"as a result of the universal practice of leaving the medullary canal open and exposed, spewing bone marrow and fat into the compromised tissues after amputation surgery". But the universal practice is to cover the bone cut with muscles and fascias for several reasons: infections, cicatrization, adductors and abductors muscles balance, cushioning for prosthesis support. What should be questioned as well is the surrounding soft tissues quality (veins +++) after septicemia and multi-level sequences amputations. Or another entry point upper in the femur. Without the actual procedure report and forensic report reading, it is hard to say what has been done.
Jean-Marc Valiadis, thank you for encouraging my clarification. Aside from the Ertl Procedure that seals the medullary canal by suturing periosteum, the universal practice "overlays" tissue over the unsealed medullary canal.
I appreciate that you provided reasons. May we look at those?
Infection and cicatrization seem ambiguous. Are you saying that our current best practice for amputees should follow the path of pseudoarthrosis of the hip joint, as they did in the 1950's? I'm merely saying that tossing out "infection and scar development!" as surgical goals don't tell me much. Either FES is an issue to address seriously, or it should be perceived universally as incidental for all. Amputees and people are all people, right? Our surgical principles should apply to people. We should not find ourselves making excuses for speculation.
Adductor and abductor muscle balance. I was surprised to read this. Are you aware that there is no rationale for seeking hip abductor/adductor balance? Is it commonplace? Yes. Is it totally insane? Absolutely. Look at my ankle. Are my dorsiflexors and plantarflexors balanced in the sagittal plane? No. Such a thing is ludicrous. Are hip ab/adductors balanced in the frontal plane on able bodied people? No. They are not. And yet, with these surgical goals, I provided proof that in the search for mystical hip "balance", surgeons end up weaking amputated side abductors by 30% compared to the intact side.
Do you consider this resulting right/left imbalance an acceptable price to pay to achieve balance that never existed in normal bodies? Please see that I'm not trying to attack you. I appreciate and admire your engagement. I'm stating that like me, you trusted in premises during the course of education. Rather, I find myself shocked, and I'm turning to you to say, "can you believe this?"
Cushioning for prosthesis support. I've provided fabrication and clinical support for amputees for 20 years. One surgeon would leave 75mm of redundant tissue for "cushioning". After 6 months, this volume would reduce by 40-60%. This isn't helpful. While I like a cushioned shoe, attaching 5 pillows to my feet creates instability. My thought: provide skeletal support. If I as the prosthetist determine that cushion is needed, I will select the appropriate amount of silicone padding in the socket for a consistent fit. The surgeon is not to leave a reservoir for volume fluctuations attached to the limb.
Hi,
What I understood is that an upper-knee amputation post infection + life threatening medical assistance + multiple sequential amputations caused a fat embolism.
I meant that in post-infected ans scared tissues with possible weak veins, it is hazardous to restrict the embolism entry to the shaft marrow since is seems there was no material pushed inside in the bone shaft; such insertions may cause fat embolism.
For upper knee amputation, by definition, we loose a lot of weight, which is changing the remaining thigh balance in the side coronal plane, since the femoral offset is not changed. Too much correction has consequences for sure.
Soft tissues tend to "melt" very quickly. Then we tend not to strip muscles (they will turn into fat) and fat regarding the bevel bone cut. And in fragile tissues, it is important not to have too tight tractions one the skin causes by the stitches. It may cause succion troubles in the prosthesis but it is another problem.
Talking about shoes, a bare foot has a lot of fat pad regarding metatarsian heads and ever stronger shell at the heel (very useful in Syme's amputation).
Cheers, JM.
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