O And P - 2 - Prosthetics Basics Hx Etc 2010

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History

Earliest amputations performed prior to antiseptics and anesthesia
Earliest record was 484 BC—Persian soldier cut off his foot to escape imprisonment
15th century prostheses made of iron
Tourniquet introduced in 1674
1846—first amputation under general anesthesia

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1867—Joseph Lister introduced antiseptic surgery
Most prosthetic advancements occurred after a war
J.E. Hanger lost leg in civil war; started J. E. Hanger Co.
After WW II, research initiated at request of Surgeon General of Army

1949 ___ (suture muscle to muscle to get it to contract, use again)introduced

1960’s ___ (suture muscle to bone) intoduced

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1949 myoplasty (suture muscle to muscle to get it to contract, use again) introduced

1960’s myodesis (suture muscle to bone) introduced

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1958 --Immediate post op fitting – still happens today
1954—Canadian hip disarticulation prosthesis
1956—SACH foot (solid ankle cushioned heel)
1959—PTB (patellar tendon bearing) prosthesis for below knee amputation (trans tibial)
1971—Endoskeletal (the pylon) prosthesis – allows to put foam covering, wear it without it looking like a leg
2000—Microprocessor controlled knee, computer in the knee, allows more normal looking gait

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Causes of Amputation

Poor circulation, accident, burns, trauma, cancer

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DEMOGRAPHICS
Statistics vary-depend on source
According to the National Limb Loss Information Center (NLLIC) 2008

Lower Extremity Amputations in US:
Transfemoral (above knee) 36,478
Transtibial (below knee) 39,479

Reason for Amputation (Gailey)
___ 70% (circulation #1 cause – diabetes included)
Trauma 22% (will increase with Iraq war)
Congenital 4%
Tumor/cancer 4%

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Dysvascular 70% (circulation #1 cause – diabetes included)

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Incidence of Amputation in Persons over 60 years of age

___ Disease 90% (diabetes also)
Trauma 7%
Tumor 2.5%
Congenital 0.5%

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Vascular Disease 90% (diabetes also)

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Amputation and Gender

Males 75%
Females 25%

Males:Females
Trauma = 9:1
Disease = 3:1
Tumor = 1:1
Congenital = 1:1

Male, over 60, with vascular disease = “typical” amputee

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Cause --LE vs UE Percents

Dysvascular
97% ___ and 3% UE

Congenital (born with no arm)
41.5% LE and 58.5% UE

Trauma
31% LE and 68.6% __

Cancer
76.1% LE and 23.9 UE

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Dysvascular
97% LE and 3% UE

Trauma
31% LE and 68.6% UE

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Factors Influencing the Metabolic Cost of Walking

1. ___ of the residual limb:
Between levels of amputation
Within levels of amputation

2. ___ of amputation:
Traumatic vs. vascular

3. ___:
Linear regardless of disability

Car accident, above the knee amputee. If short residual limb, harder to walk, vs correct length for prosthesis. Makes a difference in amount of energy to walk. More energy to walk if lose limb to vascular vs. trauma

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1. Length of the residual limb:

2. Cause of amputation:

3. Age:

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Amputation levels

Partial foot to hemi___ (half of pelvis is gone)

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Partial foot to hemipelvectomy (half of pelvis is gone)

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Partial Foot – General:

The loss of the anterior lever arm of the foot.

The functional loss of ___ of the ankle.

The tendency of the ankle joint to become fixed in ___ (PF).

Cosmesis is poor if the prosthesis must extend above the shoe. – AFO with a filler for part of foot that is missing

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The functional loss of dorsiflexion of the ankle.

The tendency of the ankle joint to become fixed in equinus (PF).

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Partial Foot Levels:

Phalangeal/Toe(s)
Ray(s)
Transmetatarsal
Lisfranc
Chopart
Boyd/Pirogoff

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Toe Amputations

Benefits: Plantar surface weight bearing, most of foot intact. Gait unaffected at normal speeds.

Challenges: Shoe selection, excessive pressure at amputation site, shear forces at suture area

Prosthetic management: Carbon foot plate with toe filler or silicone restoration

Lose big toe – lose ability to run (push off), and decreased balance

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Ray Amputations

Benefits: Plantar surface weight bearing, most of foot intact

Challenges: Shoe selection, excessive pressure at amputation site, shear forces at suture area

Prosthetic management: Carbon foot plate with toe filler, or silicone restoration

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Transmetatarsal

Benefits: Partial plantar surface weight bearing, most of ankle structure intact

Challenges: Shoe selection, excessive pressure at distal plantar metatarsal areas, shear forces at suture area

Prosthetic management: Carbon foot plate with toe filler, or silicone restoration

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Lisfranc

Def: ___ Disarticulation

Benefits: Distal bearing, ankle joint intact

Challenges: Cosmetics of prosthesis, Height discrepancy, loss of foot levers

Prosthetic Management: Fiber foot plate with toe filler, AFO/Prosthesis, tibial tubercle level prosthesis

AFO to assist in DF

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Def: Metatarsal Disarticulation

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Cho___

Def: Calcaneo-Cuboid Talo-Navicular Disarticulation

Benefits: Distal bearing, ankle joint intact

Challenges: Cosmetics of prosthesis, Height discrepancy, loss of foot levers

Prosthetic Management: Fiber foot plate with toe filler, AFO/Prosthesis, tibial tubercle level prosthesis

AFO with the prosthesis so foot is not dragging

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Chode.

j/k, its:

Chopart

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Boyd/Pirogoff

Similar to Symes amputation however the calcaneous is cut and attached to the cut end of the distal tibia.

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Symes

Def: ___ disarticulation, malleoli are partially shaved for cosmesis; heel pad reserved and anchored to distal end of tibia & fibula

Save heel pad
Malleoli are bulky – ugly bulge, and hard to put leg in there b/c prosthesis is so long
Low foot – not as functional
Can weight bear on that heel pad, can get up and go to bathroom without putting prosthesis on

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Def: ankle/foot disarticulation, malleoli are partially shaved for cosmesis; heel pad reserved and anchored to distal end of tibia & fibula

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Symes (ankle disarticulation)

Advantages:
distal end ___ (the only type for LEs)
less traumatic surgery
self suspending
long lever arm
> surface area
< stresses

Disadvantages:
length considerations
component option limitations – the foot you are given, can’t run on it
cosmesis

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distal end bearing (the only type for LEs)

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Symes Suspension Options

Windows: either medial or posterior
Expandable bladders
Partial inserts
Supramalleolar

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Symes amputations

Bulbous end of residual limb - ugly

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Transtibial

See this a lot
Good surgery – cylindrical
Bad surgery - cone

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Transtibial:

When amputation done for other than vascular reason, flaps of equal length are used and,

when vascular, very short anterior flap and very long ___ flap.

Suture line is on top, reason is more vascularity in posterior part of your leg, so it heals better (A is vascular patient), first picture is not

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when vascular, very short anterior flap and very long posterior flap.

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Through Knee—Knee Disarticulation

Good comfort & function
Poor cosmesis
Patellar tendon sutured to remnants of cruciate ligaments
Very few muscles & no bone cut

Long thigh, hard to fit with prosthesis
Will not see this very often
Very limited in what type of artificial knee he can have

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Transfemoral

___ length anterior & posterior flaps
Nerves cut at a level to ensure they are well covered
Myoplasty and/or myodesis
End of bone is smoothed

Nerves are cut way up high, we don’t want a neuroma to happen.
Myoplasty or myodesis or both

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Equal length anterior & posterior flaps

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Hip disarticulation & hemipelvectomy

Blood loss can be problem
Symphysis pubis is divided
Anterior—above & parallel to inguinal ligament
Posterior—preserves variable portion of gluteus maximus
In hemipelvectomy, all or part of ilium is removed

Primary cause for this is ___
Think about muscle control left over – not a lot
Foam cover look like other leg

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Primary cause for this is cancer

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Common Techniques Used at all Levels

Flaps:
Decreases tension
Provides cushion
Must trim to prevent dog-ears (tissue that sticks out at a side – can make one if wrap incorrectly)

Length:
Save as much length as possible (knee and ankle disarticulation not very cosmetic)

Nerves cut high:
Prevention of ___

Myoplasty or myodesis:
Muscle stabilization, shape and function

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Nerves cut high:
Prevention of neuroma

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Terminology
Old and New

Above knee - transfemoral
Below knee - transtibial
Symes - ankle disarticulation
above elbow - transhumeral
below elbow - transradial

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Four Common Vascular Pathologies

Arteriosclerosis Obliterians:

Narrowing & occlusion of the arterial lumen of the ___ arteries

Etiology:
50 or older, males, tobacco, obesity, hypertension, hyperlipidemia, sedentary

Symptoms:
Intermittent ___ (pain with walking/exertion), decreased pedal pulses, dry skin, hair loss, clubbing toenails, ischemia, ulceration, pain relieved with standing

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Narrowing & occlusion of the arterial lumen of the large arteries

Intermittent claudication (pain with walking/exertion), decreased pedal pulses, dry skin, hair loss, clubbing toenails, ischemia, ulceration, pain relieved with standing

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Four Common Vascular Pathologies

Arteriosclerosis with Diabetes:

Narrowing of the ___ & ___ arteries—often with neuropathic changes

Etiology:
Same as arteriosclerosis obliterans (ASO), 40 and older

Symptoms:
Same as ASO plus decreased foot sensation, renal complication(diabetes), impaired vision(diabetes), decreased strength

Smoking, obesity, same has before

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Narrowing of the medium & smaller arteries—often with neuropathic changes

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Four Common Vascular Pathologies

Chronic Venus Insufficiency (CVI):

Compromised blood flow of ___ as a result of perforating valves, increased systolic blood pressure, decreased blood flow, edema and cell death

Etiology:
1% of population

Symptoms:
Edema, dilated veins, dermatitis, ulcers, pain relieved by elevation

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Compromised blood flow of superficial veins as a result of perforating valves, increased systolic blood pressure, decreased blood flow, edema and cell death

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Four Common Vascular Pathologies

Thromboangitis Obliterans (Buerger’s Disease):

Inflammation of the ___ and ___ arteries and veins of both upper & lower extremities—directly related to smoking

Etiology:
Males 20-40, tobacco users

Symptoms:
Bilateral ischemia, ulcers, phlebitis, pedal claudication, pain with rest

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Inflammation of the small and medium arteries and veins of both upper & lower extremities—directly related to smoking

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Prevention—Care for the Insensitive and Fragile Vascular Limb

Daily skin inspection
Skin cleansing
Minimize negative environmental factors
Watch skin injury due to friction/shear
Lubricants and moisturizers
Footwear and skin
Foot inspection items/methods
Foot care precautions
Never walk barefoot

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