Amputations and Diabetic Foot Flashcards
(34 cards)
1
Q
History of O&P Milestones
A
- Earliest recorded amputation was 484 BC when soldier cut off his foot to escape imprisonment
- tourniquet introduced 1674
- 1863 - suction socket for TF amputee
- 1846 - first amputation under anesthesia
- 1867 - anticeptic surgery introduced
- 1949 - myoplasty introduced
- 1960s - myodesis introduced
- 1954 - hip disarticulation prosthesis
- 1956 - SACH foot
- 1959 - PTB
- 1971 - endoskeletal prosthesis
- 2000 - microprocessor controlled knee
2
Q
Incidence of Amputations
A
- TFemoral more common than transtibial
- 80,000 in US/year
- men>women 3:1
- amputation rate increases steep w/ age
3
Q
Population Base of Amputation
of Limb Loss
A
- 82% = dysvascular disease
- PVD by peripheral neuropathy (HTN, cholesterol, tobacco)
- 16.4% = Trauma -opt outcome surg<12hrs
- machinery 40%
- power tools 27%
- firearms 8%
- MVAs 8%
- .9% cancer - carcinoma
- .8% congenital limb deficiencies
4
Q
INcidence of amputations in people >60
A
- 90% vascular disease
- 7% trauma
- 2.5% tumor
- .5% congenital
5
Q
Rehabilitation Issues to Consider with Amputation
A
- determing readiness for prosthetic fitting
- involved decision about prosthetic components
- coordinates prosthetic training
- consult with prosthetist as needed
- basic mobiity training
- consuly and assist patient to return to employment/activities
- AGE IS MORE IMPORTANT THAN ETIOLOGY FOR PREDICTING TOTAL LENGTH OF TIME IN REHABILITATION
6
Q
Energy cost and Amputaiton
A
- preservation of knee joint = key determinant for potential for functional ambulation and successful outcome
- more of the limb you can leave the better the outcome**
- increased energy for persons with bilat TF
- some elderly may chose wheelchair
7
Q
Factors Which influence the metabolic cost of walking
A
- Length of residual limb
- knee = key
- longer lever arms = better
- Cause of Amputation
- trauma vs. vascular
- other complications (TBI, atrophy, SCI, soft tissue injury etc) *life vs. limb
- Age
- linear relationship regardless of disability
8
Q
Diabetes and High Risk Foot
A
- DM is the diagnosis most frequently associated with foot ulceration and LE amputation
- DUE TO PERIPHERAL NEUROPATHY
- poor circulation, is not the primary cause of most foot ulcers though closely related
9
Q
Diabetic Peripheral Neuropathy
A
- Damage to nerves (40% of DM)
- 60% of LE amp are related to DM
- characterized by:
- neuropathic pain/loss sensation
- muscle weakness later stages
- ppl w/ DMPN have 15x greater risk of foot ulcer than those with DM and intact sensat.
- PRIMARY MECHANISM FOR INJURY/ULCER W/ DMPN IS REPETITIVE MECHANICAL STRESS THAT IS UNRECOGNIZED
10
Q
Considerations and Controlling DM
A
- Hb-A1C
- Healthy = 5
- DM = less than 7 = controlled
- lower = less complications
- other systemic diseases
- stroke, TIA
- CVD
- Foot health hx
- previous ulcer
- ankle sprains
- medications
- visual deficits
- footwear
11
Q
Physical Exam of DM Foot
A
- Vascular exam - pulses, doppler, ABI <.45
- Sensory Exam - vibration, protective sens.
- soft tissue
- footwear
- balance
- gait
- ms exam - jt mob, deformity,
- Charcot’s foot - loss of arch, bones drop down, inflammatory process = bone disintegration
12
Q
Treatment for Neuropathic Ulcer
A
- Sharp debridement for necrotic tissue
- appropriate dressings applied
- pressure reduction
- total contact casting
- walking splints
- removable cast walkers
- half shoes
- can participate in WB exercise
- comprehensive foot care
- MODERATE WALKING LIKELY DOES NOT INCREASE RISK OF FOOT ULCERS
- need good footwear and daily inspection
13
Q
Amputation Levels
PARTIAL FOOT
A
General Information
- loss ant. lever arm foot affects term. stance
- functional loss of DF @ ankle
- tendency of ankle to become fixed
- many different levels
14
Q
Toe Amputations
A
Benefits
- plantar surface WBing
- most of foot intact
- gait unaffected at normal speeds
Challenges
- shoe selection
- excessive pressure at amputation site
- shear forces at suture area
Prosthetic Management
- carbon foot plate with filler or silicone restoration
15
Q
Ray Amputations
A
Benefits
- plantar surface WBing
- most of foot intact
Challenges
- shoe selection
- excessive pressure at amp site
- shear forces at suture area
Prosthetic Management
- carbon plate with toe filler or silicone restoration to minimize shear forces
16
Q
Transmetatarsal Amputation
A
Benefits
- partial plantar surface WBing
- most of the ankle structure is intact
Challenges
- shoe selection
- excessive pressure at distal plantar metatarsal areas
- shear forces at suture area
Prosthetic Management
- carbon foot plate with toe filler or silicone restoration
17
Q
Lisfranc - Metatarsal Disarticulation
A
Benefits
- distal bearing
- ankle joint intact
Challenges
- cosmetics of prosthesis
- height discrepancy - no longer have long arch
- loss of foot levers/rockers
Prosthetic Management
- fiber foot plate with toe filler
- AFO/prosthesis
- tibial tubercle level prosthesis
18
Q
Chopart Amputation
Calcaneo-Cuboid Talo-Navicular Disarticulation
A
Benefits
- distal bearing
- ankle joint intact
Challenges
- cosmetics of prosthesis
- height discrepancy
- loss of foot levrs
Prosthetic Management
- fiber footplate with toe filler
- AFO / prosthesis
- tibial tubercle level prosthesis
19
Q
Boyd/Pirgoff Amputation
A
SImilar to Symes Amputation however the calcaneus is cut and attached to the cut end of the distal tibia
20
Q
Symes Amputation
Malleoli are partially sheared off for Cosmesis
Heel Pad reserved and anchored to distal end of Tib/Fib
A
Advantages
- distal end bearing
- less traumatic surg
- sulf suspending
- long lever arm
- >surface area
- <stresses>
</stresses>
</stresses>
Disadvantages
- potential problems with the heel pad/flap
- component option limitations
- cosmesis
Suspension Options
- windows: either medial or posterior
- expandable bladders
- partial inserts
- supramalleolar
21
Q
Transtibial Amputation
A
- Conical = Larger surface area and less pointiness because you have 2 long bones providing support
- when amp is done for vascular reasons, very short anterior flap and very long posterior flap (otherwise equal flaps)
- optimal:
- typically mid tibial
- length allows space for prosth foot and sufficient muscle padding
- too much - no room for ankle
- minimum
- junction of middle 3rd and prox 3rd of tibia just below the flair of tibial plateu to allow suff. WB
22
Q
Through Knee Disarticulation KD
A
- Good comfort and function
- poor cosmesis
- patellar tendon sutured to remnants of cruciate ligaments
- few muscles and no bone cut = less traumatic surgery
23
Q
Transfemoral Amputation
A
- equal length ant/post flaps
- nerves cut at level to ensure they are well covered
- trying to avoid neuromas so you cut them high so they have less pressure on them
- myoplasty = sow muscle to other muscle
- myodesis = sow muscle to the bone
- end of bone is smoothed
- Optimal length
- allows space for uncompromised knee system
- typically above condylar flare
- Minimal Length
- junction of middle 3rd and prox 3rd (below less troch) to allow for suff fem length/lever arm to operate prosthesis
24
Q
Hip Disarticulation and HemiPelvectomy
A
- blood loss can be a problem
- symphysis pubis is divided
- anterior - above and paralleled to inguinal ligament
- posterior - preserves variable portion of gluteus maximus
- hemipelvectomy - all or part of ilium is removed
25
Determining Appropriate level of amputation prior to surgery
* patient goals and priorities
* patients general condition
* risks of additional surgery
* potential healing of the limb
* predicted probably outcome (age)
26
Common Techniques used at ALL levels of Amputation
* Flaps
* decrease tension
* trim them down - want =
* provides cushion
* nerves cut high
* prevention of neuroma
* myoplasty/myodesis
* ms stabilization, shape, fxn
27
Ateriosclerosis Obliterians
Narrowing and occlusion of the arterial lumen of the larger arteries
* etiology
* 50+
* male
* tobacco
* obesity
* HTN
* HLD
* sedentary
* symptoms
* inttermitten claudication
* decreased pedal pulse
* dry skin
* hair loss
* clubbing toe nails
* ulceration
* pain relieved w/ standing
28
Arteriosclerosis with Diabetes
Narrowing of the Medium and Smaller arteries - w/ neuropathic changes
* etiology
* same as arteriosclerosis obliterans (ASO)
* 40+
* Symptoms
* same as ASO
* decreased foot sensation
* renal complication
* impaired vision
* decreased strength
29
Chronic Venous Insuffiency CVI
Compromised blood flow of superfiscial veins as a result of perforating valves, increased SBP, decreased blood flow, edema and cell death
* 1% of population
* edema
* dilated veins
* dermatitis
* ulcers (above malleoli)
* pain relieved by elevation
30
Thromboangitis Obliterans
| (Beurger's Disease)
Inflammation of the small and medium arteries and veins of both UE and LE directly related to smoking
* male 20-40, tobacco use
* bilateral ischemia
* ulcers
* phlebitis
* pedal claudication
* pain with rest
31
Stages of Amputation
* Pre-amputation = everything before
* Pre-Prosthetic = amp to first OP fitting
* Transitional = first OP fitting to limb stab
* Mature = everything after limb stabilization
* Post Amp -\> Pre Prosthetic assess:
* pain
* residual limb size
* wound healing
* circulation
* ROM/flex
* joint mob
* muscle performance
* gait/balance
32
Phantom Limb Sensation vs. Phantom Limb p!
* 85% of amputees experience phantom sensation, pain or actual limb pain
* Phantom sensation = non painful sensation or awareness that occurs below the residual limb
* Phantom limb pain = painful sensation that occurs below the residual limb
* Residual limb pain = pain arising in the residual limb from a specific anatomical structure that can be identified
33
5 Steps of Loss with Amputation
Denial
Bargaining
Anger
Depression
Acceptance
34
Amputation in the 1st Year
Healing
Grief
Rehabilitiation
Adjustment
Integration
Reintegration
