Lecture 2: Surgical Techniques Flashcards
1
Q
4 Factors affecting level of amputation:
A
- Vascular disease
- Postoperative function is considered
- Disarticulations
- Traumatic amputation
2
Q
Vascular disease as a factor affecting level of amputation -
A
- Level selected based on anticipated viability for tissue healing
3
Q
Postoperative function as a factor affecting level of amputation -
A
- Most distal level possible
4
Q
Disarticulations as a factor affecting level of amputation -
A
- Most surgeons won’t perform disarticulation at knee or ankle due to concern that poor circulation may interfere with healing
5
Q
Traumatic amputation as a factor affecting level of amputation -
A
- Level determined based on nature of injury & viability of tissue
6
Q
General surgical principles goal -
A
Save as much limb length as possible
7
Q
How are large nerves handled with surgical amputation?
A
Large nerves are pulled down and resected sharply so that they retract into the soft tissue
8
Q
Neuromas are possible with surgical amputations. What is a neuroma?
A
- pinched nerve
- pain, a burning sensation, tingling, or numbness
9
Q
Myoplasty -
A
Attachment of anterior and posterior compartment muscles to each other over the end of the bone
10
Q
Myodesis -
A
Anchoring of muscles to bone
11
Q
Which is better in the presence of ischemia, myoplasty or myodesis?
A
myoplasty
12
Q
Which offers increased stability and muscular control, myoplasty or myodesis?
A
myodesis
13
Q
Skin flaps are as broad as what?
A
Broad as the distal end of the limb
14
Q
Skin flaps are shaped how?
A
Shaped to allow corners to retract smoothly
15
Q
How are drains used with skin flaps?
A
- Drains are utilized just under incision for removal of excess fluid
- Removed after 1-2 days
16
Q
When is an open amputation used?
A
Utilized if infection present or not enough tissue to provide good closure initially
17
Q
Closed amputation -
A
several skin flaps or incisions may be used
18
Q
When would you use equal length anterior/posterior flap in a closed amputation?
A
- When conserving bone length
- when primary healing is not a concern
19
Q
When using equal length anterior/posterior flap in a closed amputation, how are the flaps shaped?
A
Flaps shaped to reduce “dog ears” at corners
20
Q
When would you use long posterior flap in a closed amputation?
A
- Used when vascularity is of concern
- when more padding is needed
21
Q
WHen would you use skew sagittal flaps in a closed amputation?
A
- severe dysvascular cases
- Removes anterior placement of scar from high prosthetic pressures
- Helps with blood flow laterally
22
Q
Skew sagittal flaps take advantage of what nerves/arteries?
A
Takes advantage of saphenous nerve/artery and sural nerve
23
Q
Why is TT desirable length controversial?
A
- Some advocate for bone length
- Others argue that long bone length increases chance for development of distal skin problems
24
Q
What is the shortest level of TT compatible with knee function?
A
tibial tubercles
25
How is the distal fibula handled in a TT amputation?
- fibula cut 1 cm shorter than tibia for limb shaping
| - Tibia and fibula beveled to prevent soft tissue impingement
26
What is the most common level of amputation for individuals with poor circulation or gangrene of foot/ankle?
TF
27
Why is TF most common level of amputation for individuals with poor circulation or gangrene of foot/ankle?
Greater circulation above the knee
28
T/F Requires considerable energy to ambulate with a transfemoral prosthesis
True
29
3 Reasons for choosing TF over TT:
1. Trauma
2. Gangrene that has extended to knee
3. Circulatory status indicating poor chance of healing at transtibial level
30
T/F Maintenance of femoral shaft axis as close to normal as possible is critical
True
31
Why is maintenance of femoral shaft axis as close to normal difficult?
Difficult secondary to loss of adductor attachment
32
What type of surgery (myoplasty/myodesis) used for maintaining more normal alignment of femoral shaft?
myodesis of adductor magnus to femur at the level of amputation for maintaining more normal alignment
33
During surgery, the limb is in what position to maintain proper tension and alignment?
extension and adduction during surgery
34
Common issues (4) post-op for all amputations:
1. Pain
2. Wound healing
3. Fluid collection/edema
4. Heterotrophic ossification
- Trauma
35
Common issue post-op for TT amputations:
Knee flexion contracture
36
Common issues (4) post-op for TF amputations:
1. Hip adductor roll
2. Hip flexor contracture
3. Hip abduction contracture
4. Glute weakness
37
If TF amputation less than 50% of femur length, what is the most distal adductor muscle left?
pectineus - increase chance for abductor contracture
38
If TF amputation 50% of femur length, what is the most distal adductor muscle left?
adductor brevis - medium chance of abductor contracture
39
If TF amputation greater than 50% of femur length, what is the most distal adductor muscle left?
Adductor longus - least chance for abductor contracture
40
Direct structural and functional connection between the surface of implants and living bone tissue percutaneously connected to a prosthetic limb?
Osseointegration
41
Benefits of Osseointegration: (5)
1. Eliminates the need for the socket
2. Short residual limb
3. More natural feeling
4. Improved gait
5. Allows for normal swelling
42
Downsides of Osseointegration: (5)
1. Multiple surgeries
2. Prolonged period of no ambulation
3. Risk of fracture, infection
4. Reduction in activities that require high torque or axial stress
5. Not well known in the U.S.
- Multiple studies and sites working to get FDA approval
43
Hemicorporectomy -
below waist amputation, B LE amputated
44
Transpelvic:
amputation of portion of the pelvis and lower extremity
45
Hip disarticulation
amputation through hip joint capsule including the entire lower extremity
46
Hip Disarticulations & Transpelvic Amputations are usually performed under what circumstances?
Malignancy
severe infection/gangrene
severe trauma
47
Goal with Hip Disarticulations & Transpelvic Amputations -
Goal is to provide patient with good soft tissue flap for pressure tolerance and comfort with sitting
48
4 Indications for knee disarticulation -
1. Inability to provide adequate transtibial residual limb secondary to trauma
2. Knee flexion contracture >45 degrees,
3. Infection of soft tissue close to knee joint
4. Congenital deformities
49
Knee disarticulation is rarely used in people with what?
vascular compromise
50
T/F Knee disarticulation provides longer lever arm
True
51
Ankle Disarticulation (Symes) Amputations -
- Amputation through the ankle preserving the heel pad
| - Used for severe foot trauma, congenital abnormalities or gangrene of forefoot
52
For Ankle Disarticulation (Symes) Amputations, patient must have what to be successful?
Must have circulation to heel pad to be successful
53
In Ankle Disarticulation (Symes) Amputations, heel pad is adhered to what?
End of tibia
54
Why is the heel pad adhered to the end of the tibia in an Ankle Disarticulation (Symes) Amputations?
- Prevents movement between heel pad and bone that may result in pain and ineffective prosthetic fit
- Casting common immediately after to allow heel pad to heal
55
Transmetatarsal amputation -
Removal of toes and distal ends of metatarsals
56
What is important in a Transmetatarsal amputation?
Important to salvage as much metatarsal length as possible
57
Transmetatarsal amputation is mostly performed when?
secondary to infection due to dysvascularity or diabetes
58
Traumatic causes of Transmetatarsal amputation most likely due to what two things?
1. Lawnmower
| 2. MVA
59
T/F Other through the foot amputations include Lisfranc (tarsometatarsal disarticulation) & Chopart (Midtarsal disarticulation)
True
60
T/F Reason for amputation is key for treatment
True
61
T/F Level and amputation type are important for rehabilitation
true
62
T/F Limb shape is vital to prosthetic use, and therefore function
True
63
T/F Expect impairments in muscle length, strength, and motor control following amputation surgery
True
64
T/F Don’t forget about co-morbidities
True
65
Role of PT in psychosocial issues?
- Recognize the effects of changes in body image
| - Help facilitate adjustment to change
66
Effect of change in body image related to what two things?
1. How well the individual can continue to pursue previous activities
2. Whether change occurred gradually or suddenly
67
What is the most significant factor for positive adjustment for amputee?
premorbid coping mechanism
68
Positive adjustment of amputee is also dependent on what 3 things?
1. Amputee Experience: comfort, cosmesis, vocational, social
2. Amputee Behavior: are they using the part
3. Amputee Psychodynamics: perception of disability, ego, frustration
69
T/F Reported that depression and anxiety common in amputee population
True
70
Avoidance and denial are (negative/positive) coping strategies.
Negative
71
Coping strategies in amputee population that have been deemed beneficial?
1. Seeking social support
2. time since incidence
3. using problem solving strategies
72
4 stages of Emotional Adjustment to Amputation:
1. 1st prior to surgery
2. Immediately after surgery
3. After initiation of postoperative program
4. Reintegration into functional lifestyle
73
T/F Amputee will always follow 4 stages of emotional adjustment
False, May or may not follow this sequence or experience each stage
74
Stage 1 - Initial shock
- Prior to surgery
- Awareness that amputation may occur: “I’m afraid I may lose my foot.”
- Grief likely the first reaction
75
During stage 1 (initial shock) suggested to utilize what responses?
- Suggested to refrain from statements like
“Oh no, no , don’t even think that.”
- Utilize more reflective response
“I understand your concerns about your foot.”
76
Stage 2
- Immediately after surgery
- Grief also likely
- Individual may experience insomnia, restlessness and difficulty concentrating
77
Difference between traumatic response and anticipated amputation response:
Traumatic or emergent amputations - Individual may appear euphoric and overly cheerful
Anticipated amputation - May express relief
78
Stage 3 - Acknowledgement
- Postoperative program
- Many individuals mourn not only the loss of the limb but also anticipated loss of previous lifestyle (job, activity, etc)
- Feelings can alternate between hopelessness, despondency, bitterness and anger
- Overwhelming with information may lead to greater helplessness
79
Younger individual amputation responses during stage 3 acknowledgement -
Younger individuals may deny by exhibiting physical capabilities utilizing a WC or crutches
80
Men amputation responses during stage 3 acknowledgement -
Men often fear negative implications on sexual activity
81
Stage 4 - Adaptation
1. Reintegration into functional lifestyle
2. Various concerns regarding prosthesis
- Appearance
- Functionality
- Unrealistic expectations
82
Sexual issues for amputees:
1. Major trauma or amputation may affect self-concept
- How an individual views attraction
2. Disability may interfere with ability to attain usual sexual positions and may result in decreased satisfaction
3. These concerns are often left unattended
- Comfort level of discussing this topic with MDs or PTs
- Rarely considered by rehab staff to address sexual concerns
83
Phantom sensation -
- Sensation that the absent limb is still there in some form
| - Sensations usually experienced immediately after surgery include: Tingling, pressure and sometimes numbness
84
early theories of phantom sensation -
responses to nerve stimulation
85
recent theories of phantom sensation -
sensation and pain originate in cerebrum
86
What part feel phantom sensation most frequently?
most distal
87
T/F Phantom sensation occurs in majority of individuals and will only last 10 days.
False:
- Occurs in majority of individuals and may last for several years
- Can dissipate over time or the individual may experience phantom sensation over the course of life
88
Phantom pain -
- Cramping or squeezing sensation, shooting pain or burning pain
- Can be localized or diffuse; continuous or intermittent
- May diminish or become permanent
89
What treatment utilized to treat phantom pain?
Mirror box system
90
T/F Children amputees also include parental reaction.
True, May go through periods of denial or anger, guilt or shame
91
T/F Parental adjustment is important because greatly influences the child’s adjustment
true
92
T/F Children take longer to adapt to use of orthotic or prosthetic.
False, adapt fairly easily to the use of orthotic or prosthetic
Comfort is most important
93
When child amputee depressed, what will occur with their behavior?
behavior will most likely regress to more infantile level
94
Early adolescence amputee may fear what?
may fear rejection and social ostracism
95
T/F Compliance with child amputee can be an issue.
True
96
Involvement of child amputee in what is extremely helpful?
- Sports programs
| - support groups/contact with other individuals experiencing similar situation
97
Critical issue with elderly amputees:
- maintaining independence
| - May be viewed as the end to an active lifestyle
98
T/F Learning to use artificial limb or orthosis may be slow and discouraging for elderly amputees
True
99
What should you consider with elderly amputees?
- Comorbidities
| - Stress from financial limitations, loss of control over their lives and fear of becoming dependent
100
T/F Important to allow elderly amputees to have as much control as possible, including being involved in goal setting or sequencing of activities
True
101
Considerations for caregivers:
1. Stressful for caregivers as well
2. Awareness of caregiver concerns
3. Can they physically handle caring for the patient
4. Provide time for caregiver to ask questions as well
- Increase confidence in caregiver skills
102
T/F Pre-amputation coping mechanism can determine psych outcome
True
103
T/F Children adjust quickly, but compliance can be an issue throughout teen years
True
