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

1. American Orthotics and Prosthetics Association-National Assembly Trans-Femoral Osteomyoplastic Update Christian W. Ertl MD FACS FACCWS Michigan State University Seattle, 2009

2. Disclosure • I have no funding issues or support to disclose

3. 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

4. Very flaccid limb, femur poorly aligned, redundant soft tissue, poor prosthetic fit and use

5. Femur severely lateralized by pull of the abductors and no adductor stabilization

6. 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

7. 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

8. 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.

9. 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,

10. Osteomyoplastic Reconstruction • Medullary canal sealed • Broader surface area to bear weight • Allows potential end weight bearing in AKA • Improves local circulation

11. Basic ScienceClosure of Medullary Canal • Intramedullary venograms pre-/post-canal closure Loon, Prosthetics International,41-58, 1959

12. 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

13. 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

14. Myoplasty-Basic Science • Arteriogram of AKA prior to myoplastic procedure • Poor filling in adductor region of leg • Poor contour grossly • Exostosis formation Dederich, JBJS, 45-B, 60, 1963

15. Myoplasty-Basic Science • Arteriogram 3 months after myoplastic procedure • There is increased arterial flow with in the stump • Distal and medial perfusion is improved Dederich, JBJS,45-B: 60, 1963

16. 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

17. 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

18. 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.

19. Osteoplasty

20. Adductor Stabilization

21. Muscle Flaps brought over end of femur

22. 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.

23. Immediate post-op Immediate post-op Immediate post-op Adductor tubercle with adductor Magnus kept attached to cortical shell

24. 5 weeks post-op; alignment maintained; no lateralization of femur

25. 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.

26. Prosthetics

27. Physical Therapy

28. 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

29. 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

30. 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