AMPUTATION AND PROSTHESIS

Amputation is the removal of an injured or diseased body part

Causes
1. Circulatory disorders
 Diabetic foot infection or gangrene
 Sepsis
2. Neoplasm
3. Trauma
 Severe limb injuries
 Traumatic amputation. Eg: Traffic accidents, Labour accidents, Agricultural accidents, Gas
cylinder explosions
 Amputation in utero
4. Deformities of digits and limbs
5. Infection

Pre-operative Evaluation
 Assessment and resuscitation
 Tissue
› Clinical - feel pulses, skin temperature, level of dependent redness
› Doppler (U/S)– check limb circulation; inaccurate with calcified blood vessels
› Arteriogram
 Systemic
› control diabetes
› evaluate cardiac, renal + cerebral circulation
› Preoperative calorie’s control in malnourished patient.
 Psychological
› early plan for return to function
› preoperative counseling
› amputee support groups
› Informed consent –pathology, inevitability of amputation, complications, availability
of prosthesis
 Preoperative Pain Control
› Pain clinic review
› Spinal anaesthesia
 Determine the level of amputation: Goal of the surgeon is to: a) Find a place where healing
is mostly complete. b) To have an ideal stump for prosthesis fitting.

QUALITIES OF AN IDEAL STUMP

1. Should heal completely
2. Should have a rounded contour with adequate muscle padding.
3. Should have sufficient length to bear the prosthesis.
4. Should have a thin scar which does not interfere with the prosthetic function.
5. Should have adequate adjacent joint movt
6. Should have adequate blood supply.

POSTOP CARE/ REHABILITATION

Rehabilitation of the patient is a multidisciplinary approach. Aim is to bring the patient to an
optimum of physical, mental, emotional, social, vocational & economic efficiency.
General care: pain control, oedema prevention, prevention of infection, DVT prevention, care of
concurrent medical conditions, Suture removal

Stump dressing: Soft dressing: gauze, cotton wool, elastic bandage. Teach the patient or relative
stump bandaging. Rigid dressing: POP cast can be used with stump socks & padding. Elastic shrinker
socks are easy to apply and provide uniform compression. The amputee should wear a shrinkage
device 24-hours a day except for bathing

Cast changed every 5-7 days for skin care. Within 3-4 wks rigid dressing can be changed to a
removable temporary prosthesis

Physiotherapy: proper stump positioning, muscle strengthening, joints kept mobile, ROM exercises,
sensation evaluation, bed mobility, transfers, balance/coordination, ambulation with assistive
devices without a prosthesis, wheelchair mobility.
Physiotherapy Rx: Acupuncture, TENS, Vibration, Ultrasound

Benefits: a)decreased post op pain b)prevention of oedema c)enhanced wound healing d)early
maturation of stump e)allow early ambulation f)position stump to avoid contracture

PROSTHESIS : Is the substitution of a part of the body to achieve optimum function.

Eg BKA prosthesis A)patellar tendon bearing B)solid ankle cushion heel

Advantages: Disadvantages:
1) Cosmesis 1) Infection
2) Ambulation 2) Pressure ulcer
3) Function of the part. 3) Cost

Pre- prosthetic fitting evaluation and management include:

1. Pain control
2. Preparation of residual limb for prosthetic fitting
3. Maintaining ROM, especially in the remaining proximal joints of the amputated extremity
4. Independent mobility
5. Independence in self-care and activities of daily living
6. Education about prosthetic fitting and care
7. Support for adaptations to the changes resulting from the amputation.

PROSTHETIC MANAGEMENT: The socket should be cleaned daily to promote good hygiene and
prevent deterioration of prosthetic materials. As a rule, solid plastic materials are cleaned with a
damp cloth and foam materials with rubbing alcohol. The patient should also be reminded that
routine maintenance of the prosthesis should be performed by the prosthetist to ensure maximum
life and safety of the prosthesis.

COMPONENTS OF PROSTHESIS:-
1. UPPER EXTREMITY PROSTHETICS:-
 Body-powered arms:-
a) Sockets
Current body-powered arms contain sockets that are built from hard epoxy or carbon fiber.
These sockets can be made more comfortable by lining them with a softer, compressible
foam material that provides padding for the bony prominences. Supra-condylar socket
design is useful for those with short to mid range below elbow absence. Longer limbs may
 require the use of a locking roll-on type inner liner or more complex harnessing to help
augment suspension.
b) Wrists
Wrist units are either screw-on connectors or quick-release connectors, of which there are
different models.
c) Terminal devices
Terminal devices contain a range of hooks, prehensors, hands or other devices.
 Voluntary opening and voluntary closing
Two types of body powered systems exist, voluntary opening "pull to open" and voluntary
closing "pull to close".
Virtually all "split hook" prostheses operate with a voluntary opening system. More modern
"prehensors" called GRIPS utilize voluntary closing system. The differences are significant.
The users of voluntary opening systems rely on elastic bands or springs for gripping force,
while the users of voluntary closing systems rely on their own body power and energy to
create gripping force.
The users of voluntary closing systems can generate prehension forces equivalent to the
normal hand, exceeding one hundred pounds. The users of voluntary opening systems are
limited to the force their rubber bands or springs can generate which is usually below 20
pounds.
2. Lower-extremity prosthetics:-
The two main lower extremity prosthetic devices are 1.trans-tibial and 2.trans-femoral
OTHERS:-
1. Hip disarticulations – This usually refers to an amputation through the hip joint.
2. Knee disarticulations – This usually refers to an amputation through the knee joint
3. Syme’s disarticulations – This is an ankle disarticulation while preserving the heel pad.

Suction suspension socket

Suction suspension sockets are provided with a one-way valve at the distal end of the socket wall
that allows air to escape but not to enter to ensure proper fitting. Suspension socket can also be
used with Silesian belt, Total Elastic Suspension (TES) Belt or Pelvic Band and Belt with Hip Joint.

Socket
This important part serves as an interface between the residuum and the prosthesis, allowing
comfortable weight-bearing, movement control and proprioception. It is quadrilateral in shape when
viewed from above. It’s fitting is one of the most challenging aspects of the entire prosthesis. The
difficulties accompanied with the socket are that it needs to have a perfect fit, with total surface
bearing to prevent painful pressure spots. It needs to be flexible, but sturdy, to allow normal gait
movement but not bend under pressure.
Knee joint
In case of a trans-femoral amputation, there also is a need for a complex connector providing
articulation, allowing flexion during swing-phase but not during stance phase.
Microprocessor control
To mimic the knee's functionality during gait, microprocessor-controlled knee joints have been
developed that control the flexion of the knee. The main advantage of a microprocessor-controlled
prosthesis is closer approximation to an amputee’s natural gait.
Shank and connectors
This part creates distance and support between the knee-joint and the foot (in case of upper-leg
prosthesis) or between the socket and the foot. The type of connectors that are used between the
shank and the knee/foot determines whether the prosthesis is modular or not. Modular means that
the angle and the displacement of the foot in respect to the socket can be changed after fitting. In
developing countries prosthesis mostly are non-modular, in order to reduce cost. Shank can be :-
Endoskeletal or exoskeletal.
Foot
Providing contact to the ground, the foot provides shock absorption and stability during
stance. Additionally it influences gait biomechanics by its shape and stiffness. This is because the
trajectory of the center of pressure (COP) and the angle of the ground reaction forces is determined
by the shape and stiffness of the foot and needs to match the subjects build in order to produce a
normal gait pattern. The main problem found in current feet is durability, endurance ranging from
16–32 months. Different types of foot are: SACH, single axis, multi-axis, flexible keel and energy
storing.
ASSISTIVE DEVICES—AMBULATION AIDS

USES OF ASSISTIVE DEVICES:-

1. To aid mobility and confidence
2. Improve balance
3. Decrease pain
4. Increase base of support
5. Decrease loading and demand on the lower limbs
6. Assist acceleration/deceleration during locomotion
7. Compensate for weak muscles
8. Scan the immediate environment

TYPES OF ASSISTIVE DEVICES:

1. CANES
Components
• Handle
• Adjusting knob for handle
• Shaft
• Adjusting mechanism for height
• Rubber tip

TYPES OF CANES:
a) C-handle or crook top cane
b) Adjustable metal cane
c) Functional grip cane
d) Wide-based or quadruped cane

2. CRUTCHES
TYPES:
a. Axillary Crutches
Components
– Padded axillary piece
– Two upright shafts
– Handpiece
– Extension piece
– Rubber tip

b. Forearm Crutches
Components
– Forearm cuff with narrow anterior opening
– Forearm piece bent posteriorly and adjustable
– Molded handpiece
– Single aluminum tubular shaft
– Rubber tip

c. Platform Crutches

3. WALKERS
Types
– Lightweight walking frame
– Folding walking frame
– Rolling walking frame
– Forearm resting walking frame
– Hemi-walking frame