现代截肢观念及现代截肢术后康复

截肢康复是指从截肢手术到术后处理、康复训练、临时与正式假肢的安装和使用,直到重返家庭与社会的全过程。文章重点论述了截肢部位的选择,现代截肢手术的改进,儿童截肢的特点,大腿截肢手术特点以及影响假肢穿戴的非理想残肢的康复。     

现代截肢观念及现代截肢术后康复

截肢康复是指从截肢手术到术后处理，康复训练，临时与正式假肢的安装和使用，直到重返家庭与社会的全过程。文章重点论述了截肢部位的选择，现代截肢手术的改进，儿童截肢的特点，大腿截肢手术特点以及影响假肢穿载的非理想残肢的康复。     

儿童外伤性截肢的手术治疗策略

随着经济快速发展和人们生活水平提高,汽车产业也进入了一个飞速发展时代,但由汽车等引起的意外伤害也明显增多.由于儿童缺乏对危险的预测性,再加上儿童本身力量较弱,汽车等对其的伤害更是致残和致命性的,很多患儿不得不以截肢来保全性命.本研究通过对13例截肢患儿的治疗过程和术后随访进行分析,探讨对儿童意外伤害后截肢的手术治疗策略.     

如何正确选用下肢假肢部件(3)

5 大腿截肢（见图 3） 5.1 普及型 3R15 承重自锁单轴膝关节功能特点：优质不锈钢制,带膝关节伸展辅助装置,关节在支撑期承重时可自锁适用对象：对活动性要求一般、关节稳定性要求高、体重在 100公斤以下的中、短残肢的大腿截肢者,也适用于因体弱而稳定性差、但又不希望带手动锁定装置的大腿截肢者,承重自锁膝关节不适用于活动性强的截肢者。 3R20 多轴膝关节功能特点：优质不锈钢制,四连杆结构设计,关节转动中心随屈膝的角度变化而变化 (即瞬时转动中心 ),有很高的支撑期稳定性,适用范围较广。适用对象：适用体重在 100公斤以下,对功能性要求中等的大腿或髋关节离断截肢者不适用于活动性强的截肢者。 5.2 轻便型 3R33 功能特点：钛合金制,带伸展辅助装置及手动锁定装置,具有很高的支撑期稳定性和一般的摆动期控制功能。适用对象：体重 100公斤以下,对功能性要求低、对活动性很弱的大腿截肢者不适用于活动性中等或活动性强的截肢者。 3R34 单轴膝关节功能特点：钛合金制,带机械式内伸展辅助装置,助伸力可通过更换不同的弹簧来调整。适用对象：体重在 100公斤以下,对功能型要求中等的大腿截肢者,不适用于稳定性弱的截肢者。 3R40 轻便型单轴膝关节功能特点：铝合金制,带手动锁定装置。适用对象：体重在 85公斤以下,对功能型要求低,稳定性要求非常高的大腿截肢者或老年人,不适用于活动性中等或活动性强的截肢者。 5.3 功能型 3R45 单轴液压控制膝关节（铝合金）。功能特点：由轻金属制,重量轻,摆动期的屈曲和伸展阻尼可分别调整,膝关节在屈曲较大角度时,液压装置仍可提供较高的阻力,还可提供一个液压伸展终点缓冲阻力,因此伸展阻尼可调整的比较小。适用人群：体重在 100公斤以下、对功能性要求高的大腿截肢者,也适用于活动性强的髋关节离断截肢者,不适用于稳定性差、活动性弱的截肢者。 3R55 多轴液压控制膝关节（钛合金）功能特点：支撑期稳定性较低,但动态性强,膝关节的摆动期的屈曲和伸展阻尼可分别调整,步态柔和、自然。适用对象：体重在 110公斤以下、对功能性要求高的大腿截肢者,但不适用于稳定性差、活动性弱的截肢者。 3R106 多轴气压膝关节（铝合金）。功能特点：多关节轴设计,通过调整具有很好的支撑期稳定性和摆动期控制功能,最大屈膝角度可达 170°,低摩擦系数轴承使关节在伸直时非常柔和。适用对象：体重在 75公斤以下,对功能性要求高的大腿截肢者,不适用于稳定性差、活动性弱的截肢者。 3R60/3R60=1 液压控制多轴膝关节功能特点：带弹性屈膝支撑保险 (EBS),这个功能的设计是符合正常人行走过程中的自然生理状态的,具有对膝关节屈曲阻力和伸展阻力分别调整的功能,使其步态更加自然、优美。适用对象：体重在 75公斤以下 (3R60=1)或体重在 100公斤以下 (3R60)、对功能性要求中等的大腿截肢者。不适用于稳定性差、活动性弱的截肢者。 3R80 带回转式液压控制装置膝关节功能特点：可根据承重量而定的支撑期保险稳定功能和一个随行走速度而自动调节的摆动期控制功能,这个根据做到了集安全性、舒适性和运动性为一体,通过正规步态训练可以做到双脚交替下楼梯,步态自然、和谐。 适用对象：体重在 100公斤以下、对功能性要求高或对功能性要求中等的大腿截肢者,也可适用于活动量大、对安全稳定性要求特高的大腿截肢者。不适用于稳定性差、活动性弱的截肢者。 6 髋关节离断假肢（见图 4） 6.1 普及型 7E4 单轴髋关节功能特点：轻金属制,带外助伸装置,具有中等程度支撑期保险性和中等程度摆动期控制功能,可调节髋关节的屈伸角度及内外旋转角度。 适用对象：体重在 100公斤以下、对功能性要求中等的髋关节离断的截肢者和半侧骨盆切除的截肢者。 6.2 功能型 7E7 髋关节功能特点：结构高度小,当截肢者坐下时骨盆在额状面上的倾斜角度最小 ,可调节内收、外展和屈曲伸展角度,钛合金制,重量轻。 适用对象：体重在 90公斤以下,对功能型要求中等或体重在 75公斤以下、活动性强的髋关节离断的截肢者及半侧骨盆切除的截肢者。 7 儿童假肢 7.1 普及型 3R38 单轴膝关节功能特点：轻金属制,重量轻。适用对象：儿童大腿截肢者。 7.2 舒适型 3R65 单轴液压膝关节功能特点：轻金属制,带液压摆动期控制功能,步态自然、美观。适用对象：体重在 45公斤以下,对功能性要求中等的儿童大腿截肢者。 7.3 功能型 3R66 多轴液压控制膝关节功能特点：轻金属制,重量轻,带液压摆动期控制功能,根据儿童的特点设计了盘腿器的功能,适合儿童坐地玩耍。 适用对象：体重在 45公斤以下,对功能性要求中等或活动性较强的儿童大腿截肢者。 德国奥托博克假肢矫形器工业 (中国 )有限公司 假肢矫形器·医疗保健·康复用具 地址：中国·北京市朝阳区白家庄路甲 6号 邮编： 100020 电话： (010)65855059 传真： (010)65078783 电子邮件： obcmkin@public.banet.cn 奥托博克跨国集团中国有限公司     

半骨盆截肢术治疗儿童股骨骨肉瘤的护理

骨肉瘤是最常见的骨原发恶性肿瘤,儿童及青壮年常见,尤其好发于儿童的生长高峰期.骨肉瘤是从间质细胞发展而来,生长迅速,组织破坏力强,病情进展快.近年来主要采用联合大剂量化疗后保肢治疗,即行整段切除灭活后异体骨移植或关节置换,使肢体的截肢率明显降低[1].     

儿童股骨远端恶性肿瘤旋转成形术的护理

儿童股骨远端恶性肿瘤旋转成形术的护理窦灵蓉，黄云江，刘素琴关键词股骨恶性肿瘤，旋转成形术，护理Ｋｅｙｗｏｒｄｓ：ＭａｌｉｇｎａｎｔｔｕｍｏｒｏｆｆｅｍｕｒＲｏｔａｔｏｒｙ－ｐｌａｓｔｙＮｕｒｓｉｎｇｃａｒｅ治疗股骨恶性肿瘤的传统方法是大腿高位截肢或髋...     

儿童及青少年骨肉瘤的护理现状及进展

骨肉瘤(osteosarcoma,OS)是最常见的骨原发恶性肿瘤,好发于儿童及青少年,其预后一般较差,多年来一直威胁着患儿的生命.从早期的截肢手术到新辅助化疗联合保肢手术治疗,再到现在的综合治疗,儿童及青少年骨肉瘤患者的生存期明显延长.为了提高儿童及青少年患者的生活质量,综合性护理越来越受到重视.本文对骨肉瘤患者目前的护理现状进行综述,期望能对儿童及青少年骨肉瘤患者的生活质量提高提供借鉴.     

5·12汶川大地震截肢伤员55例临床分析

目的 探讨地震等大型自然灾害中截肢的问题,分析其病史特点及治疗方法,总结治疗经验。方法 回顾性分析5·12汶川大地震中55例截肢伤员的临床资料。结果 闭合性截肢41例,开放性截肢14例;二次截肢和再次清创16例;截肢伤员死亡1例,其余切口愈合康复出院。结论 截肢伤员符合医疗原则和截肢指征,效果良好。     

5·12汶川大地震截肢伤员55例临床分析

目的 探讨地震等大型自然灾害中截肢的问题,分析其病史特点及治疗方法,总结治疗经验.方法 回顾性分析5·12汶川大地震中55例截肢伤员的临床资料.结果 闭合性截肢41例,开放性截肢14例;二次截肢和再次清创16例;截肢伤员死亡1例,其余切口愈合康复出院.结论 截肢伤员符合医疗原则和截肢指征,效果良好.     

足部截肢及其康复

为了足部截肢取得更好的康复效果 ,足趾截肢时应尽可能选择远的水平 ,以保证较好的站立和行走功能 ,防止残足畸形的发生。1足部截肢水平的选择在充分保证良好皮肤愈合的前提下 ,尽量保留足的长度是足部截肢水平选择的总原则。前足杠杆力臂缩短可严重影响快步行走、跑和跳跃。经跖骨截肢时 ,前足的负重点消失 ,经跗骨近端的截肢可破坏足部肌力的平衡 ,常发生残足马蹄内翻畸形 ,影响矫形器的穿戴、站立和行走。2足各部位截肢的特点与技术2 .1足趾截肢　拇趾截肢会影响快速行走、跑步和跳跃 ;第 2趾截肢后 ,大拇趾很容易向第 3趾侧倾斜 ,产生拇…     

Health related quality of life and related factors in 539 persons with amputation of upper and lower limb

Purpose : Limb amputation is followed by an important rehabilitation process, especially when a prosthesis is involved. The objective of this study is to assess the nature of factors related to health related quality of life (HRQL) of persons with limb amputation.

Method : The Nottingham Health Profile (NHP) treated 1011 subjects with major amputation of one or several limbs. Correlations were sought in multivariate regression model analyses between the six categories of distress explored by the NHP and age, sex, cause and level of amputation and rehabilitation programme.

Results : Response rate was 53.3%. HRQL measured by the NHP was mostly impaired in the categories of physical disability, pain and energy level. Controlling for sex and age, young age at the time of amputation, traumatic origin and upper limb amputation were independently associated with better HRQL.

Conclusion : It is concluded that HRQL is largely related to factors which are inherent to the patient and the amputation.     

Partial hand amputation and work

Purpose. To determine whether or not subjects who had had a partial hand amputation were able to return to the same job and whether or not they used their silicone finger prosthesis for work.

Method. Medical records of all the patients who had undergone a traumatic partial hand amputation and who had been treated in the Upper Limb Prosthetic Clinic at the Institute for Rehabilitation in Ljubljana were reviewed. Questionnaires were sent to 112 patients. Forty-eight questionnaires which were returned and had been correctly answered were analysed.

Results. The study found that less than half the patients who had had a partial hand amputation were able to do the same work as before the amputation. Less than one-third wore their silicone prosthesis at work regularly. The subjects who did not have manual jobs and who had an amputation of only one or two fingers were able to keep the same job more easily after the amputation. Only a few subjects found their silicone prosthesis useful at work.

Conclusion. It can be concluded that partial hand amputation may present a great problem in keeping the same job after amputation. An aesthetic (cosmetic) silicone prosthesis is helpful particularly for subjects with higher education whose work involves personal contacts and for whom aesthetics is important. They use the prosthesis for certain activities, such as typing.     

A preliminary investigation of pelvic obliquity patterns during gait in persons with transtibial and transfemoral amputation

Differences in pelvic obliquity between small groups of persons with unilateral lower limb amputation and subjects without amputation were analyzed. Kinematic walking data were collected as six males with transtibial amputation and three males with transfemoral amputation walked over a range of speeds. The pelvic obliquity patterns and amplitudes from the groups with amputation were compared to normal data. Results showed that smaller peak-to-peak amplitudes of pelvic obliquity were associated with higher amputation levels. Pelvic drop during early prosthetic-limb stance tended to be smaller than during early sound-limb stance. Most of the subjects with amputation exhibited an obliquity pattern in which the hip on the prosthetic side was raised above the stance-side hip during prosthetic swing phase, indicative of a compensatory action known as hip-hiking. The subjects with transfemoral amputation exhibited this hip-hiking pattern during sound-limb swing phase as well. Results from this study suggest that further investigation is required to determine those limitations of current prosthetic technology that adversely affect pelvic obliquity in the gait of persons with amputation, and to determine if significant benefit can be realized by restoring a normal pattern of pelvic obliquity to the gait of persons with amputation.     

Partial hand amputation and work

Purpose. To determine whether or not subjects who had had a partial hand amputation were able to return to the same job and whether or not they used their silicone finger prosthesis for work.

Method. Medical records of all the patients who had undergone a traumatic partial hand amputation and who had been treated in the Upper Limb Prosthetic Clinic at the Institute for Rehabilitation in Ljubljana were reviewed. Questionnaires were sent to 112 patients. Forty-eight questionnaires which were returned and had been correctly answered were analysed.

Results. The study found that less than half the patients who had had a partial hand amputation were able to do the same work as before the amputation. Less than one-third wore their silicone prosthesis at work regularly. The subjects who did not have manual jobs and who had an amputation of only one or two fingers were able to keep the same job more easily after the amputation. Only a few subjects found their silicone prosthesis useful at work.

Conclusion. It can be concluded that partial hand amputation may present a great problem in keeping the same job after amputation. An aesthetic (cosmetic) silicone prosthesis is helpful particularly for subjects with higher education whose work involves personal contacts and for whom aesthetics is important. They use the prosthesis for certain activities, such as typing.     

Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.

OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population.     

Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations

OBJECTIVES: To examine 12-month reamputation and mortality rates as well as acute and postacute medical care costs among a large cohort of persons with dysvascular amputations. DESIGN: Retrospective cohort study. SETTING: General community. PARTICIPANTS: Medicare beneficiaries identified from the Centers for Medicare and Medicaid Services data as undergoing a lower-limb amputation secondary to vascular disease in 1996. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Twelve-month reamputation and mortality rates, and acute and postacute medical care costs, by initial amputation level and presence or absence of diabetes. RESULTS: A total of 3565 persons, corresponding to 71,300 Medicare beneficiaries nationwide, were identified from the claims data as undergoing lower-limb amputations in 1996. Twenty-six percent of them required subsequent amputation procedures within 12 months, and more than one third died within 1 year of their index amputation. Acute and postacute medical care costs associated with caring for beneficiaries with a dysvascular amputation exceeded $4.3 billion yearly. There were marked differences in patient characteristics, progression of amputation to higher levels, service use, and mortality among dysvascular amputees with and without a comorbidity of diabetes. Diabetic amputees were younger than those without diabetes; they were also more likely to be men, to have more comorbidities, and to have undergone their first amputation at an earlier age than persons with dysvascular amputations who did not have diabetes. Although diabetic amputees were less likely to die within 12 months of the index amputation, they died at a significantly younger age than their nondiabetic counterparts. Progression to a higher level of limb loss occurred most frequently (34.5%) among persons with an initial foot or ankle amputation. Diabetic amputees were more likely than nondiabetic amputees to experience progression to a higher amputation level for all initial amputation levels. CONCLUSIONS: This study provides information that can be used by physicians when counseling patients about expected outcomes of dysvascular amputations at different levels.     

Rehabilitation outcome of patients with dual disability of hemiplegia and amputation

The records of 30 patients with the dual disability of hemiplegia and amputation were reviewed. Six factors noted to have influenced the success of rehabilitation were: (1) age; (2) sequence of onset of disability, whether amputation or hemiplegia first; (3) localization of dual disability, whether ipsilateral or contralateral; (4) side of hemiplegia; (5) level of amputation; (6) availability of prolonged hospital stay and training. The final functional status was better if: (1) the amputation preceded the CVA; (2) the amputation and hemiplegia were ipsilateral; (3) amputation and hemiplegia were both on the right side. The hospital stay of patients with dual disability ranged from 4 months to 1 year. Those who had disability on contralateral sides and those who had left hemiplegia required a more prolonged hospital stay.     

四肢骨折合并主干血管损伤的诊治

目的探讨四肢骨折合并主干血管损伤的诊治。方法回顾性分析1998年至2006年17例四肢骨折合并主干血管损伤患者的临床资料,总结降低截肢率的诊治方法。结果本组四肢骨折合并主干血管损伤的截肢率为29.4%。截肢原因为:缺血时间长、组织严重损伤。结论四肢骨折合并主干血管损伤具有较高的截肢率,正确的诊断及处理是降低截肢率的关键。     

Comorbidities in amputation: a systematic review of hemiplegia and lower limb amputation

Purpose: The purpose of this review of the scientific literature was to investigate the incidence and prevalence of hemiplegia with lower limb amputation, and to identify outcomes following the dual disability of hemiplegia and amputation. Methods: Electronic searching of the literature identified major studies examining the effects of hemiplegia on rehabilitation following amputation. Data were extracted and levels of evidence assigned for each subtopic area. Results: The summary conclusions are Level 4 evidence. The prevalence of amputation and hemiplegia is 8-18% and amputation and hemiplegia occur most often in the same leg. Once individuals with hemiplegia and lower limb amputation are selected for prosthetic rehabilitation, rate of successful functional ambulation is greater than 58%. In general there is a lower rate of prosthetic success and independence with hemiplegia than without. Predictive factors associated with success include less severe hemiplegia, laterality of hemiplegia (ipsilateral and right side), transtibial level of amputation and absence of impaired mental function. There is wide variation in length of hospital stay, but a specialty multidisciplinary team reduces length of stay. Conclusions: Patients with dual disability of hemiplegia and amputation generally benefit from a prosthetic rehabilitation program. Further study on predictive factors for outcome would be beneficial. [Box: see text].