Prosthetic Management - Transtibial Amputation Part 12

Transtibial Amputation:
Prosthetic Management
Faculty of Science
Department of Sports Rehabilitation and Dental Science
Bachelor of Health Science in Medical Orthotics and Prosthetics (BPOP20)
Outcome:
• Trans Tibial (TT) Amputation
• Prosthetic evaluation
• Early prosthetic management
• Prosthetic prescription
• Socket designs
• Patella Tendon – Bearing Socket
• Total Surface Bearing Socket
• Interface Materials
• Suspensions
• Impression Techniques
• Alignment
• Additional features
• Finishing Techniques
Faculty of Science
Transtibial Amputation:
• Is the most commonly performed level for major limb
amputations
• It constitutes a major treat to the neural, muscular and
skeletal system
• Loss of the ankle joint & distal tibia, transected muscle
bodies & altered peripheral nerves
• Presents a serious physical challenges to ambulate.
Faculty of Science
Prosthetic evaluation:
“It is only with careful consideration of the person’s complete profile that the clinical team
can recommend the components & design that will lead to the most optimal prosthetic
outcomes.”
Faculty of Science
Prosthetic evaluation:
Detailed History
• ?
Physical examination:
• Inspection
• Palpitation
• Evaluation of muscles performance – manual muscle testing (MMT)
• Active & Passive ROM
• Sensory testing
• Skin Integrity
Evaluation also assesses:
• Individual’s cognitive level
• Age
• Health history
• Vocation
• Avocation
• Home living status
Faculty of Science
Other factors to consider evaluation:
• Mental status/effort:
• Motivated and wants to walk – not much effort – prosthesis
• Lack of motivation rehabilitation - ?
• Involve patient in an amputee group
• Request peer visitor
• Comorbidities complications
• Prosthetic options – addresses these issues
• Mild to moderated knee flexion contractures & weakness
• May be accommodated by altering the alignment of the prosthesis
• Skin issues:
• Example: adherent scarring & eczema
• Addressed - by selecting the appropriate interface material
• Pressure on the skin & soft tissues over prominent bones:
• Relieved by altering the socket shape
• Patients with severe upper limb dysfunction:
• Don & Doff – the prosthesis
• Overcome by prosthetic options to aid these patients
Faculty of Science
Other factors to consider evaluation:
• Design of the prosthesis:
Weight VS Function/Compromise
• Weight
• Weight is increased with added features & maintenance of the device
• Leads to increased energy expenditure & premature fatigue
VS
• Function:
• Exclusion of features that adds to the weight will lead to excessive
stresses on the limb, premature component wear or breakdown &
inefficient gait
• How can one determine this – K –levels, [Important – medical

cover]
• Prevent prescription of prosthesis that are costly for an amputee that will
not be able to manage or use effectively
Faculty of Science
Early prosthetic management:
Goals of postoperative management of the transtibial
amputee:
• Maintain full ROM of hip and knee
• Facilitate rapid healing of suture line
• Maintain or improve cardiovascular and pulmonary condition
• Enhance static and dynamic balance
• Facilitate functional strength in the remaining musculature
Faculty of Science
Nine distinct stages for lifelong
rehabilitation:
• Preoperative
• Amputation surgery and wound dressing
• Acute post-surgical
• Pre-prosthetic:
• Wound healing
• Pain control
• Proximal body motion
• Emotional support
• Phantom limb discussion
• Prosthetic prescription and fabrication:
• Team consensus on prosthetic prescription
• Prosthetic training:
• Prosthetic management an training to increase wearing time and functional use
• Community integration
• Vocational rehabilitation
• Follow up
Description OPR: Table :23-2 Page 623
Faculty of Science
Complication: TT Amputation
• Common complication is loss of knee full extension
• Failure to promote full extension of the tibiofemoral joint
can lead to delays in prosthetic fitting while ROM is restored
• What happens if there is a permanent joint contraction in
the knee?
• Prosthetic component that can aid the patient?
OR
• No hope for the patient?
• What is RRD?
• Does RRD address other issues?
• What is the goals of an RRD?
• Are there different variations of RRD?
Faculty of Science
Prosthetic prescription:
“Is a detailed description of all the features of the complete prosthesis”
Faculty of Science
Includes:
• Socket design • Suspension:
• Patella Tendon Bearing Socket • Waist Belt
• Total Surface – Bearing Socket • Joints and Corsets
• Cuff Strap
• Supracondylar Suspension
• Interface materials
• Supracondylar/Suprapatella
• Hard Socket
• Sleeve
• Socks and sheaths
• Suction
• Soft insert
• Locking Liners
• Flexible Inner socket
• Semirigid locking liner
• Expandable wall socket
• Elevated vacuum
• Gel Liner
• Additional modular
components/features:
• Torque Absorber
• Shock Absorber
• Dynamic Pylon
• Prosthetic feet
Faculty of Science
Socket:
• Interface between residual limb and prosthesis
• Transfers all the forces from the ground to the limb during gait
• All the forces from the limb needed to control motion of prosthesis, are
transferred to the prosthesis through the socket
• Care and time should be spent on socket design and fit as less than
ideal fit can lead to, pain, injury & lack of function.
• Socket design, interface and suspension should be considered
together in a prosthetic prescription?
• Function often interrelated and independent upon one another
• E.g.: soft liner functions both as an interface and as the suspension for the
prosthesis (However, could also be a socket that is designed with a different
interface may contraindicate certain suspension options)
Faculty of Science
Socket design:
• Early TT prosthesis:
• Hollowing out a block of wood and attaching metal single
knee – axis joints and leather corset
• Referred to as a “plug fit” socket
• Attached thigh corset took advantage of the conical shape of
the thigh to transfer weight proximally and transmit
mediolateral forces to & from the limb
• Patients were quite functional with this system.
• Disadvantage:
• Lack of contact on the distal end of the residual limb often lead to
painful edema in that section
• Joints and corset added weight to the prosthesis
• Restricted knee motion
Faculty of Science
Patella Tendon-Bearing (PTB) Socket:
• Used successfully for TT amputees
• Statistically loads the limb in areas that are more pressure
tolerant:
• Patellar tendon
• Medial tibial flare
• Relieve the tissue over bony prominences such as:
• Tibial crest
• Head of the fibula
The above eliminated the need for proximal weight bearing
• Goal: Increase the surface area on the residuum that is available
for weight bearing so as to eliminate the need for the knee joints
and thigh corset
• The socket described as “total contact”, which meant that there
were supposed to be no voids or air pockets between the limb &
socket
Faculty of Science
PTB Socket – Trim lines and special features:
• PTB makes use of a patellar bar
• Built into socket at the level of the center of the patellar ligament, midway between the
patella and tibial tubercle
• Socket aligned in 5 degrees knee flexion
• Allows bar to act as weight bearing surface
• Proximal trim line of the posterior wall is located just proximal to the patella bar to
stabilize the limb in the anteroposterior direction & prevent limb from sliding too far down
the socket. Note that the posterior trim line should be lower on the medial side to
accommodate the insertion of the medial hamstring during flexion
• Another major weight bearing surface – medial flare of the tibia
• Because the proximal end of the tibia broadens out medially and when stabalised by
pressure from the lateral wall of the socket, can effectively accept loading
• NB create relief for fibular head, because it is at the same level as
• Filling distal end of socket with compliant foam material
• Provides slight pressure during full weight bearing
• Necessary to control distal edema
• Medial & Lateral walls of the PTB socket extends up to the level of adductor
tubercle – provides a lever arm for mediolateral stability
Faculty of Science
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Faculty of Science
Total Surface – Bearing (TSB) Socket:
• Distributes the weight bearing load over the entire surface of the
limb, even in areas considered – pressure intolerant
• The intent of a TSB socket is to distribute uniform pressure over
the entire surface of the limb
• TSB sockets design evolved with the advent of gel liner interfaces
in an effort to fully maximise the load bearing surface area of the
limb by applying uniform pressure
• Strategic compression of soft tissue and relief for bony
prominences are tools used to direct more force into areas of the
limb that can tolerate it & less force onto areas that are prone to
skin breakdown
Pressure changes – swing & stance?
Hybrid designs?
Ertl procedure – benefits and disadvantages?
Faculty of Science
Faculty of Science
Faculty of Science
Faculty of Science
Reference:
Chapter 42 Chapter 23
• Atlas of limb amputations • Orthotics and Prosthetics
and limb deficiencies in rehabilitation
Faculty of Science
Faculty of Science

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Transtibial Amputation:

• How can one determine this – K –levels, [Important – medical

“Is a detailed description of all the features of the complete prosthesis”

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