Surgical Techniques And Outcomes; Psychosocial Issues Flashcards
What are the 3 most common levels of lower extremity amputation called?
- Transmetatarsal (midfoot)
- Transtibial (below knee)
- Transfemoral (above knee)
Disarticulation amputations occur at what level?
Level of the joint (hip, knee, and ankle disarticulations
4 Factors affecting level of amputation:
Vascular disease
-Level selected based on anticipated viability for ________ healing.
Postoperative function is considered
-Most _______ level possible.
Disarticulations
-Most surgeons won’t perform disarticulation at knee or ankle due to concern that poor __________ may interfere with healing.
Traumatic amputation
-Level determined based on _______ of injury and _______ of tissue.
- tissue
- distal
- circulation
- nature, viability
What is the goal of amputation?
Save as much limb length as possible.
What are the 2 main general surgical principles of amputation?
- Myoplasty
- Myodesis
What is myoplasty?
Attachment of anterior and posterior compartment muscle to each other over the end of the bone.
What is myodesis?
Anchoring of muscles to bone.
Myoplasty vs. Myodesis:
- Which increases stability and muscular control?
- Which is better in the presence of ischemia?
- Myodesis
- Myoplasty
In amputations, large nerves are pulled down and resected sharply so they retract into the sharp tissue, what does this prevent?
Neuromas - Thickened area of nerve tissue that are sensitive to pressure (interpreted as pain).
Skin flaps are as broad as the distal end of the limb and are shaped to allow corners to retract smoothly. Drains are utilized just under incision for removal of excess fluid and are removed after __-__ days.
1 to 2
In regards to skin flaps, when are amputations kept open?
If infection is present or not enough tissue to provide good closure.
What are the 2 main ways skin flaps are used for closed amputations?
- ) Equal length anterior/posterior flap
2. ) Long posterior flap
Equal length anterior/posterior flap is used when conserving _________ or when primary healing is not a concern. Flaps are shaped to reduce “________” at corners.
- bone length
- “dog ears”
Long posterior flap is used when _________ is of concern or when more padding is needed.
vascularity
What is a 3rd less common way skin flaps are used for closed amputations?
Skew sagittal flaps
Skew sagittal flaps are used in severe _________ cases and takes advantage of ________ nerve/artery, and ______ nerve. This helps with blood flow ________.
- dysvascular
- saphenous
- sural
- laterally
Transtibial (below knee) desireable length is controversial:
- Some advocate for bone length to help with _____.
- Others argue that long bone length increases chance for development of distal _____ problems as well as __________ tissue.
- gait
- skin, nonvascular
As a transtibial amputation gets closer to the knee, the ______ develops a mechanical advantage over the quad which can result in what?
- hamstrings
- knee flexion contractures, and difficult to extend knee (esp during swing phase)
What is the shortest level of amputation that is compatible with knee function?
tibial tubercles
In general, fibula is cut _cm shorter than the tibia for limb shaping. The tibia and fibula are also beveled to prevent soft tissue ___________.
- 1cm
- impingement
Transfemoral (above knee) is historically the most common level for individuals with poor ________ or _______ of the foot/ankle.
- circulation
- gangrene
Does a transtibial or transfemoral amputation require more energy to ambulate with a prosthesis?
Transfemoral
What are 3 reasons for choosing transfemoral over transtibial amputation?
- Trauma
- Gangrene extended into knee
- Circulatory status indicating poor chance of healing at transtibial level
In transfemoral amputations, maintanence of the __________ shaft axis as close to normal as possible is critical:
- Difficult secondary to loss of __________ attachment
- Surgeons suggest __________ of adductor magnus to femur at the level of the amputation for maintaining more normal alignment.
- femoral
- adductor
- myodesis
During surgery of a transfemoral amputation, the limb is maintained in ________ and _______ to maintain proper tension and alignment.
- extension
- adduction
What are the skin flap techniques used for transfemoral amputations?
- Equal length
- Long medial flap in sagittal plane
Common Issues Post-op (All Amputations)?
- Pain
- Wound healing
- Fluid collection/edema
- Heterotrophic ossification
Common Issues Post-op (Transtibial)?
Knee flexion contracture
Common Issues Post-op (Transfemoral)?
- Hip adductor roll
- Hip flexor contracture
- Hip abduction contracture
- Glute weakness
As the length of the femur decreases in an amputation, we have a much higher increased likelihood of hip __________ contracture due to the compromised power of the _______ muscles.
- abductor
- adductor
What is osseointegration?
Direct structural and functional connection between the surface of implants and living bone tissue percutaneously connected to a prosthetic limb.
What are the benefits of osseointegration?
- Eliminates need for a socket
- Short residual limb
- More natural feeling
- Improved gait
- Allows for normal swelling
What are the downsides of osseointegration?
- Multiple surgeries
- Prolonged period of no ambulation
- Risk of fracture, infection
- Reduction in activities that require high torque or axial stress
- Not well known in the U.S.
What is hemicorporectomy?
Below waist amputation, both LE amputated.
What is transpelvic amputation?
Amputation of portion of the pelvis and LE.
What is hip disarticulation?
Amputation through hip joint capsule including the entire LE.
When are hemicoprectomy, transpelvic, and hip disarticulations performed?
Usually performed to save the life of the patient.
- Malignancy
- Severe infection/gangrene
- Severe trauma
What is the goal of hemicoprectomy, transpelvic, and hip disarticulations?
Provide patient with good soft tissue flap for pressure tolerance for comfort with sitting.
Indications for Knee Disarticulation:
- Inability to provide adequate transtibial residual limb secondary to trauma
- Knee flexion contracture >__ degrees,
- ________ of soft tissue close to knee joint
- __________ deformities
- 45 degrees
- Infection
- Congenital
Are knee disarticulations used in individuals with vascular compromise?
Rarely, because typically disarticulations don’t have good vascular supply.
Ankle disarticulation (Symes) Amputations are through the ankle preserving the __________. They are used for severe foot trauma, congenital abnormalities, or gangrene of the forefoot.
heel pad
Is circulation to the heel pad required for ankle disarticulation to be successful?
Yes
Heel pad is closely adhered to end of tibia:
- Prevents movement between heel pad and bone that may result in ______ and ineffective prosthetic fit.
- _________ common immediately after to allow heel pad to heal.
- pain
- casting
Transmetatarsal amputations are a removal of the toes and distal ends of the __________. It is important to salvage as much metatarsal length as possible.
metatarsals
Transmetatarsal amputations are mostly performed secondary to _________ due to dyscascularity or diabetes. Also can come from _________ causes.
- infection
- traumatic
What are 2 other through the foot amputations?
- Lisfranc (tarsometatarsal disarticulation)
- Chopart (midtarsal disarticulation)
Main Takeaways:
- Reason for amputation is key for treatment
- Level and amputation type are important for _____________
- Limb _______ is vital to prosthetic use, and therefore function
- Expect impairments in muscle length, strength, and motor control following amputation surgery
- Don’t forget about ______________
- rehabilitation
- shape
- co-morbidities
PSYCHOSOCIAL ISSUES
PSYCHOSOCIAL ISSUES
What is the role of a PT in regards to phsychosocial issued steming from amputation?
- Recognize the effects of changes in body image.
- Help facilitate adjustment to change.
The effect of change in body image is related to what?
- How well the individual can continue to pursue previous activities.
- Whether change occurred gradually or suddenly.
- The most significant factor for positive adjustment to amputation is premorbid _______ mechanism.
- It is also dependent on what 3 things?
-coping
- Amputee experience: comfort, cosmesis, vocational, social
- Amputee behavior: are they using the part
- Amputee psychodynamics: perception of disability, ego, frustration
- Is depression and anxiety common in the amputee population?
- Many present with _______ and _______ which are negative coping strategies.
- Yes
- avoidance and denial
What are the 4 stages of emotional adjustment to amputation?
- 1st prior to surgery
- Immediatly after surgery
- After initiation of postoperative program
- Reintegration into functional lifestyle
Stage 1 of emotional adjustment is Initial _____.
- _____ to surgery
- Utilize more ________ responses
Shock
- prior
- reflective
Stage 2 of emotional adjustment.
- _________ surgery
- Relief and ______ are possible.
- Immediately after
- grief
Stage 3 of emotional adjustment is ___________.
- ________ program
- Younger indivduals may _____, men often fear negative implications of ________ activity.
- Overwhelming with ________ may lead to greater helplessness
Acknowledgement
- Post-op
- deny, sexual activity
- information
Stage 4 of emotional adjustment is ___________.
- Reintegration into _________ lifestyle
- Various concerns regarding prosthesis including _______, _________, and ___________ expectations.
Adaptation
- functional
- appearance, functionality, unrealistic expectations
_______ issues are concerns that are often left unattended.
Sexual
What is phantom sensation?
Sensation that the absent limb is still there in some form.
Phantom sensation is usually experienced after surgery and presents as ______, pressure, and sometimes _________.
- tingling
- numbness
In phantom sensation, the most _____ part is felt most frequently and occurs in majority of individuals and may last for _______.
- distal
- years
Is phantom pain the same as phantom sensation?
No, it is described as cramping or squeezing sensation, shooting or burning pain that is felt in the amputated limb.
Phantom pain can be ________ or diffuse; continuous or __________. Phantom pain may diminish or may become permanent.
-localized, intermittent
What is utilized to treat phantom pain?
Mirror box system/therapy
Age Considerations-Children:
- _________ adjustment is important because greatly influences the child’s adjustment
- Children adapt fairly ______ to the use of orthotic or prosthetic
- Important that parents treat the child “_________”
- parental
- easily
- normal
Age Consierations- Elderly:
- Critical issue: maintaining __________
- May be viewed as the end to an _______ lifestyle
- Learning to use artificial limb or orthosis may be slow and __________
- Consider ____________
- Important to allow the individual to have as much control as possible
- independence
- active
- discouraging
- comorbidities
Considerations: Caregivers
- Can be stressful for caregivers as well
- Can they _________ handle caring for the patient
- Provide time for caregiver to ask questions (may need to increase _________ in caregiver skills)
- physically
- confidence
Main Takeaways:
-Complex issues require ______ approach
-Pre-amputation _________ mechanism can determine psych outcome
Not just the patient
Children adjust quickly, but __________ can be an issue throughout teen years
- team
- coping
- compliance
