LE Prosthetics - 1 - Intro to Prosthetics Flashcards
How many amputations occurring annually in US
185,000
Number 1 cause for amputation in US
diabetes!
Lifestyle choices - we can have a positive impact on changing this
What percent due to disvascularity
54%
What percent due to trauma
45%
What percent due to other diseases (like CA)
less than 2%
Of people with diabetes and amputation what percent will need a contralateral amputation
55%!
within 2-3 years
African Americans ___% more/less likely than White American to have amputation
4x more likely! (higher risk of disvascularity)
1/2 the people with amputation secondary to PVD will die within __ years and why
5 years!
Is is that the amputation is an indicator of the progression of the disease, not the amputation leading to their death
2009, hospital cost associated with amputation was more than
8.3 billion
Challenges to interdisciplinary care
Ownership issue (my pt)
Focus on diff tasks/specialties
Located in various physical locations
Common outcome not established
Optimum rehab team
Focused motivated and goal oriented pt Ortho surgeon Vascular surgeon Plastic surgeon Rehab case manager Home health care nurse PT Prosthetist Insurance company Family
Maximizing prosthetic rehab requires
Early intervention and multi-disciplinary approach
Education, clear and concise expectations to reduce anxiety and stress
PT, pre and post surgery will improve func and reduce overall rehab time
PT role
Consultation with education
Evaluation
Training/coaching to optimize prosthesis
Prosthetist role
Provides pt care Prosthetic design Prosthetic fitting/alignment Long term prosthetic mnmgt Member of rehab team
Certified prosthetist requires what
Baccalaureate degree Post grad training Clinical practice residency (18 m to 2 yrs) Certification exams Continuing ed
What to expect from your prosthetist
Prosthetic rx pt and PT education Design of prosthesis Prosthetic fabrication Prosthetic fitting/alignment Long term prosthetic care
Amputations of the foot
Symes Boyd Pirogoff Chopart Lisfranc Mid metatarsal
Amputations of the foot - Symes
Takes off distal malleoli
Leaves talus intact
Take fat pad from heel and end up with tubular shape amputation that is WB (put weight on heel)
Good function but prosthetically can’t do much
Amputations of the foot - 1st toe
This one is significant because we need it for push off with gait - can cause decreased step length on contralateral side which leads to asymmetry
Will often do something prosthetically to replace that tow
Amputations of the foot - Mid metatarsal
Removing all toes
Midtarsal head is where we carry a lot of the weigh tin our foot - so if we cut above that, we will have sig impact on gait
Still functional level of ambulation - can make changes in shoe to restore gait pretty well
Amputations of the foot - Lisfranc
Disarticulating the metatarsals from the tarsal bones
So now we have a short foot
Nonfunctional amputation! Too long to do prosthetic and too short to stay put in a shoe
Amputations of the foot - Chopart
disarticulating the tarsals from the calcaneus and talus
Also nonfunctional for same reason as Lisfranc
Below knee amputations - Symes
Cutting through the tibia and fibula with this so Symes is considered below the knee (that is where the below the knee term kind of starts)
Below knee amputations -
Symes Long below knee Standard below knee Short below knee Very short below knee
Below knee amputations - Long below knee
Somewhere distal to the significant portion of the gastroc
The longer the intact limb, the more lever arm that we have but these are rare
Diff to fit in prosthesis because tibia is so “superficial” so need a lot of cushion to protect bone
Below knee amputations - Standard below knee
Somewhere between 5-7 in in length
The more SA we have, the less pound per square inch of pressure they will have
So we want that 5-7 in as long as possible to give good coverage for gastroc and good circulation for wound healing
Considerations that have to be made when determining length for amputation
Circulation
Need to have good circulation for wound healing to occur
Do we have tissue that we can wrap around is something else to consider too
Fibula shorter than tibia
Soft dressings
Need to get rid of as much post op edema as possible before starting on prosthetics
Ways to get edema down include use of soft dressings like:
ACE wrap
Compressive stockinette
Traditional shrinker
ACE wrap - adv
Inexpensice
Accessibility of wound
ACE wrap - disadv
Requires skilled application - blisters, maceration, wounds Inconsistent pressure gradient Falls off limb easily Does not prevent knee contractures No protection from falls
Shrinkers provide
Graded compression
More compression distally than proximally
Encourage edema to go up towards heart
Shrinkers adv
Consistent compression
Less expensive than RRD or IPOPS
Little skill required for application
Can be custom made for odd shapes
Shrinker disadvan
Limitations on sizing No protection from bumps or falls Smaller shrinkers have to be fit Can frequently fall down or wrinkle Can be painful to don
Shrinkers - common brand
Juzo
How long should a stump shrinker be worn
24 hours a day
But we have to have some time out of it to allow skin to breathe
Basically wearing it full time though so edema doesn’t get started again
How to apply a stump shrinker
House coffee can
Stretch shrinker over can and then place it on them to roll it out onto their skin
Avoid pulling it on like a sock
How to apply a stump shrinker - what NOT to do
Pull it up like a sock
Can put tension on suture line
Can catch and pull suture and will probably be more uncomfortable for pt
Also applies friction
Shrinker with transfemoral
NEED to include the hip
and make sure to go up to the perineum
Residual limb shaping/maturation
On day 100 that limb volume reduction stabilizes
So if we fit the socket before the 100 days, we will likely have a lot of issues from changes that occur
Prosthetic goals -
Functional restoration
- safety
- mobility
- independence
- balance (physical, mental, cosmetic)
Brief history - ortho docs came from
being brace makers
History - the verduyn leg
The first hinged knee joint TTA prosthesis
1696
History - ambroise pare
trans femoral prosthesis heavy metal, first knee joint
1561
Allows for functional knee swing
History - Angelsey leg
Cord system that DF the ankle as the knee flexed
1800s
History - Douglas Bly legs
Ball and socket joints (ankle)
Leather cord to limit motion and rubber cushions to decrease impact
Mid 1800s
History - JE Hanger
1861 - Eliminated the cord in feet and used rubber bumpers instead
History - Early 1900s what happened
Plug fit TTA with knee joints and thigh suspension
A lot of suspension devices to hold prosthesis on
History - PTB prosthetic design
PATELLAR TENDON BEARING
1946
Getting smarter about where we put pressure in the socket
Deep carve in at patellar tendon
History - Quadrilateral socket
1946
for transfemoral
Ischial tuberosity sits in it - so like sitting on bench
History - SACH foot designed by
Howard Eberhart and Charles Radcliffe
1958
SOLID ANKLE CUSHIONED HEEL
Wood heel that anchors into wood leg
Other part is foam - the heavier the person, the more dense the foam
Idea was that at heel strike, the foam would condense and simulate and try to get foot flat to take away the moment (takes away the knee flexion moment that exists at heel strike)
Primarily for transtibial
Multiple sizes of each made on an assembly line - more similar to modern
History - Hans Mauch
Introduced hydraulic knee control
1986
Faster they walked, the more resistance they would have
Helped control knee flexion with swing
History - Otto Bock
1980s
Introduces endoskeletal prosthetic design
Created internal pipe structure that allowed for acceleration of fitting process for pt and adjustments could be made more easily
History - Ossur Kristinsson
Icelandic roll on suction sockets
1980s
Silicone liner
Distribute pressure more evenly over entire residual limb
History - dynamic response prosthetic foot
introduced in 1980s
utilization of carbon fiber - lightweight, strong, return energy as walker uses it
History - materials
up to 1950 - wood and steal 1960s - polyester laminates 1970s - plastics 1980s - carbon fiber, Al 1990s - Silicon, Ti 2000s- composites, computer assisted
