Amputations and Diabetic Foot Flashcards
History of O&P Milestones
- Earliest recorded amputation was 484 BC when soldier cut off his foot to escape imprisonment
- tourniquet introduced 1674
- 1863 - suction socket for TF amputee
- 1846 - first amputation under anesthesia
- 1867 - anticeptic surgery introduced
- 1949 - myoplasty introduced
- 1960s - myodesis introduced
- 1954 - hip disarticulation prosthesis
- 1956 - SACH foot
- 1959 - PTB
- 1971 - endoskeletal prosthesis
- 2000 - microprocessor controlled knee
Incidence of Amputations
- TFemoral more common than transtibial
- 80,000 in US/year
- men>women 3:1
- amputation rate increases steep w/ age
Population Base of Amputation
of Limb Loss
- 82% = dysvascular disease
- PVD by peripheral neuropathy (HTN, cholesterol, tobacco)
- 16.4% = Trauma -opt outcome surg<12hrs
- machinery 40%
- power tools 27%
- firearms 8%
- MVAs 8%
- .9% cancer - carcinoma
- .8% congenital limb deficiencies
INcidence of amputations in people >60
- 90% vascular disease
- 7% trauma
- 2.5% tumor
- .5% congenital
Rehabilitation Issues to Consider with Amputation
- determing readiness for prosthetic fitting
- involved decision about prosthetic components
- coordinates prosthetic training
- consult with prosthetist as needed
- basic mobiity training
- consuly and assist patient to return to employment/activities
- AGE IS MORE IMPORTANT THAN ETIOLOGY FOR PREDICTING TOTAL LENGTH OF TIME IN REHABILITATION
Energy cost and Amputaiton
- preservation of knee joint = key determinant for potential for functional ambulation and successful outcome
- more of the limb you can leave the better the outcome**
- increased energy for persons with bilat TF
- some elderly may chose wheelchair
Factors Which influence the metabolic cost of walking
- Length of residual limb
- knee = key
- longer lever arms = better
- Cause of Amputation
- trauma vs. vascular
- other complications (TBI, atrophy, SCI, soft tissue injury etc) *life vs. limb
- Age
- linear relationship regardless of disability
Diabetes and High Risk Foot
- DM is the diagnosis most frequently associated with foot ulceration and LE amputation
- DUE TO PERIPHERAL NEUROPATHY
- poor circulation, is not the primary cause of most foot ulcers though closely related
Diabetic Peripheral Neuropathy
- Damage to nerves (40% of DM)
- 60% of LE amp are related to DM
- characterized by:
- neuropathic pain/loss sensation
- muscle weakness later stages
- ppl w/ DMPN have 15x greater risk of foot ulcer than those with DM and intact sensat.
- PRIMARY MECHANISM FOR INJURY/ULCER W/ DMPN IS REPETITIVE MECHANICAL STRESS THAT IS UNRECOGNIZED
Considerations and Controlling DM
- Hb-A1C
- Healthy = 5
- DM = less than 7 = controlled
- lower = less complications
- other systemic diseases
- stroke, TIA
- CVD
- Foot health hx
- previous ulcer
- ankle sprains
- medications
- visual deficits
- footwear
Physical Exam of DM Foot
- Vascular exam - pulses, doppler, ABI
- Sensory Exam - vibration, protective sens.
- soft tissue
- footwear
- balance
- gait
- ms exam - jt mob, deformity,
- Charcot’s foot - loss of arch, bones drop down, inflammatory process = bone disintegration
Treatment for Neuropathic Ulcer
- Sharp debridement for necrotic tissue
- appropriate dressings applied
- pressure reduction
- total contact casting
- walking splints
- removable cast walkers
- half shoes
- can participate in WB exercise
- comprehensive foot care
- MODERATE WALKING LIKELY DOES NOT INCREASE RISK OF FOOT ULCERS
- need good footwear and daily inspection
Amputation Levels
PARTIAL FOOT
General Information
- loss ant. lever arm foot affects term. stance
- functional loss of DF @ ankle
- tendency of ankle to become fixed
- many different levels
Toe Amputations
Benefits
- plantar surface WBing
- most of foot intact
- gait unaffected at normal speeds
Challenges
- shoe selection
- excessive pressure at amputation site
- shear forces at suture area
Prosthetic Management
- carbon foot plate with filler or silicone restoration
Ray Amputations
Benefits
- plantar surface WBing
- most of foot intact
Challenges
- shoe selection
- excessive pressure at amp site
- shear forces at suture area
Prosthetic Management
- carbon plate with toe filler or silicone restoration to minimize shear forces
Transmetatarsal Amputation
Benefits
- partial plantar surface WBing
- most of the ankle structure is intact
Challenges
- shoe selection
- excessive pressure at distal plantar metatarsal areas
- shear forces at suture area
Prosthetic Management
- carbon foot plate with toe filler or silicone restoration
Lisfranc - Metatarsal Disarticulation
Benefits
- distal bearing
- ankle joint intact
Challenges
- cosmetics of prosthesis
- height discrepancy - no longer have long arch
- loss of foot levers/rockers
Prosthetic Management
- fiber foot plate with toe filler
- AFO/prosthesis
- tibial tubercle level prosthesis
Chopart Amputation
Calcaneo-Cuboid Talo-Navicular Disarticulation
Benefits
- distal bearing
- ankle joint intact
Challenges
- cosmetics of prosthesis
- height discrepancy
- loss of foot levrs
Prosthetic Management
- fiber footplate with toe filler
- AFO / prosthesis
- tibial tubercle level prosthesis
Boyd/Pirgoff Amputation
SImilar to Symes Amputation however the calcaneus is cut and attached to the cut end of the distal tibia
Symes Amputation
Malleoli are partially sheared off for Cosmesis
Heel Pad reserved and anchored to distal end of Tib/Fib
Advantages
- distal end bearing
- less traumatic surg
- sulf suspending
- long lever arm
- >surface area
Disadvantages
- potential problems with the heel pad/flap
- component option limitations
- cosmesis
Suspension Options
- windows: either medial or posterior
- expandable bladders
- partial inserts
- supramalleolar
Transtibial Amputation
- Conical = Larger surface area and less pointiness because you have 2 long bones providing support
- when amp is done for vascular reasons, very short anterior flap and very long posterior flap (otherwise equal flaps)
- optimal:
- typically mid tibial
- length allows space for prosth foot and sufficient muscle padding
- too much - no room for ankle
- minimum
- junction of middle 3rd and prox 3rd of tibia just below the flair of tibial plateu to allow suff. WB
Through Knee Disarticulation KD
- Good comfort and function
- poor cosmesis
- patellar tendon sutured to remnants of cruciate ligaments
- few muscles and no bone cut = less traumatic surgery
Transfemoral Amputation
- equal length ant/post flaps
- nerves cut at level to ensure they are well covered
- trying to avoid neuromas so you cut them high so they have less pressure on them
- myoplasty = sow muscle to other muscle
- myodesis = sow muscle to the bone
- end of bone is smoothed
- Optimal length
- allows space for uncompromised knee system
- typically above condylar flare
- Minimal Length
- junction of middle 3rd and prox 3rd (below less troch) to allow for suff fem length/lever arm to operate prosthesis
Hip Disarticulation and HemiPelvectomy
- blood loss can be a problem
- symphysis pubis is divided
- anterior - above and paralleled to inguinal ligament
- posterior - preserves variable portion of gluteus maximus
- hemipelvectomy - all or part of ilium is removed
Determining Appropriate level of amputation prior to surgery
- patient goals and priorities
- patients general condition
- risks of additional surgery
- potential healing of the limb
- predicted probably outcome (age)
Common Techniques used at ALL levels of Amputation
- Flaps
- decrease tension
- trim them down - want =
- provides cushion
- nerves cut high
- prevention of neuroma
- myoplasty/myodesis
- ms stabilization, shape, fxn
Ateriosclerosis Obliterians
Narrowing and occlusion of the arterial lumen of the larger arteries
- etiology
- 50+
- male
- tobacco
- obesity
- HTN
- HLD
- sedentary
- symptoms
- inttermitten claudication
- decreased pedal pulse
- dry skin
- hair loss
- clubbing toe nails
- ulceration
- pain relieved w/ standing
Arteriosclerosis with Diabetes
Narrowing of the Medium and Smaller arteries - w/ neuropathic changes
- etiology
- same as arteriosclerosis obliterans (ASO)
- 40+
- Symptoms
- same as ASO
- decreased foot sensation
- renal complication
- impaired vision
- decreased strength
Chronic Venous Insuffiency CVI
Compromised blood flow of superfiscial veins as a result of perforating valves, increased SBP, decreased blood flow, edema and cell death
- 1% of population
- edema
- dilated veins
- dermatitis
- ulcers (above malleoli)
- pain relieved by elevation
Thromboangitis Obliterans
(Beurger’s Disease)
Inflammation of the small and medium arteries and veins of both UE and LE directly related to smoking
- male 20-40, tobacco use
- bilateral ischemia
- ulcers
- phlebitis
- pedal claudication
- pain with rest
Stages of Amputation
- Pre-amputation = everything before
- Pre-Prosthetic = amp to first OP fitting
- Transitional = first OP fitting to limb stab
- Mature = everything after limb stabilization
- Post Amp -> Pre Prosthetic assess:
- pain
- residual limb size
- wound healing
- circulation
- ROM/flex
- joint mob
- muscle performance
- gait/balance
Phantom Limb Sensation vs. Phantom Limb p!
- 85% of amputees experience phantom sensation, pain or actual limb pain
- Phantom sensation = non painful sensation or awareness that occurs below the residual limb
- Phantom limb pain = painful sensation that occurs below the residual limb
- Residual limb pain = pain arising in the residual limb from a specific anatomical structure that can be identified
5 Steps of Loss with Amputation
Denial
Bargaining
Anger
Depression
Acceptance
Amputation in the 1st Year
Healing
Grief
Rehabilitiation
Adjustment
Integration
Reintegration
