Walter Racette C.P.O.

Associate Clinical Professor Director, Orthotic and Prosthetic Centers@ UCSF

Defined- surgery to modify the residual limb in such a way to improve the soft tissue, bone, and underlying structures that will enable better socket comfort, improve weight bearing, and function

When? All reasonable attempts to fit the socket, align, and suspend have been taken. This should include necessary design changes and components

Much higher rate of revisions after traumatic amputation or failed limb salvage Often overlooked solution by prosthetist. Patients go from prosthetist to prosthetist. $$$$$$ Ask your patient when was the last time they had an x-ray

When? Potential change could significantly improve the function for the patient There is evidence; physical exam, x-ray etc that indicate probability of underlying issues

As in the case of trauma, revision of the residual limb is necessary as it was of secondary importance at the time of the initial amputation; other life threatening injury and or infection

WHY? The socket/skin interface is a critical element for successful full time use for an upper or lower extremity amputation

1. 2. 3.

WHY? Successful use of the prosthesis on a full time basis requires a pain free socket. Factors that affect socket fit Alignment Suspension Inappropriate use of interface; sock management

Although the upper extremity amputee need not weight bear there are just as may reasons that this patient population can benefit from revision surgery IF not more.

Issues to consider before revision surgery Residual limb length before/after Initial reason for amputation Patient age Patient desire/motivation

1.

2. 3. 4.

Soft tissue issues Scaring and adhesions Redundant tissue Neuromas Phantom limb pain/sensation????

Scaring and adhesions; why does it present such a big problem for the socket/skin interface?

Redundant tissue: Isnt good skin coverage over bone a good thing?

Neuromas: Every cut end of the nerve develops one; why and when do they become a problem?

Bone/residual limb length

Bone Spurs Hypertropic ossification Fracture fixation hardware Infection

Examples of bone

After exhausting all prosthetic options After evaluation of patient utilization and potential After determining clinical evidence useful in predicting improvement Revision surgery can greatly improve the fit and function of a prosthesis and lead to a higher functional level for the patient. It is often a delayed or forgotten avenue of total treatment.