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Lower Limb Amputation Surgery and Rehabilitation (Lessons from ISPO Workshop in Bangkok 2009)

Lower Limb Amputation Surgery and Rehabilitation (Lessons from ISPO Workshop in Bangkok 2009). Dr Roy Nario Dep’t of Rehab Med- Nepean Hospital 13 March 2009. Hx of ISPO Amputation Course. Consensus conference on amputation sx in Scotland in Oct 1990 ’92- Rungsted, Denmark

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Lower Limb Amputation Surgery and Rehabilitation (Lessons from ISPO Workshop in Bangkok 2009)

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  1. Lower Limb Amputation Surgery and Rehabilitation(Lessons from ISPO Workshop in Bangkok 2009) Dr Roy Nario Dep’t of Rehab Med- Nepean Hospital 13 March 2009

  2. Hx of ISPO Amputation Course • 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

  3. Hx of ISPO Amputation Course • 2004- course given new content and a new name: Amputation surgery and related prosthetics • 2009- first time the new course was given

  4. Suvarnabhumi Airport

  5. Suvarnabhumi Airport"su-wan-na-poom"

  6. Course Outline: • 1 • History • Epidemiology • Pre-op Mx • Decision making process in Sx • Post-op Mx • Prediction of functional outcome • Sexuality and amputation

  7. 2 • Skin problems • Physiotherapy • Phantom pain and pain mx • Psych aspects • Sports after amputation • Liners • CAD-CAM

  8. Continuation of 2 • Hip disarticulation & hemipelvectomy • Epidemiology and Sx • Rehabilitation • Biomechanics • Prosthetics

  9. 3 • Transfemoral amputation • Epidemiology and Sx • Rehabilitation • Biomechanics and gait • Prosthetics

  10. Continuation of 3 • Transtibial amputation • Epidemiology and Sx • Rehabilitation • Biomechanics and gait • Prosthetics

  11. 4 • Foot and ankle amputations • Epidemiology and Sx • Rehabilitation • Biomechanics and gait • Prosthetics

  12. Continuation of 4 • Diabetic foot • Epidemiology • Physical examination • Treatment of foot infections • Rehabilitation • Casting • Orthotics • Ortho reconstructive sx

  13. Speakers: • 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)

  14. LL Amputation nomenclature

  15. Pre-operative management • “It is not to take but to make.” • Early rehab involvement! • Although same problem everywhere, not happening or inconsistency in engaging rehab pre-op

  16. Mortality and pre-op cardiac function in vascular amputees: an N-terminal pro-brain natriuretic peptide (NT-proBNP) pilot study Clin Rehab 2008 • 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

  17. Mortality and pre-op cardiac function in vascular amputees: an N-terminal pro-brain natriuretic peptide (NT-proBNP) pilot study Clin Rehab 2008 • 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

  18. Mortality and pre-op cardiac function in vascular amputees: an N-terminal pro-brain natriuretic peptide (NT-proBNP) pilot study Clin Rehab 2008 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.

  19. Decision making in Sx • “Soft tissue is more important than bone.”

  20. http://www.ampsurg.org

  21. Sexuality and Amputation • 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

  22. Sexuality and Amputation • 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

  23. Sexuality and Amputation 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.

  24. Post-op mx • 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?

  25. Liners • General principle: “The liner has to be as thin as possible and as thick as necessary.” Selection should be based on individual circumstances.

  26. Knee Disarticulation • Historical love/ hate relationship • First described in literature in 1830 • Very little data • Most national surveys: 1-3 % of all amputations

  27. Knee disarticulation • 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

  28. North American Experience with KD with use of a posterior myofasciocutaneous flap. Healing rate and functional results in seventy-seven patients. Bowker, et al, JBJS 2000 Nov • 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

  29. Knee disarticulation • 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.

  30. Knee disarticulation • 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

  31. Knee disarticulation • 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)

  32. TFA • Consider C-knee in the elderly population! • Provides better gait • Improved stability • Improved walking speed • Less falls

  33. TFA • 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

  34. TFA • 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

  35. TFA • 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

  36. TFA • Explain the vital skills and importance • Offer prosthesis when patient masters skills • Places challenge on patient and family • Avoids arguments!

  37. A plea! • 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

  38. Foot Clinic • Minimal model • Doctor • Podiatrist and/or nurse • Intermediate • Doctor (diabetes specialist, surgeon, rehab) • Podiatrist and/or nurse • orthotist

  39. ISPO Workshop • Highly recommended • Relevant • Comprehensive, but not too overwhelming • Balanced and well-respected speakers • A Sydney venue in the future?!

  40. Remember • We are Coaches! • We must create enthusiasm! • Positive approach to Surgery • Positive approach to early rehabilitation • Positive approach to prosthetics

  41. "khorb khun"

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