Amputee & Surgery

Question 1

List the causes for amputation.

Answer 1

i) Congenital
ii) Trauma
iii) Peripheral Vascular Disease (20%)
iv) Diabetes (50%)
v) Tumour
vi) Infection
vii) Extra appendage

Question 2

In what age range to the rate of amputations peak? In what age range do they start?

Answer 2

i) 70-80 (M > F)

ii) 45-50 (M > F)

Question 3

What determines the level of amputation?

Answer 3

i) Functional expectation
ii) Patient preference
iii) Region/severity of disease
iv) Ability to heal
v) Level of election

Question 4

What is a “level of election”?

Answer 4

A predetermined series of sites for amputation that were derived from previous high stump survival rates and to fit old prosthesis. These sites are often through a joint.

Question 5

What criteria marks the prediction of healing transtibial (TT) level?

Answer 5

i) Ankle BP < 50mmHg
ii) Line of demarcation
iii) ankle/brachial BP level <0.3
iv) Transcutaneous oxygen level <30

Question 6

How common is phantom sensation?

Answer 6

Universal.

Question 7

How common is phantom pain?

Answer 7

Incidence not known. Risk factors include traumatic cause for amputation and pain in limb prior to amputation. While it usually persists, intensity can decrease over time.

Question 8

What options are available for treating phantom limb pain?

Answer 8

i) pharmacotherapy (ex. opoids, etc.)
ii) surgical (revision, nerve block, CNS stim etc.)
iii) adjuvant (ex. mirror therapy, ultrasound, biofeedback etc.)

Question 9

What are the options available for edema control following amputation?

Answer 9

i) Tensors
ii) Shrinkers
iii) Casts
iv) Removable rigid dressings

Question 10

What are the surgery goals of amputation?

Answer 10

i) Well padded
ii) Will fit a prosthesis
iii) Comfortable
iv) Will heal

Question 11

What are two techniques a surgeon can use to help skin heal?

Answer 11

i) Close without any tension on the skin

ii) Do not use toothed forceps

Question 12

How is the nerve severed and fixed in amputation surgery?

Answer 12

i) Pull down
ii) Tie high
iii) Sever
iv) Let go
v) Allow neuroma to form in well padded place.

Question 13

How is muscle severed and fixed in amputation?

Answer 13

i) myoplasty: muscle suture to muscle, pull over bone
ii) myodesis: muscle suture to bone (usually adductors & med. hamstring)
iii) trim excess

Question 14

How are blood vessels managed in amputation surgery?

Answer 14

Ligated.

Question 15

How are bones managed in amputation surgery?

Answer 15

Strip periosteum 1 cm from cut end.

Question 16

What are two types of suturing techniques? Are any better or worse than others?

Answer 16

i) Skew/Sagittal flaps that are brought together medially and cross the distal tibia sagittally.
ii) Long posterior flap: wrapped over the residuim and sutured anteriorly

Question 17

What is osseointegration? Name one indication.

Answer 17

i) The process of attaching a fixture into the bone that extends out of the limb. Mostly TF, however some are TT.
ii) Inability to tolerate prosthetic socket.

Question 18

What are the contraindications to osseointegration?

Answer 18

i) infection
ii) > 100kg
iii) immunocompromise
iv) ? diabetes
v) ? smoking

Question 19

What is an ertl procedure?

Answer 19

Bridging between the tibia and fibula post amputation surgery.

Question 20

What are the benefits of an ertl procedure?

Answer 20

i) end bearing
ii) cylindrical shape
iii) no floating fibula
iv) no bony overgrowth
v) better ambulation subscore
vi) better frustration subscore
Note: longer and more complicated surgery

Question 21

What are important rehabilitation considerations in the pre-prosthetic/non-prosthetic population?

Answer 21

i) transfers
ii) iADLs
iii) locomotion
iv) exercise (strength, balance, ROM)

Question 22

What outcome measures are valid in amputee rehabilitation?

Answer 22

i) Special Interest Group in Amputee Medicine (SIGAM) Mobility Grades
ii) Functional Independence Measure (FIM)

Question 23

Describe the SIGAM mobility scores.

Answer 23

I: Non-limb user: no functional prosthesis
II: Therapeutic: Use of prosthetic ONLY for therapeutic purpose
III: Limited: Walks <50m with or without walking aid
IV: Impaired: Walks >50m with walking aid
V: Independent: Walks >50m without walking aid
VI: Normal or near normal walking

Question 24

What is the major benefit of microprocessor knee prosthetics? What is a necessary criteria?

Answer 24

i) The ability to adapt to different walking speeds (accelerometer, position sensors etc.)
ii) Equal stance phase stability

Question 25

Where is the research on high end power prosthetics?

Answer 25

Some evidence supports improved ambulatory outcomes and patient preference. However, most research is conducted by the companies themselves - conflict of interest.

Question 26

List complications following amputation.

Answer 26

i) fractures: Tx the same as non-amputee
ii) osteoperosis: universal in TF, <50% in TT
iii) back pain: >50%, TF>TT, correlated with phantom pain
iv) OA of hip and knee: most often on amputate side for hip, only on amputated side for knee

Question 27

How often is the contralateral/unaffected limb amputated following an original amputation?

Answer 27

10% per year.

Question 28

How many amputations are then fit with a prosthesis?

Answer 28

i) TF 45%

ii) TT 65%