TRANS-FEMORAL PROSTHETICS

MUHAMMED KOCABIYIK

PHYSICAL THERAPY & REHABILITATION

III.CLASS V.GROUP

GOAL

In brief: the residual extremity should be a well contoured, functional and dynamic limb, accepting a prosthesis to allow the patient to ambulate/function in a relatively effortless and painless manner

Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit and use

Femur severely lateralized by

pull of the abductors and no adductor stabilization

Conventional AmputationEffects - Bone

Medullary canal ignored, remains openPoor ability for end weight bearingVenous gradient 0mmHg → venous

stasis Loon

Potential bone spur formation Hulth, Hansen-Leth, Reimann, Olerud

Regional osteopenia with possible adjacent joint DJD Lo

Conventional AmputationEffects - Muscle

Majority of musculature allowed to retractFatty atrophy Venous stasisSlower speed of contraction

Blix, Loon

Poor “volume” of residual extremity in prosthesis

Basic ScienceLength-Tension Relationship Normal muscle has

max force at slightly longer lengths

In amputees, muscles are divided, retract, undergo fatty degeneration, and excursion in contraction is decreased

Result is increased work to ambulate with increased fatigueLoon, Prosth Int, 1959.

Conventional AmputationEffects Incisions placed over

prominent surfacesPotential etiology of pain

Regional circulation disturbedSecondary to venous stasisAbnormal vessel formation Hansen-Leth, Hulth, Olerud

High risk of AVMDilated, tortuous vessels Hansen-Leth,

Osteomyoplastic Reconstruction

Medullary canal sealed Broader surface area to bear

weight Allows potential end weight

bearing in AKA Improves local circulation

Basic ScienceClosure of Medullary Canal

Intramedullary venograms pre-/post-canal closure Loon, Prosthetics International,41-58, 1959

Myoplasty - Transfemoral Fascial closure of opposing muscle

groups Adductor brought laterally for balance in

AKA Improves local vascularity Provides “insertion” for muscles to

restore resting length-tension relationship

Improve alignment and biomechanics of limb

Soft tissue coverage to end of residual extremity

Insertion sites of adductors; not restoring an adductor movement allows femur to lateralize creating an inefficient gait pattern; this increases oxygen demand and can create greater cardiac stress in patients with cardiopulmonary disease; would emphasize maintaining the adductor Magnus and gracilis muscles to restore the adductor moment

F. Gottschalk- U. Texas Southwest

Myoplasty-Basic Science Arteriogram of

AKA prior to myoplastic procedure

Poor filling in adductor region of leg

Poor contour grossly

Exostosis formationDederich, JBJS, 45-B,

60, 1963

Myoplasty-Basic Science Arteriogram 3

months after myoplastic procedure

There is increased arterial flow with in the stump

Distal and medial perfusion is improvedDederich, JBJS,45-B:

60, 1963

Osteomyoplastic ProcedureGoals

Osseous/soft tissue reconstructionRemove bone scar/spurs Medullary canal closureMyoplasty of opposing muscle

groups Plastic Closure

Stabilize the extremityRealign femur for proper mechanics

and gaitMuscle balancing

Osteomyoplastic ProcedureGoals

Provide a potential end weight bearing extremityClosure of medullary canal returns

normal venous gradient; distal bone remains vascularized

Create a cylindrical residual extremityImproves fitting/use of prosthesisSmooth contour aides in preventing

localized skin breakdownPressure points reduced

Osteomyoplastic ProcedureGoals

Restore normal physiologyVenous gradient in bone returnedVasculature improves in remaining

extremityMuscle length-tension relationship

reestablished, thus restoring the efficient use of the muscle Loon, Prosthetics International,1959.

Osteoplasty

Adductor Stabilization

Muscle Flaps brought over end of femur

Quadriceps

Hamstrings

Completion of the myoplasty by suturing the quadriceps to the hamstrings. This stabilizes the entire soft tissue envelope and provides distal coverage for end-bearing of the residual limb. Meticulous skin closure is then performed, removing dog-ears and redundant skin. Goal is to provide a cylindrical limb for prosthetic application.

Adductor tubercle with adductor Magnus kept attached to cortical shell

Immediate

post-op

5 weeks post-op; alignment maintained; no lateralization of femur

Orthotics/Prosthetics/P.T.

Begin comprehensive educationSupport groups, networking

Begin comprehensive therapyTransfers, stretching,

desensitization, gait training, upper extremity conditioning

Knowledgeable staff for supporti.e. ACA, nurse clinicians, etc.

Prosthetics

Physical Therapy

Post-Op protocol 0-4 weeks-Isometrics above

amputation, ROM, UE aerobic conditioning

4-6 weeks-Isometrics, ROM, towel pulls, massage, scale exercises up to 10/15 lbs

>6 weeks-advance P.T., gait training, posture, gluteal/core strengthening, socket application

Emotional, psychological supportSupport groups, starts from day one

Summary

Provides the amputee with a “sound” physiological residual extremity

Patients have high satisfaction and there is improved outcome

Can be applied to the vasculopath and diabetic

1.5 cm of bone resected on average

Can used as a primary procedure as well as reconstructive

Summary An amputation is not a benign,

static procedureThe limb is dynamic, so should the “team”

Effort must be placed on a team approach

The goal is to return to the patient a functional residual extremity

This can be accomplished by adhering to “biological” surgery principles