Transfemoral protheses

REHAB MEDICINE

1. Transfemoral Prostheses K.Soundararajan

2. objectives Introduction Transfemoral amputation Rehabilitation of Transfemoral amputation Prostheses in Transfemoral amputation Conclusion Reference

3. Introduction Individual with amputation between the femoral condyles and greater trochanter are fitted with Transfemoral / above knee prostheses. Those whose limbs retain the distal part of femur can wear a knee disarticulation prosthesis, which differ from Transfemoral in the type of knee unit & sockets. If the amputation is proximal to greater trochanter, the patient cannot retain or control a Transfemoral prosthesis & prescribed for hip disarticulation prosthesis

4. Transfemoral Amputation

5. Transfemoral Amputation Amputation is defined as surgical removal of apart or whole of a limb. It is considered only if the limb is Dead (gangrenous) Dying (gross ischemic) Dangerous (due to malignancy) Dud (useless e.g. leprosy)

6. Transfemoral Amputation Children – congenital anomalies Young – RTA, crush injury Elderly – vascular condition (diabetes) Principle Primary wound healing Preserve as much length as possible Maintain anatomical & mechanical alignment

7. Transfemoral Amputation Its most common in individual with impaired circulation & gangrene of foot & toes More energy loss during ambulation of this patient Types Short A/K Medium A/K Long A/K

8. Transfemoral Amputation The mechanical axis of LL runs from center of head of femur through center of knee & to mid point of ankle The anatomical alignment i.e. femoral shaft-axis is 9ᵒ from vertical In most cases, stump is abducted due to over action of G.medius & Minimus and loss of adductor at level of insertion (adductor magnus accounts for 70% adduction) To prevent this adductors are sutured to lateral aspect of femur with femur in maximum adduction In additionally quadriceps is sutured posteriorly and fascia lata is also sutured to femur

9. Transfemoral Amputation muscle wasting With aim of MRI the amount of atrophy in muscle in stump after 2 years was assessed & revealed Muscle that are not sectioned like G.medius , minimus , iliopsoas has 30% atrophy Muscles that lost insertion indirectly like G.maximus & tensor fascia lata due to non-attachment of fascia lata showed atrophy 37 to 47% Muscles that are sectioned & attached by myoplasty or myodesis atrophied 40 to 60%

10. Rehabilitation of Transfemoral amputation

11. Rehabilitation of Transfemoral amputation Rehabilitation can be divided into 1. Pre – op period 2.Post op period – a) Pre prosthetic stage b)Prosthetic stage 3.Community &Vocational rehabilitation 4.Life long management &Follow up

12. Rehabilitation of Transfemoral amputation Pre operative period 1.Medical &physical assessment(power of UL, LL, Trunk, crutch muscles, joint mobility, standing &sitting balance) 2.Patient education 3. Functional ability 4.Discussion about limb pain, Post-OP Exercise Plan . 5. General conditioning program(cardiopulmonary)

13. Rehabilitation of Transfemoral amputation Exercise management Breathing exercises – To maintain clear chest Strengthening exercises – For Shoulder extensors &adductors. For elbow extensors. Hip extensors , flexors , abductors &quadriceps. Joint mobilization – for hip extension knee flexion &extension.(mostly expect deformity) Pelvic bridging , Roll to prone, back to supine Transfer from bed to wheel chair & for hygienic activity. (stop, start, turn, control) Trunk stability in sitting & standing

14. Rehabilitation of Transfemoral amputation Post operative period Pre prosthetic stage : To prevent Deformity Decubitus contracture Stump edema Phantom limb

15. Rehabilitation of Transfemoral amputation Phantom limb pain Phantom limb sensation is the sense that the amputated limb is still present. Phantom limb pain is perception of pain cortically over an absent body part. Major Factor influencing quality of life post amputation

16. Rehabilitation of Transfemoral amputation Phantom limb treatment 1.Heat application 2.Biofeedback to reduce muscle tension 3.Relaxation techniques 4.wound debridement 5.physical therapy (TENS) 6.neuro stimulation techniques including spinal cord &brain stimulation 7.medications –neuroleptics,anticonvulsants,sodium channel blockers and NSAIDS.

17. Rehabilitation of Transfemoral amputation Post operative (phase 1 Acute) pre prosthetic This phase begins immediately after patient is discharged from hospital . GOALS :1.pain control &promotion of wound healing 2.optimization of ROM, strength whole body, balance, transfer 3.equipment prescription 4.General ,Functional mobility 5.phantom limb pain education and management 6. To re-educate walking

18. Rehabilitation of Transfemoral amputation Prevent post OP complication Breathing EX & Brisk EX for unaffected leg Position in bed: stump parallel to unaffected limb in neutral position without resting pillow. Pt lie in prone if possible Encourage to handle stumps as possible , it help to overcome shock of realization that leg has actually gone.

19. Rehabilitation of Transfemoral amputation Isometric exercise Control of stump edema Functional independence : pt taught to move up & down bed by pressing on sole of remaining leg. Encouraged to dress each day, propel himself to wheel chair , axillary crutch. Do’s and Don’ts

20. Transfemoral Amputation PT Management Treatment Overview 1. Functional Mobility • Transfers • Bed Mobility • Positioning/Stretching 2. Strengthening/Conditioning • Prepares the patient for prosthetic ambulation 3. Residual Limb Management • Reduce Limb Swelling using a Shrinker • Desensitization • Scar Mobilization

21. Transfemoral Amputation PT Management Transfemoral (Above Knee) Exercise Manual Within 1-2 Weeks of Post-Op Conduct Desensitization Exercises Using: • Ice Cubes • Pin • Towel • Deep Pressure • Heat • Brush

22. Transfemoral Amputation PT Management When Incision is Healed and “With Only Very Small Scabs” Begin to mobilize tissue around incision using: • Cocoa Butter (or Similar) This will also supplement a stump shrinker by bolstering venous return. Plus it will loosen subcutaneous tissues so tissues move more freely. Pay particular attention to any tissue adherence to the distal tibia or distal femur. Pressures inside of a prosthesis will displace tissues on the limb and any tissue that is “hypo-mobile” can be symptomatic and can prevent the patient from making progress in their rehabilitation

23. Goals of the Pre-Prosthetic Program 1 Trans-Femoral patients should work towards achieving 0-10 degrees of hip extension. 2 Patient should complete a minimum of 6 weeks of strength/ROM training on the primary prosthetic gait muscles outlined in this manual. The patient should be independent with the exercise program and also understand the importance of being diligent with the program. Educate your patient so that they understand these exercises will require a lifestyle change. 3 The patient should be able to tolerate a minimum of 30 minutes of physical activity. 4 Following sufficient soft tissue mobilization, the patient should be able to tolerate pressure and tissue displacement on the distal end and incision without pain. 5 The incision should be fully healed and good soft tissue mobility should be established. 6 It is imperative that patients continue an independent exercise program even after prosthetic gait training has been initiated. Preferably, the patient will continue their exercises on their own, outside of therapy, so that therapy appointments can focus on gait training. This will encourage further muscle development that will supplement any gait training conducted during regular therapy appointments. 7 They should be independent with transfers and bed mobility; this includes the independent ability to roll prone.

24. Amputee Exercises - Bridging Over Bolster

25. Amputee Exercises Single Leg Bridging

26. Amputee Exercises Short Arc Quadriceps

27. Amputee Exercises Straight Leg Raise

28. Amputee Exercises Ankle Pumps

29. Amputee Exercises Side Lying Hip Abduction - Modified

30. Amputee Exercises Side Lying Hip Abduction - Advanced

31. Amputee Exercises Prone Hip Extension

32. Amputee Exercises Prone Hip Extension (Sound Limb)

33. Amputee Exercises Prone Knee Flexion

34. Amputee Exercises Prone Abductor Squeeze

35. Amputee Exercises Push-ups

36. Amputee Exercises Quadruped Leg Lift

37. Amputee Exercises Abdominal Curl-up

38. Amputee Exercises Bosu Head Twists

39. Amputee Exercises Bosu Ball Exercises

40. Transfemoral Amputation PT Management 1. Static Gluteal Contractions Lie on your back. Keep both legs straight and close together. Squeeze your buttocks as tightly as possible. Hold for five seconds.

41. Transfemoral Amputation PT Management 2. Hip Flexor Stretch Lie on your back, preferably without a pillow. Bring your thigh towards your chest and hold with your hands. Push your opposite leg down flat on to the bed. Hold for 30 to 60 seconds, then relax.. Repeat the above with the other leg.

42. Transfemoral Amputation PT Management 3. Hip Hitching Lie on your back. Keep both legs flat on the bed. Hitch one hip up towards you on one side and push away on the other (shortening one side & stretching the other). Hold for three seconds Repeat on the other side.

43. Transfemoral Amputation PT Management 4. Bridging Lie on your back with your arms at the side. Place a couple of firm pillows or rolled up blankets under your thighs. Pull in your stomach, tighten your buttocks & lift your bottom up off the bed. Hold for five seconds. To make this exercise more difficult, place your arms across your chest as shown in the picture.

44. Transfemoral Amputation PT Management 5. Hip Flexion and Extension in Side Lying Lie on your side. Bend the bottom leg. Lift your top leg slightly. Bend your thigh fully towards your chest. Push your leg backwards as far as you can. NB: Try not to let your hips roll forwards or backwards Repeat the above with the other leg.

45. Transfemoral Amputation PT Management 6. Hip Abduction in Side Lying Lie on your side. Bend the bottom leg. Keep hips and top leg in line with your body. Slowly lift your top leg up. Slowly lower. NB: Try not to let your hips roll forwards or backwards. Repeat the above with the other leg.

46. Transfemoral Amputation PT Management 7. Hip Extension in Prone Lying Lie flat on your stomach. Lift your leg off the bed as far as you can. Be sure to keep hips flat on the bed and do not roll your body. Hold for five seconds, slowly lower Repeat the above with the other leg.

47. Transfemoral Amputation PT Management 8. Hip Adduction with Resistance Sit with both legs out in front of you. Place a pillow or rolled up towel between your thighs. Squeeze your legs together. Hold for five seconds. Repeat ___ times. NB: This exercise can also be performed when sitting in a wheelchair or at the edge of a bed.

48. Prosthesis in Transfemoral Amputation Prosthesis period

49. Prosthesis in Transfemoral Amputation Prosthetics in Greek means ‘in addition to’. Prosthesis is defined as a replacement or substitution of a missing or a diseased part . Prosthetics includes the theory &practice of the prescription ,fitting ,design, assessment &production of prosthesis.

50. Prosthesis in Transfemoral Amputation Classification (based on structure) ENDOPROSTHESIS EXOPROSTHESIS PROSTHESIS

51. Prosthesis in Transfemoral Amputation ENDOPROSTHESIS EXOPROSTHESIS PROSTHESIS Classification(based on function) Temporary prosthesis: these are implants used in orthopedics surgery to replace joints.eg:Austin moore prosthesis Permanent prosthesis : this is fitted after making a final clinical assessment.

52. Prosthesis in Transfemoral Amputation Materials used Prosthetic types Wood Socket material Prosthetic foot Leather Soft variety-suspension straps Hard variety- thigh and socket corsets Plastics Metal Plastic foam – for support of the distal stump Polypropylene -for making sockets Steel- for knee and hip joints Duraluminium - for outer shelf and socket.

53. Prosthesis in Transfemoral Amputation Difficulties in making effective prosthesis is due to Weight bearing area (ischial tuberosity is proximal to propulsive structure) (thigh). Passive mechanical replacement of two major joint (knee, ankle) and foot Limitation in prosthetics technology

54. Prosthesis in Transfemoral Amputation It consists Foot – ankle assembly, Shank Knee unit Sockets Suspension device

55. Prosthesis in Transfemoral Amputation 1. Socket: This provides a receptive area for the stump & helps in weight bearing. 2. Suspension: this fastens the prosthesis to the stump 3.Joints : these are artificial mechanical joints replacing original joints. 4.Base:the part of contact b/w prosthesis &floor

56. Variations used for transfemoral prosthesis. Feature variable 1.Sokcet Quadrilateral H- socket 2. Suspension Double swivel pelvic band Rigid pelvic band Suction socket 3.Knee Modular prosthesis Hand operated or Semi auto matic lock 4.Feet Sach or uniaxial foot .

57. Prosthesis in Transfemoral Amputation Sockets Two types of sockets commonly used are 1. Quadrilateral Sockets 2. Ischial Containment Sockets

58. Quadrilateral Sockets Developed late in 1950 & is named for its four walls. Distally the socket is contoured for total contact of residual limb Posterior wall : provide major weight bearing area. It has ischial set for ischial tuberosity & G.muscle which is thicker medially & thin laterally. Internally provide relief for hamstring muscle. Height is at level of ischial tuberosity Anterior wall : It extends 5cm above height of posterior wall with anteromedial inward femoral bulge called scrap’s projection. It keep ischial tuberosity situ anterior wall is convex laterally Lateral wall : normally it extend as high as anterior wall. For short stump it is in trimmed above trochanter to increase stability & control. The wall inclines medially with 10ᵒ adduction ( normal adduction of femur) Medial wall : it’s vertical & parallel to sagittal plane. Relief is given internally add. longus anteromedially & hamstrings posteromedially

59. Ischial Containment Sockets Developed in early 1990 & shaped differently from quadrilateral socket. The ischium and a part of pubic rambus are enclosed in socket. It contains more area side socket so more area of weight distribution. Narrow mediolateral dimension helps in keeping up ischial tuberosity within posteromedial wall of sockets The lateral wall cover trochanter to provide more stability. The distal socket is of total contact socket The 2 types of ischial containment sockets are: 1. CATCAM 2. NSANA C ontour A dducted T rochanteric C ontrolled A lignment M ethod N ormal S hape N ormal A lignment

60. Comparison between sockets Quadrilateral With four walls Ischial seat for WB Femoral bulge present Area of WB is less Long lateromedial dimension Narrow anterioposterior dimension Fair pelvic control Fair rotational stability Less energy efficient Indicated for standard stumps Lateral wall normally extends below trochanter except in short stumps Ischail Containment No walls No Ischial seat Femoral bulge absent Area of WB is more Narrow mediolateral dimension Long anterioposterior dimension Good pelvic control Good rotational stability More energy efficient Indicated for short stumps & G. Medius weakness Extends above greater trochanter

61. Transfemoral prosthesis. STATISTICS 1,285,000 People Living with Limb Loss in The U.S. 4.9 per 1,000 people Of Those 1,285,000 People: 36,478 were Transfemoral Amputations (American Amputee Coalition of America ‘96)

62. Prosthesis in Transfemoral Amputation Biomechanical principles Can be analyzed in three phases- ABSORPTION PHASE ACCELERATION DECELERATION

63. Prosthesis in Transfemoral Amputation Absorption Reduction in ground reaction force Significant difference in knee angles found at heel strike. Prosthetic absorbs and generates less energy which results in A more passive limb Absorption by soft tissue in socket Presence of isometric contraction by muscles So as foot strikes, a backward force is instantly created by prosthetic-side hip muscles.

64. Prosthesis in Transfemoral Amputation Deceleration Hip abductors and adductors and knee extensors muscles are main source of absorption. ( Sadeghi 01’) Fewer gait problems are involved in the swing phase than with the stance

65. Prosthesis in Transfemoral Amputation Acceleration Hip extensor effort is main compensation of propulsion reduction. ( Pailler 04’) Amputation of ankle reduces the ability of power to be produced through plantar flexion

66. Prosthesis in Transfemoral Amputation Biomechanics Summary Longer motions for amputated side Step length Step time Swing time Shorter motions for amputated side Stance time Single support time

67. Prosthesis in Transfemoral Amputation ENERGY EXPENDITURE Amputation Level Energy Above Baseline, % Speed, m/min Oxygen Cost, ml/kg/m Transfemoral 65 40 .28 Wheelchair 0-8 70 .16

68. Prosthesis in Transfemoral Amputation Energy cost depends on Gait speed Efficiency Not on displacement of center of mass (Detrembleur 05’) Energy consumption For Transfemoral amputees is more significant than that of transtibial amputees. Is affected by prosthetic alignment Is not affected by the use of different prosthetic feet (Schmalz 02’)

69. Prosthesis in Transfemoral Amputation Balance &Stability Significant differences found between TTA and controls during equilibrium and movement studies. Transition from bipedal to monopedal High failure rate for TTA Same difficulty on sound and prosthetic limb ( Viton 00’) Utilize remaining muscles Work on speed of contraction, not maximal force of contraction ( Gailey 03’)

70. Prosthesis in Transfemoral Amputation Fitting An exact mold of the residual limb does not make a good socket Indent in the region around the patellar tendon Many different types of sockets Foam of silicone Hard Soft (Smith, ’03)

71. Prosthesis in Transfemoral Amputation Alignment-1 Alignment is the spatial relationship between the prosthetic socket and foot. Purpose: Position the prosthetic socket with respect to the foot so that adverse patterns of force applied to the residual limb are avoided Produce a normal pattern of gait (Noelle, ’03)

72. Prosthesis in Transfemoral Amputation

73. Prosthesis in Transfemoral Amputation Transtibial vs. Transfemoral Transfemoral Amputations: Known as above the knee amputations Surgeon’s goal is to leave as much residual limb as possible, preserve the adductor muscles, and the remaining soft tissue. (Biomed, ’03) Transtibial Amputations: Known as Below The Knee Amputations The Surgeon’s goal is to leave a cylindrical shaped well-padded residual limb. Using the gastrocnemius and soleus muscles to create a muscular flap. Surgery provides some challenges (In Motion, ’03)

74. Prosthesis in Transfemoral Amputation Prosthetic rehabilitation Involves – Stump shaping &shrinking Desensitization ROM & muscle strengthening THIS IS DONE (6-8 WEEKS POST OP)WITH SOFT DRESSINGS OR 3-6 WEEKS POST OP WITH AN IPOP (IMMEDIATE POST OP PROSTHESIS).

75. Prosthesis in Transfemoral Amputation

76. Prosthesis in Transfemoral Amputation Prosthetic rehabilitation PROSTHETIC STAGE MANAGEMENT DONE AFTER 8 WEEKS INCLUDES :GAIT TRAINING- POSTURE, EVEN WEIGHT BEARING,PROPRIOCEPTION &WEIGHT SHIFTING, WEIGHT TRANSFER IN STANCE.

77. Prosthesis in Transfemoral Amputation Prosthetic rehabilitation ADVANCED GAIT TRAINING AFTER 10 WKS INCLUDES- STAIR CLIMBING,WALKING ON SLOPE OR UNEVEN FLOOR. PROGRESSION- CROWDED AREAS, PUBLIC TRANSPORT EDUCATION.

78. COMMUNITY INTEGRATION INVOLVES- Resumption of familial &community roles Addressing emotional needs Developing healthy coping strategies Resumption of previous recreational activities. Vocational rehabilitation by vocational counsellor .(including previous jobs)

79. Follow up Includes-lifelong prosthetic support, functional and medical assistance, psychological support. Patient should be sent for follow up to the team members once in 3 months for first 18 months following which they can go once in 6 months. Support groups and Ngo’s

80. Conclusion Responsibility of surgeon doesn't end with healing of wound but must include restoration of locomotion by correct limb fitting (prosthesis) and re-education Prosthesis must fit amputee not only physically but also physiologically. It must be integrated emotionally with patients and be socially acceptable

81. Reference Susan B.O’ Sullivan etal ,Amputation, Physical Rehabilitation,2014, 1000-1030; Susan B.O’ Sullivan etal ,Prosthetics, Physical Rehabilitation,2014, 1375-1379; R Chinnathurai etal, Prosthesis in Transfemoral Amputation, Short Textbook book of prosthetics & orthotics 2006,44-47; S. Sundar , Amputation & Prosthesis , Text book of Rehabilitation , 2002, 131-162;