Below Knee and Through Knee Prosthesis

(transtibial)

Posterior flap- cut the bone, save the posterior part of the skin because there are more blood vessels at the back DM closure is anterior Transtibial Stump Partial end bearing Knee flexion contracture Distal tibiofibular synostosis(produce pseudo jt. between tibia & fibula so fibula would not move to prevent fibular hypermobility & improve WB) Successful fitting 2.5 length Through Knee (Knee Disarticulation) Adult Amputee Advantage - Durable end weight bearing (direct load transfer) - retention of a long, powerful, ms-stabilized femoral lever arm - Ease of prosthetic socket suspension d/t bulbous end - surgical blood loss - resistance to infection by maintaining the cartilage barrier to infection Disadvantage - Slow wound healing - Lack of internal knee mechanical (ext. vs. polycentric) - Bulky limb appearance Pedia Amputee Preserves growth potential of distal femoral epiphysis Avoids risk of appositional bony overgrowth Prosthetic socket with direct load transfer Eventually allowing the prosthetic knee joint center to approach the same level as the normal knee Indication congenital anomalies malignant tumors nonsalvageable trauma infection Non- Walker Amputee Residual limb in the knee disarticulation amputee is muscle balanced, so these patients rarely develop early or late hip joint contracture. Large surface area for weight bearing and balance while sitting and for turning in bed is provided as well as a long lever arm for transfers

Percentage Short 0-33%

Medium 34-66% Long 67%> Transtibial Prostheses Medial tibial to medial malleolus Medial tibial plateau to end of stump Lower Ex MC (most common) ischemic, DM 1. 15- 28% of pts undergo contralateral limb amputation in 3 years. 2. Elderly persons undergo amputations, 50% survive the st 1 3 years. (PVD, problems in kidney) Maximize the fx of the residual limb Surgical Procedure should: 1. Shorten & bevel(remove sharp edges) the bone 1 inches between end of bone to stump end. 2. Transect nerve under tension to allow retraction. 3. Secure ms. myoplasty (muscles anchored to opposing muscles; plastic surgery on muscle in which portions of detached muscles are used, especially in the field of defects or deformities) & myodesis (referring to muscles anchored by sutures through the bone) for structurally stable & fxnal limb. 4. Avoid bony prominences at the far distal end of the residual limb. 5. Keep long bony lever arm adequate ms. And soft tissue coverage Preoperation Condition A large circumferential skin incision to make section the knee. The musculature & soft tissues are directed around.

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Treatment Guidelines Energy Requirements Unilateral transtibial 10 20% Unilateral transfemoral 60 70% Bilateral transtibial 20 40% Higher the energy, the higher the energy, lower capacity for function.

Transtibial Vascular Trauma O2 consumption 33% 7% Gait velocity 44% 11% To energy consumption, # of steps & stride lengths are lessened. Transfemoral O2 consumption Gait velocity Vascular 67% 55% Trauma 33% 35%

Stress Testing for Amputee Independent crutch/ walker ambulation without prosthesis indicates functional prosthetic ambulation Light weight modulator prosthesis Preferred Indirect weight transfer distribute load to a more proximal bony area incorporate a total-contact interface with the soft tissues of the extremity Direct weight transfer residual limb is capable of end weight bearing within a prosthesis. proximal articulation of the joint is maintained, functions normally, and is broad enough to distribute the end-bearing forces. Stump length leverage Unilateral wt. loss balance prosthetic wt. Complicated prosthetic fib Shorter- increase energy, more suspension Longer decrease energy, more easy to fit Skin Grafting 1. To complete wound coverage 2. Decrease tension on wound closure, while maintaining the limb length 3. Poor tolerance to axial and shear stress within the prosthetic socket. Goals: 1. Adequate wound healing 2. Pain Mx. 3. Limb shaping 4. Strength development 5. Facility of mobility 6. ADL independence Desensitization Prepare limb for prosthesis user via desensitization program Stump Shrinker 1. Gentle tapping & massage

Scar mob & massage Edema control Application of pressure to distal aspect of residual limb Post- operation IPORD (Immediate Post Op)/ Removable rigid dressing 1. Aids in edema control and leads to rapid residual limb shrinkage 2. Promotes healing by providing protection and preventing edema 3. Desensitizes the limb 4. Prevents residual limb trauma 5. Reduces wound pain Optimum ROM Transtibial - 25of knee flexion contracture 1. Below knee prosthesis 2. Surgical Intervention Transfemoral - 15 hip flexion 1. Compensatory lumbar lordosis 2. Loss of hip extension power 3. Knee instability Functional Strength Transtibial- Hip & Knee ms.group Transfemoral Hip abd., spinal ms. Group Prosthetic Prescription BKA Endoskeletal Exoskeletal Foot & Ankle System Shank Separate - - - - - - - - Socket - - - - -incorporated in shank Incorporated in socket - - - - - Suspension - - - - - Separate Transtibial Socket 1. Patellar tendon 2. Pretibial muscles 3. Posterior aspect of the residual limb over the upper portion of the gastroc-soleus muscles 4. Lateral shaft of fibula 5. Medial tibial flare Prostheric Fitting and Training Preparatory Prosthesis (6-8wks) It allows early rehab Training in the donning and removal of the prosthesis Transfer training Building of wear tolerance Attainment of balance Ambulation with the prosthesis several weeks before final residual limb volume stabilization Use 6 socks Definitive Prosthesis Sufficient trunk control Good upper body strength Adequate knee stability and control Static and dynamic balance Adequate posture Fabrication Check out alignment static / dynamic 1. 2. 3. 4. 5.

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CMS functional levels ( Centers for Medicare and Medicaid Services Class 0: The patient does not have the ability or potential ability to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility 1: The patient has the ability or potential ability to use a prosthesis for transfers or ambulating on level surfaces at a fixed cadence; this is typical of the limited and unlimited household ambulator 2: The patient has the ability or potential ability to ambulate well enough to traverse environmental barriers, such as curbs, stairs, or uneven surfaces; this is typical of the limited community ambulator 3: The patient has the ability or potential ability to ambulate with variable cadence; this is typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activities that demand prosthetic use beyond simple locomotion 4: The patient is capable or potentially capable of prosthetic ambulation that exceeds basic ambulating skills and that exhibits high impact, stress, or energy levels; this is typical of the prosthetic demands of a child, an active adult, or an athlete Most common problem Unequal knee joint Transtibial Prosthetic Gait Heel Strike 1. Slight flexion of knee 2. Ball of prosthetic ft. <4cm from floor 3. Erect pelvis and trunk 4. BW transfer from normal to prosthetic leg Heel Strike to foot flat 1. Knee flexion 10-15 2. <2.5cms head and trunk sway to prosthetic side 3. Minimum lat socket displacement 4. Pylon is perpendicular to floor 5. Prosthetic ft is flat on the floor Midstance to Toe off 1. BW transfer from prosthetic to N leg with minimal head, trunk/ pelvic sway 2. Distance between 2 feet is 5cm Swing 1. Knee flexion easily to allow toe clearance 2. Socket secured on residual limb 3. Step length equal as N leg 4. Shank & ft swing in line of progression 5. Pelvis level Gait Deviation 1. Improperly fitting socket 2. Malaligned prosthesis 3. Painful residual limb 4. Poor walking habits

Cause: Toe lever arm (toes of ft.) -ant. segment of prosthetic ft. -Support @ midstance& terminal stance for rollover

Heel lever arm -posterior segment -Support @ heelstrike to midstance through -smooth prosthetic ft. descent -knee flexion control

1. Ant. Socket 2. Long HLA 3. Short TLA

Post to knee ant to ankle premature knee flexion; sharp hip drop 4. Too hard heel cushion 5. DF ft. 1. Post socket 2. Short HLA 3. Long TLA

Ant. to knee Post. to ankle 4. Too soft heel cushion 5. PF ft. Knee hyperextension 1. 2. 3. Adducted socket Medial leaning pylon Outset ft.

Absent medial support @ stance Wide based gait Medial pressure proximal socket 1. 2. 3. Abducted socket Lateral leaning pylon Inset ft.

WB on lat. ft. Lateral pressure proximal socket Lat. Thrust

Gait Deviations Gait Cycle Specific

N gait 1. Reduce vertical displacement of COG 2. Allow floor reaction force absorption 3. Dec. energy expenditure Excessive knee extension 1. Inc. pelvic displacement 2. Ant. Distal stump post. Proximal socket brim pain 3. Increase energy expenditure 4. Apparently long prosthesis HC to FF Excessive knee extension Etiology

energy expenditure, residual limb discomfort, limited fxnal prosthetic use

Too soft heel cushion Posterior displacement of socket over knee Excessive PF of ft Lower heel/ shoe Knee instability Too short toe lever arm PF ft. Midstance 1. Excessive raising of hip on prosthetic side 2. Excessive knee pending for toe clearance prosthetic Hip & shoulder drops too short prosthe Wide-based gait outset ft; medial leaning pylon Narrow based gait inset; lateral leaning pylon Lateral thrust suspension other than sleeved PTSCSP - femoral adhesion; knee jt. varus motion Terminal Stance Drop-off toe lever arm too short Knee extension toe lever arm too long Swing Prosthesis slips off toe slubbing on floor - loss of suspension; pistoning Circumduction Etiology Long prosthesis Inadequate suspension N transfemoral prosthetic Gait Heel Contact Knee ext as ft descends to floor Forward & slight lat shift of body as wt transferred to prosthetic leg Midstance <5 pelvic drop 2.5 cm lat trunk bend 5 cm rocking base Good mediolat stability of prosthe leg Toe off Smooth heel rise Hip ext without lumbar lordosis Knee flexion Swing Smooth knee flexion Adequate ft clearance with smooth & quiet swing Knee ext towards heel strike HC Mst Knee instability lack of adequate socket - too hard cushion - too long heel lever arm - severe hip flexion contracture Terminal Impact constant friction knee mechanism - habit Foot slap too short heel lever arm - Too soft cushion - Forcible driving of ft onto making surface to ensure knee extension Midstance Very short - lateral trunk bending residual limb Painful residual Too short prosthe - Inadequate socket - too high medial wall of socket

- inadequate balance weak hip abductors - Abducted gait too long prosthesis - pelvic band positioned.. - Excessive trunk ext. increase lumbar lordosis - Insufficient flexion, hip flexion contracture, weak hip extensors, weak abs Midstance to Toe off Drop-off o Etiology: toe lever arm too short; Inadequate heel off prosthesis user insecure Swing: Contracture Too long prosthesis Too much knee friction Improper functioning stance phase control knee Fear of stubbing toe Ms. Weakness Vaulting Too long prosthesis Too much knee friction Knee lock causing knee flexion Medial / Lateral Whips Excessive ER/IR to prosthetic knee Too high socket Residual limb rotation Prosthe donned?? Uneven arm swing Poor training Fear of putting wt. on prosthesis Sources: http://emedicine.medscape.com/article/317358overview#showall http://emedicine.medscape.com/article/1232102overview#showall http://www.oandplibrary.org/alp/chap19-01.asp NYU Manual Bandaging impt. part of proper training