Amputation: Causes and Results - Essay Example

Amputation:5 The definition of amputation is: the accidental loss of a part of the body, usually an extremity, a finger, or a toe. In case the amputation is complete, the extremity is severed totally, while in a partial amputation some soft-tissue connection remains. (Girdhar et al, 2001) Causes of amputations:5,7 "The occurrence of an amputation is far more common than one might think. In fact, there are slightly more than 1.5 amputees per 1000 persons in the United States. This brings the present total of amputees in the United States to approximately 380,000." (Girdhar et al, 2001) The most widespread causes for amputations are diseases (74%), accidents stipulate 23% of those, and 3% of amputations are performed because of the in-born defects. As you see most amputations are stipulated by the diseases (like diabetes etc) (Jeffcoate et al, 2003) Types of amputations:5 There exist various types of amputations; those are generally classified by the location of the extremity lost. The types of amputations are: 1.for upper extremity a. whole arm (from shoulder) b. arm above the elbow (between shoulder and elbow) c. arm below the elbow (between the elbow and the hand) d. whole hand (above the wrist) e. whole finger (index, middle, ring, pinky; single or combinations) f. tip/part of finger g. whole thumb h. tip/part of thumb 2. lower extremity a. whole leg (from hip) b. leg above the knee (between hip and knee) c. leg below the knee (between knee and foot) d. whole foot (above ankle) e. whole toe (single or combination) f. tip/part of toe "In general, amputations through the lower limb account for 85% of all amputations at the present time. For the lower extremity are large because of amputations resulting from diseases such as diabetes." (Girdhar et al, 2001) Rehabilitation after amputation:11,4 The loss of the limb leads to a permanent disability that can impact a patient's self-image, self-care, and mobility (movement) negatively. Rehabilitation of the patient who experienced amputation has to be begun right after surgery during the acute treatment phase. When the patient feels better, a more extensive rehabilitation program has to be started. The positive effect of the rehabilitation program depends on numerous variables, including the following: Level and type of amputation Type and degree of any resulting impairments and disabilities Overall health of the patient Family support During rehabilitation it is vital to focus on helping the patient feel he/she is still capable of independent life at home and in the community. The positive reinforcement accelerates recovery by improving the self-esteem of the patient and making him feel he can still be independent from the other people's assistance. The rehabilitation program should be designed for to meet the needs of each of the patients; it should be worked out individually. Active involvement of the patient's family is a key to the success of the program, as they are the people that create the emotional atmosphere he/she lives in. It is also that the patient himself has to take active part in his rehabilitation The purpose of rehabilitation after the amputation is to help the patient attain the highest possible level of function, and let him/her feel he/she is independent. In the same time the measures have to be taken for to improve the overall quality of the patient's life, including social, personal and professional spheres Amputation rehabilitation programs usually include Pain management for both post-operative and phantom pain (a sensation of pain that occurs below the level of the amputation) Nutritional counseling Patient and family education (Pandian, Kowalske, 1999; Gibson, Certcouns, 2001) Biomechanics of transfemoral amputation:1,6 For to rehabilitation to pass more successfully, it is desirable to have a more distal level of limb amputation. The lower the limb is amputated, the lower is the energy consumption needed for ambulation. One more reason is that the higher the extremity is amputated the more complicate and expensive prosthesis the person is going to need later. For to prove this statement we can note that the amount of energy, needed for to walk, after a transfemoral amputation takes place, is much greater than that required after a transtibial amputation was made. "Technologic advances have allowed significant changes in designs, components, and manufacture of transfemoral prostheses during the last decade. However, the surgical technique of transfemoral amputation had remained unchanged until the late 1980s".( Davis et al, 2004) The mechanical and anatomic alignment which is normal for the lower limb is well defined. The mechanical axis of the lower limb runs from the center of the femoral head through the center of the knee to the midpoint of the ankle when standing on two legs. It allows the normal functioning of the abductor and hip stabilizers, and reduces the lateral motion of the center of mass of the body, which allows producing more smooth and energy-efficient gait. Patients whose limb is amputated above the knee with a conventional amputation display alteration of anatomic and mechanical alignment, because the residual femur changes its alignment with the tibia, which leaves the femoral shaft axis in abduction comparing it with the sound limb. Usually higher energy consumption and side lurch are the results of the amputation with an abducted femur. When normal adductor muscle insertion is lost, it results in a shortened effective moment arm. The fact that the transfemoral amputation leads to the decrease of the patient's muscle strength can be justified by several factors such as: reduction in muscle mass at amputation, inadequate mechanical fixation of muscles, atrophy of the remaining musculature. The muscle bulk is removed by the sectioning of the muscles. Moreover the sectioning of the muscles may also interfere with the nerve innervations to that muscle. The surgeon should aim to create a dynamically balanced residual limb with good motor control and sensation during the operation. It's well known that the patients who experienced transfemoral amputations spend more energy for normal walking as they don't have the knee joint One more cause of the patient walking with the leg abducted is the adductor roll frequently seen in patients with a transfemoral amputation. The formation of an adductor roll seems to be prevented by muscle preserving adductor myodesis, and it also allows for a more comfortable fitting socket. A patient who may have been a marginal prosthetic user could become a definitive prosthetic user by applying the biomechanics of the adductor muscles of the thing and improving the surgical technique to hold the femur in adduction. The conventional transfemoral amputation leads to the decreased muscle strength in patients, as the muscle mass also decreases. It also causes muscle atrophy, and inadequate fixation of the remaining muscles. (Davis et al, 2004; Gottschalk, 1999) Transtibial amputations:2 "The transtibial amputation is one of the most frequently performed major limb amputations in the United States". The long posterior flap technique has become the most frequently recommended one. The indicators for transtibial amputations are gangrene, ischemia, and infection, severe deformity of the foot, massive trauma, or tumors. The standard surgical technique for a transtibial amputation is long posterior flap technique. The research shows that positive results can be expected even for the majority of patients with vascular compromise. The level of tibial transaction should be as long as possible between the tibial tubercle and the junction of the middle and distal thirds of the tibia, based on the available healthy soft tissues. The goals of a transtibial amputation are: obtaining primary wound healing, avoiding infection, creating a well padded residual limb that can easily tolerate the stresses of prosthetic fitting and full weight bearing. "The surgical result should be a cylindrical shaped residual limb, not a conical shaped limb, because the cylindrical shape is must better suited to total contact prosthetic fitting techniques." (Smith, Fergason, 1999) Fundamental components:16 The following are the components all lower-limb prostheses usually have Socket- the custom made, top portion of the prosthesis that fits around the residual limb. Foot- the bottom or terminal portion of the prosthesis that contacts the ground. There is an abundance of prosthetic foot designs available, with a range of functional characteristics to suit the needs of virtually any amputee. Knee system- The prosthesis must have a knee joint that won't buckle as it rolls over the artificial foot during the stance phase of walking. Shank-: To transfer the vertical loads caused by the weight of the amputee to the foot and on to the floor. Prostheses for transtibial (blew the knee) amputees and higher levels also include: Shank- the portion connecting the foot (and ankle if used) to the upper prosthesis, usually to the socket or the knee unit. In exoskeletal prostheses the shank is most often rigid urethane foam or wood. Socket 3-The socket portion of the transtibial prosthesis is of significant importance in the overall outcome in the rehabilitation of the patient with a transtibial amputation. The prosthetic socket is the primary interface between the patient with an amputated limb and the ground. Prostheses for transfemoral (above the knee) amputees and higher levels must include: Thigh- the component between the top of the knee and bottom of the socket in transfemoral amputees, or to the hip joint in higher level amputees. Transfemoral sockets 17- The biomechanical requirements of the patient with a transfemoral amputation functioning with prosthesis do not vary; the outcomes may vary, but the needs remain the same. Suspension should not be influenced to any substantial degree by socket design. The evaluation of the patient's anatomy and careful measurements are essential for the initial socket alignment and correct socket design. For creating a fitting prosthesis evaluation of the range of motion of the residual limb flexion and adduction analysis is needed. (Schuch, 1998) 1. Heel of and terminal stance phase17 The proper initial hip flexion designed in the socket and properly assessed hip flexion analysis, provide effective heel off and terminal stance propulsion. The patient is allowed to reach more easily the 15 degree of extension required on the prosthetic side for to provide a normal stride length on the sound side by designing and aligning the socket in a position of initial flexion (Schuch, Pritham, 1999) 2. Swing phase17 The smoothness of the pathway of the prosthetic limb during the swing phase the gait cycle is addressed by the swing phase tracking addresses. The purposes are the lack of deviation in the sagittal plane as the prosthetic limb advances forward during the swing phase and lack of vertical displacement of the prosthesis with respect to the residual limb,. The geometry and volume of socket design are dritical for smooth swing phase tracking. (Schuch, Pritham, 1999) Modern prosthetic knee mechanisms10 The components of the prosthetic knee are divided in two categories on the base of how they are controlled: the purely mechanic devices, that are frequently used nowadays and the complicated devices with the computers on board. These groups then are subdivided into generic functional classes that base on the swing phase responsiveness offered by each type of knee mechanism and the degree of stance phase stability. The right choice of the prosthetic knee mechanism is crucial for the successful rehabilitation of the patient with the limb amputated at a higher level. Prosthetic knees can also be subdivided into categories according to the complexity of the stance stability and swing phase control provided. The most uncomplicated model of the knee prostheses that exists offers absolutely no swing phase control, but it has a single axis hinge that allows the knee to bend freely. During the past fifty years the fluid controlled knee prostheses have been developed, the prostheses that allowed overcoming many of the limitations of constant friction designs. In the beginning the hydraulic or pneumatic knee prostheses were expensive and uncomfortable. In addition they needed frequent servicing, like once a year or even more frequent, but now they've became more convenient and available. The pneumatic control cylinders in those prostheses usually are filled with air, which is compressible like all gases. Those models have often been recommended for slow to moderate walkers, as more vigorous ambulators may be able to out walk such units. Nowadays hydraulic dampers are the most common variable cadence control used, partly because they restrict the flow of the incompressible liquid they contain, which is usually silicone oil. It creates a very high damping force for to control the shin. Recently a new model of hydraulic prostheses appeared, which uses a simpler mechanism- the 3R80 rotary hydraulic knee prosthesis (Otto bock, Duderstadt, Germany).The geometry of this prostheses permits several degrees of controlled knee flexion during the weight acceptance phase of gait. In the last years polycentric prosthetic knees use has been increasing worldwide, as they have numerous clinical advantages over the other types of prostheses (Michael, 1999) Suspension systems for prostheses 8 The well-constructed suspension system is essential for the safe and well functioning lower extremity prosthesis. "Residual limb length, joint ligament stability, and limb volume determine suspension methods as doe's activity level, dexterity, success of previous suspension, and cosmetic requirements the supracondylar suspension cuff, prosthetic sleeves, and gel liners with locking mechanisms generally are indicated for the average to long transtibial amputation level." (Kapp, 1999).She adds that short limbs are better fitted with supracondylar and suprapatellar suspension, and waist belts generally are indicated for patients with new amputations or those with vascular compromise. The most desirable form of transfemoral suspension which is recommended for most standards to long residual limbs is suction suspension. The roll on silicone liners with or without locking in and the hyperbaric sock grant the patient systems that are easier to don yet still provide unencumbered suspension. The total elastic suspension belt provides appropriate auxiliary suspension and can is easily applied to the prosthesis by the patient. Foot system12 Prosthetic foot is the interface between the ground and prosthesis; it influences forces at the socket and residual limb interface. The proper choice of prosthetic foot provides the best functional outcome considering the patient's individual characteristics The patient is able to use effectively the functional properties of the dynamic response prosthetic foot at the more active levels of ambulation Dynamic response prosthetic feet vary in cost and complexity, and they usually are a lightweight carbon fiber construction. "The primary goal of the prosthetic foot is to replicate functionally the human foot during the stance phase of gait."(Romo, 1999) Biomechanical Analysis and remaining function after Amputation 13,14 Royer et al (2005) reported persons with unilateral, lower-extremity amputation were at risk of developing osteoarthritis in their intact limb. The purpose of that study was examining knee and hip frontal plane moments in persons with unilateral, trans-tibial amputation. They advanced a hypithesis that knee and hip internal abduction moments were greater in the intact limb compared to the prosthetic side. The authors of the study measured bilaterally the three-dimensional gait mechanics were from 10 persons with unilateral, trans-tibial amputation during walking to calculate lower-extremity joint moments. They found that "the intact limb knee and hip peak internal abduction moments were 46% and 39% greater, respectively, than on the prosthetic side. The intact side knee and hip peak internal abduction moments were 17% and 6% greater, respectively, than normal. Larger moments suggest joint loading is of higher magnitude on the intact side, which may be predisposed to premature joint degeneration, particularly knee osteoarthritis." (Royer et al, 2005) They also found that people who suffered unilateral, lower-extremity amputation were at a risk of developing osteoarthritis (OA) in the knee and/or hip of the non-amputated limb. They also concluded that the severity of the knee osteoarthritis disease among persons without amputation linked to elevated frontal plane knee moments. Figure 1: Intact limb internal knee abduction moment was greater than the prosthetic side, indicating greater loading on the medial knee compartment.(Royer et al. 2005) Figure 2: Intact limb internal hip abduction moment was greater than the prosthetic side throughout stance.(Royer et al. 2005) Sandreson et al (1996) reported the nature of gait accommodations by unilateral below-knee amputees during walking. In their study they compared the lower extremity kinematic and kinetic data for two groups of subjects, 6 below-knee amputees (both prosthetic and intact limbs) and 6 able-bodied individuals (a single limb). They were computed as subjects walked at 1.2 and 1.6 m/s. Kinematic profiles of the patients were similar for all three limb conditions. The most prominentt difference between limbs was found late in stance at the ankle joint, as the prosthetic limb displayed substantially less planter flexion because of its passive response to unloading. The most apparent joint kinetic differences between limbs were found at the knee. While the net ankle and hip moments were similar for all three limb conditions, the authors note that the net knee moment for the prosthetic leg deviated from the amputee intact and non-amputee limbs by remaining flexor throughout the stance phase. The researchers attributed this response to an effort to reduce loading on and about the knee joint and stump of the prosthetic limb. The overall support moment on the prosthetic side was sufficient to provide a normal support function despite the absence of an extensor contribution from the prosthetic knee. Future trends in management18,15 The new scientific research in medicine and prosthesis lead to: the development of creative methods for to provide movement in disabled people who have lost a limb or are paralyzed from a spinal cord injury. Insights into how technology can boost medical progress. New technologies such as batteries, microcomputers, small but sturdy circuit boards, and other electronic advances allow greater function than ever before; new materials such as composite plastics, silicones, etc., that create lighter-weight designs and more natural-looking cosmesis for both adult and child upper extremity amputees. the development of the controllers for electric hands from Motion Control. In combination with the electric terminal devices, electric wrist rotation is now used much more commonly and effectively with the new controllers allowing easy control of both hand and wrist. The lightweight advantage arm features internal cables that go directly from the harness into the top of the elbow unit. Flexible polymer cables are utilized that pull much more smoothly than steel cables. (Sears, 1999) The future development will surely depend on whether the demand will appear for some new technological improvements, or not. The devices which are cheap and low-functional will continue to be produced, as that is the class of prosthesis need in the developing countries. In the same time the high-cost complicated devices which look and function almost like natural ones will also be needed, as there are people who can allow those. Conclusions The fact that the development of the prosthesis is very rapid nowadays combined with the enhancing tools and techniques of modern gait analysis; let us hope the prosthesis research will bring us new ways of making the injured people's lives more comfortable. The analysis of literature displays some data about the current state of prosthesis research. It is obvious that the prosthesis research is developing and enhancing for to satisfy the patients' need in relatively cheap, functional and easy to use prostheses. The data provided let us make some conclusions, which are that the scientists and researchers working on this subject have to pay more attention to the question of whether the selected prostheses satisfy the needs of those who use them. It is needed for to make the prostheses more comfortable for their users, thus restoring the functionality of a person in the society. It is also that that the compromise has to be found between the low cost and limited function devices and high performance artificial limbs, the type of prostheses that will neither be too expensive or too inconvenient for the users. BIBLIOGRAPHY 1.Davis. L Brian , Kuznicki. Jennifer, Praveen. S.Solomon and ,Sferra. James 'Lower-extremity amputations in patients with diabetes: pre-and post-surgical decisions related to successful rehabilitation', Diabetes/Metabolism Reviews, 2004; Vol.20(suppl 1),pp. S45-S50. 2.Douglas, Smith; John, Fergason , 'Transtibial amputations Section I: symposium: Amputation and new prosthetic Devices', clinical orthopaedics and related research volume(361), April 1999, pp 108-115. 3.Fergason, John, Smith, Douglas G., 'Socket considerations for the patient with a transtibial amputation Section I: symposium: amputation and new prosthetic devices' ,Clinical orthopaedics and related research, Volume(361), April 1999, pp76-84 4.Gibson, Jo, Certcouns, RGN, 'Lower limb amputation Art & science: continuing professional development: amputation', Nursing Standard Owned by Nurses Run by Nurses, Volume 15(28), 28 March 2001, pp 47-55 5.Girdhar, A.,Mital, A.,Kephart,A, and Yong,A.'Design guidelines for accommodating amputees in the workplace' journal of Occupational rehabilitation , Vol.11, no.2, June 2001,pp 99-102. 6.Gottschalk, Frank, 'Transfemoral amputation: biomechanics and surgery Section I: symposium: amputation and new prosthetic devices', clinical orthopaedics and related research, vol (361), April 1999 pp 15-22. 7.Jeffcoate, William .J and Harding, PorfKeith.G, 'Diabetic foot ulcers', The Lancet, Volume 361, issue 9368, 3 may 2003, pages 1545-1551 8.Kapp, Susan, 'Suspension systems for prostheses Section I: symposium: amputation and new prosthetic devices' ,Clinical orthopaedics and related research ,Volume(361), April 1999, pp55-62 9.Marks, L.J and Michael, J.W., 'Science, medicine, and the future Artificial limbs' British medical journal, vol 323, 2001, pp732-735 10.Michael, John W, 'Modern prosthetic knee mechanisms Section I: symposium: amputation and new prosthetic devices' ,Clinical orthopaedics and related research, Volume(361), April 1999, pp39-47 11.Pandian, G. and Kowalske, K., 'Daily functioning of patients with an amputated lower extremity', Clinical Orthopaedics and Related Research, Volume (361),April 1999,pp 91-97 12.Romo, H. Duane, 'Specialized prostheses for activities: an update Section I: symposium: amputation and new prosthetic devices', Clinical orthopaedics and related research, Volume(361), April 1999, pp63-7 13.Royer, Todd.D , Wasilewski, Carolyn A., 'Hip and knee forntal plane moments in persons with unilateral, trans-tibial amputation' , Gait & Posture, accepted 1 April 2005-10-20 14.Sanderson, David.J, Martin, Philip .E, 'Lower extremity kinematic and kinetic adaptations in unilateral below-knee amputees during walking', Gait and Posture, 6 (1997) 126-136, Accepted 5 november 1996 15.Sears, Harold H., 'Advances in arm prosthetics', In Motion, volume 9-issue 3. may/june 1999 16.Schuch, C.Michael, 'Consumer guide for amputees: a guide to lower limb prosthetics Part 1- prosthetic design basic concepts' ,In Motion, Volume 8-issue 2-march/April 1998 17.Schuch, C.Michael, Pritham, Charles.H, 'Current transfemoral sockets Section I: symposium: amputation and new prosthetic devices',Clinical orthopaedics and related research ,Volume (361), April 1999, pp48-5 Internet 18.http://web.sfn.org/content/publications/BrainBriefings/robotic_limbs.html Read More