Interventions in Lower Extremity Prosthetics

Walter Racette CPO Assistant Clinical Professor Director, Orthotic and Prosthetic Centers @ UCSF

Unique patient population

In many cases, the amputation is not the major issue that the patient is dealing with

Unique patient population

Homeless

Drugs; Rx and self selected

Mental status Other medical issues

Transportation
Hygiene Medical insurance

Prosthetic terms

Prosthetics Prosthesis Socket

Suspension
Inner face prosthetist

Prosthetic terms

Redundant tissue Prosthetic components

Anterior/toe lever arm

Posterior/heel lever arm

Prosthetic Feet
It is the transmission of the lever arm force to the body that can either accelerate the COG from heel strike to mid stance and then decelerate/stabilize the knee from mid stance to toe off

Prosthetic Feet

Prosthetic Feet

Prosthetic Feet

Lower Extremity Prosthetics

levels of lower extremity amputations Post operative care Socket fitting and volumetric changes The prosthetic care process Common patient issues

Common amputation levels

Partial foot prosthetics

Missing anterior stability, push off in the gait cycle and balance

Common amputation levels

Partial foot

Common amputation levels

Partial foot

trans metatarsal
Ankle disarticulation

Common amputation levels

Ankle disarticulation; - disarticulation of the foot

Major issues with ankle disarticulations

Not capable of distal end bearing Length under heel pad to the floor for prosthetic foot Cosmetic Distal migration of pad to the medial side

Major issues with ankle disarticulations

Major issues with ankle disarticulations

Common amputation levels

Trans tibia

Common amputation levels

Trans tibia

Common amputation levels

Trans tibia

Trans tibia amputation

Function varies with length as well as reason for amputation Good mobile skin coverage distally is more important than trying to maintain extra length

Knee flexion contractures of more than 25 degrees are difficult to fit as trans tibia
Very short trans tibia have ML and AP instability

Common amputation levels

Trans femorallength is a major issue.

Better control of knee More weight bearing surface

What predictors indicate prosthetic success?

Trans femoral amputation

The need for a prosthetic knee at this level significantly complicates and lengthens rehabilitation Much higher energy consumption to ambulate

Much more difficult to don and doff

The major weight bearing area is high in the groin Weight gain/loss is the major reason for socket replacement not edema and atrophy

Common amputation levels

Common amputation levels

Bilateral lower extremity amputations

Post operative management

Good wound healing environment

Prevent contracture Compression

Protect the limb

Ambulation?

Post operative management

Post operative management

Post operative management

Prefabricated rigid stump protectors
24 hours after surgery Pull into through strap and hole in the bottom 6 compresso grip for mild compression and to hold on the dressing Contracture prevention and residual limb protection

Post operative management

Post operative management: why is it so important?

Reducing the volume of the limb prior to casting. A two to three inch reduction at mid calf level would not be unusual during the first 6 months post amputation. Less margin for patient error in volume issue Reduction in cost

Post operative management: why is it so important?

Contractures limit and compromise successful prosthetic use Reducing the time between surgery and wound healing keeps the window of opportunity open

Prosthetic care process

Evaluation, casting, and measurements

Prosthetic care process

Casting and measurements

Prosthetic care process

Clear test socket Dynamic

Prosthetic care process

Prosthetic care process

Suspension

Prosthetic care process

Dynamic alignment

Alignment issue

Prosthetic care process

Protective/cosmetic restoration

Prosthetic components

Prosthetic feet Static Dynamic response

Prosthetic Feet

So whats so important about the prosthetic foot?

Prosthetic Feet

Suspension of the prosthesis

Good suspension prevents piston action Reduces the feeling of weight Safety and confidence

Suspension of the prosthesis

Ankle disarticulationself suspending: pass the larger distal limb past more narrow proximal

Suspension of the prosthesis

Suspension of the prosthesis

Common prosthetic issues

Prosthetic socks Volume of residual limb changes and educating patient on how to understand and make good decisions

Pads placed inside the socket

Grinding material out of certain areas Replace the socket

Common prosthetic issues

Loss of edema

Weight gain/loss
Dialysis VOLUME changes Medications Trauma to the limb Not wearing consistantly

What happens and what can change volume???

Common skin issues

Pressure sores Lack of distal total contact Soft tissue adhesions Hygiene of the residual limb

Common skin issues

Common skin issues

Common skin issues

Common issues

Hypertrophic bone growth

Neuromas
Bone spurs

QUESTIONS?