Christian W. Ertl MD FACS FACCWS Michigan State University Seattle, 2009

American Orthotics and Prosthetics Association-National Assembly

Trans-Femoral Osteomyoplastic Update

Christian W. Ertl MD FACS FACCWS

Michigan State University

Seattle, 2009

Disclosure

• I have no funding issues or support to disclose

GOAL

In brief:

the residual extremity should be a well contoured, functional and dynamic limb, accepting a prosthesis to allow the patient to ambulate/function in a relatively effortless and painless manner

Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit

and use

Femur severely lateralized by

pull of the abductors and no adductor stabilization

Conventional AmputationEffects - Bone

• Medullary canal ignored, remains open– Poor ability for end weight bearing– Venous gradient 0mmHg → venous stasis

Loon

– Potential bone spur formation Hulth, Hansen-Leth, Reimann, Olerud

– Regional osteopenia with possible adjacent joint DJD Lo

Conventional AmputationEffects - Muscle

• Majority of musculature allowed to retract– Fatty atrophy Venous stasis– Slower speed of contraction

Blix, Loon

– Poor “volume” of residual extremity in prosthesis

Basic ScienceLength-Tension Relationship

• Normal muscle has max force at slightly longer lengths

• In amputees, muscles are divided, retract, undergo fatty degeneration, and excursion in contraction is decreased

• Result is increased work to ambulate with increased fatigue

Loon, Prosth Int, 1959.

Conventional AmputationEffects

• Incisions placed over prominent surfaces– Potential etiology of pain

• Regional circulation disturbed– Secondary to venous stasis– Abnormal vessel formation Hansen-Leth, Hulth, Olerud

– High risk of AVM– Dilated, tortuous vessels Hansen-Leth,

Osteomyoplastic Reconstruction

• Medullary canal sealed

• Broader surface area to bear weight

• Allows potential end weight bearing in AKA

• Improves local circulation

Basic ScienceClosure of Medullary Canal

• Intramedullary venograms pre-/post-canal closure Loon, Prosthetics International,41-58, 1959

Myoplasty - Transfemoral

• Fascial closure of opposing muscle groups• Adductor brought laterally for balance in

AKA• Improves local vascularity• Provides “insertion” for muscles to restore

resting length-tension relationship• Improve alignment and biomechanics of limb• Soft tissue coverage to end of residual

extremity

• Insertion sites of adductors; not restoring an adductor movement allows femur to lateralize creating an inefficient gait pattern; this increases oxygen demand and can create greater cardiac stress in patients with cardiopulmonary disease; would emphasize maintaining the adductor Magnus and gracilis muscles to restore the adductor moment

F. Gottschalk- U. Texas Southwest

Myoplasty-Basic Science

• Arteriogram of AKA prior to myoplastic procedure

• Poor filling in adductor region of leg

• Poor contour grossly

• Exostosis formationDederich, JBJS, 45-B, 60,

1963

Myoplasty-Basic Science

• Arteriogram 3 months after myoplastic procedure

• There is increased arterial flow with in the stump

• Distal and medial perfusion is improvedDederich, JBJS,45-B: 60,

1963

Osteomyoplastic ProcedureGoals

• Osseous/soft tissue reconstruction– Remove bone scar/spurs – Medullary canal closure– Myoplasty of opposing muscle groups – Plastic Closure

• Stabilize the extremity– Realign femur for proper mechanics and

gait– Muscle balancing

Osteomyoplastic ProcedureGoals

• Provide a potential end weight bearing extremity– Closure of medullary canal returns normal venous

gradient; distal bone remains vascularized

• Create a cylindrical residual extremity– Improves fitting/use of prosthesis– Smooth contour aides in preventing localized skin

breakdown– Pressure points reduced

Osteomyoplastic ProcedureGoals

• Restore normal physiology– Venous gradient in bone returned– Vasculature improves in remaining

extremity– Muscle length-tension relationship

reestablished, thus restoring the efficient use of the muscle

Loon, Prosthetics International,1959.

Osteoplasty

Adductor Stabilization

Muscle Flaps brought over end of femur

Quadriceps

Hamstrings

Completion of the myoplasty by suturing the quadriceps to the hamstrings. This stabilizes the entire soft tissue envelope and provides distal coverage for end-bearing of the residual limb. Meticulous skin closure is then performed, removing dog-ears and redundant skin. Goal is to provide a cylindrical limb for prosthetic application.

Immediate post-op

Adductor tubercle with adductor Magnus kept attached to cortical shell

Immediate post-opImmediate

post-op

5 weeks post-op; alignment maintained; no lateralization of femur

Orthotics/Prosthetics/P.T.

• Begin comprehensive education– Support groups, networking

• Begin comprehensive therapy– Transfers, stretching, desensitization, gait

training, upper extremity conditioning

• Knowledgeable staff for support– i.e. ACA, nurse clinicians, etc.

Prosthetics

Physical Therapy

Post-Op protocol• 0-4 weeks-Isometrics above

amputation, ROM, UE aerobic conditioning

• 4-6 weeks-Isometrics, ROM, towel pulls, massage, scale exercises up to 10/15 lbs

• >6 weeks-advance P.T., gait training, posture, gluteal/core strengthening, socket application

• Emotional, psychological support– Support groups, starts from day one

Summary

• Provides the amputee with a “sound” physiological residual extremity

• Patients have high satisfaction and there is improved outcome

• Can be applied to the vasculopath and diabetic

• 1.5 cm of bone resected on average

• Can used as a primary procedure as well as reconstructive

Summary

• An amputation is not a benign, static procedure– The limb is dynamic, so should the

“team”• Effort must be placed on a team

approach• The goal is to return to the patient a

functional residual extremity• This can be accomplished by adhering

to “biological” surgery principles