201208032201Chapter 18B - Atlas of Limb Prosthetics:Transtibial Amputation[01]

Chapter 18B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

 

Transtibial Amputation: Prosthetic Management
[01]

Susan Kapp, C.P.
Donald Cummings, C.P.

Once the patient has completed the postoperative phase of treatment and adequate wound healing is established, the goals of rehabilitation become limb maturation and return to normal activity.....

An intermediate prosthesis consists of a socket, a pylon, a foot, and a method of suspension. It is usually applied when edema is diminished and the patient's residual limb has atrophied sufficiently to allow independent donning and doffing of a prosthetic socket....

Even after initial prosthetic fitting, elastic bandages and residual limb shrinkers still play an important role in the conditioning of an amputated limb. For patients with wound complications, delayed healing, or other circumstances that delay prosthetic fitting, an elastic bandage or shrinker may be the most practical and economical form of residual limb conditioning. Bandaging is beneficial whenever the new amputee is not wearing the prosthesis. ........

An intermediate prosthesis is generally constructed on an endoskeletal pylon, which ensures that alignment changes can be made as needed throughout the intermediate period....

Once fitted with an intermediate prosthesis, the patient may progress in physical therapy to full weight bearing. In addition to gait training, it is recommended that the patient be instructed in the use of prosthetic socks,........

A patient's readiness for a definitive fitting varies depending on his activity level, weight-bearing tolerance, and limb shrinkage....

When deciding upon an appropriate prosthesis, the patient and the clinic team is faced with a wide variety of choices due to numerous innovations in prosthetic components, materials, and techniques during the last several decades....

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Transtibial Amputation: Prosthetic Management

 

    一旦患者完成截肢術後的治療階段、且當傷口癒合的差不多時,我們應該將其復健的目標轉變成,評估殘肢成熟的穩定度、並且讓患者盡量的回復到應有的活動力。而要達成這些目標,其標準做法會藉由穿戴預備性義肢、結合步態的訓練、殘肢體積的收縮計畫、與臨床團隊的緊密監督等作為協助方式。

  

    預備性義肢的組成成分包括承筒、骨幹(鋁合金)、義足與懸吊方式,而預備性義肢的應用時機通常是在水腫消除後、且患者的殘肢夠穩定到能自行穿脫義肢承筒。為了完成此目標,一般而言會先給予患者施行[硬式包紮法]或是術後立即進行[I.P.P.F]配適,之後才會進行預備性義肢的裝配。而預備性義肢穿戴的時間也許會從數個月到一年不等,不過這均須視殘肢的狀況作為評估依據。

 

    實際上在義肢的裝配初期,彈性繃帶與殘肢塑形襪(彈性襪)仍然扮演著重要的角色。此外對於有傷口併發症、傷口癒合緩慢或者是其他因素等患者,均有可能會延後義肢的裝配時間,於是彈性繃帶或是塑形襪就變成最實用與最經濟的替代方式。而對於剛截肢不久且還沒開始穿戴義肢的患者而言,或許最有效益的替代方案,就是使用繃帶包紮法。殘肢塑型襪,是將彈性繃帶織成圓柱狀並在底部加上一層襯墊,而它可以用來取代彈性繃帶,於是對於這些患者而言,他們有可能還未穿戴義肢、未使用硬式包紮法,或者是其他能給予殘肢壓力的手段,因此我們建議患者在這段空窗期內使用塑型襪,或者是彈性繃帶來減少水腫的發生。

 

    預備性義肢一般而言是種內骨骼式的義肢,其能確保在穿戴的這段期間內給予相對應的義肢調校,而這種顯著的優點可以隨時針對患者的自身狀況,做出評估,並加以改善。一旦裝配預備性義肢後,在物理治療方面我們會要求患者應要能夠漸進的達到完全負重階段。除此之外還包括步態的訓練,當然我們也會訓練患者學會使用義肢襪、教導患者注意殘肢的衛生、並定期的檢查是否有任何壓力過大的跡象。而在此期間內,義肢的調校與承筒的緊密度檢查均會由義肢師或是義肢學徒做為處理。在一般的案例中,對於截肢患者在一年之中要更換多次承筒之情形,並不常見。

 

    對於準備進行永久性義肢配適前,我們會評估患者自身的活動能力、重量承受能力、與殘肢的萎縮的情形而定。通常在4個月後殘肢萎縮的變化會趨於穩定;然而殘肢變化的持續時間更有可能長達1年之久。一但擬定給予患者裝配義肢時,患者與臨床團隊將會面臨到各式各樣的選擇,因為這幾十年來,義肢零件、材料、與製作技術的創新所致。然而每一種技術、承筒型態、懸吊方式、校準方式、與零件等均有其優缺點,因此需依照患者的不同需求裝配出最佳化的組合。

出處:http://www.oandplibrary.org/alp/chap18-02.asp

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