Lecture 21 - LE amputation

Question 1

What are the 6 guidelines for patients with neuroischemic feet?

Answer 1

1. Examine feet daily
   - broken skin, blisters, swelling, or redness
2. Report worsening symptoms
   - decreasing walking distance
   - pain at rest
   - pain at night
   - changes in skin colour
3. Keep the skin moist
   e. g. 50/50 white soft paraffin and liquid paraffin mix
4. Shoes
   - well fitting, free of friction and pressure points
   - check them for foreign objects (such as stones) before wearing
   - avoid open toed sandals and pointed shoes
   - never walk barefoot
5. Smoking cessation
6. Regular exercise

Question 2

What are the 3 main management component with foot ulcers

Answer 2

1. pressure relief
2. debridement dans infection control
3. modalities

Question 3

What are the prevention and treatement component related to pressure relief of foot ulcers?

Answer 3

Prevention / prophylaxis:
Protective footwear / diabetic shoes
- Extra padding
- Soft fabric / seamless
- Lots of styles

Treatement

• Mobility aids: crutches, walkers, wheelchairs
• Specialized shoes
• Felt padding
• Total contact cast: redistributes weight bearing directly to the leg
• Prefabricated cast (Aircast, Scotchboot)
• Pressure relief ankle/foot orthosis (heel ulcers)

Question 4

What are the components related to debridement and infection control of foot ulcers?

Answer 4

• Remove all necrotic or devitalized tissue (including callus, slough, etc.).
• Cleanse wound with sterile saline
• Apply appropriate wound dressing

Question 5

Name different modalities used in the management of foot ulcers

Answer 5

Negative pressure (vacuum) wound therapy

Electrical modalities

Question 6

what’s the Lisfranc procedure?

Answer 6

amputation of the tarsal metatarsal joint

Question 7

what’s the chopart procedure?

Answer 7

amputation at the midtarsal (talonavicular and calcaneocuboid) joints

Question 8

What’s the syme ankle disarticulation

Answer 8

• talus is removed from its mortise
• distal points of malleoli are trimmed to create a flat surface
• posterior heel pad is drawn upward to close the wound

Question 9

Why is short transtibial amputation not the standard/preffered?

Answer 9

Too short for a prosthetic

Question 10

what’s a simple knee disarticulation?

Answer 10

no modification of patella or femur

residual limb is long and bulbous
center of the prosthetic knee is generally lower than that of the intact limb

Question 11

what’s a transcondylar amputation

Answer 11

shape of residual femur resemble a long transfemoral residual limb

bulbous shapes can lead to sin breakdown

Question 12

Describe a transfemoral amputation

Answer 12

• residual limb is a tapered cylinder
• knee center generally matches that of the intact limb
• difference based largely on length of femur that is preserved in the former

Question 13

When doing an amputation, there is a loss of distal insertion point of the muscle attatchement that requires surgical repair

What are the 3 types?
Which one is preffered?

Answer 13

muscle-to-bone fixations (myodesis) - preferred

muscle-to-muscle fixation (myoplasty)

muscle-to-fascia fixation (myofascial)

Question 14

What’s the biomechanical effect of the amputation on the musculature (4) ?

Answer 14

• altered line of pull of the muscles
• loss of force generating capacity (loss of muscle mass)
• altered / loss of distal connective tissue (tendon, etc.)
• shift in functional position on the length-tension curve

Question 15

As the length of the residual femur decreases, power and efficiency of ?????? muscles groups are more and more compromised.

Which muscle group are we talking about?

Answer 15

Adductors

Question 16

What should be included in patient/family education about amputation?

Answer 16

Wound insepction
residual limb care
mobility*
locomotion*
Self-care/ADL
Exercise program*
Follow up plan (MD, PT...)

Question 17

The projection of rehabilitation potential and prosthetic use after amputation is based on what 3 component?

Answer 17

pre-morbid level of mobility
ADL status
level of amputation

Question 18

What caracteristics are we evaluating on the residual limb (6)

Answer 18

1. Residual limb length (bone length, soft tissue length)
2. Residual limb girth: Circumference measures – multiple levels
3. Redundant tissue (“dog ears,” adductor roll)
4. Residual limb shape (bulbous, cylindrical, conical)
5. Assessment of type and severity of edema
6. Effectiveness of edema control strategy being used
   “shrinkers” are worn for the initial period following amputation, when not using prosthetic

Question 19

What are the requirements for the prosthetic (6)?

Answer 19

1. Potential for functional prosthetic use
2. Readiness for prosthetic fitting/prescription
3. Prosthetic design, components, suspension
4. Residual limb characteristics
5. Energy cost of ambulation:
   - older patients, deconditioning, co-morbid conditions
   - level of amputation: loss of joints, long bone length, muscle insertion
6. Level of amputation

Question 20

For the level of amputation (prosthetic requirements), what are the differences between:

1. transtibial amputation w/ intact anatomical knee joint
2. Bilateral transfemoral amputation

Answer 20

1. transtibial amputation w/ intact anatomical knee joint
   - more energy-efficient prosthetic gait pattern and postural responses
   - more likely to ambulate without additional assistive devices (walkers, crutches, or canes)
   - more likely to be full-time prosthetic wearers
2. Bilateral transfemoral amputation
   - Increased energy consumption for prosthetic ambulation: can prevent long-distance ambulation
   - wheelchair mobility may be more energy-efficient and effective means of locomotion
   - ambulation potential depends on cardiac function, strength, balance, and endurance

Question 21

how is the pain managed in LE amputation?

Answer 21

Primarily pharmacological

Other:
- acupressure/acupuncture
- modalities (varying degrees of success)
T.E.N.S.
ultrasound
cold or ice
massage

Question 22

To what is due phantom limb sensation / pain
A. Neuroplastic changes in the brain
B. Neuroplastic changes in the periphery
C. Spinal cord factors
D. The one ring to rule them all
E. Psychological factors
F. Modification of the vasculature

Answer 22

A. Neuroplastic changes in the brain
(Areas responsible for amputated limb are taken over due to disuse)
C. Spinal cord factors
E. Psychological factors

Question 23

How is phantom limb sensation or pain managed?

Answer 23

Medical / pharmacological management is common

Experimental therapies “exercise” for phantom limb:
Mental imagery
Mirror box

Question 24

Is there a hyposensitivity or a hypersensitivity problem, or both?

Explain.

Answer 24

Both!

Hyposensitivity

• Risk for skin breakdown
• Must be monitored: Skin inspection with mirror, Before and after prosthetic use
• Sensory testing

Hypersensitiity:

• Common
• bombard with tactile stimulus (various textures and pressures, intensity based on tolerance… slide 44)

Question 25

What are some tips to reduce edema?

Answer 25

WB activities in prosthetic socket - decreases limb edema - accelerates maturation of the residual limb - contact within the socket - pumping from muscle contractions Accommodating for fluctuation of residual limb size over course of the day - add/remove of layers socks

Question 26

What does adhesions around incision scar & surrounding area affects?

Answer 26

prosthetic tolerance, comfort, and use

Question 27

What is important in soft tissue mobility of the residual limb?

Answer 27

Adhesions around incision scar & surrounding area Deeper scarring/adhesions from surgical procedure Soft tissue must move independently of scar tissue or skeletal structures (stress can lead to tissue breakdown and discomfort)

Question 28

T/F | functional single limb ambulation is a prerequisite for prosthetic fitting

Answer 28

F | functional single limb ambulation is not a prerequisite for prosthetic fitting

Question 29

With ??? type of amputation there is a high risk of knee flexion contracture. - what is the type of amputation? - what's the negative impact? -

Answer 29

Transtibial amputation - high risk of knee flexion contracture - negative impact on future prosthetic use prolonged dependence of residual limb in knee flexion when sitting causes distal edema - can delay readiness for prosthetic fitting - wheelchair with elevating leg rests - posterior trough splint

Question 30

What can be done to increase ROM for transtibial amputation in prone position?

Answer 30

``` Prone positioning for stretching of posterior soft tissue manual passive stretching PNF prevention of knee flexion contracture deep effleurage massage moist heat or ultrasound ```

Question 31

what are the consequences of a decreased hip extension

Answer 31

Inability to achieve upright posture in stance Compensatory knee flexion causes instability in gait LBP due to compensatory anterior pelvic tilt Decreased stride length of contralateral limb in gait

Question 32

what are the consequences of a decreased hip adduction

Answer 32

Abducted stance in gait Abductor lurch on ipsilateral side in gait

Question 33

what are the consequences of a decreased hip IR

Answer 33

Toe-out stance and gait Knee joint pain or pathology due to lack of anterior/posterior orientation of knee joint

Question 34

what are the consequences of a decreased knee ext

Answer 34

Limb functionally shorter w/ associated gait deviations Decreased mid-stance stability in gait Prosthetic alignment adjustments to compensate

Question 35

what are the consequences of a decreased knee flex

Answer 35

Inability to place foot flat on the floor when sitting Inability to bear weight through prosthesis during sit-to-stand transfers Difficulty managing steps and curbs

Question 36

T/F with a transtbial amputation, attachments of the quadriceps and hamstrings are typically affected

Answer 36

F | attachments of the quadriceps and hamstrings are typically intact

Question 37

In a transtibial amputation, pre-prosthetic strengthening exercises emphasize on what?

Answer 37

control of the knee hip strength for stability in stance

Question 38

Give one exercise example for (transtibial amputation) 1. hip extensors 2. hip abductors 3. hip flexors 4. hip er/ir 5. knee extensors 6. knee flexors

Answer 38

1. Hip extensors Manual resistance +/- gravity Prone leg lifts +/- weights Bridging - residual limb over ball, padded stool, etc. Standing (parallel bars) vs. pulley, elastic bands, etc. 2. Hip abductors Manual resistance +/- gravity Side lying abduction – residual limb on top +/- manual resistance or weights Side-lying bridges – residual limb on bottom small ball or padded stool under knee of residual limb Standing hip abduction with pulleys or elastic bands 3. Hip flexors Supine SLR +/- manual resistance or weights Standing hip flexion with pulleys or elastic bands 4. Hip ER/IR Seated hip ER and IR +/- manual resistance or elastic bands caution re: knee ligaments 5. Knee extensors Seated knee extension CKC or OKC +/- manual resistance or weights 6. Knee flexors Seated knee flexion manual resistance, pulleys, elastic bands Prone knee flexion manual resistance or weights Bridging - residual limb over ball, padded stool, etc.

Question 39

With transfemoral amputation, the risk of ??? contracture is increased 1. Which contracture 2. What's the impact 3. What positionning can avoid that?

Answer 39

1. Risk of hip flexion contracture 2. negative impact on future prosthetic use; associated risk of tightness of hip abductors & ERs - Patients sit with hip out to increase BoS 3. Positioning Prone, towel roll under the distal anterior residual limb Pelvis neutral / slight posterior tilt (avoid Lx lordosis)

Question 40

With transfemoral amputation, which muscles have their distal attachement altered (7)? What's the consequence?

Answer 40

``` hamstrings rectus femoris sartorius tensor fasciae latae/iliotibial band +/- adductor longus +/- adductor magnus ``` Consequence - altered line of pull - loss of muscle mass - change in length-tension profile relative to joint ROM

Question 41

With transfemoral amputation, which muscles have their distal attachement intact?

Answer 41

gluteus maximus gluteus medius Iliopsoas +/- adductors (Pectineus, Add Brevis, Add. Longus, Add. Magnus)

Question 42

Give an example of exercise for transfemoral amputation - hip ext - hip abd - hip add

Answer 42

Hip ext: Slide 72 Hip abd: slide 73 Hip add: slide 74

Question 43

What should be addressed in a posture and balance training?

Answer 43

Sitting & Standing - with and without prosthetic Specific balance training - Change in CoM & BoS due to amputation - Loss of proprioceptive sensation from amputated limb Address ↓ ROM & muscle function

Question 44

Give some examples of gait and balance training (tot:10)

Answer 44

``` Static weight bearing Simple dynamic weight-shifting activities Reaching activities Repeated stepping activities Parallel-bar training Step-up/stairs (with the uninvolved limb) Gait training Sit-to-stand and stand-to-sit activities Floor-to-sit-to-stand Community activities ```

Question 45

Knee stability in stance is an important goal in transfemoral prosthetics Name an important trade off, and 3 main variables.

Answer 45

Trade-off with ability to flex knee during swing Three main variables: - voluntarily control using muscular strength / power (primarily hip extensors) - alignment of prosthesis vs. trochanter-knee-ankle line - inherent mechanical stability of the knee unit

Question 46

T/F oxygen uptake for patients with unilateral transtibial amputation is correlated to residual limb length and may be slighlty higher than that of individuals without amputation

Answer 46

F oxygen uptake for patients with unilateral transtibial amputation is correlated to residual limb length and may be 10% to 40% higher than that of individuals without amputation

Question 47

Gve some examples of advances exercises and activities

Answer 47

Range of motion & flexibility training - Independent stretching of hamstrings, quadriceps, hip flexors, hip internal rotators, and external rotators Resistance training - hip musculature, quads and hamstrings - closed-chain exercises step ups, leg press, wall or ball squats, involved limb lunges - involved limb stance with opposite limb resistance - multiple plane stepping exercises Balance and coordination - Involved single-limb stance; Static and Dynamic - Uneven & unstable surfaces - Beam walking Speed and agility - Figure-of-eight walking, progressing to running, - Shuttle walk to run - Sprinting - Obstacle course Cardiovascular activities - Swimming, running, cycling, treadmill walking, stair/stepper climbing, etc.