Presentation on theme: "American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State University."— Presentation transcript:
American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State University Seattle, 2009
Disclosure I have no funding issues or support to disclose
GOAL In 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
Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit and use
Femur severely lateralized by pull of the abductors and no adductor stabilization
Conventional Amputation Effects - Bone Medullary canal ignored, remains open –Poor ability for end weight bearing –Venous gradient 0mmHg → venous stasis Loon –Potential bone spur formation Hulth, Hansen- Leth, Reimann, Olerud –Regional osteopenia with possible adjacent joint DJD Lo
Conventional Amputation Effects - Muscle Majority of musculature allowed to retract –Fatty atrophy Venous stasis –Slower speed of contraction Blix, Loon –Poor “volume” of residual extremity in prosthesis
Basic Science Length-Tension Relationship Normal muscle has max force at slightly longer lengths In amputees, muscles are divided, retract, undergo fatty degeneration, and excursion in contraction is decreased Result is increased work to ambulate with increased fatigue Loon, Prosth Int, 1959.
Conventional Amputation Effects Incisions placed over prominent surfaces –Potential etiology of pain Regional circulation disturbed –Secondary to venous stasis –Abnormal vessel formation Hansen-Leth, Hulth, Olerud –High risk of AVM –Dilated, tortuous vessels Hansen-Leth,
Osteomyoplastic Reconstruction Medullary canal sealed Broader surface area to bear weight Allows potential end weight bearing in AKA Improves local circulation
Myoplasty - Transfemoral Fascial closure of opposing muscle groups Adductor brought laterally for balance in AKA Improves local vascularity Provides “insertion” for muscles to restore resting length-tension relationship Improve alignment and biomechanics of limb Soft tissue coverage to end of residual extremity
Insertion 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 moment F. Gottschalk- U. Texas Southwest
Myoplasty-Basic Science Arteriogram of AKA prior to myoplastic procedure Poor filling in adductor region of leg Poor contour grossly Exostosis formation Dederich, JBJS, 45-B, 60, 1963
Myoplasty-Basic Science Arteriogram 3 months after myoplastic procedure There is increased arterial flow with in the stump Distal and medial perfusion is improved Dederich, JBJS,45-B: 60, 1963
Osteomyoplastic Procedure Goals Osseous/soft tissue reconstruction –Remove bone scar/spurs –Medullary canal closure –Myoplasty of opposing muscle groups –Plastic Closure Stabilize the extremity –Realign femur for proper mechanics and gait –Muscle balancing
Osteomyoplastic Procedure Goals Provide a potential end weight bearing extremity –Closure of medullary canal returns normal venous gradient; distal bone remains vascularized Create a cylindrical residual extremity –Improves fitting/use of prosthesis –Smooth contour aides in preventing localized skin breakdown –Pressure points reduced
Osteomyoplastic Procedure Goals Restore normal physiology –Venous gradient in bone returned –Vasculature improves in remaining extremity –Muscle length-tension relationship reestablished, thus restoring the efficient use of the muscle Loon, Prosthetics International,1959.
Muscle Flaps brought over end of femur
Quadriceps Hamstrings Completion 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.
Immediate post-op Adductor tubercle with adductor Magnus kept attached to cortical shell Immediate post-op Immediate post-op
5 weeks post-op; alignment maintained; no lateralization of femur
Orthotics/Prosthetics/P.T. Begin comprehensive education –Support groups, networking Begin comprehensive therapy –Transfers, stretching, desensitization, gait training, upper extremity conditioning Knowledgeable staff for support –i.e. ACA, nurse clinicians, etc.
Post-Op protocol 0-4 weeks-Isometrics above amputation, ROM, UE aerobic conditioning 4-6 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 application Emotional, psychological support –Support groups, starts from day one
Summary Provides the amputee with a “sound” physiological residual extremity Patients have high satisfaction and there is improved outcome Can be applied to the vasculopath and diabetic 1.5 cm of bone resected on average Can used as a primary procedure as well as reconstructive
Summary An amputation is not a benign, static procedure –The limb is dynamic, so should the “team” Effort must be placed on a team approach The goal is to return to the patient a functional residual extremity This can be accomplished by adhering to “biological” surgery principles