1 / 19


LOWER LIMB LEVEL AMPUTATION. 1) PARTIAL FOOT AMPUTATION. 2) TRANS TIBIAL AMPUTATION. 3) THROUGH KNEE AMPUTATION. 4) TRANS FEMORAL AMPUTATION. 5) HIP DISARTICULATION. Introduction. Indication for leg amputation have undergone a big change during the last 100 years:

Download Presentation


An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.


Presentation Transcript


  2. Introduction • Indication for leg amputation have undergone a big change during • the last 100 years: • Before it was a life-saving surgical intervention with a high mortality rate in the 19th century • Today, plastic surgery and microsurgery are employed to obtain • a “functional residual limb with weight-bearing ability at its distal end." • Anatomical configuration does largely predetermine the required • weight-bearing ability at the distal end of the residual limb and • reveals the benefits of knee disarticulation. • - Whenever possible "peripheral amputations” should be carried out, • especially in cases of foot level indications. They offer the best • preconditions for the fitting, including good weight bearing ability, • and also recommend a “residual limb according to patient requirements."

  3. 1) PARTIAL FOOT AMPUTATION • Foot amputation levels range from: • Removal of individual distal toe segments • Disarticulations in the basal toe joint • Removals in the mid-foot area such as metatarsal amputations • Disarticulation in Lisfranc joint , Chopart joint • Amputations of the calcaneal part of the foot. • The trans-malleolar amputation according to Syme is a transition • amputation from foot level to lower limb level amputation. • -The basic principle is to always conserve as much of the limb as possible, • because with increasing amputation level the standing surface • becomes smaller. • Amputation technologies are aimed at the conservation of the foot sole • in order to make use of both its load bearing capability and its proprioception. • -This way a patient with calcaneal stump will be able to walk a short distance • even when not wearing the prosthesis.

  4. 1 2 8 1) Distal Phalanx 3 2) Disarticulation proximal Inter Phalangeal joint 4 3) Disarticulation of toes 4) Distal Metatarsal 6 6) Lisfranc – Tarso Metatarsal disarticulation 7 7) Chopart – Talonavicular + Calcaneo Cuboid disarticulation 8) Metarsal /phalangeal Ray Foot amputations levels 5 5) Proximal Metatarsal

  5. Lisfranc a) Lisfranc Amputation • Advantages: • Good proprioception. • No PTB suspension / weight bearing. • - Patient can walk short distance without prosthesis. • Disadvantages: • Appearance of equino-varus deformity. • Prosthesis creates a leg length discrepancy. • Bony & sensitive stump – adaptation problems. • - Difficult to accommodate in standard shoes.

  6. Chopart b) Chopart Amputation Avantages and Disavantages are the same as the Lisfranc amputation • Advantages: • Good proprioception. • No PTB suspension / weight bearing. • - Patient can walk short distance without prosthesis. • Disadvantages: • Appearance of equino-varus deformity. • Prosthesis creates a leg length discrepancy. • Bony & sensitive stump – adaptation problems. • - Difficult to accommodate in standard shoes.

  7. Pirogoff c) Pirogoff Amputation • Advantages • End-bearing capabilities. • Self-suspension due to bulbuous shape. • Good proprioception. • - Long lever-arm: reduced surface pressure. • Disadvantages: • Too long to use standard foot. • No possibility to use standard prosthetic foot • and alignment system. • - Poor cosmetic.

  8. Syme d) Syme Amputation • Advantages: • End-bearing capabilities. • Self-suspension (bulbuous end). • Long lever arm: reduced surface pressure. • Good proprioception / control. • - Possible to use standard foot & alignment system. Disadvantages: Poor healing. Poor cosmetic, bulbous contour of distal end. Movement of distal stump-pad. Difficult donning & doffing of the prosthesis.

  9. Foot amputation : Summary a) Advantages - A full end bearing stump - A limited functionnal loss - Patient can walk for short distances without prosthesis • Proprioception : proprioceptive properties of the sole of the foot • are kept good in most cases • Balance : relatively easy for patients to keep their balance especially • on uneven ground • Phsycological aspect: The usual aspects of an amputation are • probably reduced because of the limited loss of function and appearance. • In the case of vascular operations where amputation of the other limb • can be expected at a later stage, it is an advantage to keep • as much function as possible.

  10. b) Disavantages • Poor wound healing specially in case of poor peripheral blood supply • (eg: peripheral vascular disease ) The scar is quite often large areas of scarring - Bony overgrows may become sharp and cause problems - Adherence of the suture to the underlying bones = more sensitive to pressure or rubbing action • Destruction of the normal weight bearing structure of the foot: this will lead • to a changes of distribution forces along the sole of the foot. • Ex: in case of total or partial toes disarticulation = more metatarsal head pressure.

  11. Muscle imbalance : • between the flexors ( tibialis anterioris) and the extensors ( triceps surae) = • the Achilles tendon is pulling the stump in equinus. • between the supinators (tibialis anterioris) and the absence of pronators ( LPL). • the stump is pulled into a inversion/supination deformity. ( Chopart Amputation) - Cosmetical problem due to the posterior migration of the calcaneus • Problems with donning and doffing with bulbous end stump: it can be solved by • making a removable panel or leaving a panel section completly open. - Reduced body balance due to a reduced area of support • Contractures : the toe stump of a partial toe amputation often develops • contractures in dorsi-flexion

  12. 2) TRANS TIBIAL AMPUTATION • Advantages: - Good prospect for prosthetic rehabilitation. - Longer stump = better control & less surface pressure. • Disadvantages: • - Socket fit must be very accurate due to bony mapping. • - No end-baring possibility – reduced proprioception. • - Very short stump = risk of stump – socket pseudarthrosis. • - Very long stump = distal stump is bony; • acute risk of abrasion / wound.

  13. 3) THROUGH KNEE AMPUTATION • Advantages: • End-bearing possibility • Long lever-arm: reduced surface pressure • + good control during gait • Self suspension • No need of ischial weight bearing • - No need of suspension belt • - For children: bone growth is conserved • - Better proprioception than in TF amputations • - No bone section – lighter surgical act.

  14. Disadvantages: • Need to use specific knee-joint to avoid • thigh length discrepancy • - Cosmetically less attractive than TF prostheses • Bulbous-end = donning & doffing is more difficult • than in TF socket

  15. - The knee disarticulation amputation (through-knee-amputation) is executed if it is no longer possible to maintain a short residual section of the lower leg. -Due to the anatomical prerequisites, functional and cosmetic requirements, it is more convenient to use modular componentry for better fitting. - In contrast to a trans-femoral amputation, the residual limb can be fully loaded after knee disarticulation. Because the femoral condyles transfer body weight to the prosthetic socket, no tuberosity seat is required. -The bulky shape of the condylar residual limb provides for a rotationally-stable connection to the prosthetic socket. -A soft socket of thermoplastic PE foam is anatomically shaped inside, and by compensating for the undercuts offers a conical shape outside. This makes for easy donning of the prosthesis during sitting. -The musculature of the residual limb remains balanced because the adductors have not been transected, while the long lever arm allows for good control of the prosthesis. - When compared with the qualities of a trans-femoral amputation, knee disarticulation offers advantages to both geriatric and athletic patients.

  16. 4) TRANS FEMORAL AMPUTATION • Advantages: • Healing rate is greater than for more • distal amputations. • The residual limb in many cases is easier to • fit with a socket. • - Longer stump = better control & less surface pressure. • - Few bony prominences = less problem of socket adaptation. • - Medium length stumps with good end-cushioning are ideal.

  17. TF: Disadvantages: • - Mortality is greater for more proximal amputations. • - More surgical complications. • Cut muscle bellies retract, atrophy and • lose their function; myoplasty will prevent this problem. • Rehabilitation for prosthetic walking is less successful • than with more distal amputations • - No end-bearing possibilities as for knee disarticulation. • - Need of a suspension (suction or belt). • Mobility is reduced – increased energy is needed • during gait.

  18. 5) HIP DISARTICULATION Advantages: - None. • Disadvantages: • - Heavy prosthetic device. • Reduced mobility & Increased energy • needed during gait. • - Uncomfortable in sitting position – hip unbalance.

  19. The various amputations in the hip area, such as the inter-trochanteric • amputation, the hip disarticulation and the hemipelvectomy • are fitted with pelvic prostheses. • In case of accidents or tumors, a more distal amputation • level is not possible, a prosthesis of this type is indicated. • As opposed to a "true disarticulation" in the hip joint area, • in this case, an amputation is performed in the upper portion of • the femur with proximal sections of the femur retained. • - If one pelvic half must be partially or completely removed, • it is called a hemi-pelvectomy. In this case the conditions • of support and encasement are especially difficult. • - By removing the ischial tuberosity the seating area is lost, • and due to the loss of the os ilium the encasement surface decreases • so that the lower thoracic area may require enclosure by the pelvic socket. • -In the case of hemi-pelvectomies, not only are the organs of motion involved, • but often artificial outlets for the bladder or intestine are required, • making orthopaedic technical fitting even more difficult.

More Related