1
Q
Most common causes of amputation
A
- Peripheral Vascular Disease (54%)
- Trauma (45%)
- Malignany (<1%)
- Congenital limb deficiency (<1%)
2
Q
People with DM2 are ____x more likely to have an amputation
A
10
3
Q
Consequences of Type 2 DM
A
- PVD
- Peripheral neuropathy - insensate
- Non-healing neuropathic ulcers
4
Q
3 most common predisposing factors for LE amputation
A
- DM2 w/HTN (10x+ risk)
- DM2 w/o HTN
- HTN w/o DM2
5
Q
Most at risk ethnicity for amputation
A
- Native Americans
Likely due to lack of access to healthcare
6
Q
Most individuals who have an amputation from trauma are due to
A
- MVA
- Accidents with machines
- war
- GSW (Gunshot wounds)
7
Q
Most individuals who have a trauma amputation are very ____ and active prior to amputation.
A
healthy
8
Q
What is a more common trauma amputation for civilians? UE or LE?
A
UE
9
Q
____ is a more common amputation for military than civilans
A
LE
10
Q
What type of malignancy often results in amputation?
A
- Osteogenic Sarcoma (Tumors in the muscles, tissue and bone)
- Adolescence/young adults
- Femur, tibia and humerus account for 85% of cases
11
Q
What is more common for people with Osteogenic Sarcoma: Amputation or limb salavage technique?
A
- Limb Salvage Technique (plus chemotherapy)
- Survival rate for this condition is low
12
Q
What is a congenital limb deficiency? Why does it require amputation?
A
- Genetic variation due to environmental exposure to teratogens (hot tubs)
- Most commonly seen in the UE
13
Q
Types of Congenital Limb Deficiency
A
- Transverse Amelia: Complete loss of limb (Ex: Arm or Leg)
- Transverse Hemimelia: Loss of limb below level of next joint (Ex: Keep humerus, lose elbow distal; Keep Tibia, lose knee distal
- Paraxial Terminal: Complete loss of one bone in a region (Ex: Have fibula, not tibia)
- Paraxial Intercalary: Portion of a bone is absent
14
Q
How is the level of amputation determined?
A
Goals:
* Maintain greatest bone length and save all possible joints while providing adequate soft tissue coverage
* Produce a comfortable and functional residual limb (RL)
15
Q
Levels of Amputation: Transmetatarsal
A
Amputation through the midsection of all metatarsals
16
Q
LOA: Transtibial
How many types?
A
- Below Knee
- 3 (Long Trans, Trans, Short Trans)
17
Q
For people who have the big toe amputated, what deficits will you see?
A
- Balance and gair training needed.
- Most common compensation is short step length on the left if right amputation
18
Q
Ankle Disarticulation
A
- Also called Symes
- Amputation through the ankle joint
- Foot removes, heel pad preserved and placed on the bottom to help with weight bearing
Goal:
* Remove diseased tissues or non-usable foot
* Create functional painless limb
19
Q
Transtibial Amputation
A
- “below-knee amputation”
- Superior tibiofibular joint preserved (distally gone)
- Preservation of knee joint
- Amputations distal to the lower thrid of the leg are avoided due to lack of soft tissue (think of gastrocnemius muscle belly)
20
Q
Knee Disarticulation
A
- Also known as “through knee amputation”
- Directly at the knee joint, leaving femur and patella intact
- No dissection of bone or muscle
- Quadriceps muscle preserved
- Stump permits total end bearing and easy/firm attachment of the prothesis
- Weight Bearing for Bilateral
21
Q
Anyone who can weight bear with an amputation can only weight bear for ____
A
Short Distances
22
Q
Rotationalplasty
A
- Van Nes Procedure
- Portion of the leg is removed, the remaining lower leg is rotated and reattached.
- Converts knee into hip and the ankle into knee
- Hip is stable as the femur is fused to the pelvis
- Dorsiflexion is now bending knee, Plantarflexion is now extending knee
- Most commonly seen with Ewing’s Sarcooma or osteosarcoma in children
23
Q
Transfemoral Amputation
A
- “Above knee amputation”
- Amputation of the femur of some length
- Presevation of the distal 1/3 of adductor magnus preserved for biomechanical alignment.
- The longer this is, the less energy expenditure needed
24
Q
What amputation uses the most energy expenditure?
A
- Transfemoral (65% increase)
- This is more than Bilateral Transtibial
25
Hip Disarticulation
* Removal of the **entire lower limb** by transection through the hip joint
Indications:
* * Malignant tumor of bone/soft tissue of the thigh, hip or pelvis
* Extensive trauma
* Uncontrolled infections
* Congenital limb anomaly (rare)
26
Hemipelvectomy
* "transpelvic amputation"
* Amputation of the affected bone of the hip and the ipsilateral extremity
* Rarest form of LE amputations
* Indications: Malignant tumor/sarcome or trauma
27
Factors Affecting Selection of Amputation level:
* Conservation of RL length
* **Uncomplicated wound healing**
* Creation of a **pain free limb** that can be fitted with a prosthesis that maximizes the individual's functional mobility
28
Types of skin graft types for amputation surgery
* Equal length skin flap
* Long posterior flap
* Skew flap
29
Equal length skin graft
* Anterior and posterior flaps equal length; incision is in the middle at the base of the amputation
* Disadvantage: location of scar and pressure do not mix well
30
Long posterior flap
* Fold the posterior muscle tissue anterior; scar in front
* Advantage: Full weight is not directly sitting on the scar and posterior muscles is thicker and has better blood supply
31
Skew Flap
* Angular medial-lateral incision
* Scar placed away from bony prominences
* Rarely seen
32
What amputation skin graft type is best?
* Research hasn't been conducted so we can't saw but in theory long posterior flap is best
* Largely based on what the surgeon wants and what the tissue allows.
33
What is special about the surtures being taken out for amputes?
* When removing sutures, 1 out of 3 is removed every few days. This allows for them to stress the tissue and see how it responds.
* Removal of all sutures could lead to many issues with wound healing if done improperly.
34
What are some types of reassemably of the amputation area?
* Myofascial closure (Muscle to fascia; TTA and TFA)
* Myoplasty (Muscle to muscle; TTA and TFA)
* Myodesis (Muscle attaches to periosteum or bone
* Tenodesis (Tendon attached to bone)
35
What reassembly is best?
* **Myodesis**: Stable, contracts and relaxes without effecting other structures. **The best!**
Other and why not these?
* Myofascial: Everytime a muscle contract it moves fascia, not very stable
* Myoplasty: dual opposing contractions of muscle, slightly more stable. Not ideal.
* Tenodesis: 2nd most stable, LONG healing times
36
Nerve Care
* Nerve must be surrounded by soft tissue
* Pulled under tension and then cut to allow it to retract back into soft tissue; helps prevent neuroma (nerve irritated because too close to the base)
37
Bone Care
* Sectioned at length to allow wound closure
* Bone end is smoothed/rounded (w/o stripping periosteum)
* Ertle/Osteoplasty: cut fibula shorter than tibia to decrease pressure; bone is then place between tibia and fibula and fused.
38
Alternative amputation technique - Osteointegration
* Prothesis surgically conencted into residual bone
* Fixture placed in the center of the bone and secured
* Benefit: Elimination of socket residual limb fit and improved sensory feedback (proprioception)
* Problems: High risk of infection at site of metal at bone and high facture rates in long bone when running and jumping.
39
Surgical consideration for the PT
* Type of flap (How does this effect WB)
* Type of Closure (How does this effect muscle function; Certain stabilizations have protocols)
* Bone and nerve care during and after surgery
40
What amputations are allowed to remain open?
* Dirty wounds!
* Can't close until clean and ensure no infection
41
____ weeks post-amputation is the average time to posthetic
12
