Transcript Lower Limb Amputation Surgery and Rehabilitation (Lessons

Consensus conference on amputation sx in Scotland in Oct 1990
 ’92- Rungsted, Denmark
 ’92- Groningen, The Netherlands
 ’93- Moshi, Tanzania
 ’94- Pattaya, Thailand
 ’94- Ljubljana, Slovenia
 ’94- Panama City, Panama
 ’96- Madras, India
 ’97- Jaipur, India
 ’97- Helsinborg, Sweden
 ’98- Hanoi, Vietnam
 ’98- Tokyo, Japan
 ’99- San Salvador, El Salvador
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2004- course given new content and a
new name: Amputation surgery and
related prosthetics
 2009- first time the new course was given
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Course Outline:
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1
› History
› Epidemiology
› Pre-op Mx
› Decision making process in Sx
› Post-op Mx
› Prediction of functional outcome
› Sexuality and amputation
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2
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Skin problems
Physiotherapy
Phantom pain and pain mx
Psych aspects
Sports after amputation
Liners
CAD-CAM
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Continuation of 2
› Hip disarticulation & hemipelvectomy
 Epidemiology and Sx
 Rehabilitation
 Biomechanics
 Prosthetics
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3
› Transfemoral amputation
 Epidemiology and Sx
 Rehabilitation
 Biomechanics and gait
 Prosthetics
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Continuation of 3
› Transtibial amputation
 Epidemiology and Sx
 Rehabilitation
 Biomechanics and gait
 Prosthetics
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4
› Foot and ankle amputations
 Epidemiology and Sx
 Rehabilitation
 Biomechanics and gait
 Prosthetics
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Continuation of 4
› Diabetic foot
 Epidemiology
 Physical examination
 Treatment of foot infections
 Rehabilitation
 Casting
 Orthotics
 Ortho reconstructive sx
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Surgeons:
› Douglas Smith (USA)
› Takaaki Chin (Jpn)
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Rehab physicians:
› Dirk van Kuppevelt (The Netherlands)
› Jan Geertzen (The Netherlands)
› Carolina Schiappacasse (Argentina)
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P&Os:
› Donald Cummings (USA)
› Siegmar Blumentritt (Germany)
Official name given by the ISO
Previous used names
Partial foot amputation
Chopart amputation
Lisfranc amputation
Ankle disarticulation
Syme amputation
Pirogoff amputation
Through ankle disarticulation
Trans-tibial amputation
Below-knee amputation
Knee disarticulation
Through knee amputation
Trans-femoral amputation
Above-knee amputation
Hip disarticulation
Through-hip amputation
Trans-pelvic amputation
Hemipelvectomy
Hindquarter amputation
Sacroiliac amputation
“It is not to take but to make.”
 Early rehab involvement!
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› Although same problem everywhere, not
happening or inconsistency in engaging
rehab pre-op
Peri-op mortality in LLA is high
 MI is the most common cause of post-op
mortality
 Cardiac function is relevant during rehab
because of required increased energy
expenditure
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Obj: to determine pre-op ventricular
function in vascular amps by measuring NTproBNP and to analyse the relationship b/w
NT-proBNP and 30-day post-op mortality
 Prospective pilot study
 19 pxs; four died w/in 30 days after sx
 In 17 of 19, levels were found to be more
than 2 SDs above age-corrected reference
values
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Clinical messages:
 Pre-op NT-proBNP levels in vascular
amputees are not statistically related to
30-day mortality and level of amputation
 Pre-op NT-proBNP levels in vascular
amputees are high, indicating that
serious ventricular disease may be
present.
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“Soft tissue is more important than
bone.”
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http://www.ampsurg.org
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Lack of research
After thorough publication database
search: only 11 eligible studies found
Amputees remain to be sexual beings
Sexual activities are hindered in different
ways, related to type, level, and cause of
amp’n
Effects of pain and body image on libido
Erectile dysfunction; decreased lubrication
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Higher impact on sexual functioning in
the elderly compared to younger
amputees
› ?effect of age vs amputation
Being married or having a steady partner
as an amputee give fewer problems
than being single
 13-75% are not satisfied with their sexual
life, despite unchanged interest in sex
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Conclusion
 Assessment of sexual functioning should
be an integral component of the
periodic evaluation scheme in the
Rehab team.
 One or more members of the Team
should be trained for that assessment.
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Wrong concept:
› Rehab only starts after the stump has healed
completely
Consider x-ray of stump
 trial antiperspirant spray or roller for
problematic sweaty stumps?
 May need less wash (q2-3 days) of
stumps during colder months?
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General principle:
“The liner has to be as thin as possible and
as thick as necessary.”
Selection should be based on individual
circumstances.
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Historical love/ hate relationship
 First described in literature in 1830
 Very little data
 Most national surveys: 1-3 % of all
amputations
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Dr Douglas Smith’s experience
› 12 year data base (1995-2008)
› 1787 total amputation procedures
 950 primary
 827 secondary
› 62 knee disarticulation (3.5%)
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Trauma= 27 pxs
Infection= 11 pxs
Vascular dse= 10 pxs
SCI= 4 pxs
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80 KDs in 77 pxs
Aged b/w 19-92 (average of 64)
31 DM; 29 PVD; 14 trauma; 2 sarcoma; 1
Ollies Dse
5 pxs died early in post-op pd
63 of 67 healed primarily; 7 dehisced and
revised to TF level
22 of 27 who walked pre-op successfully,
used a prosthesis and walked post-op
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Non-ambulatory pxs have different
concerns and goals than ambulatory
pxs.
› How will the px transfer?
› What contractures are present?
› What contractures will occur?
› Consider surface area and support for sitting.
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For ambulatory pxs, KD is usually more
functional than a TFA
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Longer lever arm
Balanced thigh muscles
Improved suspension
End bearing
Lower proximal socket brim
Sitting comfort
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Walking velocity (Pinzur, et al, Ortho, 1992 Sep)
› Slightly lower than TTAs, but significantly faster than TFAs
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Function (Hagberg, et al, PO Int 1992 Dec)
TTA
TKA
TFA
Don and doff
100%
70%
56%
Daily use
96%
76%
50%
>9hrs/day
54%
41%
22%
6-9hrs/day
17%
11%
6%
3-6hrs/day
13%
24%
28%
<3hrs/day
13%
12%
28%
No use
4%
12%
39%
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Consider C-knee in the elderly
population!
› Provides better gait
› Improved stability
› Improved walking speed
› Less falls
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Hip flexion contracture
› 1st year: try to stretch to correct or lessen
degree of contracture
› After 1 year: provide prosthesis which will
accommodate to contracture
 Not cosmetic- but more functional
Who/When to prescribe a Prosthesis?
 TTA:
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› Patient has their own knee power
› Prosthesis helps w/ transfer
› Prosthesis helps with STS
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TFA:
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Patient has no knee power
Prosthesis has no knee power
Transfers- often easier without prosthesis
STS- prosthesis makes it more challenging
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Before a TF Prosthesis is prescribed,
patient must master the following vital
skills: (UW guidelines)
› Transfer independently (both in/out of bed,
on/off toilet)
› STS independently
› Walk in parallel bars or walker (one leg gait),
for at least 6-8 meters
Explain the vital skills and importance
 Offer prosthesis when patient masters
skills
 Places challenge on patient and family
 Avoids arguments!
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A multidisciplinary Foot
Clinic
 In developed
countries:
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› Up to 4% of people w/
DM have a foot ulcer
› Uses 12-15% of
healthcare resources
for DM
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Multidisciplinary foot
team has been shown
to bring 49-85%
reduction in
amputation rates
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Minimal model
› Doctor
› Podiatrist and/or
nurse
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Intermediate
› Doctor (diabetes
specialist, surgeon,
rehab)
› Podiatrist and/or
nurse
› orthotist
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Highly
recommended
› Relevant
› Comprehensive,
but not too
overwhelming
› Balanced and wellrespected speakers
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A Sydney venue in
the future?!
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We are Coaches!
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We must create enthusiasm!
› Positive approach to Surgery
› Positive approach to early rehabilitation
› Positive approach to prosthetics