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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