Artificial Limbs - Principles of Amputation PDF

Artificial Limbs Dr. Hassanain Ali Lafta Principles of Amputation Assist. Prof. Dr. Hassanain Ali Lafta [email protected] Limb amputation is one of the most ancien...

Artificial Limbs Dr. Hassanain Ali Lafta Principles of Amputation Assist. Prof. Dr. Hassanain Ali Lafta [email protected] Limb amputation is one of the most ancient of all surgical procedures with earliest historical references dating to back to Babylonian code of Hammurabi 1700 BC and to the time of Hippocrates in 385 BC. Amputation represents the - ↓ cutting off or the removal of limb/extremity or part thereof by trauma, prolonged constriction or surgery. As a surgical measure, it is used to control pain or a :19s disease process in the affected limb such as a malignancy, infection or gangrene. In some cases an amputation is carried out on individuals as a preventative surgery for such problems and other people are born with amputations due to congenital disorders. Every care should be taken to assure that the amputation is done only when clinically indicated. Amputation should only be considered if the 1 /52 is ij limb is non-viable (gangrenous or grossly ischemic, dangerous, malignancy or Si infection), or non-functional. A well-planned and executed amputation can -jjb remove a painful, dysfunctional limb and allow rehabilitation with a prosthetic Sy15 % limb to a functional, painless state. 1|Page Artificial Limbs Dr. Hassanain Ali Lafta The earliest amputations were generally undertaken to save lives; however, = - their outcomes were often unsuccessful—many resulted in death from shock => - Ois & 5. I ② Id caused by blood loss or onset of infection and septicemia in those who survived - a - the operation. In these early amputations, removal of the compromised limb segment as quickly as possible was essential. With the advent of antisepsis, asepsis, and anesthesia in the mid nineteenth century, physicians focused increasingly on the surgical procedure and conservation of tissue. The development of modern medical treatment has provided alternatives to amputation. Today, when amputation is necessary, surgery is undertaken with consideration for the functional aspects of the residual limb. Causes of Amputation Joging - In developed countries, peripheral vascular disease is the major cause; ① -inding ① / whereas, trauma, infections, uncontrolled diabetes mellitus and malignancies are the leading causes for amputation in developing countries, according to World -1,6 surveys. Most amputees in developed countries are elderly patients with vascular problems. However in the developing countries, most patients with amputation are young and the major cause of limb amputation varies from one hospital to another. 2|Page  Artificial Limbs Dr. Hassanain Ali Lafta The main causes for amputation may include any of the following: Congenital igid -  Congenital limb deficiency. & mmmp) ps5 Phocomelia: "a congenital deformity in which the limbs are extremely shortened ES1 so that the feet and hands arise close to the trunk". S Acquired jog - ste -S1S1. :S  Vascular; Ischemia, Diabetes, Frostbite, Arterial insufficiency leading to death or S15 5 5 941 , decay of body tissue (gangrene), and Chronic leg ulcer leading to septicemia. 896 ses Ele print  Infection e.g. Bone infection (Osteomyelitis). g's sidivips  Malignant tumors e.g. sarcoma (cancer of the connective tissue). - - 5jjnj ) , is ·i j  Trauma (limb buried under / crushed by heavy object, limb damaged by car na NA - accident, stabbing, gunshot, animal bite etc.) Levels of Amputation ① & d Amputation can be performed as a disarticulation of a joint or as a transection Ips sin through a long bone. The classification of amputations is based on the level at which the amputation occurs. When it occurs across a bone shaft, an amputation - - is considered transverse, as in a “trans” radial amputation of the forearm or a ~ “trans” tibial amputation occurring through the tibia. When an amputation occurs across a joint, it is considered a disarticulation, as in an elbow or hip disarticulation. The level of amputation is usually named by the joint or major bone through which the amputation has been made. An amputation that involves lower extremity can affect an individual's ability to stand and walk, requiring the - G ② use of prosthetics and, often, an assistive device for mobility. - - 3|Page Artificial Limbs Dr. Hassanain Ali Lafta - 4|Page Artificial Limbs Dr. Hassanain Ali Lafta CADL) Amputation involving upper extremity can affect other activities of daily - living, such as feeding, grooming, dressing, and a host of activities that require - manipulative skills. Because of the complex nature of skilled hand function, prosthetic substitution for upper limb amputation does not typically restore function to the same degree that lower extremity prosthetics do. Upper Limbs Amputations  Transcarpal and Partial Hand Amputations: Finger, thumb and portion of the hand below the wrist.  Wrist Disarticulation: Limb is amputated at the level of the wrist.  Elbow Disarticulation: Limb is amputated at the level of the elbow.  Transradial (Below Elbow Amputations): Amputation occurring in the forearm, from the elbow to the wrist.  Transhumeral (Above Elbow Amputations): Amputation occurring in the upper arm, from the elbow to the shoulder.  Shoulder Disarticulation: Amputation at the level of the shoulder, with the shoulder blade remaining.  Forequarter Amputation: Amputation at the level of the shoulder in which both the shoulder blade and collar bone are removed. Lower Limbs Amputations  Foot Amputations: Amputation of greater toes and other toes, partial foot C mputation through the metatarsal bones (Chopart amputations).  Syme’s Amputation: Removal of both medial and lateral malleoli. Ankle - ,Dis  Ankle Disarticulation: Amputation at the level of the ankle joint.  Transtibial (Below Knee Amputations): Amputation at any level from the knee to the ankle. 5|Page  Artificial Limbs Dr. Hassanain Ali Lafta  Knee Disarticulation: Amputation at the level of the knee joint.  Transfemoral (Above Knee Amputations): Amputation at any level from the hip to the knee.  Hip Disarticulation: Amputation is at the hip joint with the entire thigh and lower portion of the leg being removed. Assessment of Amputation A decision to amputate a limb should be made through discussion with the interdisciplinary team - including the patient - wherever possible; in an emergency situation, the decision should be made based on medical need. There are a number of different investigations that can be carried out to assess the need for an amputation; these examinations assess the bones and soft tissues to establish limb viability. s  X-ray – images of bones to view fractures or disease. i Computerised Tomography (CT) scan – detailed billsi images of bone, tissue and blood vessels. gipsi ,  Angiogram – outlines blood vessels. 96 , - ·I -  Doppler ultrasound – occlusion of blood vessels. & Venogram and arteriogram – detailed imaging of blood vessels. These investigations will help the surgeons to find out if the blood supply to the limb is intact. The lower limb is supplied by the popliteal artery ① - which subdivides into the posterior tibial, anterior ③ tibial, and the fibular arteries. 6|Page  Artificial Limbs Dr. Hassanain Ali Lafta These investigations will help the surgeons to find out if the blood supply to the limb is intact. The lower limb is supplied by the popliteal artery which subdivides into the posterior tibial artery, anterior tibial artery, and the fibular artery. jy i In vascular diseases these arteries can become blocked or narrowed over time 91 is ① Ele je which reduces the circulation to the legs; this can cause pain, ulceration and ③ sinjps - - blackened areas. If left untreated this can lead to gangrene or infection and an - amputation is needed to avoid this becoming life threatening. & &5 In trauma one or more of these blood vessels may be ruptured beyond repair due - to the nature of the injuries sustained – e.g. in a car accident, gunshot wound or blast. In this situation an amputation is performed as the limb does not have any blood supply beyond the level of injury and is therefore deemed non-viable. After an amputation, the bit that's left beyond a healthy joint is called a residual limb, or more commonly, a stump. Once a decision has been made to remove - part of a limb, the level of amputation needs to be decided; this can have significant consequences so there are a number of factors to take into account when planning the surgery: -S Silk - I Boundary of dead or diseased tissue - if the infection or disease is not - completely eradicated the patient may need to undergo further operations or - - treatment so it is important that the amputation is done at a level where this - can be achieved. &MiBy 2  Suitability for prosthesis - if the patient is likely to be a candidate for prosthetic rehab the level of amputation needs to be carefully considered. -dis ISI 3  Mobility and function - it is useful to consider the patients’ pre-morbid level of mobility and function. ↓ 8451 Y Cosmesis - length and shape of stump affect the aesthetic appearance. 7|Page  Artificial Limbs Dr. Hassanain Ali Lafta Clinical Management ShLevel of amputation( is the one of the most important characteristics in determining post amputation function. In upper limb amputations, preservation - of the thumb to allow opposition with the remaining fingers will preserve some - - fine motor skills. A residual limb that is too long or too short may hinder the ideal - fitting and prosthesis use. - Longer residual limbs provide an extended lever arm to power prosthesis and allow for more area of contact to secure the prosthesis. In addition, longer limbs & my) have more proprioception, or the ability to sense where joints are in space. seri Pediatric amputations are often performed such that joints are disarticulated. - ps Main This preserves the epiphyses, or growth plates of the bones, so extremities can = grow to their normal lengths. Surgeons must keep biomechanical principles in mind when choosing 1 I surgical techniques. Myoplastic closure, the technique of drawing the muscle and - fascia over the end of the severed bone, creates a cylindrical shape desirable for prosthetic fitting, anchors the lever arm of the limb, and provides adequate padding for the distal portion of the residual limb (stump). jinib criticIdeal Stump r9· > better prostitic fitting in The ideal stump should be characterized by the following properties:  It should have optimum length to bear prostheses. -  It should be smooth, firm and free from tenderness. - - -  The opposing group of muscles should be sutured together over the bone end. - jj  The muscles are sutured in such a way that they will be converted into(fibrous - tissueSand serve as an effective cushion. - 8|Page Artificial Limbs Dr. Hassanain Ali Lafta  In case of upper limp amputations, the scar can be terminal, but in lower limb amputations, a posterior scar is desirable to avoid pressure of weight of the - artificial limb.  It should heal adequately by (first intention and have adequate blood supply.( -  It should have rounded, gentle end with adequate muscle padding. i s is i i te m  It should have thin scar which is freely mobile over underlying tissues and does - - not interfere with prosthetic functions. - Postsurgical Management Rehabilitation after surgery is often necessary to prepare the patient for wearing a prosthesis. This phase helps shape the residual limb so that it is amenable to fitting into a prosthesis. Muscle atrophy contributes to changes in limb shape. Volume of the residual limb also fluctuates due to fluid accumulation and reabsorption. A postsurgical cast, removable rigid dressing (RRDs), ace bandages, or a shrinker, which is a gradient pressure sock garment, may be used to help prevent fluid accumulation. Terminal devices such as hands or pylons with prosthetic feet can be added directly to RRDs for immediate postsurgical prosthetic training. Prefabricated fittings and adjustable, postoperative preprosthetic systems (APOPS) are available for immediate postsurgical fittings 9|Page Artificial Limbs Dr. Hassanain Ali Lafta and volume control. The APOPS offers the rigidity of a postoperative cast but can be opened to visualize the residual limb to evaluate volume and wound healing and to perform dressing changes. Studies have shown that up to 60% of individuals with upper limb amputations and 85% of individuals with lower limb amputations may experience phantom pain or sensation after surgery. Desensitization techniques can be used for overly sensitive limbs. In addition, symptoms of overuse injury may begin to occur in the unaffected limb. Multiple rehabilitation goals are established following surgery, with emphasis on pain management and controlling swelling of the residual limb to promote wound healing and skin integrity. Patient education is vital at this point - and may include proper positioning and volume-control techniques in addition to maintaining strength and range of motion, developing independence in activities of daily living (ADLs) and mobility, and promoting psychological well-being. The most successful rehabilitation of individuals with amputations is completed with a team approach which includes a prosthetist, occupational and physical therapists, doctors specializing in rehabilitation, such as physical medicine and rehabilitation doctors, and biomedical engineers. 10 | P a g e