MUHAMMED KOCABIYIK

PHYSICAL THERAPY & REHABILITATION III.CLASS V.GROUP

GOAL
In brief: the residual extremity should be a well contoured, functional and dynamic limb, accepting a prosthesis to allow the patient to ambulate/function in a relatively effortless and painless manner

Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit and use

Femur severely lateralized by pull of the abductors and no adductor stabilization

Conventional Amputation
Effects - Bone

Medullary canal ignored, remains open

Poor ability for end weight bearing Venous gradient 0mmHg venous stasis
Loon

Potential bone spur formation

Hansen-Leth, Reimann, Olerud

Hulth,

Regional osteopenia with possible

adjacent joint DJD Lo

Conventional Amputation
Effects - Muscle

Majority of musculature allowed to retract

Fatty atrophy
Blix, Loon

Venous stasis Slower speed of contraction

Poor volume of residual extremity in

prosthesis

Basic Science Length-Tension Relationship

Normal muscle has max force at slightly longer lengths In amputees, muscles are divided, retract, undergo fatty degeneration, and excursion in contraction is decreased Result is increased work to ambulate with increased fatigue

Loon, Prosth Int, 1959.

Conventional Amputation
Effects

Incisions placed over prominent surfaces Regional circulation disturbed

Secondary to venous stasis Abnormal vessel formation
Hansen-Leth, Hulth, Olerud

Potential etiology of pain

High risk of AVM Dilated, tortuous vessels Hansen-Leth,

Osteomyoplastic Reconstruction
Medullary canal sealed Broader surface area to bear weight Allows potential end weight bearing in AKA Improves local circulation

Basic Science Closure of Medullary Canal

Intramedullary venograms pre-/post-canal closure Loon, Prosthetics International,41-58, 1959

Myoplasty - Transfemoral

Fascial closure of opposing muscle groups Adductor brought laterally for balance in AKA Improves local vascularity Provides insertion for muscles to restore resting length-tension relationship Improve alignment and biomechanics of limb Soft tissue coverage to end of residual extremity

Insertion sites of adductors; not restoring an adductor movement allows femur to lateralize creating an inefficient gait pattern; this increases oxygen demand and can create greater cardiac stress in patients with cardiopulmonary disease; would emphasize maintaining the adductor Magnus and gracilis muscles to restore the adductor moment
F. Gottschalk- U. Texas Southwest

Myoplasty-Basic Science
Arteriogram of AKA prior to myoplastic procedure Poor filling in adductor region of leg Poor contour grossly Exostosis formation

Dederich, JBJS, 45-B, 60, 1963

Myoplasty-Basic Science
Arteriogram 3 months after myoplastic procedure There is increased arterial flow with in the stump Distal and medial perfusion is improved

Dederich, JBJS,45-B: 60, 1963

Osteomyoplastic Procedure

Goals

Osseous/soft

tissue reconstruction

Stabilize

Remove bone scar/spurs Medullary canal closure Myoplasty of opposing muscle groups Plastic Closure

Realign femur for proper mechanics and

the extremity

gait Muscle balancing

Osteomyoplastic Procedure

Goals

Provide a potential end weight bearing extremity

Closure of medullary canal returns normal

Create a cylindrical residual extremity

localized skin breakdown Pressure points reduced

venous gradient; distal bone remains vascularized

Improves fitting/use of prosthesis Smooth contour aides in preventing

Osteomyoplastic Procedure

Goals

Restore

normal physiology

Venous gradient in bone returned Vasculature improves in remaining

extremity Muscle length-tension relationship reestablished, thus restoring the efficient use of the muscle Loon, Prosthetics International,1959.

Osteoplasty

Adductor Stabilization

Muscle Flaps brought over end of femur

Quadriceps

Hamstrings

Completion of the myoplasty by suturing the quadriceps to the hamstrings. This stabilizes the entire soft tissue envelope and provides distal coverage for end-bearing of the residual limb. Meticulous skin closure is then performed, removing dog-ears and redundant skin. Goal is to provide a cylindrical limb for prosthetic application.

Immediate post-op

Adductor tubercle with adductor Magnus kept attached to cortical shell

5 weeks post-op; alignment maintained; no lateralization of femur

Orthotics/Prosthetics/P.T.

Begin comprehensive education

Support groups, networking

Begin comprehensive therapy

Transfers, stretching, desensitization,

gait training, upper extremity conditioning

Knowledgeable staff for support

i.e. ACA, nurse clinicians, etc.

Prosthetics

Physical Therapy

Post-Op protocol
0-4 weeks-Isometrics above amputation, ROM, UE aerobic conditioning 4-6 weeks-Isometrics, ROM, towel pulls, massage, scale exercises up to 10/15 lbs >6 weeks-advance P.T., gait training, posture, gluteal/core strengthening, socket application Emotional, psychological support

Support groups, starts from day one

Summary
Provides the amputee with a sound physiological residual extremity Patients have high satisfaction and there is improved outcome Can be applied to the vasculopath and diabetic 1.5 cm of bone resected on average Can used as a primary procedure as well as reconstructive

Summary

An amputation is not a benign, static procedure The limb is dynamic, so should the

Effort must be placed on a team approach The goal is to return to the patient a functional residual extremity This can be accomplished by adhering to biological surgery principles

team