of the midshaft of the 5th metatarsal 3 Continue incision medially start incision from the medial aspect of the dorsal incision and continue it down to the level of the first metatarsal head 4 Make lateral incision start incision from the lateral aspect of the dorsal incision and continue it down to the level of the first metatarsal head 5 Join incisions curve both incisions in a plantar fashion make a transverse incision on the plantar surface along the metatarsal heads H Deep Dissection 1 Dissect through underlying fascia dissect through the subcutaneous tissue 2 Identify the neurovasculature identify the dorsalis pedis artery and ligate identify the peroneal and posterior tibial nerves place gentle traction and resect nerves using sharp dissection this prevents postoperative neuromas 3 Identify tendons identify the flexor and extensor tendons of the foot pull distally and perform sharp transection 4 Expose bone use sharp dissection to create myocutaneous skin flaps 5 Maintain flaps use an elevator to reflect tissues from the metatarsals proximally reflect back to the level of the metatarsal shafts make sure that the plantar flap is longer than the dorsal flap I Resect Bone 1 Resect metatarsal heads use a small oscillating saw and transect heads at the level of the dorsal skin incision transect the metatarsal heads in a dorsal distal to proximal plantar direction preserve the peroneus brevis when resecting the 5th metatarsal head bevel the resected ends of the 1st and 5th metatarsals bevel medially and laterally this is done to prevent skin ulcerations J Wound Closure 1 Prepare Flap use sharp dissection to debulk the plantar flap 2 Irrigation, hemostasis and drain irrigate with pulse irrigation place drain 3 Deep closure 0-vicryl for deep fascia subcutaneous with 2-0 vicryl 4 Superficial closure skin closure with 3-0 nylon (vertical/horizontal mattress) soft incision dressing well padded to reduce pressure in incision
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids pain meds advance diet as tolerated DVT prophylaxis wound care keep dressing on for 1 week remove drain on POD 2 continue postoperative antibiotics until the drain is removed appropriately orders and interprets basic imaging studies inpatient pt nonweighbearing appropriate medical management and medical consultation 2 Discharges patient appropriately pain meds outpatient PT wound care schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans