Lower Extremity Amputations Lower Extremity Amputations Orthopedic Rounds Orthopedic Rounds MUMC MUMC February 21, 2007 February 21, 2007 Presenters: Presenters: Dan Mead – prosthetist Dan Mead – prosthetist Dr. Sharon Grad - physiatrist Dr. Sharon Grad - physiatrist
Classification of Amputations Classification of Amputations � 1) Traumatic (~ 15%) � 1) Traumatic (~ 15%) - Usually healthy - Usually healthy - Limb salvage - Limb salvage - Often grafted tissues - Often grafted tissues - May require revision surgery/debridement - May require revision surgery/debridement
Classification of Amputations Classification of Amputations 1) Traumatic 1) Traumatic - Limb salvage can lead to multiple - Limb salvage can lead to multiple surgeries surgeries - - End result may be a fragile limb with less End result may be a fragile limb with less function than with an amputation function than with an amputation - Complications of infection and fracture - Complications of infection and fracture are common are common
Classification of Amputations Classification of Amputations 1) Trauma 1) Trauma - A lower limb without sensation functions poorly - A lower limb without sensation functions poorly - Limb salvage may be worse than prosthetic - Limb salvage may be worse than prosthetic replacement unless the residual limb: replacement unless the residual limb: -can tolerate full weight bearing -can tolerate full weight bearing -is painfree -is painfree -has durable skin and soft tissue coverage that -has durable skin and soft tissue coverage that doesn’t break down when walking is attempted doesn’t break down when walking is attempted
Classification of Amputations Classification of Amputations 1) Trauma 1) Trauma Decision Making in Trauma Decision Making in Trauma - Base decision on providing a limb that can - Base decision on providing a limb that can tolerate weight bearing; have enough tolerate weight bearing; have enough sensation to provide protective feedback; sensation to provide protective feedback; and have durable skin and soft tissue and have durable skin and soft tissue cover cover
Classification of Amputations Classification of Amputations 2) Tumor (~ 5%) 2) Tumor (~ 5%) - Amputation level is determined by extent of - Amputation level is determined by extent of cancer cancer - Goal is to avoid violating anatomic - Goal is to avoid violating anatomic compartments where the tumor is located compartments where the tumor is located
Classification of Amputations Classification of Amputations 3) Vascular and Diabetic (~ 70 -80%) 3) Vascular and Diabetic (~ 70 -80%) - Pre-op evaluation very important - Pre-op evaluation very important - Vascular assessment necessary - Vascular assessment necessary
Classification of Amputations Classification of Amputations Ask: Is the foot worth saving? Ask: Is the foot worth saving? -soft tissues – will ulcer heal, stay healed, or new -soft tissues – will ulcer heal, stay healed, or new ulcers form? ulcers form? -deformities – claw toes, bunion, Charcot collapse -deformities – claw toes, bunion, Charcot collapse -sensation – to protect after salvage -sensation – to protect after salvage -contractures – Achilles tendon, knee, toes -contractures – Achilles tendon, knee, toes -rehab goals – does/will patient ambulate? -rehab goals – does/will patient ambulate?
The Most Distal Amputation is not The Most Distal Amputation is not Always the Wisest! Always the Wisest! 1) 1) Biologic Healing Level Biologic Healing Level -the lowest level the skin will heal -the lowest level the skin will heal 2) 2) Functional Level Functional Level -the amputation level the patient will function best with -the amputation level the patient will function best with --previous level of ambulation --previous level of ambulation --intelligence --intelligence --cognitive status --cognitive status --motivation --motivation --cardio-pulmonary capacity --cardio-pulmonary capacity --spasticity or contractures --spasticity or contractures --rehabilitation goals --rehabilitation goals
Classification of Amputations Classification of Amputations 4) Congenital Amputation (~ 5%) 4) Congenital Amputation (~ 5%) - Revision of lower extremity deformity to - Revision of lower extremity deformity to improve the weight bearing capacity and improve the weight bearing capacity and durability durability - - Usually don’t revise upper extremity Usually don’t revise upper extremity deformities – even rudimentary digits can deformities – even rudimentary digits can have useful function have useful function
Goals of Prosthetic Rehabilitation Goals of Prosthetic Rehabilitation � Restoration of functional mobility � Restoration of functional mobility � Maintain/increase ROM � Maintain/increase ROM � Attempt return to independent lifestyle � Attempt return to independent lifestyle � Pain management � Pain management � Wound management � Wound management � Psychosocial counselling and support � Psychosocial counselling and support
Levels of Amputation in the Levels of Amputation in the Lower Extremity Lower Extremity � Partial Foot � Partial Foot � Symes (ankle disarticulation) � Symes (ankle disarticulation) � Transtibial � Transtibial � Through knee (knee disarticulation) � Through knee (knee disarticulation) � Transfemoral � Transfemoral � Hip Disarticulation � Hip Disarticulation
Physical Assessment Physical Assessment
Assessment Assessment Assess Assess - Wound/incision line - Wound/incision line - Sensation - Sensation - Adhesions - Adhesions - Contractures - Contractures - Strength - Strength - Balance - Balance - Endurance - Endurance
Post operative Edema Post operative Edema Goal: Goal: -reduce swelling -reduce swelling -shape residual limb -shape residual limb
Stump Shrinkers Stump Shrinkers � Elastoband wrap (figure 8) � Elastoband wrap (figure 8) � Tubi-grip � Tubi-grip � Compression Stocking measure to fit T/T or � Compression Stocking measure to fit T/T or T/F T/F
Bandaging Bandaging
Transtibial Amputation Transtibial Amputation
Biomechanics of Socket Fit Biomechanics of Socket Fit
Biomechanics of Socket Fit Biomechanics of Socket Fit
Length Comparison Length Comparison
Exposed Bone Exposed Bone
Bevel Tibia Bevel Tibia
Transtibial Foot Selection Transtibial Foot Selection Consider Consider � Activity level, weight of amputee, weight of � Activity level, weight of amputee, weight of foot, action at heel strike and toe-off, foot, action at heel strike and toe-off, function demands (terrain, lifestyle, etc.) function demands (terrain, lifestyle, etc.)
Transtibial Feet Categories Transtibial Feet Categories � SACH – simple, low activity/function, rigid � SACH – simple, low activity/function, rigid � Single Axis – Rapid foot flat, increases knee � Single Axis – Rapid foot flat, increases knee stability stability � Multi-Axis – Adapts to uneven terrain, good for � Multi-Axis – Adapts to uneven terrain, good for walking outdoors, may reduce impact on skin walking outdoors, may reduce impact on skin � Elastic Keel/Dynamic – Smooth rollover, comfort, � Elastic Keel/Dynamic – Smooth rollover, comfort, responsive, may not propel responsive, may not propel � Energy Storing – Carbon keel, stores energy in � Energy Storing – Carbon keel, stores energy in early stance, gives back at toe off, good for higher early stance, gives back at toe off, good for higher activity levels activity levels
SACH SACH � Solid Ankle, Cushioned Heel � Solid Ankle, Cushioned Heel � Impact absorbed at heel strike, simulated PF � Impact absorbed at heel strike, simulated PF � Simple, low activity/function, rigid � Simple, low activity/function, rigid
Single Axis Single Axis � Foot plantar flexes at heel strike, to foot flat � Foot plantar flexes at heel strike, to foot flat � Move line of action of GRF anteriorly � Move line of action of GRF anteriorly � Increased knee stability, important for TF � Increased knee stability, important for TF � Heavier, rigid rollover � Heavier, rigid rollover
Multi Axis Multi Axis � Adapts to uneven terrain, good for walking � Adapts to uneven terrain, good for walking outdoors, may reduce impact on skin outdoors, may reduce impact on skin � Rubber or Urethane may serve as material � Rubber or Urethane may serve as material being deformed being deformed
Elastic Keel/Dynamic Elastic Keel/Dynamic � Smooth rollover, improved comfort, � Smooth rollover, improved comfort, responsive responsive � May not propel � May not propel � Increased cost � Increased cost
Energy Storing Energy Storing � Carbon Keel � Carbon Keel � Stores energy in early stance, gives back at � Stores energy in early stance, gives back at toe off toe off � Good for higher activity levels � Good for higher activity levels � Significantly higher cost � Significantly higher cost
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