Presentation on theme: "American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State."— Presentation transcript:
1American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic UpdateChristian W. Ertl MD FACS FACCWSMichigan State UniversitySeattle, 2009
2DisclosureI have no funding issues or support to disclose
3GOALIn 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
4Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit and use
5Femur severely lateralized by pull of the abductors and no adductor stabilization
6Conventional Amputation Effects - Bone Medullary canal ignored, remains openPoor ability for end weight bearingVenous gradient 0mmHg → venous stasis LoonPotential bone spur formation Hulth, Hansen-Leth, Reimann, OlerudRegional osteopenia with possible adjacent joint DJD Lo
7Conventional Amputation Effects - Muscle Majority of musculature allowed to retractFatty atrophy Venous stasisSlower speed of contraction Blix, LoonPoor “volume” of residual extremity in prosthesis
8Basic Science Length-Tension Relationship Normal muscle has max force at slightly longer lengthsIn amputees, muscles are divided, retract, undergo fatty degeneration, and excursion in contraction is decreasedResult is increased work to ambulate with increased fatigueLoon, Prosth Int, 1959.
9Conventional Amputation Effects Incisions placed over prominent surfacesPotential etiology of painRegional circulation disturbedSecondary to venous stasisAbnormal vessel formationHansen-Leth, Hulth, OlerudHigh risk of AVMDilated, tortuous vessels Hansen-Leth,
10Osteomyoplastic Reconstruction Medullary canal sealedBroader surface area to bear weightAllows potential end weight bearing in AKAImproves local circulation
12Myoplasty - Transfemoral Fascial closure of opposing muscle groupsAdductor brought laterally for balance in AKAImproves local vascularityProvides “insertion” for muscles to restore resting length-tension relationshipImprove alignment and biomechanics of limbSoft tissue coverage to end of residual extremity
13Insertion 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 momentF. Gottschalk- U. Texas Southwest
14Myoplasty-Basic Science Arteriogram of AKA prior to myoplastic procedurePoor filling in adductor region of legPoor contour grosslyExostosis formationDederich, JBJS, 45-B, 60, 1963
15Myoplasty-Basic Science Arteriogram 3 months after myoplastic procedureThere is increased arterial flow with in the stumpDistal and medial perfusion is improvedDederich, JBJS,45-B: 60, 1963
16Osteomyoplastic Procedure Goals Osseous/soft tissue reconstructionRemove bone scar/spursMedullary canal closureMyoplasty of opposing muscle groupsPlastic ClosureStabilize the extremityRealign femur for proper mechanics and gaitMuscle balancing
17Osteomyoplastic Procedure Goals Provide a potential end weight bearing extremityClosure of medullary canal returns normal venous gradient; distal bone remains vascularizedCreate a cylindrical residual extremityImproves fitting/use of prosthesisSmooth contour aides in preventing localized skin breakdownPressure points reduced
18Osteomyoplastic Procedure Goals Restore normal physiologyVenous gradient in bone returnedVasculature improves in remaining extremityMuscle length-tension relationship reestablished, thus restoring the efficient use of the muscleLoon, Prosthetics International,1959.
22QuadricepsHamstringsCompletion 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.
23Adductor tubercle with adductor Magnus kept attached to cortical shell Immediate post-opImmediate post-opImmediatepost-opAdductor tubercle with adductor Magnus kept attached to cortical shell
245 weeks post-op; alignment maintained; no lateralization of femur
25Orthotics/Prosthetics/P.T. Begin comprehensive educationSupport groups, networkingBegin comprehensive therapyTransfers, stretching, desensitization, gait training, upper extremity conditioningKnowledgeable staff for supporti.e. ACA, nurse clinicians, etc.
28Post-Op protocol0-4 weeks-Isometrics above amputation, ROM, UE aerobic conditioning4-6 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 applicationEmotional, psychological supportSupport groups, starts from day one
29SummaryProvides the amputee with a “sound” physiological residual extremityPatients have high satisfaction and there is improved outcomeCan be applied to the vasculopath and diabetic1.5 cm of bone resected on averageCan used as a primary procedure as well as reconstructive
30Summary An amputation is not a benign, static procedure The limb is dynamic, so should the “team”Effort must be placed on a team approachThe goal is to return to the patient a functional residual extremityThis can be accomplished by adhering to “biological” surgery principles