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(PDF) Prosthetic Rehabilitation After Hip Disarticulation

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Added on  2021-04-05

(PDF) Prosthetic Rehabilitation After Hip Disarticulation

   Added on 2021-04-05

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Evolution of Surgical and Prosthetic Management of Hip Disarticulation PatientsIn the UK in 2006/07 there were 4574 patients referred to a prosthetic service centre. Of this just 1%were hip disarticulation patients[ CITATION NAS09 \l 2057 ].This type of amputation is associated with severe increases in energy consumption for walking and is performed today commonly for patients with severe vascular problems or for patients who suffered severe trauma. However the most common indication for a hip disarticulation amputation is as a result of a tumour. During the 1960s – 1970s there were a lot of these amputation performed due to osteo-sarcomas and the beliefat that time that it was better to remove the entire affected bone. Today the vast majority of lower limb osteo-sarcoma patients are treatable using other methods with those unable to keep their limb having trans-femoral amputations[ CITATION PSu01 \l 2057 ].The hip-disarticulation amputation is not favoured and is considered to be a poor choice with patients having severely affected gait and vastly increased energy expenditure with some figures putting the energy increase as high as 200% for patients[ CITATION Ger01 \l 2057 ]. The hip disarticulation amputation was first performed successfully in 1774 by Perault. However in this era of pre-anaesthetic it was associated with a very high mortality rate and so was rarely undertaken usually as a last resort[ CITATION SWa04 \l 2057 ]. It was namely done to military patients who had been shot or had blast wounds from explosions. In the civilian realms this type of amputation was at that time mostly performed as a result of infection and to a lesser extent tumours[ CITATION HLo57 \l 2057 ].Since that time there have been vast improvements in medical care with the discovery of anaesthetics and the use of blood transfusions helping to vastly improve the survival rates of patients. Initially mortality rates were as high as 91%. One of the main reasons for this was due to hemorrhagic shock. This was very problematic to treat as the femur contains a major blood supply with several branches making it difficult to control blood loss. A tourniquet is also difficult to fit, so there have been several, perhaps radical, methods designed. One such innovative method was Wyeth’s system which used pins to hold rubber tubing in place. Other radical ideas for minimising blood loss included the suppression of the aorta[ CITATION HLo57 \l 2057 ]. Nowadays a modified version of Harold Boyd’s dis-articulation amputation is used by many surgeons as it utilises racket shaped incision on the anterior portion of the leg to help the surgeon access the blood vessels and tohelp prevent blood loss. Boyd also tried to minimise this blood loss by cutting the muscles at either their origin or their insertion. This racket shaped incision also leaves a large posterior flap which thenin turn allows for an anterior scar which can help isolate any pressure sensitive areas[ CITATION HBo47 \l 2057 ]. There is also another form of incision known as the semi-oval incision which is perhaps preferred due to the decrease risk of causing a pressure point under the prosthesis that can occur with the racket shape if the shape is too long[ CITATION RTo01 \l 2057 ]. There have also been drastic changes to the shaping of the stump since the original amputations twocenturies ago. During the early history of hip-disarticulation surgery, leaving a large soft tissue stumpwas quite popular amongst surgeons. Another version of this was devised by Lyons in 1859 which left some periosteal tissue. However this procedure was difficult to perform although it did have
(PDF) Prosthetic Rehabilitation After Hip Disarticulation_1
some merits, with some surgeons claiming that this procedure allowed the residual tissue to be flexed, extended, adducted and abducted powerfully. One of the main pitfalls with this operation was that it was quite common for undesirable growths tooccur with bony spurs. It was also the case that this operation could not be performed for patients with malignancies. Today the stump shape tends to be a compact one where soft tissues are removed wherever possible[ CITATION HLo57 \l 2057 ]. Ever since the first successful hip disarticulation surgery there has been a need for prostheses for patients. However even today a lot of patients choose to use crutches or a wheelchair rather than try and use a prosthesis. There have been a few different types of sockets designed for hip disarticulation patients. One of the first of these was the “tilting table prosthesis”, this was quite a heavy prosthesis and utilised a leather socket and was attached by a belt around the pelvis. This prosthesis then had metal bars attached to the lateral side. This was then attached to the components of the prosthetic leg. This socket type often had a semi-automatic lock which afforded the patient some control and stability during stance phase[ CITATION CMc57 \l 2057 ]. Figure 1 Tilting table prosthesis[ CITATION CMc57 \l 2057 ]Fig.2 US Navy Hydraulic Prosthesis[ CITATION CMc57 \l 2057 ]This socket type was, however, quite cumbersome and so difficult for patients to utilise effectively and efficiently. The tilting table prosthesis also required the patient to thrust their pelvis quite forcefully to propel it forward, thus vaulting was quite a common occurrence amongst tilting table users. The tilting table prosthesis was quite common until around 1954 when the “Canadian” socket type was introduced. There were however other socket designs that existed at this time, such as the U.S Navy hydraulic prosthesis which was developed at the close of the Second World War. This used a manually controlled valve and hydraulic piston about the knee which gave the patient some shock absorption as well as the patient having the ability to lock the valve in any position. The valve also had some automation, for instance if there was fast movement around the hip the valve would closegiving the patient knee stability. This prosthesis design was lighter and relatively cost effective when compared with the tilting table due to its use of an aluminium alloy as a base material. However there were problems with the technology involved such as the noise of the pistons and its maintenance[ CITATION CMc57 \l 2057 ].
(PDF) Prosthetic Rehabilitation After Hip Disarticulation_2

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