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Amp/Pros > Lecture 2: Surgical Techniques > Flashcards

Lecture 2: Surgical Techniques Flashcards

1
Q

4 Factors affecting level of amputation:

A
  1. Vascular disease
  2. Postoperative function is considered
  3. Disarticulations
  4. Traumatic amputation
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2
Q

Vascular disease as a factor affecting level of amputation -

A
  • Level selected based on anticipated viability for tissue healing
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3
Q

Postoperative function as a factor affecting level of amputation -

A
  • Most distal level possible
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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
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5
Q

Traumatic amputation as a factor affecting level of amputation -

A
  • Level determined based on nature of injury & viability of tissue
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6
Q

General surgical principles goal -

A

Save as much limb length as possible

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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

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8
Q

Neuromas are possible with surgical amputations. What is a neuroma?

A
  • pinched nerve

- pain, a burning sensation, tingling, or numbness

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9
Q

Myoplasty -

A

Attachment of anterior and posterior compartment muscles to each other over the end of the bone

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10
Q

Myodesis -

A

Anchoring of muscles to bone

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11
Q

Which is better in the presence of ischemia, myoplasty or myodesis?

A

myoplasty

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12
Q

Which offers increased stability and muscular control, myoplasty or myodesis?

A

myodesis

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13
Q

Skin flaps are as broad as what?

A

Broad as the distal end of the limb

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14
Q

Skin flaps are shaped how?

A

Shaped to allow corners to retract smoothly

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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
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16
Q

When is an open amputation used?

A

Utilized if infection present or not enough tissue to provide good closure initially

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17
Q

Closed amputation -

A

several skin flaps or incisions may be used

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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

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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

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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

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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
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22
Q

Skew sagittal flaps take advantage of what nerves/arteries?

A

Takes advantage of saphenous nerve/artery and sural nerve

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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

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24
Q

What is the shortest level of TT compatible with knee function?

A

tibial tubercles

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25
Q

How is the distal fibula handled in a TT amputation?

A
  • fibula cut 1 cm shorter than tibia for limb shaping

- Tibia and fibula beveled to prevent soft tissue impingement

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26
Q

What is the most common level of amputation for individuals with poor circulation or gangrene of foot/ankle?

A

TF

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27
Q

Why is TF most common level of amputation for individuals with poor circulation or gangrene of foot/ankle?

A

Greater circulation above the knee

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28
Q

T/F Requires considerable energy to ambulate with a transfemoral prosthesis

A

True

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29
Q

3 Reasons for choosing TF over TT:

A
  1. Trauma
  2. Gangrene that has extended to knee
  3. Circulatory status indicating poor chance of healing at transtibial level
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30
Q

T/F Maintenance of femoral shaft axis as close to normal as possible is critical

A

True

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31
Q

Why is maintenance of femoral shaft axis as close to normal difficult?

A

Difficult secondary to loss of adductor attachment

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32
Q

What type of surgery (myoplasty/myodesis) used for maintaining more normal alignment of femoral shaft?

A

myodesis of adductor magnus to femur at the level of amputation for maintaining more normal alignment

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33
Q

During surgery, the limb is in what position to maintain proper tension and alignment?

A

extension and adduction during surgery

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34
Q

Common issues (4) post-op for all amputations:

A
  1. Pain
  2. Wound healing
  3. Fluid collection/edema
  4. Heterotrophic ossification
    - Trauma
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35
Q

Common issue post-op for TT amputations:

A

Knee flexion contracture

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36
Q

Common issues (4) post-op for TF amputations:

A
  1. Hip adductor roll
  2. Hip flexor contracture
  3. Hip abduction contracture
  4. Glute weakness
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37
Q

If TF amputation less than 50% of femur length, what is the most distal adductor muscle left?

A

pectineus - increase chance for abductor contracture

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38
Q

If TF amputation 50% of femur length, what is the most distal adductor muscle left?

A

adductor brevis - medium chance of abductor contracture

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39
Q

If TF amputation greater than 50% of femur length, what is the most distal adductor muscle left?

A

Adductor longus - least chance for abductor contracture

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40
Q

Direct structural and functional connection between the surface of implants and living bone tissue percutaneously connected to a prosthetic limb?

A

Osseointegration

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41
Q

Benefits of Osseointegration: (5)

A
  1. Eliminates the need for the socket
  2. Short residual limb
  3. More natural feeling
  4. Improved gait
  5. Allows for normal swelling
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42
Q

Downsides of Osseointegration: (5)

A
  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
Q

Hemicorporectomy -

A

below waist amputation, B LE amputated

44
Q

Transpelvic:

A

amputation of portion of the pelvis and lower extremity

45
Q

Hip disarticulation

A

amputation through hip joint capsule including the entire lower extremity

46
Q

Hip Disarticulations & Transpelvic Amputations are usually performed under what circumstances?

A

Malignancy
severe infection/gangrene
severe trauma

47
Q

Goal with Hip Disarticulations & Transpelvic Amputations -

A

Goal is to provide patient with good soft tissue flap for pressure tolerance and comfort with sitting

48
Q

4 Indications for knee disarticulation -

A
  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
Q

Knee disarticulation is rarely used in people with what?

A

vascular compromise

50
Q

T/F Knee disarticulation provides longer lever arm

A

True

51
Q

Ankle Disarticulation (Symes) Amputations -

A
  • Amputation through the ankle preserving the heel pad

- Used for severe foot trauma, congenital abnormalities or gangrene of forefoot

52
Q

For Ankle Disarticulation (Symes) Amputations, patient must have what to be successful?

A

Must have circulation to heel pad to be successful

53
Q

In Ankle Disarticulation (Symes) Amputations, heel pad is adhered to what?

A

End of tibia

54
Q

Why is the heel pad adhered to the end of the tibia in an Ankle Disarticulation (Symes) Amputations?

A
  • 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
Q

Transmetatarsal amputation -

A

Removal of toes and distal ends of metatarsals

56
Q

What is important in a Transmetatarsal amputation?

A

Important to salvage as much metatarsal length as possible

57
Q

Transmetatarsal amputation is mostly performed when?

A

secondary to infection due to dysvascularity or diabetes

58
Q

Traumatic causes of Transmetatarsal amputation most likely due to what two things?

A
  1. Lawnmower

2. MVA

59
Q

T/F Other through the foot amputations include Lisfranc (tarsometatarsal disarticulation) & Chopart (Midtarsal disarticulation)

A

True

60
Q

T/F Reason for amputation is key for treatment

A

True

61
Q

T/F Level and amputation type are important for rehabilitation

A

true

62
Q

T/F Limb shape is vital to prosthetic use, and therefore function

A

True

63
Q

T/F Expect impairments in muscle length, strength, and motor control following amputation surgery

A

True

64
Q

T/F Don’t forget about co-morbidities

A

True

65
Q

Role of PT in psychosocial issues?

A
  • Recognize the effects of changes in body image

- Help facilitate adjustment to change

66
Q

Effect of change in body image related to what two things?

A
  1. How well the individual can continue to pursue previous activities
  2. Whether change occurred gradually or suddenly
67
Q

What is the most significant factor for positive adjustment for amputee?

A

premorbid coping mechanism

68
Q

Positive adjustment of amputee is also dependent on what 3 things?

A
  1. Amputee Experience: comfort, cosmesis, vocational, social
  2. Amputee Behavior: are they using the part
  3. Amputee Psychodynamics: perception of disability, ego, frustration
69
Q

T/F Reported that depression and anxiety common in amputee population

A

True

70
Q

Avoidance and denial are (negative/positive) coping strategies.

A

Negative

71
Q

Coping strategies in amputee population that have been deemed beneficial?

A
  1. Seeking social support
  2. time since incidence
  3. using problem solving strategies
72
Q

4 stages of Emotional Adjustment to Amputation:

A
  1. 1st prior to surgery
  2. Immediately after surgery
  3. After initiation of postoperative program
  4. Reintegration into functional lifestyle
73
Q

T/F Amputee will always follow 4 stages of emotional adjustment

A

False, May or may not follow this sequence or experience each stage

74
Q

Stage 1 - Initial shock

A
  • Prior to surgery
  • Awareness that amputation may occur: “I’m afraid I may lose my foot.”
  • Grief likely the first reaction
75
Q

During stage 1 (initial shock) suggested to utilize what responses?

A
  • 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
Q

Stage 2

A
  • Immediately after surgery
  • Grief also likely
  • Individual may experience insomnia, restlessness and difficulty concentrating
77
Q

Difference between traumatic response and anticipated amputation response:

A

Traumatic or emergent amputations - Individual may appear euphoric and overly cheerful
Anticipated amputation - May express relief

78
Q

Stage 3 - Acknowledgement

A
  • 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
Q

Younger individual amputation responses during stage 3 acknowledgement -

A

Younger individuals may deny by exhibiting physical capabilities utilizing a WC or crutches

80
Q

Men amputation responses during stage 3 acknowledgement -

A

Men often fear negative implications on sexual activity

81
Q

Stage 4 - Adaptation

A
  1. Reintegration into functional lifestyle
  2. Various concerns regarding prosthesis
    - Appearance
    - Functionality
    - Unrealistic expectations
82
Q

Sexual issues for amputees:

A
  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
Q

Phantom sensation -

A
  • Sensation that the absent limb is still there in some form

- Sensations usually experienced immediately after surgery include: Tingling, pressure and sometimes numbness

84
Q

early theories of phantom sensation -

A

responses to nerve stimulation

85
Q

recent theories of phantom sensation -

A

sensation and pain originate in cerebrum

86
Q

What part feel phantom sensation most frequently?

A

most distal

87
Q

T/F Phantom sensation occurs in majority of individuals and will only last 10 days.

A

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
Q

Phantom pain -

A
  • Cramping or squeezing sensation, shooting pain or burning pain
  • Can be localized or diffuse; continuous or intermittent
  • May diminish or become permanent
89
Q

What treatment utilized to treat phantom pain?

A

Mirror box system

90
Q

T/F Children amputees also include parental reaction.

A

True, May go through periods of denial or anger, guilt or shame

91
Q

T/F Parental adjustment is important because greatly influences the child’s adjustment

A

true

92
Q

T/F Children take longer to adapt to use of orthotic or prosthetic.

A

False, adapt fairly easily to the use of orthotic or prosthetic
Comfort is most important

93
Q

When child amputee depressed, what will occur with their behavior?

A

behavior will most likely regress to more infantile level

94
Q

Early adolescence amputee may fear what?

A

may fear rejection and social ostracism

95
Q

T/F Compliance with child amputee can be an issue.

A

True

96
Q

Involvement of child amputee in what is extremely helpful?

A
  • Sports programs

- support groups/contact with other individuals experiencing similar situation

97
Q

Critical issue with elderly amputees:

A
  • maintaining independence

- May be viewed as the end to an active lifestyle

98
Q

T/F Learning to use artificial limb or orthosis may be slow and discouraging for elderly amputees

A

True

99
Q

What should you consider with elderly amputees?

A
  • Comorbidities

- Stress from financial limitations, loss of control over their lives and fear of becoming dependent

100
Q

T/F Important to allow elderly amputees to have as much control as possible, including being involved in goal setting or sequencing of activities

A

True

101
Q

Considerations for caregivers:

A
  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
Q

T/F Pre-amputation coping mechanism can determine psych outcome

A

True

103
Q

T/F Children adjust quickly, but compliance can be an issue throughout teen years

A

True

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