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An Illustrated Guide to Prosthetic Care: Transfemoral Amputation
In the United States, 1.6 million people live with limb loss and over 185,000 amputations are performed each year. The leading causes of amputation are trauma, heart disease, cancer, and diabetes. Experiencing an amputation can leave you feeling apprehensive and full of questions. The purpose of this manual is to address some of those questions by explaining the processes involved in receiving an artificial limb, from post-surgical recovery and early post-operative fitting to pre-prosthetic care and the delivery of a finished prosthesis. The rehabilitation team is led by your physician and may consist of a physical therapist, social worker, occupational therapist, and prosthetist. Ultimately, you will play a major role in the success of your recovery as you prepare for life as an amputee.
Immediate Post Surgical Care
There are several methods of immediate post-surgical care, all of which are determined by your physician. Typically after amputation, the surgeon will apply a dressing intended to reduce swelling, protect, and shape your limb for future prosthetic fitting. A TFPOD (Transfemoral Post-Operative Dressing) is a soft dressing that protects the limb, provides compression to help decrease swelling, and allows for inspection of the wound. It is applied immediately after surgery and consists of a post-op sock with a soft, semi-rigid foam protector that is held in place by a waist belt A rigid dressing is another method and may be applied immediately after surgery or 3-5 days post-operatively. It is left in place for 10-14 days with 2-3 cast changes occurring until the sutures are removed. A foot section with a walking knee may be applied to the cast to facilitate light-touch weight-bearing or gait training even before the healing process is complete. A post-op temporary prosthesis is made from a rigid co-poly plastic formed to your limb’s shape, with a manual lock knee, a pylon section and a foot. It is worn in conjunction with several prosthetic socks of varying thicknesses. The prosthesis is utilized for 6-8 weeks of light-touch weight-bearing until your limb has healed and is ready for casting for a definitive prosthesis. A rigid removable dressing or protector, as it is commonly called, provides protection and compression to the residual limb. Compression is achieved by using compression socks or by applying an ace wrap over the residual limb in a figure of eight pattern. The rigid removable dressing consists of compression socks and spacer socks, all held in place by a rigid shell suspended onto the thigh by an elastic stocking and waist belt. This dressing is changed several times a day and is worn for 2-3 weeks leading up to and beyond the fitting of your prosthesis.
Initial Prosthetic Fitting
Six to eight weeks after your amputation, the healing process may be complete. At this time your physician will prescribe a prosthesis designed to enable you to return to your regular daily activities. You will be seen at Prosthetic Laboratories for casting of your residual limb. This process will yield a plaster model of your limb from which a test socket prosthesis will be custom fabricated. The test socket consists of a clear plastic socket, adjustable components, an adjustable pylon, a prosthetic knee, and a prosthetic foot.
Gait Training
Once you are fit with a test socket, you will meet with a physical therapist. Over the course of approximately two weeks, a physical therapist will offer instruction on the use of your prosthesis, including donning and doffing the prosthesis, sock management, and how to ambulate on a variety of surfaces throughout the community. You will also be followed closely by your prosthetist during this time for minor adjustments to the socket fit and alignment changes. In addition, your prosthetist will be happy to answer any questions you may have about the componentry in your device.
The Definitive Prosthesis
Your definitive prosthesis will be fabricated after three steps have been completed: attainment of the desired fit and alignment of your test socket prosthesis; stability in your limb size and skin condition; and completion of your physical therapy. The test socket prosthesis will be taken through a duplication process and transformed into a more durable product containing carbon fiber, acrylic resin, and ultralight definitive components. Your first definitive prosthesis will last on average 3-6 months. During this time, adjustments to the fit of the socket will be required on a periodic basis to prolong the life of the device until no further adjustments can be made. After regular follow-up appointments with your physician and prosthetist, you will be prescribed a replacement socket or second definitive prosthesis. The second definitive prosthesis is typically worn 1-3 years. It is not uncommon to require a new prosthesis every 3-5 years.
Socket Design
Your physician and prosthetist will determine the best socket design option for you based on several criteria, including the condition of your residual limb and range of motion. The traditional quadrilateral socket design is best known for its square shape. The brim of the socket supports the residual limb of the amputee primarily on the ischium and gluteal musculature. The most common type of socket design is Ischial Containment. This socket design contains the ischial tuberosity to create a boney lock for side to side stability. The latest design on the market is called the M.A.S (Marlo Anatomical Socket) which is indicated for patients with a stable limb volume. The M.A.S. socket design provides several clinical benefits such as ease of donning, fuller range of motion, improved cosmesis, and more comfort while sitting.
Suspension Techniques
There are several suspension techniques available to securely attach the prosthesis to your residual limb. Total suction suspension provides the wearer with the most intimate fit possible. Total suction is most commonly achieved by skin to socket contact, or by using a silicone seal-in liner as an interface. Another form of positive suspension is the use of a suspension locking mechanism. This is the mechanical attachment of a silicone gel liner which is rolled onto the residual limb and secured to the prosthesis by a lanyard attached to the end.
Prosthetic Knees
Your lifestyle and activity level will determine the type of knee you will use. There are several classifications of prosthetic knees based on the benefits of the design. Manual lock knees are mechanically (inherently) stable for those patients who are limited in their ability to ambulate. Single axis knees require more voluntary control from the patient. The gait cycle is enhanced by the addition of a hydraulic or pneumatic cylinder to control the swing of the knee. Polycentric design, or a four bar linkage system, imitates natural knee motion and incorporates an adjustable bumper to act as a shock absorber, simulating the flexing action that occurs while walking or running. For the advanced walker, microprocessor swing and stance knee systems that utilize the power of artificial intelligence are available. The knee is capable of independent thought; it learns how the amputee walks, recognizing and responding immediately to changes in speed, load and terrain.
Prosthetic Feet
Prosthetic feet on the market today offer the amputee many options and features. There are several classes of prosthetic feet: SACH, Single Axis, Dynamic Response, Multi-Axial and Bionic Technology. A basic style SACH foot (solid ankle cushion heel) is made from wood and soft flexible foam. Single axis feet provide cushioned plantar flexion and dorsiflexion features. More advanced prosthetic feet are classified as Dynamic Response or Multi-Axial. These feet are made from carbon fiber and urethane and provide energy return to the amputee while walking. The Proprio Foot by Ossur utilizes bionic technology; it has on-board sensors and artificial intelligence that identifies changes in terrain and automatically instructs the ankle to flex appropriately.
Commonly Asked Questions
Q: How long after amputation will it be before I am fit with a prosthesis? A: Typically around 6-8 weeks. This time may vary due to your current health status and the time it takes your limb to heal properly. Ultimately, your physician will determine the exact time frame for fitting. Q: Why do I need compression socks and how long do I need to wear them? A: Compression is imperative to a successful fitting of your prosthesis. In early stages of healing it is used to control swelling and help shape your limb. It is recommended that you wear your compression socks until there is little change in your volume from day to day. Once you are wearing a prosthesis daily, you may only have to wear compression socks at night, if at all. Q: What is involved in the casting process for a new prosthesis? A: When your physician writes the prescription for your prosthesis, you will then see your prosthetist for casting. This procedure is done in the office. Your prosthetist will evaluate your limb, take a set of measurements and outline the important features of your limb. He or she will then apply plaster of paris to your limb to obtain an impression. This impression is then filled with plaster. Once the proper modifications have been made to your model, the technicians will fabricate a prototype prosthesis called a check socket. You will be seen back in the office approximately 3-5 days later for fitting. Q: What can I expect at the fitting of my temporary prosthesis? A: The first fitting is usually done in the office or physical therapy department. It is important that you wear loose, comfortable clothing. Your prosthetist, and/or physical therapist, will explain how to don your prosthesis and how to manage the soft socks or liner that you may be using. Your prosthetist will then check the height of your prosthesis and the fit while you are standing. Once the proper height is attained, you will begin gait training. Q: How often will I be seen for physical therapy? A: Your physician will determine the length of therapy you need; this will depend on your abilities and level of amputation. Patients are typically seen twice a day for two weeks, possibly longer for higher levels of amputation. Other facilities may vary. It will be up to you and your physical therapist to create a schedule that works for you. Q: After I receive my definitive prosthesis, how often will I need to see my prosthetist? A: After you are fit with a definitive prosthesis you may not need to see your prosthetist for months. It will depend on the fit and feel of your prosthesis. Your limb will continue to shrink and this may cause the original fit of your prosthesis to change. Everyone is different and changes happen at different rates. Any time you feel irritation or discomfort you will need to see your prosthetist immediately. You are your best line of defense against an unsuccessful prosthetic experience. Q: Will I be able to participate in the leisure activities I did prior to my amputation surgery? A: YES! As long as your physician agrees, you should be able to return to the activities you once enjoyed. Prosthetic components today offer the amputee a variety of options that make participation in vocational or recreational activities and sports a reality. You will need to help your rehabilitation team by making them aware of your goals so the best possible options are chosen when it comes to your prosthetic care. Q: Where can I go for more specific information? A: Below you will find a list of organizations, literature and websites you may find helpful. Remember, your rehabilitation team is still the best source of information.
Resources for People with Amputations
For more information on prosthetic services and a complete list of resources, please visit Prosthetic Laboratories of Rochester’s homepage at www.plor.net.
Websites • • • • • • • • • • • • • • • Amputee Coalition of America. (888) AMP-KNOW (267-5669). www.amputee-coalition.org The Association of Children’s Prosthetic-Orthotic Clinics. www.acpoc.org Orthotic and Prosthetic Assistance Fund. www.opfund.org The Global Resource for Orthotics & Prosthetics information. www.oandp.com For families and friends of children with limb differences. www.limbdifferences.org Surviving Limb Loss. www.survivinglimbloss.org Amputee Information Network. www.limbless-association.org AgrAbility Project – Disability in Agriculture and Rural America. www.agrabilityproject.org Mayo Clinic. www.mayoclinic.com/health/search. Keyword: Amputation Online Magazine for Amputees. www.amputee-online.com/amputee For female amputees. www.ladyamp.com Active Living Magazine. www.activelivingmagazine.com Access to Recreation. www.accesstr.com National Center on Physical Activity and Disability. www.ncpad.org National Amputee Golf Association. www.nagagolf.org Books • • • • Challenged by Amputation: Embracing a New Life. Carol S. Wallace. 1995. Inclusion Concepts Publishing House. Conditioning with Physical Disabilities. Kevin F. Lockette, PT, CSCS and Ann M. Keyes, PT, CSCS. 1994. Coping With Being Physically Challenged. Linda Le Ratto, M.Ed. 1991. The Rosen Publishing Group. Coping With Limb Loss. Ellen Winchell, PhD. 1995. Avery Publishing Group.
We gratefully acknowledge the assistance of Otto Bock and Ossur for information contained in this publication. Photos courtesy of Otto Bock HealthCare.
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