List factors affecting level of amputations
- vascular disease
- postop function is considered
- disarticulations
- traumatic amputation
what are general surgical principles for amputations?
save as much limb length as possible
large nerves are pulled down and resected sharply so that they retract into soft tissue and prevent formation of neuromas
what is a myoplasty?
surgical tech in which attachment of A/P compartment muscles to each other over the end of bone
better in the presence of ischemia
what is a myodesis?
surgical technique in which anchoring of muscles to bone
allows for increased stability and muscular control
when are open amputations utilized?
if infection is present or not enough tissue to provide good closure initially
what are the types of skin flaps used during a closed amputation?
- equal length A/P flap
- used when conserving bone length or when primary healing is not a concern
- flaps shaped to reduce “dog ears” at corners
- long posterior flap
- used when vascularity is of concern or when more padding is needed
- skew sagittal flaps
- used in severe dysvascular case
how is a skew sagittal flap performed??
- takes advantage of saphenous nerve, artery and sural nerve
- removes anterior placement of scar from high prosthetic pressures
- helps with blood flow laterally
why is a longer residual limb more functional?
longer limb = longer level arm = more functional gait
Describe a transtibial amputation including it’s pros/cons
amputation is behind the knee, allows for a longer length and smoother gait. Disadvantages is that some argue that the longer bone length increases the chance for development of distal skin problems.
- Tibial and fibula are beveled to prevent soft tissue impingement
- Generally, the fibula is cut 1 cm shorter than tibia
- Knee flexion contracture can occur
describe a transfemoral amputation including it’s pros/cons
amputation is above the knee. Most common level for individuals with poor circulation or gangrene of foot/ankle
- Allow for greater circulation above the knee
- Much harder time with gait. Attempt to maintain as much femoral length as possible.
- Hip adductor roll, flexor contracture, abductor contracture, and glute weakness can all occur.
what is heterotrophic ossification?
overgrowth of bone
define osseointegration
direct structural and functional connection between the surface of implants and living bone tissue percutaneously connected to a prosthetic limb
what is the difference between phantom sensation and pain?
sensation - sensation that the absent limb is still there in some form
pain - cramping or squeezing sensation, shooting pain or burning pain.
Why/how does the length of the femur determine likelihood of a hip abduction contracture?
The shorter the femur the less room there is for attachments of the adductor muscles meaning there is no opposing force to hip abductors resulting in a hip abduction contracture.
list the pros of osseointegration?
- Eliminates the need for the socket
- Short residual limb
- More natural feeling
- Improved gait
- Allows for normal swelling
what are the cons of osseointegration?
- Multiple surgeries
- Prolonged period of no ambulation
- Risk of fracture, infection
- Reduction in activities that require high torque or axial stress
- Not well known in the USA
List the pros of disarticulation surgery/amputation?
- Knee disarticulations provide a longer lever arm, remove knee flexion contractions as a concern
- Hip disarticulations remove the possibility of contractures at the hip (abductors and flexors)
- Ankle disarticulations can still be very functional
List the cons of disarticulation surgery/amputations
- Knee disarticulations make it difficult to fit a prosthetic around the remaining lightbulb type structure
- Ankle disarticulations prevent movements between heel pad and bone which can result in pain and an ineffective prosthetic fit.
when are hip disarticulation surgies/amputations appropriate?
usually performed to save the life of a patient in the presence of a malignancy, severe infection/gangrene or severe trauma
when are knee disarticulation surgeries/amputation appropriate?
indicated when there is:
- an inability to provide adequate transtibial residual limb secondary to trauma
- if there is a strong knee flexion contracture >45 degrees,
- infection of soft tissue close to knee
- with some congenital deformities
when are ankle disarticulation surgeries/amputations appropraite?
used for severe foot trauma, congenital abnormalities, or gangrene of forefoot. Must have circulation to heel pad to be successful
List some common impairments that would be expected following any LE amputation surgery
- Ambulation difficulties
- Infection risk
- Pain
- Contractures
What are some factors that determine psychological adjustment following amputation surgery?
- Premorbid coping mechanisms
- Also dependent on:
- Amputee experience: comfort, cosmesis, vocational, social
- Amputee behavior: are they using the part?
- Amputee psychodynamics: perception of disability, ego, frustration
What are examples of negative coping mechanisms displayed by amputees following surgery?
- Denial
- Being overly optimistic and not taking time to process
- Insomnia, restlessness and difficulty concentration
