trans femoral prosthetics
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TRANS-FEMORAL PROSTHETICS
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 AmputationEffects - Bone
Medullary canal ignored, remains openPoor ability for end weight bearingVenous gradient 0mmHg → venous
stasis Loon
Potential bone spur formation Hulth, Hansen-Leth, Reimann, Olerud
Regional osteopenia with possible adjacent joint DJD Lo
Conventional AmputationEffects - Muscle
Majority of musculature allowed to retractFatty atrophy Venous stasisSlower speed of contraction
Blix, Loon
Poor “volume” of residual extremity in prosthesis
Basic ScienceLength-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 fatigueLoon, Prosth Int, 1959.
Conventional AmputationEffects Incisions placed over
prominent surfacesPotential etiology of pain
Regional circulation disturbedSecondary to venous stasisAbnormal vessel formation Hansen-Leth, Hulth, Olerud
High risk of AVMDilated, 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 ScienceClosure 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 formationDederich, 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 improvedDederich, JBJS,45-B:
60, 1963
Osteomyoplastic ProcedureGoals
Osseous/soft tissue reconstructionRemove bone scar/spurs Medullary canal closureMyoplasty of opposing muscle
groups Plastic Closure
Stabilize the extremityRealign femur for proper mechanics
and gaitMuscle balancing
Osteomyoplastic ProcedureGoals
Provide a potential end weight bearing extremityClosure of medullary canal returns
normal venous gradient; distal bone remains vascularized
Create a cylindrical residual extremityImproves fitting/use of prosthesisSmooth contour aides in preventing
localized skin breakdownPressure points reduced
Osteomyoplastic ProcedureGoals
Restore normal physiologyVenous gradient in bone returnedVasculature improves in remaining
extremityMuscle 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.
Adductor tubercle with adductor Magnus kept attached to cortical shell
Immediate
post-op
5 weeks post-op; alignment maintained; no lateralization of femur
Orthotics/Prosthetics/P.T.
Begin comprehensive educationSupport groups, networking
Begin comprehensive therapyTransfers, stretching,
desensitization, gait training, upper extremity conditioning
Knowledgeable staff for supporti.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 supportSupport 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 procedureThe limb is dynamic, so should the “team”
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
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