At McCleve Orthotics & Prosthetics, we take a multi-faceted approach to our patient’s overall health and well-being.  With offices in both Mesa and Phoenix Arizona, McCleve O&P is conveniently located to better serve you.  Our goal is to not simply provide a Custom Prosthetic device – we address the medical, physical and emotional needs of each and every patient we see.  We’re not satisfied until you are, and we go to extraordinary lengths to get it right!  Experience the difference at McCleve O&P –Arizona’s Leader in Prosthetic Limb & Amputee Care!

Coping with an amputation poses challenges on many levels including physical, emotional, social, spiritual, financial and may temporarily affect one’s ability to think clearly and even solve routine problems.  Emotional responses to amputation are different for every individual and their family.  At McCleve O&P, we take a well rounded TEAM Approach to helping you reach your goals and getting you up and loving life again.

Although your clinician will be caring and thoughtful, nothing replaces talking to a fellow amputee. A “Peer Mentor” or “Peer Visitor” is an amputee that will be available to speak with you about your worries and concerns. They can truly understand and relate to the challenges and fears of our amputee patients and will make themselves available to meet you in our office or your home to discuss those issues that are on your mind. They can answer questions, offer support and be a trusting friend when you need them most. After all, many of them have experienced similar feelings and will be a valuable asset to aide in your recovery.

Possible Questions You May Ask:

  • What’s it like to actually lose a limb?
  • What will my stump or limb look like?
  • When will I receive my prosthetic device?
  • What limitation should I expect as an amputee?
  • Can I pursue my old activities and interests?

The McCleve Prosthetic Centers in Mesa & Phoenix Arizona will help match you with an amputee peer that your comfortable with. Our Arizona patients range in age from young to old and many are trained as Peer Mentors to help you get comfortable with your prosthesis and new way of life. Whether you have lost both of your legs or one arm, we have an amputee peer mentor that can relate to you and discuss what it’s like to be an amputee, from first-hand knowledge. The sooner you talk to another amputee, the sooner you’ll start to understand that you can still achieve all your hopes and dreams.

Article in full available online at KSU – 2013

Amputation Levels

 Amputation levels above the knee include the following:

  • Hemipelvectomy is the loss of any part of the ilium, ischium, and pubis.
  • Hip disarticulation is the loss of all of the femur. The hemipelvectomy and hip disarticulation procedures are usually done in cases of malignant tumors, extensive gangrene, massive trauma, or advanced infection.
  • Short transfemoral amputations occur when lessthan 35% of femoral length is present. A larger weight bearing surface can be created if femoral transaction can be done at the level of the lesser trochanter. This level retains the femoral head and neck and the greater trochanter, resulting in improved prosthetic fit. The number of transfemoral amputations has declined since the 1980s. This decline is due to improved surgical techniques and better preoperative assessment of vascular status.
  • Medium tansfemoral amputations occur when between 35 and 60% of femoral length is present. Ideally, tansfemoral limbs should be at least 4 inches or 10 cm above the lower end of the femur to allow room for the prosthetic knee. In a transfemoral amputation, both anterior and posterior muscular surfaces are well vascularized; therefore, equal flaps are fashioned.
  • A rotationplasty is applicable to patients who have a malignant tumor in the middle or distal femur. It is also done in cases of PFFD. A rotationsplasty involves an osteotomy in the proximal third of the femur, distal to the lesser trochanter, and in the proximal part of the tibia, distal to the tibial tuberosity. The foot is rotated 180° and the tibia reattached to the remaining femur. The foot is fit into the prosthesis and acts as a knee joint. Prosthetically, this amputation has the advantage of preserving the anatomic ankle joint, which acts as a knee joint, and a long lever arm for better prosthesis control. The rotationsplasty procedure is illustrated in Figure 2.
  • Long transfemoral amputations occur when more than 60% of femoral length is present but not capable of end bearing. A transfemoral amputation is depicted in Figure 1-14.
  • In a supracondylar amputation, the patella may be left for better end bearing. However, the area created between the end of the femur and the patella may delay healing.
  • A knee disarticulation amputation offers good weight distribution and retains a long, powerful, muscle – stabilized femoral lever arm. In addition, the thigh muscles are completely preservfed, thereby ensuring good muscular balance. This amputation maintains the femoral length in growing children by preserving the growth potential of the distal femoral epiphysis. However, the knee disarticulation amputation yields a noncosmetic socket because of the need for an external joint mechanism and resulting difficulty with swing-phase control. Knee disarticulation amputation is often performed on the patient who will not become a prosthetic walker. This amputation avoids the possibility of knee flexion contractures and provides an excellent platform for sitting and transfers.

Transtibial amputation levels include the flowing:

  • A very short transtibial amputation occurs when less than 20% of tibial length is present. This amputation may result from trauma and is usually not done as an elective procedure. A very short transtibial amputation results in a small-moment arm, making knee extension difficult. Moment arms are further described in Chapter 5, “Biomechanics Implications of Prosthetic and Orthosis”.
  • A standard transtibial amputation occurs when between 20 and 50% of tibial length is present. An elective amputation in the middle third of the tibia, regardless of measured length, provides a well-padded and biomechanically sufficient lever arm. At least 8 cm of tibia is required below the knee joint for optimal fitting of a prosthesis.
  • A long transtibial amputation occurs when more than 50% of tibital length is present. This amputation is not advised because of poor blood supply in the distal leg.

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. A long posterior flap for transtibial amputations is advantageous because it is well vascularized and provides an excellent weight-bearing surface. In addition, the scar is on the anterior border, an area that is subject to less weight bearing. The deep calf musculature is often thinned to reduce the bulk of the posterior flap.

In a transtibial amputation, the fibula is transected 1 to 2 cm shorter than the tibia to avoid distal fibula pain. If the fibula is transected at the same length as the tibia, the patient senses that the fibula is too long, which may cause pain over the distal fibula. If the fibula is cut too short, a more conical shape, rather than the desired cylindrical – shape residual limb results. The cylindrical shape is better suited for total contact prosthetic fitting techniques. A bevel is placed on the anterior distal tibia to minimize tibial pain on weight bearing. To avoid a painful neuroma, a collection of axons and fibrous tissue, nerves should be identified, drawn down, severed, and allowed to retract at least 3 to 5 cm away from the areas of weight-bearing pressure.

A Syme amputation was named for James syme, a noted University of Edinburg surgeon, in the mid-1800s. This amputation is an ankle disarticulation in which the heel pad is kept for good weight bearing. The Syme amputation results in a residual limb that possesses good function due to the long lever arm to control the prosthesis and the ability to ambulate without the prosthesis.

Associated problems with the Syme amputation include an unstable heel flap, development of neuromas of the posterior tibial nerve, and poor cosmesis. Performed properly, the residual limb is ideally suited for weight bearing and lasts virtually the life of the patient.

The bulky residual limb that results from a Syme amputation may be streamlined by trimming the remaining metaphyseal flares of the tibia and fibula

Foot amputations levels include the following:

  • A transmetatarsal amputation (TMA) may be performed for deformities resulting from trauma to the toes, infection or gangrene due to frostbite, diabetes, arteriosclerosis, or autoimmune circulatory connective tissue disorders. There are approximately 10,000 TMAs a year in the United States, with a failure rate of about 30%. Of all the amputations done in the United Kingdom, this amputation has the highest failure rate. This high failure rate is due to a combination of substantial loss of weight-bearing areas on the neuropathic foot and the decreased foot length available to generate a plantarflexor moment. As a result, the remaining tissues bear an increased load. This amputation should b elimited to patients with an intact posterior tibial pulse, a warm foot, and localization of osteomyelitis or gangrene to the phalanges. A dorsal incision is made through the mid-to proximal metatarsal shafts. A long, thick, myocutaneous plantar flap including the flexor tendons is used, with closure of this flap onto the dorsum of the foot. The transmetatarsal procedure is depicted in Figure. 1-20.
  • The Lisfranc amputation is done at the tarsometatarsal joint and involves a disarticulation of all five metatatarsal and digitis.
  • The Chopart amputation, at the talonavicular and clacaneocuboid joints, involves a disarticulation through the midtarsal joint leaving only the clacaneus and talus. Both the Lisfranc and Chopart amputations were introduced before blood transfusions and antibiotics were available. They were planned as diarticulations to be performed as rapidly as possible. These amputations often result in an equines and varus deformity due to the pull of the plantarflexors and loss of dorsiflexor and peroneal muscles. In addition, a distal sensitive end often leads to skin breakdown. There is much less indication for their use today.
  • A trransphalangeal (toe disarticulation) amputation is done at the metatarsophalangeal joint. Toe disarticulations result in biomechnical deficiencies. Amputation of the great toe affects push-off during fast walking and running; as a result, patients with PVD often have a nonpropulsive gait pattern. If the base of the proximal phalanx with the insertion of the flexor hallucis brevis issaved, stability is enhanced. Second-digit amputation results in severe hallux valgus.
  • Phalangeal or partial toe amputation involves excision of any part of one or more toes. The lesser toes serve little function in patients with ischemic PVD. As a result, gait is not markedly affected with amputation of the lessor toes. Prosthesis is usually not necessary for toe amputations.

In general, as much viable tissue as possible should be preserved after hand injury and partial amputation. This view must, however, be tempered with an appreciation of what will remain functional. The retention of a finger or part of one which is anaesthetic, cold and stiff dose no service to the patient and will actively discourage use of the hand and ability to work and, even after amputation, pain and a lack of desire to return to normal function will persist.

Upper limb levels of amputation

  • Amputation of Digits – Generally the level will be determined by the degree of injury fig.5. If the injury is solely to the index or little finger, useful function is unlikely unless one and a half phalanges are still present. Even at this level initial acceptance of this limited loss by the patient is often transmuted into a desire for cosmesis and later amputation is requested. The best cosmesis is achieved by amputation through the metacarpal shaft with suitable beveling. This, however, reduces the span of the hand and power of the grip and it may be better in larger manual workers to amputate through the metacarpophalangeal joint.  The long and ring fingers are best amputated through whatever level will leave a mobile and comfortable stump. Even a very short stump, for example the proximal phalanx, may have some definite functional value and in the half-closed position be at least cosmetically acceptable. Amputations of either of these fingers in which the metatarsal ray is excised for cosmetic reasons may seriously disturb function and are seldom desirable.  As much of the thumb as can be must be preserved for as long as possible. Any stump covered with sensitive skin may be of great value.
  • Wrist disarticulation – Indications for wrist disarticulation are rare but usually related to severe trauma to the hand with considerable loss of tissue and loss of sensation. Any tissue with sensation should be preserved. Even carpal bones and remnants of metacarpals, providing they are covered by viable skin, may be useful as the wrist extensors and flexor may be preserved as well.
  • The Forearm – The usual indications for amputation through the forearm are for severe trauma affecting the wrist and hand and occasionally it is used as treatment for chronic sepsis or tumor of the hand.  Ideally as with other amputations, the stump should be as long as possible. A too distal amputation, however, whilst having the advantage of a long lever and ease of fitting, often suffers from cold and cyanotic skin with little subcutaneous and muscular tissue covering the bone ends. Therefore the ideal distance is 17cm measured from the olecranon in the average adult and this roughly corresponds to the junction of the proximal two-thirds and the distal one-third of the forearm.  Occasionally the extent of the trauma or disease affecting the hand and forearm may be too great to allow a useful below-elbow stump to be fashioned. In the past conventional treatment would have been to amputate at the level of the distal humerus but as a result of the recent improvements in prosthetic design, disarticulation at the elbow is preferable. It looks as though it will be possible, by retaining the bulbous stump, to have a self-retaining socket and a better joint in the future.  Technique. The skin flaps will often be determined by whatever skin is available but where possible equal anterior and posterior flaps should be made the incisions beginning at the level of the humeral epicondyles and extending distally 4 cm beyond the point of the olecranon posteriorly and to point just distal to the insertion of the biceps anteriorly.
  • Amputation through the Humerus – The commonest indication is severe trauma of the forearm. Occasionally this amputation may be used for sepsis or malignant tumors  As elsewhere in the upper limb the level may be determined by factors beyond the surgeon’s control. The ideal is 10cm above the elbow joint, which leaves room for the elbow mechanism in the prosthesis and provides the best length of stump for fitting. Above this level as long a stump as possible should be retained.
  • Amputation through the Neck of the Humerus – This operation does not leave the patient with any functional stump and should not be performed when it is possible to leave a humeral stump extending to three finger breadths below the anterior axillary fold. This is the critical minimal length to which an upper limb Prosthesis can be fitted. If the amputation is being performed for malignant tumor at the lower end of the humerus there is no alternative but disarticulation at the shoulder joint. To leave the humeral head in site when it is permitted on pathological grounds, however, produces a better cosmetic appearance, particularly when wearing clothes, by preserving the rounded contour of the shoulder.

Shoulder disarticulation – The arm completely lost

  • Forequarter Amputation – Clavicle, scapula, and arm are excised. This amputation is rarely performed and is indicated only for malignant tumors around the shoulder joint, particularly where the tumor has spread into the surrounding muscles so that the less mutilating procedures of disarticulation of the shoulder or amputation through the neck of the humerus are no longer practicable.

Arizona prosthetic patients will benefit from visiting with CPO Dean McCleve for a free initial evaluation.  Need a new prosthetic leg or adjustment?  Mesa, Tempe, Scottsdale, Phoenix – Call to make your appointment today.

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