AMPUTEE INTERVENTIONS, TRAINING, OI Flashcards
What is osteointegration?
Bone anchored prosthesis
“The anchoring of a surgical implant by the growth of bone around it without fibrous tissue formation at the interface”
Where did OI first have its start?
dentistry
ex: dental implant - first one 1965
What is the most difficult part of OI surgery?
soft tissue closure
Screw fit vs press fit system OI
SCREW FIT
-FDA approved
PRESS FIT
-usually transfemoral amputees
-also for ease, functionality
-great for those who don’t tolerate a socket
-NOT FDA approved; done under exemption
-pressure holds the prosthetic in place
-very quick to don and doff with less skin problems
OI rehab vs Socket rehab
Not much different
-myodesis: muscle to bone
-myoplasty: muscle to muscle
*both used to foster distal muscle stabilization after amputation
-rehabilitation to prevent contractures
-improved biomechanics after OI rehab compared to socket rehab
–> glut med function
–> closed chain
–> better proprioceptive feedback
Rehab screw fit vs press fit
SCREW FIT
-2 stage surgery: 1st: implant, close 4-6 months rest, then 2nd surgery with more ST attention
-REHAB: 6 MONTHS
* 3 wks progressive exercise
* 3 wks progressive WB on short prosthesis
* 3 wks progressive WB on long prosthesis
* 4 wks progressive WB gait in II bars/crutches
* 4 wks full WB gait 2 crutches
* 6 wks single crutch/cane short distance 2 canes/crutches longer distance, uphill, downhill, speed
* 3 wks single A device community level, unlimited distance
PRESS FIT
-2 stage surgery; single stage for TTA
-stage 1- 6 wks rest
-stage 2- 2 days rest
REHAB:
-3 wks: full WB progressing from standing–> 2 crutches community level
-3-6 wks: progress through 2 crutches –> canes–> walking sticks–> no A device
-SHORTER PROCESS
-keep pain level <4/10
-keep biomechanical symmetry
Position of femur with OI compared to standard amputation with socket
-femur is not aligned properly with the socket as opposed to OI
-with the socket, the femur is pushed to the left –> makes you trunk lean
–> glutes and stabilizers are on stretch
-alters the biomechanics of gait
-with OI–> since the femur is aligned properly–> the glut med can actually work to stabilize the hip
BIOMECHANICAL ADVANTAGE OF OI:
-OI: closed chain
-can maintain level pelvis
-proximal stability from gluteus medius
Outcomes and data of OI
-100% of patients would do it again (even those with complications)
-Patient-reported outcomes (comparing OI to standard transfemoral amputation socket prosthesis)
-improved PROMs overall
Biomechanics changes one-year following OI in individuals with transfemoral lower limb amputation
-glut med activation increased
-glut max activation inc.
-increased knee extension moment
-increased trunk lateral flexion moment
Adverse events after OI
pain
infection
-20% rate of infection over 15 year follow up
-superficial most common
loosening or hardware failure
-may need revision
poor healing
fracture (test sensation)
HO
granulation tissue
WATCH FOR
-pain
-infection
-loosening hardware
-poor healing
-poor sensation
-TTA:
–longer lever arm
–rotation
–knee OA
Conservative pain management
pendulums
decreased WB
bike with no resistance
rest
pain killers
modalities
wrapping/compression
manual therapy
stoma considerations
Activities to avoid with OI
plyometric and high level activities:
running
football
powerlifting
snowboarding
soccer
wakeboarding
skydiving
How long does post-amputation/pre-prosthetic mobility training take?
3- 6 months to fully walk and use their prosthetic independently
Supine strengthening
hip adduction/abduction
quad and glute sets
hamstring stretches
ab crunches
Prone strengthening
lying prone propped on elbows
isometric glute sets–> hip extension
side lying strengthening
hip abduction/extension
seated strengthening
seated push-ups
trunk twists
marching
quad sets, knee extension
standing strengthening
hip raises
mini squats
hip 4 ways
Goal for household ambulation pre-prosthetic
goal: modified independent for 50 feet with LRAD
Goal for stairs pre-prosthetic
single-limb hopping or bumping using LRAD and railings
Interventions for phantom limb sensation/pain
mirror therapy
-looking at sound limb
desensitization techniques
visual imagery
Interventions for residual limb pain
movement and positioning
compression
habituation and desensitization
Guidelines for donning and doffing
- Invert liner as far as possible - contact directly against the end of
residual limb, roll on the interface - No wrinkles, folds or trapped air inside the liner
- Add appropriate ply of socks
- Stand and weight bear to expel air
- Progress wear schedule
- Continue residual limb management and skin checks for tolerance
Training for weight acceptance onto socket/prosthetic
PARALLEL BARS
-sit to stands
standing trials
-scales to see how much weight on each (weight shiting)
-rhythmic stabilization
Dynamic weight acceptance training
-stepping in place
-toe taps
-step-ups
–tap sound limb on step
—>promote weight shift onto the prosthetic side
-proprioception: roll ball under sound side to promote dynamic balance and weight shift
-pre-gait activities
Progression of support
parallel bars–> FWW–> bilateral forearm crutches–> unilateral forearm crutch–> cane –> no AD
Criteria for taking the leg home; approximately 2-8 visits depending on progress:
-can don/doff independently and correctly without cueing
-sit to stand independently with the use of AD
-can stand x2 min independently with use of AD
-can ambulate 100 feet with LRAD on surface compliant with home floor
-can negotiate single step with LRAD independently
-able to negotiate stairs ind. if they are present at home
Functional mobility goals with prosthetic
TRANSFERS
Goal: Modified independent sit to stand with prosthesis with least restrictive assistive device (LRAD)
HOUSEHOLD AMBULATION
Goal: modified independent for 50-100 feet with prosthesis with LRAD
Goal: modified independent for lateral walking and pivoting
in tight spaces with LRAD
COMMUNITY AMBULATION
Goal: modified ind. negotiation of slopes, uneven surfaces, and curbs with LRAD
STAIRS
Goal: modified independent for single limb hopping or bumping with prosthesis
Criteria needed to disengage knee (locking knee)
knee must be in full extension
70% BW toe load (DF moment)
-default is resistance to flexion
Walking with mechanical knee key points
-need strong extension of glutes/hams
-often lateral trunk flexion compensation for improper trunk/pelvic rotation and knee flexion
-often uneven stride length/rhythm
Benefits of microprocessor knee
- Stumble recovery
- Ability to ride the knee down stairs,
ramps, rough terrain - Stability on uneven surfaces
- Controlled sitting and kneeling
movements are possible - Less user concentration on the
prosthesis - Energy-efficient gait with greater
symmetry - can perform reciprocal stepping on stairs
GAIT TRAINING PROGRESSION
IN PARALLEL BARS
-practice riding knee in standing
-step length practice
-loading the toe
-smooth rhythm
-equal sound for heel strike
OUT OF BARS:
-resisted pelvic rotation
-facilitate shoulder rotation
-speed changes
-flat treadmill
