More responses on the residual limb length issue

More responses on the residual limb length issue

Ian Gregson

7/17/1999

Fellow OandP'ers

More responses on the residual limb length issue


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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 Address Redacted>

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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 < <Email Address Redacted> >

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From: Walter P Afable < <Email Address Redacted> >

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 Address Redacted>

thanks again,
walter

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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 Address Redacted>

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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

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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

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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 Address Redacted>

-------------------

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 Address Redacted>

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From: Phillip Francis < <Email Address Redacted> >

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





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