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 Consensus conference on amputation sx in Scotland in Oct 1990  ’92- Rungsted, Denmark  ’92- Groningen, The Netherlands  ’93- Moshi, Tanzania  ’94-

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Presentation on theme: " Consensus conference on amputation sx in Scotland in Oct 1990  ’92- Rungsted, Denmark  ’92- Groningen, The Netherlands  ’93- Moshi, Tanzania  ’94-"— Presentation transcript:

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2  Consensus conference on amputation sx in Scotland in Oct 1990  ’92- Rungsted, Denmark  ’92- Groningen, The Netherlands  ’93- Moshi, Tanzania  ’94- Pattaya, Thailand  ’94- Ljubljana, Slovenia  ’94- Panama City, Panama  ’96- Madras, India  ’97- Jaipur, India  ’97- Helsinborg, Sweden  ’98- Hanoi, Vietnam  ’98- Tokyo, Japan  ’99- San Salvador, El Salvador

3  course given new content and a new name: Amputation surgery and related prosthetics  first time the new course was given

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6 Course Outline:  1 › History › Epidemiology › Pre-op Mx › Decision making process in Sx › Post-op Mx › Prediction of functional outcome › Sexuality and amputation

7  2 › Skin problems › Physiotherapy › Phantom pain and pain mx › Psych aspects › Sports after amputation › Liners › CAD-CAM

8  Continuation of 2 › Hip disarticulation & hemipelvectomy  Epidemiology and Sx  Rehabilitation  Biomechanics  Prosthetics

9  3 › Transfemoral amputation  Epidemiology and Sx  Rehabilitation  Biomechanics and gait  Prosthetics

10  Continuation of 3 › Transtibial amputation  Epidemiology and Sx  Rehabilitation  Biomechanics and gait  Prosthetics

11  4 › Foot and ankle amputations  Epidemiology and Sx  Rehabilitation  Biomechanics and gait  Prosthetics

12  Continuation of 4 › Diabetic foot  Epidemiology  Physical examination  Treatment of foot infections  Rehabilitation  Casting  Orthotics  Ortho reconstructive sx

13  Surgeons: › Douglas Smith (USA) › Takaaki Chin (Jpn)  Rehab physicians: › Dirk van Kuppevelt (The Netherlands) › Jan Geertzen (The Netherlands) › Carolina Schiappacasse (Argentina)  P&Os: › Donald Cummings (USA) › Siegmar Blumentritt (Germany)

14 Official name given by the ISOPrevious used names Partial foot amputationChopart amputation Lisfranc amputation Ankle disarticulationSyme amputation Pirogoff amputation Through ankle disarticulation Trans-tibial amputationBelow-knee amputation Knee disarticulationThrough knee amputation Trans-femoral amputationAbove-knee amputation Hip disarticulationThrough-hip amputation Trans-pelvic amputationHemipelvectomy Hindquarter amputation Sacroiliac amputation

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16  “It is not to take but to make.”  Early rehab involvement! › Although same problem everywhere, not happening or inconsistency in engaging rehab pre-op

17  Peri-op mortality in LLA is high  MI is the most common cause of post-op mortality  Cardiac function is relevant during rehab because of required increased energy expenditure

18  Obj: to determine pre-op ventricular function in vascular amps by measuring NT- proBNP and to analyse the relationship b/w NT-proBNP and 30-day post-op mortality  Prospective pilot study  19 pxs; four died w/in 30 days after sx  In 17 of 19, levels were found to be more than 2 SDs above age-corrected reference values

19 Clinical messages:  Pre-op NT-proBNP levels in vascular amputees are not statistically related to 30-day mortality and level of amputation  Pre-op NT-proBNP levels in vascular amputees are high, indicating that serious ventricular disease may be present.

20  “Soft tissue is more important than bone.”

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22  Lack of research  After thorough publication database search: only 11 eligible studies found  Amputees remain to be sexual beings  Sexual activities are hindered in different ways, related to type, level, and cause of amp’n  Effects of pain and body image on libido  Erectile dysfunction; decreased lubrication

23  Higher impact on sexual functioning in the elderly compared to younger amputees › ?effect of age vs amputation  Being married or having a steady partner as an amputee give fewer problems than being single  13-75% are not satisfied with their sexual life, despite unchanged interest in sex

24 Conclusion  Assessment of sexual functioning should be an integral component of the periodic evaluation scheme in the Rehab team.  One or more members of the Team should be trained for that assessment.

25  Wrong concept: › Rehab only starts after the stump has healed completely  Consider x-ray of stump  trial antiperspirant spray or roller for problematic sweaty stumps?  May need less wash (q2-3 days) of stumps during colder months?

26  General principle: “The liner has to be as thin as possible and as thick as necessary.” Selection should be based on individual circumstances.

27  Historical love/ hate relationship  First described in literature in 1830  Very little data  Most national surveys: 1-3 % of all amputations

28  Dr Douglas Smith’s experience › 12 year data base ( ) › 1787 total amputation procedures  950 primary  827 secondary › 62 knee disarticulation (3.5%)  Trauma= 27 pxs  Infection= 11 pxs  Vascular dse= 10 pxs  SCI= 4 pxs

29  80 KDs in 77 pxs  Aged b/w (average of 64)  31 DM; 29 PVD; 14 trauma; 2 sarcoma; 1 Ollies Dse  5 pxs died early in post-op pd  63 of 67 healed primarily; 7 dehisced and revised to TF level  22 of 27 who walked pre-op successfully, used a prosthesis and walked post-op

30  Non-ambulatory pxs have different concerns and goals than ambulatory pxs. › How will the px transfer? › What contractures are present? › What contractures will occur? › Consider surface area and support for sitting.

31  For ambulatory pxs, KD is usually more functional than a TFA › Longer lever arm › Balanced thigh muscles › Improved suspension › End bearing › Lower proximal socket brim › Sitting comfort

32  Walking velocity (Pinzur, et al, Ortho, 1992 Sep) › Slightly lower than TTAs, but significantly faster than TFAs  Function (Hagberg, et al, PO Int 1992 Dec) TTATKATFA Don and doff100%70%56% Daily use96%76%50% >9hrs/day54%41%22% 6-9hrs/day17%11%6% 3-6hrs/day13%24%28% <3hrs/day13%12%28% No use4%12%39%

33  Consider C-knee in the elderly population! › Provides better gait › Improved stability › Improved walking speed › Less falls

34  Hip flexion contracture › 1 st year: try to stretch to correct or lessen degree of contracture › After 1 year: provide prosthesis which will accommodate to contracture  Not cosmetic- but more functional

35  Who/When to prescribe a Prosthesis?  TTA: › Patient has their own knee power › Prosthesis helps w/ transfer › Prosthesis helps with STS  TFA: › Patient has no knee power › Prosthesis has no knee power › Transfers- often easier without prosthesis › STS- prosthesis makes it more challenging

36  Before a TF Prosthesis is prescribed, patient must master the following vital skills: (UW guidelines) › Transfer independently (both in/out of bed, on/off toilet) › STS independently › Walk in parallel bars or walker (one leg gait), for at least 6-8 meters

37  Explain the vital skills and importance  Offer prosthesis when patient masters skills  Places challenge on patient and family  Avoids arguments!

38  A multidisciplinary Foot Clinic  In developed countries: › Up to 4% of people w/ DM have a foot ulcer › Uses 12-15% of healthcare resources for DM  Multidisciplinary foot team has been shown to bring 49-85% reduction in amputation rates

39  Minimal model › Doctor › Podiatrist and/or nurse  Intermediate › Doctor (diabetes specialist, surgeon, rehab) › Podiatrist and/or nurse › orthotist

40  Highly recommended › Relevant › Comprehensive, but not too overwhelming › Balanced and well- respected speakers  A Sydney venue in the future?!

41  We are Coaches!  We must create enthusiasm! › Positive approach to Surgery › Positive approach to early rehabilitation › Positive approach to prosthetics

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