Amputation Levels - SportsEngine
Amputation Levels
Hemipelvectomy – loss of part of ilium/ischium/pubis
Hip Disarticulation – loss of whole femur
TFA – A & P flaps =; myodesis & myoplasty
Short - ( fit if @ lesser trochanter
Med – make sure there’s room for prosth knee
Long - ( end WBing
Knee Disarticulation – loss of whole tibia/fibula
(+) – good WBing, long lever, OK growth plate
(–) – knee sticks out
TTA – calf attach to front; suture @ A tib.; short fib.
Short – small lever; ( lig. probs.
Stand – good padding & lever
Long – poor dist. blood supply
Symes – ankle disarticulation
(+) heel pad, long lever, walk w/o prosth
(–) looks, neuromas, ( length
TMA – high failure rate; plantar flap to dorsum
** Mostly older ♂ minority feet/toes 2o disease**
** (B) TTA > Combo TFA/TTA > (B) TFA**
** young / trauma > older / vascular**
**Want length for: ( contact, lever, healing
K-Levels
0 – ( potential for ambulation / transfer w/ prosthesis
1 – Household ambulator, can use for transfers also
2 – Limited community ambulatory
3 – Community-dwelling; variable cadence
4 – high impact/stress/energy; child or athlete
Can (s)he use a prosthesis?
Hx, E-use, cogn., amp. level, ROM/strength
Residual Limb Care & Assessment
Length, shape, circumference; sensation
Skin care / scar mobilization
Edema – shrinker sock, splint, semi-rigid, IPOP
ROM / contractures
TTA (Knee F, Hip ER / Abd / F)
TFA (Hip ER / Abd / F)
Strength – ½ grade less for TTA, full grade less for TFA
Post-Op Protocol
Rigid Dressing – (KF contract, (edema, protection
Removable “” (RRD) – monitor surg. site
IPOP – walk w/ WBing, (contract, early Fxn
Compression – shrink sock +/- RRD or IPOP
Prep Prosth – b4 size stable, continual adjustment
Defin Prosth – custom socket + with “skin/flesh”
Socket Concepts
Want total contact
Wt dist, ( circulation, ( sensory feedback
Contain residual limb
Suspends prosthetic limb
Distribute forces to residual limb
Hard plastic (foam liner) vs. flexible (thermoplastic)
TFAs use flexible sockets
Socks ( shearing, keep V const, ( piston, ( WBing
Shank Concepts
Provide leg length / shape
Transmit Wt from socket to foot
Endoskeletal – Easy adjustment, ( looks, athletics
Exoskeletal – durable, for active Pt, cheap
Foot Concepts
Absorb shock, allow PF at LR
Allow MTP E at TSt & PSw
Transmit force to shank/residual limb
Keel – (rigid or flex) Wt support from heel to MTP
Toe lever
Long ( quick knee F at LR & MSt
Short ( PF & stay knee E
Heel lever
Long ( PF & stay knee E
Short ( quick knee F at LR & MSt
Heel stiffness
Stiff ( encourage knee F at IC & LR
Soft ( maintain knee E
SACH foot – K = 1, any level amp, rigid keel, (artic
SAFE foot – K = 2, mimic windlass, cush heel
Dyn Resp – K = 3-4, E-store, stiff/flex keel
Seattle – C-shape keel
Flex-foot – leaf-spring shank
1-axis foot – mvmt control by bumpers, ( shock abs
Multi-axis foot – bumpers, stab @ eROM only
Partial Foot Amputations
Toes
(+) high Fxn
(–) ( balance / toe off / arch; shear Fs
Midfoot
(+) high Fxn
(–) PFcontract, risk of 2nd amp., long limb
Gait problems
( contra step
( shear F
( ipsi knee stability
Prostheses
Toe filler – support body WBing
Complex AFO – control Tib prog in MSt/TSt
Symes Amputations
(+) heel pad for shock, stump-walk, hi Fxn
(–) ( length, M drift of heel pad, wide prosth, hard to fit
Gait problems
(PF & knee F at LR
( contral knee F at LR (for shock)
( trailing limb at TSt / ISw
Prostheses
Socket up to patellar Tend
Expandable wall / window for bulbous end
TTAs
(+) ( outcome, ( phantom P!, easy to fit
(–) may have to have 2nd amp. (esp for DM/infxn)
Benchmark alignment
Socket ER & F & Add (3-5o)
(WB area for pat. Tend
Accommodate contractures
( if lack of knee F during gait
Inset foot (varus force) see picture
Breakdown L prox, M dist
Socket force to M prox, L dist
Outset foot (valgus force)
Breakdown M prox, L dist
Socket force to L prox, M dist
Socket
Total contact (not end-WBing)
Relief – A tib, fib head, fib nerve
WBing – Pat Tend, M tib, tib/fib shafts
Hard socket, soft liner
Suspension
Supracondylar cuff – K ( 2
Supracondylar socket (ears) – ( M/L stability
Supracon/Suprapat – short limb, high A wall
Thigh corset – (WBing area, weak quads
Waist belt – for elderly, (B), or conical limb
Suction – ( proprio, may need more fixing
Sleeve – cosmetic, hot, tears, hard to don
TFAs
(+) looks, decent fit
(–) conical limb hard to fit
Benchmark alignment
Socket 6-7o Add, 5o F
Foot inset
Knee & foot 5-7o ER
Need TKA line A to knee t/o stance
Socket
Total contact (not end WBing)
Quadrilateral see picture
P shelf for isch tub & glutes
A wall high w/o hip F interference
P wall F’d (hip E stretch)
L wall 6-7o Add, high
M wall counter-pressure to L wall
Relief – Add Long, Hams, Sci nn, Glute
max, Rect Fem
(–) rot probs, ( short limb, ( frontal stab
Ischial Containment see picture
M & L more narrow
Socket in IR & F
Relief – L femur end, pub symph, perineal
WBing – Isch tub, glute, L limb, end limb
Suspension
Pull-in Suction – VASS, mm tension, skin friction
Don by pull sock or liquid powder
(+) ( piston, ( contact, ( proprio, comfy
(–) “burp”, hard to don, may fall off
Roll-on Liner – pin on end of sock
(+) easy to don, OK for scars, OK for short
(–) may tear, expensive
Total elastic – see picture
(+) comfy, OK V (, OK for scars
(–) rot prob., hot
Silesian band – belt + buckle + strap
(+) ( rot, light, comfy, adjustable, OK V (
(–) piston, min rot prob
Pelvic belt & hip joint – heavy duty Silesian
(+) OK for short, ML stab, ( Trendelenburg
(–) heavy
Knee Units
Durable, stable, allow shank advancement
1-axis – cheap, sag only, ( stab at IC
Multi-axis – AP translation, ( stab at IC, heavy
Manual lock – K = 1-2 or very weak
Make shorter by 1cm, good for IPOP
Stance phase control – K = 1-3, locks in stance
( maintenance
Friction device – K = 1-2
Constant – 1 cadence only, swing phase control
Variable – multi-cadence
Hydraulic & Pneumatic – young/active, $
Microprocessor – K = 3-4
Swing – smooth swing, $, maintenance
Swing/Stance – efficient & stable, $, maint.
Knee Disarticulation Amputations
(+) good lever, socket fit, distal WBing, natural hip
Add preserved, hip Abd’s ML stab
(–) ( space for knee, bulbous end
Socket
Modified Quadrilateral or Ischial containment
Window for bulb, ( WB prox
Suspension
Snug supracondylar contour /suction + ancillary
Knee component
1-axis w/ hydraulic/pneumatic
Or hard to fit polycentric knee joint
Hip Disarticulation & Hemipelvectomy Amputations
Socket
Molded to accommodate pelvis
WBing – isch tub, iliac crest
Total contact
Suspension
Via opposite side
How to get stability
Hip E
TKA line A to knee, P to hip
Knee joint – stability-enhanced types only
Long-Term Prosthetic Use Complications
OA
2-3x more likely... TFAs > TTAs
Mainly in knee
LBP
75%
Scoliosis
65%...work on posture & prosth fit
Osteoporosis of amputated hip
( WB status & blood flow
Further amputation
50% have another (same or sound) in 4yrs
Must ( foot care (esp DM)
Regular follow-up, good shoes, education
*Watch for weight ( to affect socket fit
*Use crutches if not using prosth (don’t hop)
*Keep good posture (seated & standing)
Gait Disturbances & Differences
Initial Contact
Abduction of prosthesis ( ( stability
Adduction of sound limb ( ( stability
( double limb support time ( ( WBing on MTPs
Forceful knee E
*Concentric glute/ham for propulsion
Loading Response
( knee F ( ( efficiency & pivot over prosthesis
Prosthesis rotation ( ( shearing
*Concentric glute/ham for propulsion
Mid-Stance
L trunk lean ( keep socket Add…short contra step
( balance / proprioception from ankle
Ipsi hip drop ( ( efficiency
( contra step
Varus thrust – ( foot inset, ( socks
From L lig lax, narrow walk, short limb
Valgus thrust - ( foot outset, ( socket Add, ( socks
From M lig lax, wide walk
Hip Abd – ( socket fit, ( leg length, ( socks
From limb P!, ( Wt shift, hip Abd contracture
L Trunk lean – ( socket fit, (/( leg length, ( socks
From limb P!, habit, cane use, hip Abd weak
Terminal Stance
*keep socket flexed (compensate for ( initial hip F)
( Lordosis ( 2o A pelvic rot / ( knee F
( hip E if contracture ( ( contra step length
Lack of KE storage in prosthetic foot
* hip E’s active to compensate for (PF’s
Drop-off – ( toe lever, ( socket F, PF foot
From knee F contracture
Pre-Swing
Kick prosthesis forward via P tilt of pelvis
( demand on hip E’s 2o late knee F & A pelvic rot
Poor pelv rot ( quick prog to sound toes from heel
Initial Swing
P tilt pelvis ( ( stability, posture problems
( transv rot ( ( knee F ( ( foot clearance (
vault or Circumduction
Mid-Swing
*TTA can control forward prog of tibia
*TFA use cadence & knee joint components to control forward prog of tibia
Hip Abd / Hike / Contra Vault / Drag - ( leg length,
( socks, ( knee F friction
From ( knee F ROM, hip Abd contracture
M / L Whip – ( suspension fit, ( socks
From put on wrong, weak prox mm
Uneven heel rise – ( knee friction, ( knee type
From forcing hip F
Terminal Swing
*Need neutral foot placement (no abduction)
*Regain arm swing for efficient gait
The Rehab Process
Phase I
Residual limb care (casting, contracture mgmt, etc)
Transfer training & W/C mobility, etc
Phase II
Pre-prosthetic training
Pt education
Strengthening & ROM exercises
Isometric / isotonic / isokinetic & UEs too!
Remove prosthetic
Prone stretch (30min 2x/day)
Glute/HS bridges
Abductor & Adductor bridges
Partial sit-ups & core training
Balance / Agility / Coordination exercises
Short sit, long sit, high kneel, Qped
Ball toss, sport cord, rotation
Phase III
Pre-gait activities (learn to use / WB on prosth)
SLS restoration exercises
Learn CoM over BoS
Learn where foot is in space (tapping)
Promote WBing & confidence
Standing progression of Phase II ex’s
Weight shift A-P, side, hip strategy
SLS, stair step, side-step, cross/braid
Phase IV
Gait & Skill training
Ball rolling
Cup walking
Backward walking
Sport cord kicks / resisted walking
Toe box jumps / agility cone drills
*balance over both feet, = WBing, use mm in socket effectively, hip/knee timing
Phase V
Intervention tailored to social/work roles
Training to run
Trust prosthesis…reach out with limb, land squarely on foot.
Backward extension…pull back on IC/LR
Sound stride…keep pulling back on prosth
Symmetric stride…
Regain normal arm swing/carriage
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