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AMPUTATION, CAUSES, KEY, RISK FACTORS, Due to:
perforated valves
…
AMPUTATION
PROSTHETICS
- Def: the technical and medical process of creating artificial limbs and fitting them on individuals who underwent an amputation surgery
- can also be used as an adjective: Prosthetic Device
PROSTHESIS
pl: PROSTHESES
- Def: an artificial device to replace or augment a missing or impaired part of the body
PROSTHETIST
- Def: is an allied health professional specifically educated and trained to make and fit prostheses and manage comprehensive prosthetic patient care
- can be board certified after completing exams
- requires 2 year graduate degree + residency
RX VARIABLES
- Amputation Level: limb clearance
- Type of Prosthesis: post-op, temporary, preparatory, definitive
- Structure: endoskeletal, exoskeletal, frame, etc
- Socket style: diagnosistic (clear), definitive (opaque, durable)
- Interface
- Suspension System
- Components
- Foot (type, size, heel height, heel cushion durometer)
- Rotators
- Shock Absorbers
- Socks
- Sheaths
- Alignment considerations
Joint Mechanisms
-
Hip
-
- Rare
- ANT mounted (always)
- some single axis
Knee
Types
Axis
Single
-
Indication
- Single-speed walking
- only if hip control is good/better
- when MAX durability required
-
-
Disadvantages
- Fixed cadence
- low stability
- high friction
Polycentric
Description
- 3/4-bar linkage that provides more than 1x point of rotation/multiple articulations
- uses principles of geometry to create motion/stability
- Oblique/parallel = open/closes joint
- oblique: stable
- Parallel: swing
- mechanically complex: provides changing instantaneous center of rotation btwn prosthetic thigh and shank, depending on relative amount of FLX/EXT of these components
- can have stance FLX -- changes gait/balance training
- osteokinematics simulated (roll/glides): most similar to anatomic knee/not just hinge
Advantages
- varying mechanical stability through gait cycle (stable w/o disrupting swing phase)
- enhanced stability during heel strike
- decreased stability at toe-off = easier initiation of swing (improves foot clearance)
- inherent shortening of shank during FLX = dont have to bend knee as much
- ability to ROT shank under knee during sitting = enhances sitting cosmesis for long RLs (Special design)
-
FXN
- positive stability
- ease of FLX for swing phase
- special design available that provides sitting cosmesis for long residual limbs
Indication
- enhance knee stability
- special design for knee disarticulation - shorten limb during swing
Disadvantage
- increased weight maintenance and intial cost
Locking
Weight Activated Locking
-
-
Description
- when wt applied --> braking mechanism mechanically prevents the knee from flexing or buckling
- amount of wt required to engage brake can be adjusted depending on:
- pt wt
- activity level
- stance-control needs
- braking mechanism effective to: MAX ROM 15-20deg of FLX
FXN
- incr weight-bearing stability
- Adv: prevent rapid FLX/buckling (SLS: MSt/TSt) = improves knee stability
- mechanical design/hydrolics adds resistance to prevent bending too fast
- to descend/FLX = ride the resistance
- helps with:
-
Indication
- general debility
- poor hip control
Disadvantage
- delayed swing phase
- must unload fully to FLX (i.e. sit) bc wt activated
Manual Locking
-
Description
- clear string with component that attach to socket proximally
- Key = to determining a manual lock
- locks knee: stable for standing
FXN
- automatically locks in EXT
- most stable during stance
- lack of knee FLX during swing phase = increased energy expenditure and gait deviations
- unlocks by voluntary action
- ambulation with lock disengaged = possible
- knee of last resort
Indications
- weak, unstable, debilitated amputees
- amputees in unstable situations (uneven terrain/unstable surfaces)
- ultimate knee stability
-
Disadvantages
- abnormal gait
- awkward sitting
Electronic
Power Knee
FXN
- locks in stance: stability in standing on level/unlevel surfaces
- powered swing:
- toe clearance
- maintains momemtum by getting power back to aid lift
- Lift assistance: lift body without/decr glute strength or not enough body strength to move prosthesis
- STS assist
- kneeling
- stairs
- creates active EXT moment
- helps push up (without pure hip EXT strength needed)
RHEO Knee
-
Description
- top piece attached to femur = moves in relation to shank
- microprocessor knee = computer chip
- magnetic properties to aid gait by changing property depending on stage of gait (Incr/decr stability at correct time)
Design Considerations
swing phase control
Friction for one speed ambulators (K1, K2)
Fluid for multiple speed (K3, K4)
-
Fluid Controlled
Fluid allows for:
- Bent knee ambulation (stance) = stance FLX
- Variable gait (Swing)
- Increased stability
- more 'natural' gait
-
PT observations
- pylon lean
- toe out angle
- intact joint angle
Viewing positions
- Lateral
- Posterior
Pylon lean
too much DF
- angle smaller in SLS
- ANT lean = may have MED/LAT lean in frontal plane
ideal alignment
- pylon vertical in sagittal & Frontal plane
-
-
Assessing Socket Fit
- Comprehensive Lower-Limb Amputee Socket Survey (CLASS)
- pt perspective
- Prosthetists use these
- Socket Fit Comfort Score
- "Rate the comfort of your socket on a 0-10 scale where 0 and 10 represent the most uncomfortable and the most comfortable socket imaginable"
- Socket Interfaces = SOCKS
Volume changes in the RL are managed with addition/removal of prosthetic socks
- due to edema
- how much thickness (ply) is needed to fill in space
- volume fluctuates day-to-day and minute-by-minute if doing activities
- look at skin pressure to help determine when fit is not ideal
too many ply socks
may need new socket
- 10+ ply (consistently) = new socket indicated
- too much movement wont walk well
- pt N2K how to fit RL well in socket
too much sock = void at bottom of socket
- creates suction at bottom of tissue (like hickey)
- RL not getting to bottom of socket
- no suspension with too many socks = limb will fly off with swing phase
Volume Loss management
- RL goes deeper into socket
- puts pressure on locations that cannot handle the pressure
- fib head in more narrow area
- patella compressed
- management: add extra sock to realign pressure points
Variability of prosthetic socks
- level of amputation
- suspension system
- Thickness (PLY)
- varies by manufacturer
- Think cotton sock = 1 ply (generally)
- wool socks = 3 or 5 ply (generally)
- different materials
Structure
Skeleton
EXOskeletal: external, outward
- pylon, joints = uncovered/shown
- easy to access/adjust
- most seen in USA (doesnt mean cant get cosmetic covers)
-
ENDOskeletal: inner, containing
- all components inside cosmetic hard cover
- socket inside
- looks like 1x piece (filled with foam)
-
- Socket
- Suspension: external sleeve + suction
- ex/ velcro loop --> clip --> attaches = pull and keep in ; lanyard
- Knee
- Pylon: metal tubes that fill space and make sure axis of joints line up
- Ankle/Foot
- Foot Shell
- foot goes inside foot shell
- different colors to match skin tone
- can customize (i.e. space between 1st and 2nd toe for sandals ; can paint toe nails)
SURGERY
-
CONSIDERATIONS
Shape of Residual Limb
- allow suspension of prosthetic device
Length of residual limb
- bony lever arm
- clearance for prosthetic componentry
- level of infection/injury
- vascular status --> healing potential
- growth status (pediatric)
- keep growth plates intact
- energy cost for ambulation
- preserve length to help gait
Amputation Level
Determined by:
- Level & Extent of injury = what is needed to remove
- wound healing potential
Key considerations
- fxnl length
- shape = to fit into device (hard if its bigger at bottom)
- Appearance: evagination of scar (flipped inside out) --> rubbing --> wound
-
Post-surgical restrictions (general)
- depending on how tissue attached --> determines what must do for healing
Post-op Days 1-7: Goals
- fxnl mobility
- RL management and self-care
- conditioning and balance
- if deconditioned = seated exercises
- pain management
- contracture prevention
- Identify barriers (ICF) to rehab
- Determine MFCL (K-Level)*
CAUSES
-
CONGENITAL
Congenital Dysmelia
- def: malformation of the limb
Longitudinal deficiencies
- def: limb length (long bone) abnormalities
Amelia
-
Effects
- distal bone density
- growth plates (kids)
- bone structure (bowing)
-
-
Hemimelia
-
ex: fibular hemimelia
Effects
- decreased ankle stability
tx:
- transfemoral amputation
- other limb saving tx
Population
- low incidence: 3.8-5.3/10,000 births
- majority of paraolympians
VASCULAR DZ
Diabetes Mellitus (DM)
incidence
- 2014
- 29.1 M in USA
- 422 M worldwide
Preventable!
- 50-85% amputation preceded by an ulcer
- education is key
amputation risk
- at risk even if no ulcer with DM
- annual foot exam
-no "no risk", still at risk, just "low risk"
- high risk = if missed 1x spot with monofillament test
- educate about foot wear (i.e. supported sandals, etc)
-
-
-
Thromboangiitis Obliterans (TAO)
Def: inflammation of SMALL AND MEDIUM ARTERIES AND VEINS
- directly related to smoking
- UE & LE involvement
- Distal --> Proximal: toes/fingers first --> leads to multiple amputations
- mix of ischemia & saturation/edema
-
ETIOLOGY
- Men 20-40
- tobacco use
- incidence 12/100,000
SIGNS/SX
- Bilateral Ischemia
- Ulcers
- Superficial phlebitis
- Dyesthesia
- Discoloration: rubor or cyanosis*
- Pedal claudication
CLINICAL PRESENTATIONS
Type: Neurotrophic
Cause: DM
-
-
Key Signs/SX
- Wounds: small --> deep
- periwound callous
- infection*
Type: Venous
Cause: CVI
-
-
Key Signs/SX
- EDEMA
- COLOR CHANGES: dark/skin staining
- Wet wound
- red base
-
TUMOR
- "-sarcoma" = malignant
- tx differs depending on type of tumor
-
Osteosarcoma
location
- near growth plate near distal limb
-
Tx: different procedures
- want to keep growth plate open
INFECTION
-
Bacterial Meningitis
def: inflammation of the protective membranes covering the CNS
- microorganisms --> blood and CSF
- rapidly progressive, potentially fatal
Population
- 3000 Americans/year
- recent reduction due to vaccination
amputation
- distal --> proximal
- multiple amputations
SIGNS/SX
- ~ Migraine sx
- headache
- neck rigidity (part of triad)
- photophobia
- phonophobia
- Severe bacterial meningitis --> progresses rapidly --> results in amputation
- triad: nuchal (neck) rigidity, fever, AMS (altered mental status)
signs
- purulent discharge: change in volume in area
- Foul odor
- Signs of inflammation
- erythema
- pain
- warmth
- induration
- Necrosis: black tissue (over time)
- failure of wound healing
-
TRAUMA
(in USA)
UE Amputation Causes
-
Explosions
- burns included
- brace with hands
-
-
-
-
Population
- 76% Males
- Age: 36 +/- 17 Years
- similar to SCI dx with risky behavior
-
-
-
-
RISK FACTORS
-
- AGE: > 65 years
- SEX: Male
- RACE: Non-White 2* socioeconomic disparities
- Native Americans
- African Americans = 2-4x
- Hispanics = 3.5x
- DIABETIC COMORBIDITY (10-25x risk)
- borderline and type II included
- Death: 5-year survival rate < 50%
- 55% CL amputation 2-3 years s/p initial Lower Leg Amputation (LLA)
Due to:
- perforated valves
- systolic BP
-
-
-
ETIOLOGY
- Age: > 40 (younger population)
- LE > UE (due to biomechanical stresses)
- associated with weight gain
-
ETIOLOGY
- Male > Female
- Age: > 50
- obesity/sedentary
- tobacco use
- comorbidities = high risk
-
Heterotrophic Ossification
- the presence of bone in soft tissue where bone does not normally exist
- amputation indicated = depending on Mechanism of Injury (MOI)
- common in SCI
- hard to get socket on RL with XS bone tissue bc sharp
- if take out tissue = it grows back
-
NOT OUR PRIME INTERVENTION/SCOPE OF PRACTICE
- JUST NEED TO KNOW WHEN TO REFER OUT
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