TRANSTIBIAL AMPUTATIONS

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TRANSTIBIAL AMPUTATIONS

• Dr. Karen Friel, PT DHS

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Post-surgical Considerations

• Dr. Karen Friel, PT, DHS

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SURGICALTECHNIQUES AND LEVELS

• Myoplasty vs. Myodesis
• Levels
• transtibial
• transfemoral
• toe or ray
• transmetatarsal
• disarticulation, ankle, knee, hip
• hemipelvectomy

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Criteria for B/K

• Popliteal bifurcation is patent and good
  collaterals at knee and 1/3 leg
• If femoral blockage with no collaterals, do A/K
• If post tibial artery is present with no
  collaterals, do A/K

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General Criteria

• Presence of ischemia is not indication for A/K
• If infected, use open flap method
• Excessive edema is cause of failure

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PHANTOM SENSATION

• Touch
• Pressure
• Cold
• Wet
• Itching
• Fatigue
• Phantom movement

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Neuromatrix Theory of Phantom Sensation

• Neural processes in brain left intact
• Brain processes activated regardless of whether
  input is present
• Origins of patterns that underlie sensation are
  in neural networks
• Body is perceived as a unit
• Processes that perceive self are genetic

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Neuromatrix Theory

• Normal phantom occurs whenever nerve impulses
  from the periphery are blocked or otherwise
  removed (Wall)

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PHANTOM PAIN

• Aching
• Burning
• Knife
• Sticking
• Squeezing
• Shocks
• Pre-op pain

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Phantom Pain Theories

• Pain magnification from lack of peripheral
  inhibition
• Changes in dorsal horn neurons secondary to
  peripheral nerve injury
• Damage to neurons generates pain impulses
• Spontaneous firing
• Hyperexcitable

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• Closed self-sustaining reverberating circuits
  are set up by the release of SC cells from
  inhibitory control through the loss of afferent
  input. When abnormal impulses reach the brain
  they are perceived as painful.

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Neuromatrix Theory

• Involves area of the brain
• Carry info from periphery
• Carry messages about emotions
• Responsible for recognizing self
• Basic output is neurosignature
• Sensory input, psych or social can all trigger

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RESIDUAL LIMB PAIN

• Secondary to
• prosthetic
• neuroma
• referred
• abnormal tissue
• joint pain
• bone pain
• residual limb change

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Transtibial Specifics

• Dr. Karen Friel, PT, DHS

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TERMINOLOGY

• Residual limb
• Socket
• End-bearing
• Hard socket
• Soft-end socket
• Total Contact socket

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Transtibial Amputations

• Pressure Sensitive Areas
• cut ends of bone
• tibial crest and tuberosity
• head of fibula
• tibial condyles
• hamstring tendons

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Transtibial Amputations

• Pressure Tolerant areas
• patellar tendon
• medial and lateral flares
• posterior gastrocs

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COMPONENTRY

• The Socket
• Inserts
• Foam, silicone gel,
• Shank
• endoskeletal vs. exoskeletal
• Suspension
• supracondylar cuff, waist belt, sleeve, PTBSPSC,
  suction, thigh corset
• Foot/ankle assembly

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The Socket
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PTBSPSC
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Inserts
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Liners
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Inserts
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Silicone Suction with and without distal pin
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Orthogel with and without distal pin
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Shank/Pylon
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Suspension
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Supracondylar Suspension
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Supracondylar Cuff
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Supracondylar Cuff
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Suspension Sleeve
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Waist Belt
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Silicone Suction with and without distal pin
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Foot/Ankle Assembly
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SACH foot
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Allurion foot
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Flex foot with keel
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Foot covering
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Pyramid foot
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Bumper System
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Keel
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K Levels

• KO
• K1
• K2
• K3
• K4

• Non ambulator
• Household ambulator
• Limited cmty ambulator
• Variable cadence user
• High activity user

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Biomechanics and Gait

• Dr. Karen Friel, PT, DHS

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TRANSTIBIAL BIOMECHANICS

• 1. Increase WB capacity of residual limb
• To patellar tendon, pretibials, posterior distal
  aspect of stump, popliteal fossa, lateral fibula,
  tibial flares

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Transtibial Biomechanics

• 2.Medial/Lateral Stabilization
• Must replicate normal varus at midstance
• Prevent excessive varus with
• proper fit
• set foot 1/2 medial to center of socket
• Must avoid valgus moment at knee

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CONTROL OF VARUS/VALGUS

• Lat Med Lat Med

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Transtibial Biomechanics

• 3. A/P Stabilization
• Always want a little knee flexion for proper
  distribution of WB forces
• Place foot slightly posterior to center of socket
• If socket too far anterior, get anterodistal and
  posteroproximal pressure
• If socket too far posterior, get hyperextension

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A/P Stabilization

• Post Ant Post Ant

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CHECKOUT

• Static Alignment
• Dynamic Alignment
• Gait Deviations

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GAIT CHARACTERISTICS

• Comfort
• 2-4 between heel centers
• Knee flex 10-15 degrees after heel strike
• Foot with smooth and rapid contact to floor
• Proper socket fit, no gapping or excessive
  pressure
• Knee extends over foot with WB, and flex
  pre-pushoff

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GAIT CHARACTERISTICS

• Swing phase natural in appearance, no pistoning
• Toe clears floor adequately, but not excessively

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Gait Deviations

• Heel Contact to Foot Flat
• Excessive knee extension
• Knee instability
• Midstance
• Excessive rise or drop
• Wide-based gait
• Narrow-based gait with lateral thrust

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Gait Deviations

• Terminal Stance
• Knee Instability
• Knee extension, vaulting
• Swing Phase
• Pistoning
• Uneven step length
• Circumduction