재활의방법과시기 / 길이는얼마가적당한가?

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Edward Lyons
5 years ago
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1 BK amputation 재활의방법과시기 / 길이는얼마가적당한가? Soo-Kyung, Bok. M.D., Ph.D Chungnam National University Hospital

2 Contents Level selection of BKA Rehabilitation Preoperative management Immediate postoperative management Prosthetic management

3 BKA vs AKA Near-normal ambulation Overall life-style Less energy than transfemoral amputees Reduced perioperative mortality Healing Transfemoral > transtibial

4 CIx of BKA Inadequate vascularity Severe rest pain or gangrenous changes in proximal part Severe knee flexion contracture Children with congenital foot anomalies

5 Level selection (I) Highly individualized Etiologic factors Clinical & laboratory evaluation

6 Level selection (II) The shortest level : Including the tibial tubercle Effective length : approximately 15 cm The longer the residual limb -> the better the gait Popliteal pulse(-) Proximal half of the leg The junction of the proximal and middle thirds Good blood flow The junction of the middle and distal thirds

7 Level selection (III) Bone tumor Adequate margins free of disease Dysvascular pts Reconstructive vascular surgery Trauma Accident and previous treatment

8 Vascularity Touch and sight Peripheral pulses, skin warmth & texture, color of the foot, hair growth, indolent ulcers, ts necrosis, gross infection or lymphangitis No pulse Obscured by edema, hypotension, obesity Femoral pulse(+) -> healing 81% Collaterals to the calf by profunda femoral a Trial skin incision If skin bleeds within 3 min No correlation Arteriography d/t vascular reconstruction

9 < Residual limb >

10 Cylindrical limb Beveling of the tibia with careful smoothing of the bone edges Bevel of 45 to 60 Fibula No more than 0.5 to 1cm shorter than the tibia Tapered shape vs Conical shape

11 Case 1. 박 O 희 73/F

12 Case 2 김 O 영 58/M

13 REHABILITATION

14 Preoperative management Trauma : concomitant injuries Peripheral vascular ds DA, CHF, arrhythmias, H/T, DM Adequate nutritional support Physiatrist Prosthetic fitting Smoking cessation(1 week before surgery and continuing throughout wound healing) Psychologist

15 Immediate postoperative management Rigid dressing Soft dressing Pain control Early mobilization Psychological counselling

19 Prosthetic management Patient evaluation Preparatory and definitive prosthesis Socket and foot design Checkout of prosthesis Prosthesis fitting and gait training

20 Patient evaluation Activity level Geographic location Time since amputation Shape of residual limb Soft ts and skin problem Knee joint Patient goals, medical condition

21 Functions of prostheses (stance phase) Shock absorption Advace of ibia GCM and soleus Forefoot flexibility Control of plantar flexion MTP dorsiflexion

22 Staging of care Elastic bandages, prosthetic shrinkers, rigid dressing Immediate postoperative prosthesis Preparatory prosthesis Definitive prosthesis

23 Socket Patellar tendon-bearing socket Total surface-bearing socket Hydrostatic socket Socket variants Hard socket Soft inserts Gel liners Distal pads

27 Pressure-toleant / sensitive area

28 Suspension : silicon suction socket

30 Suspension : thigh corset 2 inches below the perineum Need not be higher than 7 in. from the prosthetic center Knee joint instability Partial unlading of residual limb

31 Suspension ; cuff and sleeve Cix Short residual limb Sensitive skin

32 Suspension : PTB-SC / PTB-SCSP

33 Foot-ankle assembly Joint simulation Shock absorption A stable weight bearing base of support Muscle simulation cosmetics

34 SACH No movable component Excellent stability, geriatric amputee Cosmetic Durable, light, inexpensive

35 Single axis Plantar bumper, dorsiflexion stop Increased knee stability at heel strike High maintenance, heavier, less durable

36 Multi-axis P/F, D/F, inversion, eversion, some rotation Uneven terrain Less stable Increased wt & maintenance

37 Energy storing feet

38 Checkout of prosthesis Standing Sitting Walking Prosthesis off Alignment Length piston action Gait pattern Skin color

TRANSTIBIAL AMPUTATION General Principles & Update on Surgical Techniques

TRANSTIBIAL AMPUTATION General Principles & Update on Surgical Techniques Douglas G. Smith, MD Harborview Medical Center and University of Washington - Emeritus Prosthetic Research Study Amputee Coalition