الفهرس 
OVERVIEW AND INDICATIONS FOR AMPUTATIONOnly 14 pages are availabe for public view
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Abstract
SUMMARY
Lower extremity amputation is one of the oldest and most commonly performed surgical procedures. Amputation should not be regarded as ‘failure’ of treatment but should be seen by patients as well as clinicians as a positive procedure.
Amputation should aim to relieve pain, remove dead, severely ischaemic or infected tissue, and improve quality of life.
Despite advances in limb-salvage surgery, lower extremity amputation is still commonly required as an end result of the progression of arterial occlusive disease or failed arterial reconstruction.
A below-knee amputation is a transtibial amputation that involves removing the foot, ankle joint and distal tibia and fibula with related soft tissue structures. It is the most commonly performed amputation.
indications for below knee amputation include: gangrene of several toes extending to or beyond the adjacent metatarsal lesion and showing no tendency to demarcate, spreading gangrene of the foot with or without associated gangrene of the heel or ankle, spreading gangrene of several toes associated with uncontrollable infection of the foot, and failure of a transmetatarsal or Syme amputation contraindications to below knee amputation include: extensive gangrene and infection of the leg with absence of the femoral pulse at the groin, gangrene of the foot associated with irreducible flexion contracture of the knee joint, and recent acute occlusion of the femoral or iliac artery with inadequate collateral supply at below - the - knee level
Below knee amputations have three major advantages over above knee amputations: lower mortality rates, preservation of the knee joint with the prospect of rehabilitation, and minimal stump pain
Four techniques for below knee amputation are available, which are: use of anterior and posterior myocutaneous flaps, either unequal or equal, use of long posterior myocutaneous flaps, use of equal medial and lateral flaps, and use of osteomyoplasty
The level of amputation is determined by a balance between the natural tendency to try to save as much as possible of the extremity and the surgeon’s need to be sure that the amputation will heal at the chosen level. The surgeon’s goal is to avoid an inappropriately high level of amputation and revision of an amputation to a higher level
For the optimal selection of an amputation level, physical findings (pulses, skin quality, extent of foot ischemia or infection, skin temperature), noninvasive hemodynamic tests (segmental arterial pressures, Doppler waveforms, toe pressures), invasive anatomic tests (angiographic scoring systems), and physiologic tests (skin blood flow, skin perfusion pressure, muscle perfusion, transcutaneous oxygen measurements) have all been investigated.
Factors affecting wound healing include local factors as tissue oxygenation, presence of local infection or foreign body, and systemic factors as age, sex, stress, obesity, alcoholism, smoking, medical illnesses like diabetes and hypothyroidism, some medications like steroids, NSAIDs and cytotoxic drugs, and nutritional status.
In this study we used the popliteal brachial pressure index to predict wound healing after below knee amputations performed with absent popliteal pulse.
Popliteal brachial pressure index is the ratio of systolic blood pressure measured at the popliteal artery to that measured at brachial artery.
Follow up of patients for 12 weeks yielded 3 outcomes: primary healing within 4 weeks, delayed healing beyond 4 weeks but before 12 weeks, and failed healing with subsequent above knee amputation.
Measurement of popliteal brachial pressure index is an easily performed bed side test. In addition results showed its reliability to predict healing of below knee amputations in patients with peripheral arterial disease and chronic limb ischemia.