Surgical Techniques and Outcomes

Question 1

List factors affecting level of amputations

Answer 1

1. vascular disease
2. postop function is considered
3. disarticulations
4. traumatic amputation

Question 2

what are general surgical principles for amputations?

Answer 2

save as much limb length as possible

large nerves are pulled down and resected sharply so that they retract into soft tissue and prevent formation of neuromas

Question 3

what is a myoplasty?

Answer 3

surgical tech in which attachment of A/P compartment muscles to each other over the end of bone

better in the presence of ischemia

Question 4

what is a myodesis?

Answer 4

surgical technique in which anchoring of muscles to bone

allows for increased stability and muscular control

Question 5

when are open amputations utilized?

Answer 5

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

Question 6

what are the types of skin flaps used during a closed amputation?

Answer 6

1. equal length A/P flap
   
   • used when conserving bone length or when primary healing is not a concern
   • flaps shaped to reduce “dog ears” at corners
2. long posterior flap
   
   • used when vascularity is of concern or when more padding is needed
3. skew sagittal flaps
   
   • used in severe dysvascular case

Question 7

how is a skew sagittal flap performed??

Answer 7

• takes advantage of saphenous nerve, artery and sural nerve
• removes anterior placement of scar from high prosthetic pressures
• helps with blood flow laterally

Question 8

why is a longer residual limb more functional?

Answer 8

longer limb = longer level arm = more functional gait

Question 9

Describe a transtibial amputation including it’s pros/cons

Answer 9

amputation is behind the knee, allows for a longer length and smoother gait. Disadvantages is that some argue that the longer bone length increases the chance for development of distal skin problems.

• Tibial and fibula are beveled to prevent soft tissue impingement
• Generally, the fibula is cut 1 cm shorter than tibia
• Knee flexion contracture can occur

Question 10

describe a transfemoral amputation including it’s pros/cons

Answer 10

amputation is above the knee. Most common level for individuals with poor circulation or gangrene of foot/ankle

• Allow for greater circulation above the knee
• Much harder time with gait. Attempt to maintain as much femoral length as possible.
• Hip adductor roll, flexor contracture, abductor contracture, and glute weakness can all occur.

Question 11

what is heterotrophic ossification?

Answer 11

overgrowth of bone

Question 12

define osseointegration

Answer 12

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

Question 13

what is the difference between phantom sensation and pain?

Answer 13

sensation - sensation that the absent limb is still there in some form

pain - cramping or squeezing sensation, shooting pain or burning pain.

Question 14

Why/how does the length of the femur determine likelihood of a hip abduction contracture?

Answer 14

The shorter the femur the less room there is for attachments of the adductor muscles meaning there is no opposing force to hip abductors resulting in a hip abduction contracture.

Question 15

list the pros of osseointegration?

Answer 15

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

Question 16

what are the cons of osseointegration?

Answer 16

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 USA

Question 17

List the pros of disarticulation surgery/amputation?

Answer 17

1. Knee disarticulations provide a longer lever arm, remove knee flexion contractions as a concern
2. Hip disarticulations remove the possibility of contractures at the hip (abductors and flexors)
3. Ankle disarticulations can still be very functional

Question 18

List the cons of disarticulation surgery/amputations

Answer 18

1. Knee disarticulations make it difficult to fit a prosthetic around the remaining lightbulb type structure
2. Ankle disarticulations prevent movements between heel pad and bone which can result in pain and an ineffective prosthetic fit.

Question 19

when are hip disarticulation surgies/amputations appropriate?

Answer 19

usually performed to save the life of a patient in the presence of a malignancy, severe infection/gangrene or severe trauma

Question 20

when are knee disarticulation surgeries/amputation appropriate?

Answer 20

indicated when there is:

1. an inability to provide adequate transtibial residual limb secondary to trauma
2. if there is a strong knee flexion contracture >45 degrees,
3. infection of soft tissue close to knee
4. with some congenital deformities

Question 21

when are ankle disarticulation surgeries/amputations appropraite?

Answer 21

used for severe foot trauma, congenital abnormalities, or gangrene of forefoot. Must have circulation to heel pad to be successful

Question 22

List some common impairments that would be expected following any LE amputation surgery

Answer 22

1. Ambulation difficulties
2. Infection risk
3. Pain
4. Contractures

Question 23

What are some factors that determine psychological adjustment following amputation surgery?

Answer 23

1. Premorbid coping mechanisms
2. Also dependent on:
   
   • Amputee experience: comfort, cosmesis, vocational, social
   • Amputee behavior: are they using the part?
   • Amputee psychodynamics: perception of disability, ego, frustration

Question 24

What are examples of negative coping mechanisms displayed by amputees following surgery?

Answer 24

1. Denial
2. Being overly optimistic and not taking time to process
3. Insomnia, restlessness and difficulty concentration

Question 25

What are the 4 proposed stages of emotional adjustment following amputation surgery?

Answer 25

1. Initial shock
2. Grief? (slide was missing a title)
3. Acknowledgement
4. Adaptation

Question 26

How does age influence a patient’s ability to emotionally adjust following surgery?

Answer 26

1. Younger individuals adjust faster and better, but their caretakers usually struggle
2. Older individuals have a harder time adjusting