ABOVE KNEE AMPUTATION : Indication, Exercise, Prosthesis

The above-knee amputation is the most common type of amputation performed in the femur. The above-knee amputation is a lengthwise amputation of the femur just above the knee. It is often performed to remove part of the femur for a malignant tumor or to prevent the spread of cancer or Infection. The above-knee amputation is a mutilating procedure and it requires a long recovery period.

Defination of Amputation:

• Amputation define as a Removal of limb partly or totally from body.

Indication Of Above Knee Amputation:

• Malignant tumors
• Nerve injuries and infection
• Extreme heat and cold
• Peripheral Vascular Insufficiency
• Congenital absence of limbs or malformations
• severe infections like gas gangrene,
• osteomylitis
• Trauma

Levels Of Amputation:

Level Of Amputation In Above Knee

• Hemipelvectomy
• Hip Disarticulation
• Transfemoral (Above Knee Amputation)
• Knee Disarticulation

Above Knee Amputation Treatment :

• The Optimal Length of the above knee Amputation is 23 to 30 cm as measured from the tip of greater trochanter.The minimal length for useful stump is 7.5cm.

Before Surgery

• Before your surgery, your physical therapist may Prescribe exercises according to your preoperative conditions, and to improve the flexibility and strength of the hip and knee. Physiotherapist teach you how to walk with a assistive device like walker or crutches. Educate you about procedure.

Preoperative Training Programm

• Prevent the formation of thrombosis by maintaining the circulation by movement of limbs.
• Prevention of chest complication by deep breathing,coughing and postural drainage preserve mobility of all joints
• Improve mobility of other areas like trunk, pelvis, shoulder girdle
• Teach how to position the limb in bed Teach the patients how to transfer,monitoring of wheelchair,single leg standing and balancing
• in the recovery of amputation Psychological re-asurance plays the important role.

Early postoperative stage

• To check the efficicacy of Preoperative training
• Prevent the chest complication and thrombosis
• Prevention of contracture and deformities:
• the common contracture is knee flexion contracture. contracture is prevented by proper positioning of amputated limb.
• Maintenance of strength and mobility
• The patient can be motivate to move in the bed by pusing up the body on the arms.This push up exercise has a advantage of strengthening the muscles in upper limb which necessary for using assistive device a later on. strengthening exercise should be given to the whole body except joint proximal to above knee amputation.
• Bed activity like bridging , rolling can be useful to start bed mobility.
• Active assisted and self resisted exercise can be initiate after 3-4 days of surgery.Assisted hip flexion, extention ,abduction and adduction movements can be performed. Isometric exercise also initiate.

Management of the stump:

• Improper management of stump is one of the common cause of delayed rehabilitation.Surgical trauma is one of the common cause of stump oedema, it may occure because of bad bandanging, associated degenerative joints disease,poor venous returen , kidney disease and diabetes.
• How to control edema of stump:Stimulation of limb in elevation with elastic bandage.
• Resisted exercise of stumb and other joints.

stump bandaging and conditioning:

• Bandaging plays a important role in conditioning and shaping of the stump by reducing oedematous stump.
• 6 inch of elastic bandage used for above knee amputation.The elastic bandage should be taken off during exercise.

Principles of bandanging the stump:

• The pressure of bandage should be mild firm and distributed evenly.
• Extra pressure is necessary at corners to maintains conical shape of the stump.pressure should be reduced proximally.
• During bandagind diagonal,oblique or spiral turns should be used.In above knee amputation the bandage must extend up to groin to prevent a roll flesh forming over the adductor tendons which may later on lead to a follicle infection due to friction with socket of prosthesis.
• An above knee stump should be bandaged with position of the hip in extension and adduction.

Intermittent variable air pressure machine:

• Intermittent variable air pressure machine also called controlled air pressure machine.It is used to controle oedema by improving circulatuon of blood and lymph.
• Shrinker socks:oedema can be treated by elastic stump socks.
• Rigid dressing:Rigid plaster of paris dressing given to the patient with younge age.It also helps to reduced the oedema.
• stump hygiene: Stump hygiene includes regular washing of the stump with disinfected warm water soap and after dry the part.
• The amputed patient should be educated on protecting the areas and positions of affected limb.
• After Stitches removed : When the stitches are removed and the suture line healed satisfactory, the most important in amputation is stump conditioning.

stump conditioning :

• An ideal stump is perfect healed, firm, conical and with minimal flabby tissue.
• Bandaging: During elastic bandaging pressure and application should be proper.
• Exercise: Isometric exercise for the muscles of the stump, specially two joint muscles,which origenated above the joint proximal to the amputation
• Massage:massage can be helpful for improving tone of the muscles.
• Stimulation:Electrical stimulation with the stump elevation is used to decreased oedema and improve muscles tone.
• Pressure:Exposing the stump to pressure by either early use of pylon or gradual training weight bearing on the terminal weight bearing area of stump.It can be done by providing soft cushion and adjusting the height of the stool in the parallel bars.

Mobility Stage:

• Mobility stage is a stage of mobilization and restoration of functional independence.
• It start with crutch walking.Elderly patients may need initial ambulation practice in parallel bar.
• Mobilization and strengthening exercise :Mobilization of the body segment proximal Amputation.
• PNF techniques, Progressive resistance exercise and strong endurance exercise to the specific muscles groups are needed to facilitate effective body function with the prosthesis.
• Above knee amputation: Hip Flexion, abductors,Flexors and shoulder girdle muscles

Complications Of Amputation:

• Excess bleeding
• Blood clots
• Oedema
• Poor healing
• deep vein thrombosis (DVT)
• wound infection
• pneumonia
• “phantom limb” pain
• depression
• Stump ulceration
• Flap necrosis
• Joint stiffness
• Osteomyelitis
• Osteoporosis

Prosthesis For Above Knee Amputation

• The prosthetic design:
• Socket:
• Quadrilateral H type socket,in which most of the weight of body is transmitted through the ischeal seat and then posterior brim of socket.
• Suspension:
• Suspension with double swivel pelvic band with a multiaxial joint provides all movements at the hip joints.However,a rigid pelvic band only allow flexion and extention is preferred in cases where muscle control and stability are deficient.Suction socket with valve or modular prosthesis are the alternative method of Above Knee Prosthesis.
• Knee Mechanism:
• Hand operated or semi automatic locking mechanism along with constant friction device or knee joint with free mechanism in which swing can be given.
• Feet.Uniaxial or multiaxial SACH foot is preffered.It stimulates planter flexion through compression of rubber heel.Uniaxial foot allows both dorsiflexion and planterflexion.The biaxial foot also allows eversion and inversion.The foot made of wood moulded with plastic material is incorporated with rubber bumpers to provide necessary movements of joints.

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