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Lower Limb Prosthetics | Musculoskeletal Key

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This website and the general handout I provide in the office will outline all the general principles of hip and knee replacement surgery, the realistic outcomes and things you need to be aware of. This handout provides extra information that you may find useful.
BEFORE SURGERY

Before surgery you will need to attend a pre-admission clinic at the hospital where you will meet a clinical nurse who will go over the basic admission process and post operative course. In addition there are routine pre-operative blood tests and an ECG that are performed. Occasionally a chest X-ray is needed.
If any significant abnormality is detected in your pre-operative visit, the appropriate action/referral will occur to investigate and treat any issue needing attention.
If you see a cardiologist routinely and are on a regular blood thinner, please advise your cardiologist you are having a joint replacement and that you need to stop blood thinners such as warfarin, plavix/clopidigrol and aspirin. I am happy to perform the replacement under low dose aspirin (100mg) if your cardiologist insists.

MEDICATION YOU NEED TO STOP

Please stop all anti-inflamatories (mobic, celebrex, nurofen, voltaren etc ) 1 week before surgery.
Herbal medication (fish oils, garlic, echinacea, kava, glucosamine etc ) need to be stopped 1 week before surgery as they can cause excessive bleeding.

If you are diabetic it is important that your diabetes is under proper control. Your GP will usually see to this.
Dental issues. If you have any major dental issues requiring attention please get this done before your joint replacement.
If you have any prostate issues (Males), please inform me as every patient needs a urinary catheter for 24-48 hrs and prostate problems can result in a difficult catheterisation therefore it is best to have a urologist consult if need be.

ANTISEPTIC SHOWER SOAP

You will be given an antiseptic soap at the pre-admission clinic that you need to shower with for the 2 days prior to surgery. This will reduce the risk of a skin infection after surgery.
Please DO NOT shave hair around the hip or knee before surgery. The hospital nursing staff will shave the area if needed using special clippers that do not cut the skin.

THE SURGERY

The surgery is usually carried out under a combined spinal anaesthetic and light general / sedation. Spinal anaesthesia is safe and has been shown to assist in reducing complications during joint replacement surgery. It provides excellent post operative pain relief. The Anaesthetist will discuss this with you in detail.
A urinary catheter is used in all cases. Patients with a spinal as well as those who don't have a spinal but get morphine for pain relief, will invariably have difficulty passing urine for 12-18 hrs and hence the need for a catheter. It is much easier to pass a urinary catheter when you are sedated just before surgery than to pass a catheter when you are awake on the ward with a full bladder.
Removing a catheter is a very easy process done by the ward nurses and is not painful at all.
Antibiotics are given intravenously for 24-36 hrs and your IV cannula will remain in your arm for this period. The cannula is also often attached to a PCA machine which allows you to administer pain killers when needed. I do not use a PCA in all patients as often (such as in the minimally invasive hip approach) the local anaesthetic and oral pain tablets are sufficient.
You will be given the appropriate pain relief regime that the anaesthetist will order. This regime is tailored to each individual's needs.

EARLY MOBILISATION

The key to preventing thrombosis is mobilisation and exercise . Every patient is fitted with a calf compressor after surgery. This machine compresses the calf intermittently which promotes venous blood flow back to the heart and prevents clots. The compressors are used whilst in bed for the first 48 hrs. The sooner you get out of bed and walk the less the risk of a thrombosis.
In addition to early mobilisation and calf compressors you will either be given oral aspirin or clexane injections to assist in reducing the incidence of thrombosis.
I encourage 2 walks a day whilst in hospital. The more you can manage the better but don't overdo things.
Whilst the risk of a thrombosis is low despite all preventative measures they can still occur and are treated accordingly. I do not perform a routine Doppler scan to check for thrombosis as all studies have shown that routine scanning is a waist of time.

ANTIBIOTIC POLICY FOR PROCEDURES FOLLOWING JOINT REPLACEMENT

The risk of getting an infection in your replaced joint is extremely rare following routine procedures such as dental work and colonoscopies.
DENTAL procedures:
For routine dental cleaning after joint replacement surgery there is no need to take antibiotic prophylaxis. For major dental work after a joint replacement ( such as root canal etc) I recommend a single dose of 2gm amoxicillin 1 hour before provided you are not allergic to amoxil.
COLONOSCOPY, Prostate, Bladder or Gynaecological procedures after joint replacement :
Routine colonoscopy without any major biopsies or risk of bleeding do not require prophylactic antibiotic cover.
Surgery to the bladder, bowel, gynaecological and prostate surgery require a single intravenous antibiotic dose that is administered by the surgeon at the time of the procedure. Please advise them that you have a joint replacement.

Some other things about replacements:

All knee replacements have some numbness on the outer side of the wound. This is unavoidable as there is a skin nerve that goes directly across the skin incision and hence is purposefully cut in order to open up the knee joint. It is a minor nerve and the numbness will tend to lighten up over time but is never completely eliminated.
All knee replacements click. This is normal. It is simply the metal and polyethylene parts touching each other and is no cause for alarm. It is how the joint functions. The clicking noise will tend to get quieter over time.
Hip Replacements can occasionally click at the extreme of motion. No cause for alarm. Some ceramic on ceramic hip bearings can squeak (rare) again no cause for alarm.
Intraoperative stability is important in hip replacements. Rarely one may need to tension the hip which can lead to a leg length discrepancy. Various techniques are used to minimise this possibility.
The key to a successful recovery is motivation to mobilise and to do the exercises the physiotherapist will show you. Hip and Knee replacement surgeries have excellent outcomes provided the patients assist in a motivated recovery.

Chapter 29 Lower Limb Prosthetics Gary M

The bionic leg is the result of a seven-year research effort at the , directed by , the H. Fort Flowers Professor of Mechanical Engineering. The project was initially funded by a seed grant from the , followed by a development grant from the. Key aspects of the design have been patented by the university, which has granted exclusive rights to develop the prosthesis to , a leading developer and manufacturer of lower limb prosthetic devices.

Lower Limb Prosthesis, Orthopedic Equipment & …

Microprocessor-controlled lower limb prosthetics

One publication by Hafner and others (2007) reports the findings of a small, nonrandomized, cross-over controlled design study in which each subject was exposed to two different prosthetic limb conditions (mechanical and microprocessor controlled C-Leg) twice during the trial. This study included 21 subjects, each of whom used both a standard mechanical knee and lower limb prosthesis and the C-Leg microprocessor controlled prosthesis. Subjects were recruited for participation from a local amputee population. Seventeen subjects completed the study. Subjects were told at the time of enrollment that they would be allowed to keep the test prosthesis whether or not they completed the trial. The subjects began the trial with a 2 month period using their standard prosthesis followed by an activity assessment and functional, performance and subjective perception evaluation. Next, all subjects used the microprocessor controlled prosthesis until acclimation was demonstrated. This was then followed by a 2 month acclimation period with the microprocessor controlled prosthesis, ending with an activity assessment and functional, performance and subjective perception evaluation. Subjects were then reverted back to the standard prosthesis for 2 weeks and again an activity assessment and functional, performance and subjective perception evaluation was done. In the final stage of the trial, participants were allowed to use either one or both prosthetic devices over a 4-month period. Daily use and activity levels were measured for each device. The study concluded with a final activity assessment and functional performance and subjective perception evaluation with the microprocessor controlled device. A variety of objective and subjective outcome measures were reported. The authors reported no significant differences between the two prosthetic devices in terms of daily activity as measured by mean daily step frequency and mean estimated step distance, in performance on level or varied surfaces, or in cognitive demand during use of the devices. They did note a significant improvement with the C-Leg prosthesis in subjects' Stair Assessment Index (SAI) scores, time to descend scores, and a surveyed preference for the microprocessor controlled C-Leg as compared with a mechanical prosthetic knee. There was no difference noted in ascending stairs, but self-reported frequency of stumbles and falls was lower for the C-Leg prosthesis. Limitations of this study include its small size, lack of outcome comparisons to a group randomized to continued use of a standard prosthesis, and lack of control of the type of mechanical prosthesis used. In addition, the period of time allowed for the subject to revert back to a standard prosthesis (2 weeks) for a functional assessment prior to the 4-month combined use measures was quite limited.

A new lower-limb prosthetic developed at Vanderbilt University allows amputees to walk without the leg-dragging gait characteristic of conventional artificial legs.

Prostheses for Lower Limb - Netter Images

“With our latest model, we have validated our hypothesis that the right technology was available to make a lower-limb prosthetic with powered knee and ankle joints,” said Goldfarb. “Our device illustrates the progress we are making at integrating man and machine.”

The Vanderbilt prosthesis is designed for daily life. It makes it substantially easier for an amputee to walk, sit, stand, and go up and down stairs and ramps. Studies have shown that users equipped with the device naturally walk 25 percent faster on level surfaces than when they use passive lower-limb prosthetics. That is because it takes users 30 to 40 percent less of their own energy to operate.

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Clinical Guideline - Lower Limb Prosthesis

At this time, the available peer-reviewed published literature addressing the clinical benefit of a microprocessor controlled lower limb prostheses is mostly limited to nonrandomized controlled clinical trials, and case series of limited size. Additionally, the majority of these studies have involved highly selected subjects who were otherwise in good health.

05/08/2013 · Powerscooter & Lower Limb Prosthesis

This group published another study involving 30 MFCL-2 subjects using a randomized cross-over design (Theeven, 2012). Full datasets were available for only 19 subjects at the completion of the study, but all 30 were included in the intent-to-treat analysis. Subjects underwent three separate trial periods using three different knee joint prostheses, including one mechanical knee joint and two microprocessor controlled joints. The latter two prosthetic joints included one with microprocessor controlled stance and swing phase and another with only a microprocessor controlled stance phase. Subjects were assessed using each prosthesis for a 1-week period in the home and community setting. The perceived performance and satisfaction were measured using the Prosthesis Evaluation Questionnaire (PEQ). Subject activity levels were monitored via uniaxial accelerometer. The results indicated that the subjects' perceptions regarding ambulation, residual limb health, utility, and satisfaction were significantly higher when subjects used the microprocessor controlled devices vs. the mechanical knee devices. There were no significant differences between groups with regard to activity level. The authors conclude that MFCL-2 amputees report benefitting in terms of their performance from using an MPK; this is not reflected in their actual daily activity level after 1 week of using an MPK.

Prostheses – artificial limbs – Art Limbs

In 2015, Prinsen and others published the results of a randomized controlled cross-over study involving 10 subjects assigned to begin the study with either a standard knee prosthesis or the Rheo Knee II device. Following an 8-week acclimation period to their assigned device, subjects were given a battery of tests including the TUG test, Timed Up and Down Stairs Test, and Standardized Walking Obstacle Course. Following these measurements, subjects were crossed over to use the other device, acclimated for another 8 weeks, and then retested. The authors reported that significantly higher scores were found for the Rheo Knee group on the Residual Limb Health subscale of the Prosthesis Evaluation Questionnaire when compared to the standard device group (p=0.047). Interestingly, Rheo Knee subjects needed significantly more steps to complete an obstacle course compared to the non-microprocessor controlled prosthetic knee (p=0.041). On other outcome measures, no significant differences were found. The authors concluded that transition towards the Rheo Knee had little effect on the studied outcome measures.

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