L20 - LE Amputee

Question 1

What is relevant about the biomechanics of a transfemoral amputation (hint: has to do with adduction)?

Answer 1

Loss of attachment points for adductor magnus (which provides 70% of adduction strength and provides extension force) results in hip being positioned in flexed and abducted position.
The loss of AM muscle attachment shortens the lever arm for adduction, requiring the remaining adductor muscles to work harder to produce the same movement.

Question 2

When is a knee disarticulation performed?

Answer 2

Trauma: when the residual length of the tibia is less than 4 cm
PVD: surgeon’s choice

Question 3

When are the advantages and disadvantages of a knee disarticulation?

Answer 3

Advantages: WB distally is possible, better lever arm and prosthesis control
Disadvantages: Long and bulbous residual limb, less aesthetic, and knees of different lengths when seated

Question 4

Describe the surgery behind a symes disarticulation

Answer 4

The foot is amputated, and the heel pad is repositioned and stitched to distal tibia and fibula. A cast is then used to help the heel pad attach properly, followed by the smoothing of malleoli.

Question 5

What are the advantages of a symes disarticulation?

Answer 5

WB is possible at distal end of residual limb after healing. The residual limb can function effectively with a prosthetic limb.

Question 6

What are the disadvantages of a symes disarticulation?

Answer 6

The appearance is not cosmetically pleasing and can result in a limb that looks like an elephant’s leg due to its shape.

Question 7

What determines amputation level for people with PVD?

Answer 7

Healing potential established by clinical examination and laboratory tests.

Question 8

What are the considerations for amputation level in cases of trauma or cancer?

Answer 8

Nature of the trauma or tumor and tissue viability.

Question 9

What are the consequences of choosing an amputation segment length that is too long?

Answer 9

Bony prominence, non-aesthetic prosthesis, limits on prosthesis components, reduced moment of force.

Question 10

What are the consequences of choosing an amputation segment length that is too short?

Answer 10

Decreased stability, suspension issues with the prosthesis, reduced moment of force.

Question 11

How does energy expenditure differ between vascular transtibial and traumatic transfemoral amputations?

Answer 11

They are roughly equal. Energy expenditure from transfemoral vascular is much higher than transfemoral traumatic.

Question 12

How long does rehabilitation following a lower limb amputation take on average?

Answer 12

Between 12 and 18 months

Question 13

What are the objectives of PT in the pre-operative phase?

Answer 13

Improve pain management, minimize deconditioning, improve patient participation, and inform about rehabilitation and the impact of amputation.

Question 14

What are the PT interventions in the pre-operative phase?

Answer 14

Positioning for comfort, education on pain, encouraging mobilization, falls prevention, ROM/STR exercises, and general endurance exercises.

Question 15

Why is pain management a crucial part of the PT’s role in the pre-operative phase?

Answer 15

Studies showed that the more stable and well-managed the pain is before the amputation, the less likely the pt is to get phantom pain

Question 16

What is the PT intervention for preventing lower extremity contractures in the acute post-op phase?

Answer 16

Positioning the LE in extension and teaching ROM exercises for knee/hip extension.

Question 17

What is the recommended practice for edema management post-op?

Answer 17

Introduce compression at the residual limb as tolerated and educate on positioning the limb in elevation intermittently.

Question 18

What is the focus for mobility in the acute post-op phase?

Answer 18

Practice bed mobility, basic transfers, and unipodal mobility with walking aid.

Question 19

What positioning should be avoided when sitting post-op?

Answer 19

Positioning where skin is pulled at the staples and where knee and hip are in flexion should be avoided.

Question 20

What is the duration of pre-prosthetic training?

Answer 20

4 to 8 weeks

Question 21

When does pre-prosthetic training phase end?

Answer 21

When the surgical wound is healed and the residual limb is mature and ready for prosthetic training

Question 22

What are the overall PT objectives during pre-prosthetic training?

Answer 22

1. Restore and maximize autonomy in unipodal and/or with wheelchair 2. Evaluate potential for prosthetic prescription 3. Prepare the residual limb to prosthetic fitting

Question 23

What are the most 4 common residual limb shapes?

Answer 23

Cylindrical, conical, bulbous, dog eared

Question 24

What are common joint contractures for transtibial amputation?

Answer 24

Knee flexion contracture

Question 25

What are common joint contractures for transfemoral amputation?

Answer 25

Hip flexion contracture > hip abduction

Question 26

What are the main muscles to target strengthening following a TT amputation?

Answer 26

Knee flexors, knee extensors, hip muscles

Question 27

What is the purpose of the AMPPRO/AMPnoPRO questionnaire?

Answer 27

Standardized test used to predict functional mobility protential after prosthetic fitting

Question 28

How can joint contractures be prevented/treated?

Answer 28

Positioning education, stretching agonist muscle, strengthening antagonist muscle, manual therapy

Question 29

What are some immediate post-op compression methods?

Answer 29

Rigid dressing, Immediate post-op cast/prosthesis, Semi-rigid dressing

Question 30

What is the purpose of immediate post-op compression?

Answer 30

To provide constant pressure on soft tissue and improve circulation

Question 31

What are some drawbacks of immediate post-op compression methods?

Answer 31

Risk of infection, Requires specialized expertise, Must be redone once edema decreases

Question 32

What are the advantages of elastic bandages in wound care?

Answer 32

Low cost, able to visualise the wound, allow limb mobility and strength training, can be adapted to the individual’s shape of residual limbs

Question 33

What are the disadvantages of elastic bandages in wound care?

Answer 33

Requires proper patient education to apply it, has to be redone regularly, careful of tourniquet (when applied in circular manner vs figure of 8), elastic bandaging is unreliable and unsafe in terms of pressure distribution