American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic...
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![Page 1: American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State University.](https://reader036.fdocuments.us/reader036/viewer/2022070411/56649cdf5503460f949a8f57/html5/thumbnails/1.jpg)
American Orthotics and Prosthetics Association-National Assembly
Trans-Femoral Osteomyoplastic Update
Christian W. Ertl MD FACS FACCWS
Michigan State University
Seattle, 2009
![Page 2: American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State University.](https://reader036.fdocuments.us/reader036/viewer/2022070411/56649cdf5503460f949a8f57/html5/thumbnails/2.jpg)
Disclosure
• I have no funding issues or support to disclose
![Page 3: American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State University.](https://reader036.fdocuments.us/reader036/viewer/2022070411/56649cdf5503460f949a8f57/html5/thumbnails/3.jpg)
GOAL
In brief:
the residual extremity should be a well contoured, functional and dynamic limb, accepting a prosthesis to allow the patient to ambulate/function in a relatively effortless and painless manner
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Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit
and use
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Femur severely lateralized by
pull of the abductors and no adductor stabilization
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Conventional AmputationEffects - Bone
• Medullary canal ignored, remains open– Poor ability for end weight bearing– Venous gradient 0mmHg → venous stasis
Loon
– Potential bone spur formation Hulth, Hansen-Leth, Reimann, Olerud
– Regional osteopenia with possible adjacent joint DJD Lo
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Conventional AmputationEffects - Muscle
• Majority of musculature allowed to retract– Fatty atrophy Venous stasis– Slower speed of contraction
Blix, Loon
– Poor “volume” of residual extremity in prosthesis
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Basic ScienceLength-Tension Relationship
• Normal muscle has max force at slightly longer lengths
• In amputees, muscles are divided, retract, undergo fatty degeneration, and excursion in contraction is decreased
• Result is increased work to ambulate with increased fatigue
Loon, Prosth Int, 1959.
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Conventional AmputationEffects
• Incisions placed over prominent surfaces– Potential etiology of pain
• Regional circulation disturbed– Secondary to venous stasis– Abnormal vessel formation Hansen-Leth, Hulth, Olerud
– High risk of AVM– Dilated, tortuous vessels Hansen-Leth,
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Osteomyoplastic Reconstruction
• Medullary canal sealed
• Broader surface area to bear weight
• Allows potential end weight bearing in AKA
• Improves local circulation
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Basic ScienceClosure of Medullary Canal
• Intramedullary venograms pre-/post-canal closure Loon, Prosthetics International,41-58, 1959
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Myoplasty - Transfemoral
• Fascial closure of opposing muscle groups• Adductor brought laterally for balance in
AKA• Improves local vascularity• Provides “insertion” for muscles to restore
resting length-tension relationship• Improve alignment and biomechanics of limb• Soft tissue coverage to end of residual
extremity
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• Insertion sites of adductors; not restoring an adductor movement allows femur to lateralize creating an inefficient gait pattern; this increases oxygen demand and can create greater cardiac stress in patients with cardiopulmonary disease; would emphasize maintaining the adductor Magnus and gracilis muscles to restore the adductor moment
F. Gottschalk- U. Texas Southwest
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Myoplasty-Basic Science
• Arteriogram of AKA prior to myoplastic procedure
• Poor filling in adductor region of leg
• Poor contour grossly
• Exostosis formationDederich, JBJS, 45-B, 60,
1963
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Myoplasty-Basic Science
• Arteriogram 3 months after myoplastic procedure
• There is increased arterial flow with in the stump
• Distal and medial perfusion is improvedDederich, JBJS,45-B: 60,
1963
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Osteomyoplastic ProcedureGoals
• Osseous/soft tissue reconstruction– Remove bone scar/spurs – Medullary canal closure– Myoplasty of opposing muscle groups – Plastic Closure
• Stabilize the extremity– Realign femur for proper mechanics and
gait– Muscle balancing
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Osteomyoplastic ProcedureGoals
• Provide a potential end weight bearing extremity– Closure of medullary canal returns normal venous
gradient; distal bone remains vascularized
• Create a cylindrical residual extremity– Improves fitting/use of prosthesis– Smooth contour aides in preventing localized skin
breakdown– Pressure points reduced
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Osteomyoplastic ProcedureGoals
• Restore normal physiology– Venous gradient in bone returned– Vasculature improves in remaining
extremity– Muscle length-tension relationship
reestablished, thus restoring the efficient use of the muscle
Loon, Prosthetics International,1959.
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Osteoplasty
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Adductor Stabilization
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Muscle Flaps brought over end of femur
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Quadriceps
Hamstrings
Completion of the myoplasty by suturing the quadriceps to the hamstrings. This stabilizes the entire soft tissue envelope and provides distal coverage for end-bearing of the residual limb. Meticulous skin closure is then performed, removing dog-ears and redundant skin. Goal is to provide a cylindrical limb for prosthetic application.
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Immediate post-op
Adductor tubercle with adductor Magnus kept attached to cortical shell
Immediate post-opImmediate
post-op
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5 weeks post-op; alignment maintained; no lateralization of femur
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Orthotics/Prosthetics/P.T.
• Begin comprehensive education– Support groups, networking
• Begin comprehensive therapy– Transfers, stretching, desensitization, gait
training, upper extremity conditioning
• Knowledgeable staff for support– i.e. ACA, nurse clinicians, etc.
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Prosthetics
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Physical Therapy
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Post-Op protocol• 0-4 weeks-Isometrics above
amputation, ROM, UE aerobic conditioning
• 4-6 weeks-Isometrics, ROM, towel pulls, massage, scale exercises up to 10/15 lbs
• >6 weeks-advance P.T., gait training, posture, gluteal/core strengthening, socket application
• Emotional, psychological support– Support groups, starts from day one
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Summary
• Provides the amputee with a “sound” physiological residual extremity
• Patients have high satisfaction and there is improved outcome
• Can be applied to the vasculopath and diabetic
• 1.5 cm of bone resected on average
• Can used as a primary procedure as well as reconstructive
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Summary
• An amputation is not a benign, static procedure– The limb is dynamic, so should the
“team”• Effort must be placed on a team
approach• The goal is to return to the patient a
functional residual extremity• This can be accomplished by adhering
to “biological” surgery principles