Amputation Belo th Kne e Ernes M Burgess M - PDF document

Amputation Belo th KneErnes M Burgess M.D1 Investigator Prosthetic ResearcStudy Seattle Wash. an Directo o Amputationan Congenita Defect Service Children' Orthopedi Hospital Seattle Wash Thi stud wa conducte unde Contrac V5261P-43 wit th VeteranAdministrationJosep H C.P2 Prosthetic Researc Study SeattleWashAH electiv amputatio mus b considere suspende anteriorl an i a proxima directio b a assistant A simpl adjustabl shoulder-suspensio harnes whic iinterchangeabl fo righ an lef ca bsubstitute t achiev th sam resultRelie pad o fel o polyurethan arglue t appropriat location o thstum soc t provid relie fo bon prominences Prefabricate pad ar availabli a standar size righ an left bumus b trimmed skived an bevele iappropriat area t sui individua requirements Th pad ar designe anlocate t provid relie o pressure oveth patella th tibia tubercl includinth tibia crest an th distal-anterio(bevel aspec o th tibia Do Corninmedica adhesiv i use t secur th felrelie pad i plac whil th polyurethan relie pad ar provide wit a adhesiv backing A steril reticulate polyurethan dista pa o th prope siz iselecte an applie t th dista stumen ove th tibia relie pad (Fig 2)Fo th initia par o th rigi dressingelasti plaste bandag i use becausewhe pulle limit o it elasticitythi bandag provide saf an beneficiacompressio t th stum whil conformin wel t it contours providin a smooth effective rigi dressingBefor th wra i started th tibiarelie an dista relie pad ar secure iplac wit one-and-three-quarte turn oelasti plaste bandag (Fig 3) Fir tensio i applie t th dista portio o thstum fro a posterior-to-anterio direction whil th plaste bandag i pullealmos t th limi o it elasticity Bsupportin th posterio ski flap tensioo th sutur lin i reduce an th softissue ar immobilized Th wra i thestarte o th dista en an carrie proximall t a leve slightl pas mid-thigwhil tensio i maintaine i th bandage A minimu o tw layer i requiredCircumferentia wrappin i carrie oufro th latera t th media aspect wheviewe fro th front i orde t avoi anterio displacemen o th gastrocnemiuFig 1 Below-kne stum o nonischemi patienimmediatel afte closureFig 2 Applicatio o dista polyurethan padOthe relie pad ar alread i placeFig 3 Beginnin th rigi dressin b securinth tibia relie an dista relie pad i plac witelasti plaste bandage (Fig 4) Tensio i th wra decreaseprogressivel a th applicatio proceedproximall t th leve o th kne joinwher i simpl rolle o u t slightlpas mid-thigh I i importan t appl thdressin wit fir tensio t th distaportio o th stum an t avoi proximaconstrictio t bloo flow Th kne i heli 5 t 1 deg o flexio controlle blongitudina tensio applie t th stumsoc fro th proxima end Owin t thinheren structura weaknes o elastiplaste bandage th initia wra mus breinforce wit conventiona plaste bandag an splints Tw splint ar applieove th dista portio o th rigi dressingA minimu o tw layer o conventionaplaste bandag i applie startin a thdista thir an wrappin proximall witeven overlappin circula wrap (Fig 5)A th proxima borde o th cas a suspensio stra i incorporate anteriorlyFo a obes patien wit excessiv softissu ove th thigh a secon suspensiostra i applie posterolaterally Wit thplaste o Pari stil wet th cas i gentlcompresse wit th bas o eac hanjus proxima t th femora tprovid a effectiv built-i suspensiomechanismAfter th plaste ha hardene sufficiently th contoure i applie t th patien an connecte t thstra o strap o th rigi dressing Thprostheti uni i locate an attache tth cas wit a rol o conventiona plastebandag (Fig 6) Th pylo i size ancu t correspon t th lengt o thsoun extremity A windo i cu ou oth plaste ove th patell t insur comFig 4 Applicatio o th firs layer o th rigidressingFig 5 Complete rigi dressing Not alignmenreferenc lineFig 6 Attachmen o uppe portio o prosthetiuni t th rigi dressing Not alignmen referencline plet relie i thi are (Fig 7) Th prostheti uni i the disconnecte fro thcas socke befor th patien i take tth recover roomPOSTSURGICA CARA a rule a minimu amoun o pai iexperience b patient tha hav beeprovide wit a rigi dressing I i unusua fo drug stronge tha mil opiatean sedative t b require fo relief A sligh degre o weight-bearin o thstum will usuall ten t reduc an discomfor tha migh b presentTh patien shoul b encourage tstan u an bea som weigh o thprosthesi a soo afte th firs 24-houperio postoperativel a i practicableTh tim an exten o ambulatio musb determine b th responsibl surgeon Walkin trainin shoul b carrieou onl unde th directio o a physicatherapis o othe qualifie personnel Activit shoul b increase dail a th patient' conditio permits Paralle barswalkerettes crutches an cane ar usea aid i ambulation Tw bathrooscale ma b use t determin th degre o weight-bearin tha i take o thamputate side Thes measurement provid a goo guid t th clini tea concernin th progres bein mad b thpatient Th patien shoul neve b allowe t ambulat withou supervisionFurthermore ambulatio shoul no bpermitte withou th prosthesi becausi thi cas th effec o gravit tend tpul th socke awa fro th stumpthereb reducin th pressur betweestum an socketO th secon postoperativ da (4hour afte surgery th drai i removedI ther doe no appea t b an reasofo removin th cast suc a elevatebod temperature extrem discomforto excessiv loosenes o fit th cas ikep i plac u 1 days I fo an reaso th cas i removed whethe intentionall o unintentionally i i mandator that i a ne cas i indicated i bapplie immediately Durin th firs twpostoperativ week edem wil for rapidl upo remova o th cas and unlesa ne cas i reapplie withi a ver shorperiod th patien will hav t treatei th conventiona manner Th ol casshoul neve b reapplie becaus o thtraum tha i ap t result Whe thesocke i remove purposely a cas cuttei used Ofte th suture ca b takeou a th tim o remova o th firs cast1 t 1 day afte surgery Sometime ii necessar t wai unti remova o thsecon cast 1 t 2 day postoperativelyI man instance th stum wil bsufficientl matur an stabl fo us oa definitiv prosthesi a th tim th secon cas i removed Whe thi i so a cas o th stum i take an appropriatFig 7 Windo i rigi dressin t provid complet relie ove patella measurement ar recorde s tha fabricatio o a permanen prosthesi ca procee immediately Whe th definitivprosthesi i delivered a ligh plastesocke mobilizin th kne join i provide fo us whe th definitiv prosthesi i removed Us o a plaste socke haprove t b superio t elasti bandaget preven edema I delay ar anticipatei providin th patien wit a definitivprosthesis th prostheti unit pylon anfoo ar applie t th shor cas t continu ambulatio activitiesTH ISCHEMI PATIENThroughou th Unite State an Canad a estimate 8 pe cen o al majorelective civilia amputation resul froischemia Al bu a relativel fe involvth lowe extremity Significan advancei surgica an postsurgica managemencouple wit th us o improve prosthese no allo amputatio belo thkne i th grea majorit o thes patientsI i difficul t overestimat th importanc o th kne i ampute rehabilitation especiall i th older classica ischemi patient Debility impaire visionpoo balance neuropathy compromisecirculatio an join functio i th remainin lowe limb an chroni systemiillness al emphasiz th critica nee tsav th knee Th olde bilatera le amputee especially need hi knee t approac th rehabilitatio goa tha permita reasonabl degre o ambulatio anself-sufficiency I a consecutiv serie o12 unselecte majo lower-extremit amputation fo periphera vascula diseas(196 throug 1968) w hav bee abl tobtai primar healin a below-kneleve i 8 pe cent Onc healed thstump remai healed Wit adequatprostheti care secondar breakdow wilseldo occur Thes patient wer amonth approximatel 300 case requirin amputatio o th lowe extremit tha weruse i studyin an developin th technique o fittin prosthese immediatelafte surgery A a resul o thes experiences separat surgica technique havbee develope fo th ischemi patienan fo th nonischemi patientLEVE O AMPUTATIOTh grea achievement i surgica reconstructio o th periphera vasculasyste represen a leadin chapte i medica progres durin th pas tw decadesContinuin basi an clinica researcthroughou th worl support th hoptha a eve highe percentag o lim salvag ca b expecte i th year aheadHowever despit th practica effectivenes o moder vascula reconstructiv surgery statistic indicat tha amputationfo ischemi ar increasin bot relativelan absolutel i relatio tthroughou th wester worldWhe acut o chroni compromis oarteria bloo suppl reache a leve insufficien t suppor tissu viabilit anwhe reconstructiv surger an nonsurgica supportiv measure fail amputatio will b requiredPatient requirin amputatio ar entitle t comparabl medica an surgicaconsideration comparabl tea effort anth sam high-leve rehabilitatio managemen attendin simila patient whosischemi limb ar treate b vascula reconstruction To often ablativ surgerdoe no comman thi hig estateDecisio t amputat ma b simpl anevident Gros necrosi o tissu wit demarcation uncontrollabl infection painirreversibl neuropathy alon o combination an wit result o specifi testt assa circulation will establis th neet amputate Whe al availabl informatio pose a seriou questio a t thpossibilit o lim salvag b reconstructiv surger rathe tha amputation iha bee commo practic t attemp sucsurgery eve thoug extensive Beforquestionabl extensiv reconstructiv arteria surger i carrie out th surgeoshoul conside criticall th overridinprobabilit o it failur wit mandatorsubsequen amputation Wil th proposesurger compromis th leve o amputa Fig 8 Left, stum o 33-year-ol patien o 26t da afte amputatio becaus o infectio owin t nonunio o th tibia Right, permanen prosthesi provide sam patien o 26t da postoperativeFig 9 Outlin o ski flap fo below-kne amputatio o typica ischemi patient leve shoul b mad promptly Re-amputatio rat i th PR serie t throughkne o above-kne ove th four-yeaperio ha bee 9. pe cent A experienc an technique hav improved thre-amputatio rat fo below-kne casewit ischemi ha continue t decreaseTh surgeon o course like t avoi alre-amputations However salvag o thkne i suc paramoun importanctha a occasiona re-amputatio ma brequire i w ar t sav al kne jointpossibl i vie o ou inadequat meanfo determinin th bes leve fo amputationSUMMAR AN CONCLUSIONBelow-kne amputatio i statisticallb fa th mos importan majo amputatio use today Th vas majorit omajo lower-extremit amputation performe fo ischemi will hea primarilan remai heale a below-kne levelTh below-kne amputatio fo ischemii shor i length th posterio ski anmyofascia flap ar fashione long anth techniqu i precise Th resultinstum i cylindrica i shape well-padded comfortable an easil fitte witmoder below-kne prosthese o th total-contac type A immediat postsurgica prosthesi i a integra par o thover-al below-kne ampute managemeni bot th ischemi an nonischemi patient Restoratio o functio an rehabilitatio o th below-kne amputeebot unilatera an bilateral hav improve i almos spectacula fashio wheth guideline an managemen whichav bee outline ar followedBIBLIOGRAPH1 Baddeley R M. an J C Fulford The use oarteriography in conservative amputations for lesions o the feet 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