Friday, May 20, 2022

More responses on the residual limb length issue

Ian Gregson

Fellow OandP’ers

More responses on the residual limb length issue

————-

Hi Ian,

Sorry I do not have any knowledge of such practices but I find the

whole thing disgusting. If this is really happening (no smoke

without fire), something needs to be done to stop it.

Vicky [email protected]

————

Ian

This practice irks me as well.

My surgeon based the level of my first amputation on

the same premise. Only for me to find out later that

he really did not know ‘how’ a prosthesis is fitted, nor

did he understand the physics behind one.

It would seem this is one that ‘should’ be covered in

med school [by and instructor who knows what they are

talking about]

Michael Dix “ML Dix”

————-

From: “Walter P Afable”

Now, I’m not a practicing prosthetist–yet. But from what I’ve seen

while shadowing and what I’ve researched on LE prostheses, a great

emphasis is placed on, yes fit–but more importantly successful

rehabilitation post-fitting.

>From what I’ve seen, long AK’s are much easier to fit AND successfully

rehabilitate than through knees. 1) Comfortable weight bearing, 2)

wound health, (enough skin and residual tissues to promote healing)

3) static alignment, (standing on two equal length legs) seem to be

the most important factors aside from fit.

I would venture to guess that the availability of componentry is an

added incentive to the AK length versus TK.

Again, I am just a student–but this is what I understand of the

subject–it’s a great question. Thanks for asking it.

If you wouldn’t mind, I would be interested in receiving some of the

responses you get to your inquiry.

Send them to [email protected]

thanks again,

walter

—————

Ian, in my opinion, having worked with fitting both knee-disarticulation and

long AK’s, there is no argument as to which residuum gives the best results

in terms of function and cosmesis for the amputee. The ‘thru-knee’ stump

certainly can be walked on, but the necessity to play around with the knee

axis, frequent problems with the end-bearing nature of the stump and

relative thigh length discrepancies (especially while sitting) all point to

a less satisfactory result for the amputee.

The surgeon sounds to me like an enlightened one, unless he could have saved

the knee.

kind regards, Richard Ziegeler

[email protected]

—————-

Ian, my two cents!! Although I am not an a/k amputee , as a partial

foot amputee and recepient of many requests for prosthetic funding

thru our Foundation, I can certainly attest to the fact that the

majority of orthopedic surgeons and vascular surgeons in the U. S.,

have no or very little knowledge of advanced amputee surgery

techniques or the science and application of prosthetics. A perfect

world would be where the surgeon,prosthetist and physical therapist

could consult prior to the actual surgery which is prohibited in most

traumatic conditions but quite possible for amputation as the result

of vascular conditions.Our Foundation is always exposed to amputees

who really believe or want to believe that a proper fitting

prosthesis will eliminate the pain they are experiencing as the

result of less than modern amputation surgery techniques.In my own

personal case,the surgeon should of initially performed a syme or

conventional B/k amputation for immediate prosthetic rehabilitation.

His personal philosophy, to save as much of the limb as

possible,resulted in a dozen more modification surgeries and skin

grafts as well as the impossible search for a prosthesis. Most CPs

will confirm that partial foot fittings are a pain!!

His recommendation after the surgery was to fill my shoe with

newspaper! Fortunately,after 20+ years and just as many attempts of

properly fitting prosthetics,technology caught up with my personal

situation and I have been properly fitted. It turns out that the

surgeon did make the right decision ,but it took alot pain,

frustration and time.

As indicated in Dons message, most surgeons tend to go to a higher

level of amputating, without not knowing or being required to

know,the physics and advancements of modern prosthetic technology.

Saving as much of the remaining limb as possible is often times not

the best scenario either.The answer lies in education and continuing

educations.However,in my opinion,many surgeons are not willing to be

reeducated about modern amputation techniques when they have a

feeling of personal failure when amputating any limb. Failure to be

able to reattach a limb as the result of a traumatic cause and

professional failure to be able to cure the disease that resulted in

the amputation.

Perhaps one day this consulting technique between the three

professions maybe possible instead of one of the professions pointing

fingers at the other for not doing the best job! Tony

Tony Barr

——————

Dear Ian:

The short answer is: I hope not! I once had a surgeon call with that

question. It was my recommendation to talk to the person about to have the

surgery re: cosmesis v. function. I would be very willing to talk to the

person. Since, the surgeon knew the person did not care about cosmesis the

Knee Disarticulation was performed. Once, I learned who the person was, I

understood why the physician was so sure she would not care. He was indeed

correct.

Speaking as a prosthetist, I find the Knee Disarticulation easier to “work”

with and much more functional for the person. I also cringe that function

would be lost without input from the human being living with the result. I

find it challenging to make decisions for my life much less to try and make

decisions that someone else will have no recourse to change.

I hope you get some surgeons who reply.

Best wishes,

Don McGovern, CPO

——————

Absolutely not, dear Ian,

This would definetely contradict the habits of a responsible surgeon. Each

cm or inch is necessary for the final fitting and the well being of the

patient. From the orthopedic point of view nothing has to be sacrificed in

order to make the work of prosthetist easier in case there is no medical

indication.

There are some “black sheep” as we say here in Germany, but there is also

a net of information within each staff which can filtrate obvious fast cuts.

I already heard a lot about your work and I greatly appreciate it. Such an

amputee movement is almost non existent here in Europe.

Best wishes

Dorothea Müller

EuroRehab

[email protected]

——————-

Ian,

You bring up a good topic for discussion. In my experience the through

knee amputation is a reasonable option in traumatic injuries where the

wound can be closed without the excessive use of skin grafts and the

associated risk of inflexible scar tissue or adhesions. The surgery often

involves trimming the posterior condylar surfaces from the end of the

femur and the surgeon can retain the patella, tying the transected

patellar tendon to the anterior cruciate ligament. The hamstring tendons

can also be secured to the femur, resulting in a residual limb that is

not excessively bulky and retains excellent muscular power.

The drawbacks are not necessarily in prosthetic fitting, as this can be

accommodated through a number of different socket / insert designs, with

self suspending properties. Rather, through knee prostheses have their

downfall in the cosmetics department. They do look bulky and generally

have to be fit with a discontinuous foam cover. Very few women would

care to use a prosthesis like that, but most men may not particularly

care about the extra 2 – 4 cm femoral leg length difference.

I will bring this question up for further discussion at the regular Gorge

Road Hospital Clinic rounds on Monday.

Regards,

Geoffrey Hall, Certified Prosthetist,

Custom Prosthetic Services, Victoria, BC

[email protected]

————————-

From: “Phillip Francis”

Dear Ian

It is common in Australia for surgeons to perform AK amputations rather

than TK amputations supposedly for ease of fitting.

Historically AK amputations were performed in preference to TK due to poor

surgical techniques and poor healing, the perceived difficulty with fitting

and also in past days the lack of appropriate componentry.

Effectively prior to the development of 4Bar linkage knees the only options

for TKs was outside joints which most believe was not much of a choice.

Further the “efficient” and fast TK amputations (Gritti Stokes etc)

produced bulky and bulbous stumps. Better surgery which involves reduction

osteoplasty of the femoral condyles (such as that described by Mazet)

greatly reduces the boney bulk and improves cosmesis and fitting. However

many surgeons are unaware of such procedures and hence perform AKs.

We are slowly educating surgeons regarding our preferences but in my

opinion unless there is a good reason to do an AK I would normally

recommend a TK if possible.

My only reservation is the lack of stance phase hydraulic comonentry which

is available. ie Mauch SNS which is really only available in a single axis

knee.

When I did P&O it was a diploma and I recently did the conversion to degree

with a major assignment on TK amputation surgery. I am more than happy to

debate the issues and email my project.

Cheers

Phillip Francis

Chief Prosthetist/Orthotist

Grace McKellar Cente

Geelong, Victoria, Australia

Ian Gregson ([email protected])

Amputee WEB Site <> AMPUTATION Online Magazine

http://amputee-online.com

Moderator Amputee & D-Sport Listservs

icq # 27356900

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