Orthotic, adaptive, protective, and assistive devices are implements and equipment used to support or protect weak or ineffective joints or muscles, and serve to enhance performance.1 The uses of appropriate orthotic, protective, and supportive devices are outlined in this chapter.
The major rationales for amputation include disease (diabetes, peripheral vascular disease [PVD]), infection (post joint replacement, osteomyelitis), tumor, trauma, and fractures that fail to heal (non-union).
- Amputation refers to the cutting of a limb along the long axis of the bone.
- Disarticulation refers to cutting of a limb through the joint.
Major improvements in noninvasive diagnosis, revascularization, and wound healing techniques have lowered the overall incidence of amputations for vascular disease.2
Traumatic amputations may be performed at any level (Table 15–1). Whatever the level the surgeon attempts to maintain the maximum bone length and to keep as many joints intact as possible.2 The specific type of surgery depends on the status of the extremity at the time of amputation. Conservation of the residual limb and uncomplicated wound healing are both important.
Table 15–1. Levels of Amputation |Favorite Table|Download (.pdf)
Table 15–1. Levels of Amputation
LEVEL OF AMPUTATION
Excision of any part of one or more toes
Disarticulation of one or more toes at the metatarsophalangeal joint
Partial foot/ray resection
Resection of the third, fourth, fifth metatarsals and digits
Tarsometatarsal (LisFranc) disarticulation
The disarticulation of all five metatarsals and the digits
Amputation through the midsection of all metatarsals leaving only the calcaneus and talus
Ankle disarticulation which may include removal of the malleoli and distal tibial/fibular flares to create a smooth bony distal end with the attachment of the heel pad to the distal end of the tibia.
Long transtibial (below knee)
More than 50% of tibial length
Transtibial (below knee)
Between 20% and 50% of tibial length
Short transtibial (below knee)
Less than 20% of tibial length
Amputation through the knee joint with shaping of the distal femur, squaring the condyles for an even weight-bearing surface. The knee disarticulation is most often used in children and young adults, but is nearly always avoided in the elderly and patients with ischemic disease. Several advantages of the knee disarticulation include:
- A large distal end covered by skin and soft tissues that is naturally suited for weight bearing
- A long lever arm controlled by strong muscles
- Increased stability of the patient's prosthesis
A main disadvantage of the knee disarticulation is cosmetic—the patient's prosthetic leg will have a knee that extends far beyond his own knee in the sitting position.
Long transfemoral (above knee)
More than 60% of the femoral length
Transfemoral (above knee)
Between 35% and 60% of the femoral length