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:
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
2004- course given new content and a new name: Amputation surgery and related prosthetics 2009- first time the new course was given
Course Outline: 1 › History › Epidemiology › Pre-op Mx › Decision making process in Sx › Post-op Mx › Prediction of functional outcome › Sexuality and amputation
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)
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
“It is not to take but to make.” Early rehab involvement! › Although same problem everywhere, not happening or inconsistency in engaging rehab pre-op
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
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
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.
“Soft tissue is more important than bone.”
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
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
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.
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?
General principle: “The liner has to be as thin as possible and as thick as necessary.” Selection should be based on individual circumstances.
Historical love/ hate relationship First described in literature in 1830 Very little data Most national surveys: 1-3 % of all amputations
Dr Douglas Smith’s experience › 12 year data base (1995-2008) › 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
80 KDs in 77 pxs Aged b/w 19-92 (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
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.
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
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%
Consider C-knee in the elderly population! › Provides better gait › Improved stability › Improved walking speed › Less falls
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
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
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
Explain the vital skills and importance Offer prosthesis when patient masters skills Places challenge on patient and family Avoids arguments!
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
Minimal model › Doctor › Podiatrist and/or nurse Intermediate › Doctor (diabetes specialist, surgeon, rehab) › Podiatrist and/or nurse › orthotist
Highly recommended › Relevant › Comprehensive, but not too overwhelming › Balanced and well- respected speakers A Sydney venue in the future?!
We are Coaches! We must create enthusiasm! › Positive approach to Surgery › Positive approach to early rehabilitation › Positive approach to prosthetics