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 Amputation Effects - 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 Amputation Effects - 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 Science Length-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 Amputation Effects
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 Science Closure 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 Procedure Goals
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 Procedure Goals
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 Procedure Goals
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. Adductor tubercle with adductor Magnus kept attached to cortical shell
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