lower extremity amputations

7/26/2019 Lower Extremity Amputations

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Lower Extremity AmputationsLower Extremity Amputations

Orthopedic Rounds

February 21, 2007Presenters:

Dan Mead – prosthetistDr. Sharon Grad - physiatrist

Orthopedic RoundsMUMC

February 21, 2007Presenters:

Dan Mead – prosthetistDr. Sharon Grad - physiatrist

Classification of AmputationsClassification of Amputations

1) Traumatic (~ 15%)- Usually healthy

- Limb salvage- Often grafted tissues

- May require revision surgery/debridement

1) Traumatic (~ 15%)- Usually healthy

- Limb salvage- Often grafted tissues

- May require revision surgery/debridement

1) Traumatic- Limb salvage can lead to multiple

surgeries

- End result may be a fragile limb with lessfunction than with an amputation

- Complications of infection and fractureare common

1) Traumatic- Limb salvage can lead to multiple

surgeries

- End result may be a fragile limb with lessfunction than with an amputation

- Complications of infection and fractureare common

1) Trauma- A lower limb without sensation functions poorly

- Limb salvage may be worse than prosthetic

replacement unless the residual limb:-can tolerate full weight bearing

-is painfree

-has durable skin and soft tissue coverage thatdoesn’t break down when walking is attempted

1) Trauma

- A lower limb without sensation functions poorly

- Limb salvage may be worse than prosthetic

replacement unless the residual limb:-can tolerate full weight bearing

-is painfree

-has durable skin and soft tissue coverage thatdoesn’t break down when walking is attempted

1) TraumaDecision Making in Trauma

- Base decision on providing a limb that cantolerate weight bearing; have enough

sensation to provide protective feedback;

and have durable skin and soft tissuecover

1) TraumaDecision Making in Trauma

- Base decision on providing a limb that cantolerate weight bearing; have enough

sensation to provide protective feedback;

and have durable skin and soft tissuecover

2) Tumor (~ 5%)- Amputation level is determined by extent of

cancer

- Goal is to avoid violating anatomic

compartments where the tumor is located

2) Tumor (~ 5%)- Amputation level is determined by extent of

cancer

- Goal is to avoid violating anatomic

compartments where the tumor is located

3) Vascular and Diabetic (~ 70 -80%)- Pre-op evaluation very important

- Vascular assessment necessary

3) Vascular and Diabetic (~ 70 -80%)- Pre-op evaluation very important

- Vascular assessment necessary

Ask: Is the foot worth saving?-soft tissues – will ulcer heal, stay healed, or new

ulcers form?

-deformities – claw toes, bunion, Charcot collapse

-sensation – to protect after salvage

-contractures – Achilles tendon, knee, toes-rehab goals – does/will patient ambulate?

Ask: Is the foot worth saving?-soft tissues – will ulcer heal, stay healed, or new

ulcers form?

-deformities – claw toes, bunion, Charcot collapse

-sensation – to protect after salvage

-contractures – Achilles tendon, knee, toes-rehab goals – does/will patient ambulate?

The Most Distal Amputation is not

Always the Wisest!

The Most Distal Amputation is not

Always the Wisest!1) Biologic Healing Level

-the lowest level the skin will heal

2) Functional Level

-the amputation level the patient will function best with

--previous level of ambulation--intelligence

--cognitive status

--motivation

--cardio-pulmonary capacity--spasticity or contractures

--rehabilitation goals

1) Biologic Healing Level

-the lowest level the skin will heal

2) Functional Level

-the amputation level the patient will function best with

--previous level of ambulation--intelligence

--cognitive status

--motivation

--cardio-pulmonary capacity--spasticity or contractures

--rehabilitation goals

4) Congenital Amputation (~ 5%)- Revision of lower extremity deformity to

improve the weight bearing capacity and

durability

- Usually don’t revise upper extremity

deformities – even rudimentary digits canhave useful function

4) Congenital Amputation (~ 5%)- Revision of lower extremity deformity to

improve the weight bearing capacity and

durability

- Usually don’t revise upper extremity

deformities – even rudimentary digits canhave useful function

Goals of Prosthetic RehabilitationGoals of Prosthetic Rehabilitation

Restoration of functional mobility Maintain/increase ROM

Attempt return to independent lifestyle Pain management

Wound management Psychosocial counselling and support

Restoration of functional mobility Maintain/increase ROM

Attempt return to independent lifestyle Pain management

Wound management Psychosocial counselling and support

Levels of Amputation in the

Lower Extremity

Levels of Amputation in the

Lower Extremity

Partial Foot Symes (ankle disarticulation)

Transtibial Through knee (knee disarticulation)

Transfemoral Hip Disarticulation

Partial Foot Symes (ankle disarticulation)

Transtibial Through knee (knee disarticulation)

Transfemoral

Hip Disarticulation

Physical AssessmentPhysical Assessment

AssessmentAssessment

Assess

- Wound/incision line

- Sensation

- Adhesions- Contractures

- Strength

- Balance

- Endurance

Assess

- Wound/incision line

- Sensation

- Adhesions- Contractures

- Strength

- Balance

- Endurance

Post operative EdemaPost operative Edema

Goal:-reduce swelling

-shape residual limb

Goal:-reduce swelling

-shape residual limb

Stump ShrinkersStump Shrinkers

Elastoband wrap (figure 8) Tubi-grip

Compression Stocking measure to fit T/T orT/F

Elastoband wrap (figure 8) Tubi-grip

Compression Stocking measure to fit T/T orT/F

BandagingBandaging

Transtibial AmputationTranstibial Amputation

Biomechanics of Socket FitBiomechanics of Socket Fit

Length ComparisonLength Comparison

Exposed BoneExposed Bone

Bevel TibiaBevel Tibia

Transtibial Foot SelectionTranstibial Foot Selection

Consider

Activity level, weight of amputee, weight offoot, action at heel strike and toe-off,

function demands (terrain, lifestyle, etc.)

Consider

Activity level, weight of amputee, weight offoot, action at heel strike and toe-off,

function demands (terrain, lifestyle, etc.)

Transtibial Feet CategoriesTranstibial Feet Categories

SACH – simple, low activity/function, rigid

Single Axis – Rapid foot flat, increases knee

stability

Multi-Axis – Adapts to uneven terrain, good forwalking outdoors, may reduce impact on skin

Elastic Keel/Dynamic – Smooth rollover, comfort,responsive, may not propel

Energy Storing – Carbon keel, stores energy inearly stance, gives back at toe off, good for higheractivity levels

SACH – simple, low activity/function, rigid

Single Axis – Rapid foot flat, increases knee

stability Multi-Axis – Adapts to uneven terrain, good for

walking outdoors, may reduce impact on skin

Elastic Keel/Dynamic – Smooth rollover, comfort,responsive, may not propel

Energy Storing – Carbon keel, stores energy inearly stance, gives back at toe off, good for higheractivity levels

SACHSACH

Solid Ankle, Cushioned Heel Impact absorbed at heel strike, simulated PF

Simple, low activity/function, rigid

Solid Ankle, Cushioned Heel Impact absorbed at heel strike, simulated PF

Simple, low activity/function, rigid

Single AxisSingle Axis

Foot plantar flexes at heel strike, to foot flat Move line of action of GRF anteriorly

Increased knee stability, important for TF

Heavier, rigid rollover

Foot plantar flexes at heel strike, to foot flat Move line of action of GRF anteriorly

Increased knee stability, important for TF

Heavier, rigid rollover

Multi AxisMulti Axis

Adapts to uneven terrain, good for walkingoutdoors, may reduce impact on skin

Rubber or Urethane may serve as material

being deformed

Adapts to uneven terrain, good for walkingoutdoors, may reduce impact on skin

Rubber or Urethane may serve as material

being deformed

Energy StoringEnergy Storing

Carbon Keel

Stores energy in early stance, gives back attoe off

Good for higher activity levels

Significantly higher cost

Carbon Keel

Stores energy in early stance, gives back attoe off

Good for higher activity levels

Significantly higher cost

Suspension (T/T)Suspension (T/T)

Fork Strap and waist belt Cuff Suspension

Supracondylar (PTS)

Sleeve (Neoprene, Silicone), (2S)

Liner and Pin (3S)

One way valve and Sleeve (suction)

Harmony (elevated vacuum)

Fork Strap and waist belt Cuff Suspension

Supracondylar (PTS)

Sleeve (Neoprene, Silicone), (2S)

Liner and Pin (3S)

One way valve and Sleeve (suction)

Harmony (elevated vacuum)

Fork Strap and Waist beltFork Strap and Waist belt

Supracondylar (PTS)Supracondylar (PTS)

Medial wedge iscreated overadductor

tubercle Self suspends

Increase height

of brim,improving MLknee stability

Medial wedge iscreated overadductortubercle

Self suspends

Increase height

of brim,improving MLknee stability

Cuff Suspension (T/T)Cuff Suspension (T/T)

What are Interface Liners?What are Interface Liners? Interface – a surface forming a common boundary

of two bodies, spaces, or phases; to connect bymeans of an interface

Liner – one that lines or is used to line or back

something

Interface – a surface forming a common boundary

of two bodies, spaces, or phases; to connect bymeans of an interface

Liner – one that lines or is used to line or back

something

What are Interface Liners?What are Interface Liners? Interface liners relating to prosthetics, refers to a

lining that is placed on the residual limb whichwill act as a boundary between the skin and the

hard weight bearing socket

Many different types of liners

Polyurethane

Silicone

Elastic Polymers

Interface liners relating to prosthetics, refers to a

lining that is placed on the residual limb whichwill act as a boundary between the skin and the

hard weight bearing socket

Many different types of liners

Polyurethane

Silicone

Elastic Polymers

General DescriptionGeneral Description Liners act as excellent forms of protection vs

friction, they distribute dynamic pressure due tothe flow characteristics of the liner, and they may

act as a form of suspension

4 goals: ⇓ average and peak pressures on the limb

⇓ rate of skin breakdown

⇑ weight bearing capabilities

Improves comfort and suspension

Liners act as excellent forms of protection vs

friction, they distribute dynamic pressure due tothe flow characteristics of the liner, and they may

act as a form of suspension

4 goals: ⇓ average and peak pressures on the limb

⇓ rate of skin breakdown

⇑ weight bearing capabilities

Improves comfort and suspension

Li d Pi (3S)Li d Pi (3S)

Liner and Pin (3S)Liner and Pin (3S)

• Liner has pin attachment

• Different pin types exist

Li d Pi (3S)Li d Pi (3S)

Liner and Pin (3S)Liner and Pin (3S)

Locking Liner Suspension

Techniques Locking Pin systems

a serrated pin engages a gear

in locking mechanism a smooth pin engages a clutch

mechanism

Pin systems can take upsignificant space

problems with elongation of

liner simple and can be effective

Locking Liner SuspensionTechniques

Locking Pin systems

a serrated pin engages a gearin locking mechanism

a smooth pin engages a clutchmechanism

Pin systems can take upsignificant space

problems with elongation of

liner simple and can be effective

U th liU th li

Urethane linersUrethane liners

available from some manufacturers in standard sizes andcan be custom fabricated by TEC Interface Systems

cannot currently be manufacture in-house

University of Minnesota study showed that urethane behaves more like human tissue than silicone or mineraloil gel when stressed

Excellent results with very delicate skin

Can be used with Vacuum Assisted fittings (Harmony) Cast mods are very different from any other socket type

available from some manufacturers in standard sizes andcan be custom fabricated by TEC Interface Systems

cannot currently be manufacture in-house

University of Minnesota study showed that urethane behaves more like human tissue than silicone or mineraloil gel when stressed

Excellent results with very delicate skin

Can be used with Vacuum Assisted fittings (Harmony) Cast mods are very different from any other socket type

Custom Urethane Liner Custom Urethane Liner

H ( l d )H ( l d )

Harmony (elevated vacuum)Harmony (elevated vacuum)

ROTATING - The new rotational feature allowswearers to move more naturally — whether they

are walking, running errands or golfing. INCREASED RELIABILITY - Offered through

a double filtration system, shorter tubing and

fewer in-line connections.

IMPROVED VOLUME CONTROL - TheHarmony System’s elevated vacuum pullsoxygenated fluids into the residual limb during

swing phase and pushes fluids out during weight bearing. The result is less than 1% volume lossduring the course of the day.*

ROTATING - The new rotational feature allowswearers to move more naturally — whether they

are walking, running errands or golfing. INCREASED RELIABILITY - Offered through

a double filtration system, shorter tubing and

fewer in-line connections.

IMPROVED VOLUME CONTROL - TheHarmony System’s elevated vacuum pullsoxygenated fluids into the residual limb during

swing phase and pushes fluids out during weight bearing. The result is less than 1% volume lossduring the course of the day.*

H ( l d )H ( l d )

Linkage - Not only does the elevated vacuum

between the socket and the liner control volume,

it helps the prosthesis become one with the user.

Improved Volume Control controlling volume

fluctuations can improve fit for many amputeeshelping reduce pressure points on the limb.

Proprioception - Elevated vacuum leads toheightened proprioception, the awareness a user

has of her or his leg in space. This leads to

increased balance, stability and control over the prosthesis.

Linkage - Not only does the elevated vacuum

between the socket and the liner control volume,

it helps the prosthesis become one with the user.

Improved Volume Control controlling volume

fluctuations can improve fit for many amputeeshelping reduce pressure points on the limb.

Proprioception - Elevated vacuum leads toheightened proprioception, the awareness a user

has of her or his leg in space. This leads to

increased balance, stability and control over the prosthesis.

C S dC S d

Case Study

Mr. R. F.

Case Study

Mr. R. F.

Uses TEC urethane

liner, harmony pump

and urethane sleeve

Patient has donnedurethane liner and is

now donning socket

Uses TEC urethane

liner, harmony pump

and urethane sleeve

Patient has donnedurethane liner and is

now donning socket

Seal is created

between liner, leg and

sleeve

Suspends prosthesiswith up to 25mmHg

Accurate “Total

Surface WeightBearing” fit is critical

Seal is created

between liner, leg and

sleeve

Suspends prosthesiswith up to 25mmHg

Accurate “Total

Surface WeightBearing” fit is critical

Transfemoral AmputationTransfemoral Amputation

Suspension (T/F)Suspension (T/F)

Silesian Bandage & Billet

Liner and Pin

Seal-In Liner

Suction

TES Belt

Hip Joint and Pelvic Band

Silesian Bandage & Billet

Liner and Pin

Seal-In Liner

Suction

TES Belt

Hip Joint and Pelvic Band

S i (T/F)S i (T/F)

Suspension (T/F)Suspension (T/F)

Billet attachment

-Anteromed 1/3

-at level of IT

Billet attachment

-Anteromed 1/3

-at level of IT

Silesian attachment

-posteroprox to GT

Silesian attachment

-posteroprox to GT

S l I LiS l I Li

Seal-In Liner Seal-In Liner

Used with Icelock

Expulsion Valve

Good for all

impact levels Available for both

TT/TF patient

Used with Icelock

Expulsion Valve

Good for all

impact levels Available for both

TT/TF patient

Prosthetic Knee CategoriesProsthetic Knee Categories Locked

Safety (stance control)

Polycentric

Single Axis, Friction

Fluid Controlled (pneumatic or hydraulic)

Microprocessor Hybrid (ie. 4 bar with hydraulic)

Locked

Safety (stance control)

Polycentric

Single Axis, Friction

Fluid Controlled (pneumatic or hydraulic)

Microprocessor

Hybrid (ie. 4 bar with hydraulic)

Manual Locking KneeManual Locking KneePROS

Safety

Gait Deviations

Safety KneeSafety Knee

Safety Knee

(Weight-activated Stance Control)

Safety Knee

(Weight-activated Stance Control)PROS

Inexpensive

Foot clears in swing

Inexpensive

Foot clears in swing

Possibility of falling if

user is distracted

Brake wears over time

Gait deviations

Single cadence

Possibility of falling if

user is distracted

Brake wears over time

Gait deviations

Single cadence

Polycentric Knee (aka: 4 bar)Polycentric Knee (aka: 4 bar) PROS

Stability

Sitting cosmesis for

long residual limb Improved swing

clearance

Stability

Sitting cosmesis for

long residual limb Improved swing

clearance

Weight

Must be a hybrid forvariable cadence

Some 4 bar designs

have up to 15 degreesof stance flexion builtin for loading response

Weight

Must be a hybrid forvariable cadence

Some 4 bar designs

have up to 15 degreesof stance flexion builtin for loading response

Fluid ControlledFluid Controlled

Fluid Controlled

Pneumatic or Hydraulic

Fluid Controlled

Pneumatic or Hydraulic

Variable Cadence

Stance and Swing

control More ‘normalized’gait

Good for higher

activity levels

Variable Cadence

Stance and Swing

control More ‘normalized’gait

Good for higher

activity levels

Weight

Maintenance

Weight

Maintenance

Microprocessor Controlled KneeMicroprocessor Controlled Knee PROS

Variable Cadence

Stumble recovery

Stability in Stance

Ability to walk down

stairs/ramps step over step

Second mode

Improved confidence

Variable Cadence

Stumble recovery

Stability in Stance

Ability to walk down

stairs/ramps step over step

Second mode

Improved confidence

C Leg Case StudyC Leg Case Study

Symes AmputationSymes Amputation

SymesSymes Symes Amputations have many unique

Advantages

Heel pad retention

Bulbous distal configuration Self suspension

Length advantageous Longer lever arm

Increased ability to perceive distal pp & increased SA

of Pros/residual limb contact, therefore: >proprioception

>prosthetic control

Symes Amputations have many uniqueAdvantages

Heel pad retention

Bulbous distal configuration Self suspension

Length advantageous Longer lever arm

Increased ability to perceive distal pp & increased SA

of Pros/residual limb contact, therefore: >proprioception

>prosthetic control

SymesSymes

Thank you!!Thank you!!

RESIDUAL LIMBSKIN CONDITIONS

Skin Problems of the Amputee Page 56

UlcerationUlcerationSkin Problems of the Amputee, Page 56

Click picture for additional photos

Keloid ScarringKeloid Scarring

UlcerationUlceration

Delayed Wound HealingDelayed Wound Healing

Choking of Residual LimbChoking of Residual Limb

Skin Problems of the Amputee, Page 149

HemorrhageHemorrhage

Click title to return to slide show

Contact DermatitisContact Dermatitis

Stasis DermatitisStasis Dermatitis

Verrucose HyperplasiaVerrucose Hyperplasia

Click title to return to slide show

Distal Bursa with Chronic InfectionDistal Bursa with Chronic Infection

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