Consensus conference on amputation sx in Scotland in Oct 1990 ’92- Rungsted, Denmark ’92- Groningen, The Netherlands ’93- Moshi, Tanzania ’94- Pattaya, Thailand ’94- Ljubljana, Slovenia ’94- Panama City, Panama ’96- Madras, India ’97- Jaipur, India ’97- Helsinborg, Sweden ’98- Hanoi, Vietnam ’98- Tokyo, Japan ’99- San Salvador, El Salvador

2004- course given new content and a new name: Amputation surgery and related prosthetics

2009- first time the new course was given

Course Outline: 1

› History› Epidemiology› Pre-op Mx› Decision making process in Sx› Post-op Mx› Prediction of functional outcome› Sexuality and amputation

2› Skin problems› Physiotherapy› Phantom pain and pain mx› Psych aspects› Sports after amputation› Liners› CAD-CAM

Continuation of 2› Hip disarticulation & hemipelvectomy

Epidemiology and Sx Rehabilitation Biomechanics Prosthetics

3› Transfemoral amputation

Epidemiology and Sx Rehabilitation Biomechanics and gait Prosthetics

Continuation of 3› Transtibial amputation

Epidemiology and Sx Rehabilitation Biomechanics and gait Prosthetics

4› Foot and ankle amputations

Epidemiology and Sx Rehabilitation Biomechanics and gait Prosthetics

Continuation of 4› Diabetic foot

Epidemiology Physical examination Treatment of foot infections Rehabilitation Casting Orthotics Ortho reconstructive sx

Surgeons: › Douglas Smith (USA)› Takaaki Chin (Jpn)

Rehab physicians:› Dirk van Kuppevelt (The Netherlands)› Jan Geertzen (The Netherlands)› Carolina Schiappacasse (Argentina)

P&Os:› Donald Cummings (USA)› Siegmar Blumentritt (Germany)

Official name given by the ISO Previous used names

Partial foot amputation Chopart amputation

Lisfranc amputation

Ankle disarticulation Syme amputation

Pirogoff amputation

Through ankle disarticulation

Trans-tibial amputation Below-knee amputation

Knee disarticulation Through knee amputation

Trans-femoral amputation Above-knee amputation

Hip disarticulation Through-hip amputation

Trans-pelvic amputation Hemipelvectomy

Hindquarter amputation

Sacroiliac amputation

“It is not to take but to make.” Early rehab involvement!

› Although same problem everywhere, not happening or inconsistency in engaging rehab pre-op

Peri-op mortality in LLA is high MI is the most common cause of post-

op mortality Cardiac function is relevant during

rehab because of required increased energy expenditure

Obj: to determine pre-op ventricular function in vascular amps by measuring NT-proBNP and to analyse the relationship b/w NT-proBNP and 30-day post-op mortality

Prospective pilot study 19 pxs; four died w/in 30 days after sx In 17 of 19, levels were found to be more

than 2 SDs above age-corrected reference values

Clinical messages: Pre-op NT-proBNP levels in vascular

amputees are not statistically related to 30-day mortality and level of amputation

Pre-op NT-proBNP levels in vascular amputees are high, indicating that serious ventricular disease may be present.

“Soft tissue is more important than bone.”

http://www.ampsurg.org

Lack of research After thorough publication database

search: only 11 eligible studies found Amputees remain to be sexual beings Sexual activities are hindered in different

ways, related to type, level, and cause of amp’n

Effects of pain and body image on libido Erectile dysfunction; decreased lubrication

Higher impact on sexual functioning in the elderly compared to younger amputees› ?effect of age vs amputation

Being married or having a steady partner as an amputee give fewer problems than being single

13-75% are not satisfied with their sexual life, despite unchanged interest in sex

Conclusion Assessment of sexual functioning

should be an integral component of the periodic evaluation scheme in the Rehab team.

One or more members of the Team should be trained for that assessment.

Wrong concept:› Rehab only starts after the stump has

healed completely Consider x-ray of stump trial antiperspirant spray or roller for

problematic sweaty stumps? May need less wash (q2-3 days) of

stumps during colder months?

General principle:“The liner has to be as thin as possible

and as thick as necessary.”Selection should be based on individual

circumstances.

Historical love/ hate relationship First described in literature in 1830 Very little data Most national surveys: 1-3 % of all

amputations

Dr Douglas Smith’s experience› 12 year data base (1995-2008)› 1787 total amputation procedures

950 primary 827 secondary

› 62 knee disarticulation (3.5%) Trauma= 27 pxs Infection= 11 pxs Vascular dse= 10 pxs SCI= 4 pxs

80 KDs in 77 pxs Aged b/w 19-92 (average of 64) 31 DM; 29 PVD; 14 trauma; 2 sarcoma; 1

Ollies Dse 5 pxs died early in post-op pd 63 of 67 healed primarily; 7 dehisced and

revised to TF level 22 of 27 who walked pre-op successfully,

used a prosthesis and walked post-op

Non-ambulatory pxs have different concerns and goals than ambulatory pxs.› How will the px transfer?› What contractures are present?› What contractures will occur?› Consider surface area and support for

sitting.

For ambulatory pxs, KD is usually more functional than a TFA› Longer lever arm› Balanced thigh muscles› Improved suspension› End bearing› Lower proximal socket brim› Sitting comfort

Walking velocity (Pinzur, et al, Ortho, 1992 Sep) › Slightly lower than TTAs, but significantly faster than

TFAs Function (Hagberg, et al, PO Int 1992 Dec)

TTA TKA TFA

Don and doff 100% 70% 56%

Daily use 96% 76% 50%

>9hrs/day 54% 41% 22%

6-9hrs/day 17% 11% 6%

3-6hrs/day 13% 24% 28%

<3hrs/day 13% 12% 28%

No use 4% 12% 39%

Consider C-knee in the elderly population!› Provides better gait› Improved stability› Improved walking speed› Less falls

Hip flexion contracture› 1st year: try to stretch to correct or lessen

degree of contracture› After 1 year: provide prosthesis which will

accommodate to contracture Not cosmetic- but more functional

Who/When to prescribe a Prosthesis? TTA:

› Patient has their own knee power› Prosthesis helps w/ transfer› Prosthesis helps with STS

TFA:› Patient has no knee power› Prosthesis has no knee power› Transfers- often easier without prosthesis› STS- prosthesis makes it more challenging

Before a TF Prosthesis is prescribed, patient must master the following vital skills: (UW guidelines) › Transfer independently (both in/out of bed,

on/off toilet)› STS independently› Walk in parallel bars or walker (one leg

gait), for at least 6-8 meters

Explain the vital skills and importance Offer prosthesis when patient masters

skills Places challenge on patient and family Avoids arguments!

A multidisciplinary Foot Clinic

In developed countries:› Up to 4% of people w/

DM have a foot ulcer› Uses 12-15% of

healthcare resources for DM

Multidisciplinary foot team has been shown to bring 49-85% reduction in amputation rates

Minimal model› Doctor› Podiatrist and/or

nurse

Intermediate› Doctor (diabetes

specialist, surgeon, rehab)

› Podiatrist and/or nurse

› orthotist

Highly recommended› Relevant› Comprehensive,

but not too overwhelming

› Balanced and well-respected speakers

A Sydney venue in the future?!

We are Coaches!

We must create enthusiasm!› Positive approach to Surgery› Positive approach to early

rehabilitation› Positive approach to prosthetics