Wk 2- LE Amputation Sx & Post-Op Care
What factors that are associated with poorer outcomes should be assessed with acquired limb loss?
- smoking - comorbid injuries or illnesses - psychosocial functioning - pain
Of the Burgess and the Ertl procedure, which is better?
- still awaiting more info in this HOWEVER - anytime you put bone where it doesn't belong you run the risk of more complications
What are the cons of the Ertl procedure?
- technically more complex procedure, increased operative time, implant related complications (non-union, dislocation, etc.)
The perception of feeling the distal end of limb & not the mid portion is known as?
- telescoping
When attaching tendon to bone, it is called?
- tenodesis
What is the consensus on optimal duration, frequency & total duration of mirror therapy treatment?
- there is a LACK of consensus
In the study by Van de Meent, what was seen of osteointegration users in the 6MWT?
- they ambulated further as evidenced by the 6MWT
Do open or closed chain exercises w/ PRE help improve gait, mobility, strength, cardiovascular fitness and ADL performance to help maximize function?
- trick question, BOTH OPEN & CLOSED CHAIN EXERCISE SUPPORT IT
What should be included in history taking during postsurgical examination?
- type and level of amputation - status of RL - OOB status - review orders
List the non- predictive risk factors of LE amputation in diabetics:
- type of diabetes - cigarette smoking - total cholesterol
What would be considered a cylindrical shaped RL?
- uniform in shape all the way down
When looking at amputation levels, what are some of the surgical considerations?
- viability of tissue: having tissue that is going to provide & thrive post-op - nature of injury: vascular vs. traumatic vs cancer --> changes prognosis & how much limb can be spared - post-op function: RL length = IMPORTANT, ex: a shorter limb is harder to secure a prosthetic to
What should be included in systems review during postsurgical examination?
- vital signs (pre & post activity) - cardiovascular (i.e. pulses/ edema) - respiratory - integumentary (i.e. skin integrity/ intact limb) - neuromm (i.e. sensation)
What would be considered a conical shaped RL?
- wider at the top and smaller at the bottom
When does phantom limb sensation usually resolve?
- within 2-3 yrs of amputation
What would be considered a bulbous shaped RL?
- smaller at the top and wider at the bottom
Where should girth measurements be taken with transfemoral amputation?
- ischial tuberosity, GT, or origin of adductor longus - then every 3-4 inches distally
List the independent predictors of LE amputation in diabetics:
- level of glucose control - duration of diabetes - baseline systolic BP - microvascular changes (retinopathy, neuropathy & nephropathy) - h/o stroke
What is the Burgess procedure?
- long posterior flap that overlaps the distal RL
In terms of promoting healing of residual limb, what should be done to attain this goal?
- manage RL pain/phantom limb pain and sensation - optimize UE/LE ROM w/o compromising healing - optimize UE/LE strength w/o compromising healing
Where should girth measurements be taken with transtibial amputation?
- medial joint line and then every 2-3 inches distally
Where should length measurements be taken with transtibial amputation?
- medial joint line to the end of bone/ end of ST
When anchoring muscle to bone, it is called?
- myodesis
What are the general preprosthetic phase goals?
- (I) in RL care - (I) in mobility, transfers, & functional activities - perform HEP - management of uninvolved LE - demonstrate cardiorespiratory endurance necessary for prosthetic use
Describe the level of the following amputation: short transtibial
- < 20% of tibia length
Describe the level of the following amputation: short transfemoral
- < 30% femoral length
Describe the level of the following amputation: long transfemoral
- > 60% femoral length
Describe the level of the following amputation: long transtibial
- >50% of tibia length
Patient education is important in what population?
- DIABETICS - 60% of non-traumatic amputations occur in individuals >20yrs w/ diabetes - 90% of diabetics who underwent an amputation had a pre-existing foot ulcer
List some preprosthetic phase interventions:
- RL management (RL wrapping vs. shrinking) - skin care - ROM exercises - strengthening exercises - balance/mobility activities - cardiopulmonary endurance exercises - pain management - psychological support
What should be included in tests and measures during postsurgical examination?
- ROM - gross functional mm performance of intact extremities - balance (seated/ standing) - functional status
In the study by Van de Meent, what was seen of osteointegration users in terms of TUG scores?
- TUG values improved by 44%
What is the difference b/t virtual reality (VR) and augmented reality (AR)?
- VR: artificial, immersive environment experienced through a head set - AR: virtual enhancements layered on a real-world video feed
Is there a strong level of evidence to support that pt's birth sex & self-identified gender identity should be considered in developing an individualized tx plan?
- YES
Are positive effects shown for the use of TENS for pain management?
- YES, however poor quality of evidence
Are positive effects shown for the use of acupuncture for pain management?
- YES, however poor quality of evidence
Are positive effects shown for the use of motor imagery for pain management?
- YES, however poor quality of evidence
Are positive effects shown for the use of virtual reality for pain management?
- YES, however poor quality of evidence for VR & AR
Describe the level of the following amputation: hemicorporectomy
- amputation of both lower limbs & pelvis below L4-5
Describe the level of the following amputation: hip disarticulation
- amputation thorough the hip w/ pelvis intact
Describe the level of the following amputation: knee disarticulation
- amputation through knee joint
Describe the level of the following amputation: transmetatarsal
- amputation through the midsection of all metatarsals
Describe the level of the following amputation: Syme's ankle disarticulation
- ankle disarticulation w/ attachment of heel pad to distal end of tibia
Describe the level of the following amputation: transtibial
- b/t 20 and 50% of tibia length
Describe the level of the following amputation: transfemoral
- b/t 30 and 60% of femoral length
What are the advantages of semirigid dressings?
- better edema management (than soft dressing) - residual limb protection
What is the Ertl procedure?
- bone bridge - take left over bone & create a bridge for WBing
Give some examples of desensitization techniques:
- brushing skin - tapping - rubbing - applying lotion
What should be included in systems review during preprosthetic examination?
- cardiopulmonary (vitals) - integumentary - lesions/skin conditions/ trophic changes - grafts - dermatological conditions - neuromm (mental status, pain, sensation, coordination, balance - vascular ( pulses, color, temp, edema, intermittent claudication - Msk ( ROM & RL limb measurements) - strength & endurance
What are the disadvantages of elastic wraps?
- difficult to don properly (may produce areas of high pressure) - minimal limb protection - requires reapplication (frequent rewrapping) - increased likelihood of knee flexion contractions (w/ transtibial amputation)
Describe the level of the following amputation: toe disarticulation
- disarticulation at the metatarsal phalangeal joint
In a transtibial amputation, what is the typical end state of the distal bones?
- distal ends are beveled for comfort - fibula ~1 cm shorter than tibia
With edema management during post-op care, should it take place until RL is fully matured or prosthetic is available?
- don ace wrap, shrinker or rigid dressing until maturation of RL or prosthetic is ready
What are the advantages of shrinkers?
- easy to apply (particularly for transfemoral level) - effective edema management (w/ even pressure)
What are the advantages of removable rigid dressings?
- effective edema management - residual limb protection - access to incision
What are the two possible types of skin flaps/incisions for a transtibial amputation?
- equal length AP flaps (equal length on both sides) - long posterior flap (increased padding/ improved vascularity) - more common for final suture to be on anterior part of residual limb
What are the two possible types of skin flaps for a transfemoral amputation?
- equal length flaps - long medial flap (sagittal plane)
What are the advantages of immediate post-op prosthesis (IPOP)?
- excellent edema management - excellent residual limb protection - control of RL pain - decreased time to fitting w/ prosthesis
Describe the level of the following amputation: partial toe
- excision of any part of one or more toes
What would be considered dog ear abnormalities on RL?
- flaps on either side of incision on RL
In terms of being (I) in transfers & bed mobility, what should be done to attain this goal?
- functional sitting/ standing balance - initiate upright mobility - walker vs crutches
What are the more common types of contractures s/p LE amputation?
- hip flexion contracture - hip abduction contracture - hip ER contracture
A myodesis of which muscle to which bone typically happens in a transfemoral amputation?
- myodesis of the adductor magnus to the femur - attachment of the major adductor mm are lost in amputations at the transfemoral level - may impact femoral alignment - myodesis of the quads w/ the hamstring tendons attached to either the adductor magnus or quads
When muscles is attached to fascia, it is called?
- myofascial
When anterior & posterior compartment muscles are attached over the end of the bone, it is called?
- myoplasty
What are the disadvantages of immediate post-op prosthesis (IPOP)
- no incisional access - more expensive (than other dressings) - requires proper training to use - requires skilled practitioner for frequent reapplications or frequent fittings - pts must carefully adhere to all procedures
Was there adequate evidence to recommend mirror therapy for first-intention treatment?
- no, there was INadequate evidence
In terms of skin care, what types of lotions should you suggest to those with amputations?
- non-alcohol based - hypoallergenic - fragrance-free
What are the disadvantages of shrinkers?
- not used until sutures are removed - requires changes as limb shrinks - expensive to replace - increased likelihood of knee flexion contracture ( w/ transtibial amputation)
List some peak aerobic capacity tests:
- one-legged cycle - UE ergometry - treadmill training w/ & without BWS
Direct attachment of a prosthesis to the body via an implant in the amputated bone is known as?
- osteointegration - may require more than one surgery - extensive recovery time (WB does not typically begin until 6 wks post - infection control is problem
Does a prosthetic socket or osteointegration require less energy?
- osteointegration required less energy (18% less) as measures via O2 consumption during preferred walking speed
Do osteointegration or socket prosthetic users have improvement in QOL rating scores?
- osteointegration users
Why is appropriately prescribed aerobic exercises important?
- peak aerobic capacity is an important factor in walking ability - consider target HR, duration and frequency
In terms of friction scar massage, when should it be performed?
- performed ONLY on fully healed wounds
The perception that the part of the limb that has been amputated is still present is known as?
- phantom limb sensation
Is there strong or poor evidence of efficacy of mirror therapy for phantom limb pain?
- poor evidence
List some postsurgical phase interventions:
- positioning/ AROM of RL (RL resistive exercises contraindicated) - functional training ( instruct on techniques to protect the RL and minimize pressure/ drag) - standing/ seated balance - ambulation training - exercises for intact extremities - maintain ROM/ strength/ cardioresp endurance - limb care (intact & RL)
The time period b/t surgery and D/C from an acute care hospital can be defined as what?
- postsurgical phase
The time period b/t D/C from an acute care hospital & fitting of a definitive prostheses or decision that the individual is not a candidate for a prostheses can be defined as what?
- preprosthetic phase
What are the main postsurgical phase goals?
- promote healing of RL - protect remaining limb - (I) in transfers & bed mobility - demonstrate proper positioning to avoid contractures
What should be included in pt education during postsurgical phase?
- proper bandaging/ post-op dressing use - discuss continuum of care - caregiver training - potential referral for assessment of behavioral health/ psychosocial functioning - D/C planning
In terms of protecting remaining limb, what should be done to attain this goal?
- proper footwear/foot care - frequent skin checks - HEP for general strengthening/stretching
What are the pros of the Ertl procedure?
- proposed to provide a more stable base for prosthetic WBing resulting in better limb health & prosthetic fit
In the study by Van de Meent, did osteointegration or socket prosthetic users have increased use of their prosthesis?
- prosthetic use increased from 56 hrs to 101 hrs/wk in osteointegration
Where should length measurements be taken with transfemoral amputation?
- proximal landmark to end of bone/ end of ST
What should be included in history taking during preprosthetic examination?
- psychological/ emotional status - amputation hx - associated disease/ co-morbidities
In a transfemoral amputation, a myoplasty of which two muscles is typical?
- quadriceps & hamstrings
What are the advantages of elastic wraps?
- readily available/ accessible - inexpensive - allows access to incision
How often is phantom limb pain reported in amputees?
- reported in about 80% of those with amputations
What are the disadvantages of semirigid dressings?
- requires frequent changing (no access to incision) - unable to be donned by the pt
What are the disadvantages of removable rigid dressings?
- requires skilled clinician to fabricate - more expensive
Describe the level of the following amputation: transpelvectomy or hemipelvectomy
- resection of part of the pelvis
Describe the level of the following amputation: partial foot/ray resection
- resection of the 3rd, 4th or 5th metatarsals & digits (ray= metatarsal + associated phalanges)
What are the 4 principles of amputation surgery?
1) limb length 2) management of potentially painful neuromas 3) management of severed mms 4) incisions (management of skin flaps/ RL shape)
List the four main goals of post-op dressings:
1) protect incision/ RL 2) facilitate healing of incision 3) manage post-op edema/ swelling 4) manage post-op pain
What are the top three primary causes are of limb loss?
1) vascular disease (54%; includes Diabetes & PAD) - half of those w/ an amputation due to vascular disease will die w/in 5 yrs. - of those w/ diabetes & a lower limb amputation, 55% will require amputation of the second leg w/in 2-3 yrs 2) trauma (45%) 3) CA (< 2%)
T/F: Prosthetic users have a higher energy cost of walking, walker slower, at less efficient speeds resulting in poorer walking endurance compared to non-prosthetic users.
TRUE