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L18 le amputations
- 1. Traumatic Amputations Douglas G. Smith,MD Harborview Medical Center and the University of Washington Prosthetics Research Study Amputee Coalition of America
- 2. I Sometimes Hear -Very Few Patients - Not a Big Deal - Just save Everything You Can Traumatic Limb Loss All Not True !!
- 3. Ischemia 75-80% Half ofThese Folks Have Diabetes Trauma 10-15% Tumors 5% Congenital 5% Incidence Data (We’ve All Seen These Numbers)
- 4. Prevalence Data University ofWashington Survey of Pacific Northwest, 2000 Upper Limb (N=108) Lower Limb (N=747) Trauma 85.2% 52.3% Infection 10.2% 23.2% Vascular Disease 3.7% 21.7% Gangrene 8.3% 20.9% Diabetes 0.0% 16.2% Tumor 1.9% 4.3% Congenital Deformity 1.0% 3.1% (Patients Frequently Identified More Than One Etiology) “Dysvascular” 10.2% (11 / 108) 36.9% (276 / 747) PVD, Diabetes, Diabetic Infection or Ulcer
- 5. Incidence versus PrevalenceData: Estimate of Incidence Data in United States UE Amputation from: Trauma - 15% Dysvascular Issues - 80% Prevalence Data from University of Washington Survey LE Amputation from: Trauma - 52% Dysvascular Issues - 37% Trauma Is A Big Deal !
- 6. Limb Salvage High Tech Glamorous MediaAttention Profound Effects Life Style Emotional Marital Financial Addictive
- 8. After 18 Monthsand after Multiple Surgeries: The docs are very happy as they look at the x-rays. The man looks at his leg and says - This is it? I thought it would be normal. This is lousy. Over the 18 months, the man’s life has totally unraveled, and he has no clue which why to go !!
- 9. Hansen ST: Thetype IIIC Tibial Fracture. J Bone Joint Surg (Am) 1987; 69:799-780. Hansen ST: Overview of the Severely Traumatized Lower Limb. Reconstruction versus Amputation. Clinic Orthop 24: 17-19, 1989. Dr Sig Hansen has Pointed Out the Danger of “Saving Limbs and Ruining Lives” Sometimes Amputation Can Be a Better Path
- 10. Care of PatientWith Traumatic Amputation Care of the Amputated Part Care of Patient With a Mangled Limb In the Field (What to Tell the Team)
- 11. Care of Patient WithTraumatic Amputation Control Hemorrhage 1. Compression Dressing 2. Dangers of Tourniquet 3. Dangers of Clamping Splints 1. Decrease Pain 2. Protect Soft Tissues 3. Help Control Hemorrhage
- 12. Care of theAmputated Part Place Part in Plastic Bag and Seal Put Bag in Ice:Water (1:3) Do Not Soak in Water - Maceration Do Not Place Part Directly on Ice - Direct Thermal Injury
- 13. Care of Patient witha Mangled Limb Control Hemorrhage 1. Compression Dressing 2. Dangers of Tourniquet 3. Dangers of Clamping Splints 1. Decrease Pain 2. Protect Soft Tissues 3. Help Control Hemorrhage If Perfusion Exists Do Not Cool in (Ice:Water)
- 14. Decision Making Traumatic Amputations MajorDifferences Between Mangled Upper and Lower Limbs
- 15. Upper Limb Non-Weight Bearing CanFunction with Decreased Sensation Assistive Upper Limb Often Functions Better than Prosthesis Decision to Salvage: Based on the Technical Possibility and The Chance of Maintaining Some Useful Function
- 16. Lower Limb Weight Bearingis Mandatory Increased Risks with Decreased Sensation Modern Prosthesis Often Better than Salvaged Lower Limb Decision to Salvage: Based on Providing a Limb that can Tolerate Weight Bearing Have Some Protective Sensation Have Durable Skin and Soft Tissue
- 17. M Mangled E Extremity SSeverity S Score Skeletal & Soft Tissue Injury Limb Ischemia Shock Age Initial Reports: Score 1-6 : All Saved Score > 7: All Amputated Later Report: Not Quite So Confident Bosse MJ, MacKenzie EJ, Kellam JF, et al: A Prospective Evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg 83(1): 3-14.
- 18. Many Situations thatLead to Amputation Simply are Not 100% Predictable: Severe Infection Chronic Osteomyelitis Nonunion Chronic Pain and “Dysfunction” Patient Choice Best Indicators are Hard to Measure: Severity of Soft Tissue Injury Volume of Muscle Loss It Makes Sense (That We Do NOT Have a Great Crystal Ball)
- 19. Do What YouFeel Is Right ! On the First Night ! Do Not Delay an Inevitable Amputation I Believe that Only Makes the Emotional Process Harder for Both the Patient and the Doctor
- 20. Common Scenario: Doctor: “IKnow that it Needs to Come Off, But, We’ll Just Keep the Limb On So That We Can Talk with the Patient Again, and Let Them Decide” Patient: “If it Really Is that Bad, Why Didn’t They Cut it Off Yesterday” End Result: Confusion, Doubt, Loss of Trust in Surgical Team
- 22. Tips in theEmergency Room: Ask the Patient if They Saw Their Foot or Leg Ask if They Know Anyone with an Amputation Tell the Patient that You Will Carefully Examine the Limb in the OR, That You Will Save the Limb if it is Possible to Give Them a Foot They Can Use, BUT that an Amputation Could Well Be Required.
- 23. Criteria for Amputation: Absolute -Non-Reconstructable Vascular Injury - Severe Bone and Soft Tissue Loss with Tibial Nerve Disruption Relative - Shock and Elderly with Mangled Limb - Massive Muscle Loss associated with Bone Loss - MESS ≥ 7, Especially with No Plantar Sensation Unknown Long Term (dogma being questioned) - Isolated Tibial Nerve Disruption The Sicker the Patient, the More Urgent the Need for Amputation
- 24. Details of MESS Skeletaland Soft Tissue Injury Low Energy (Closed 0,1, Open 1) = 1 pt Med Energy (Closed 2, Open 2) = 2 pts High Energy (Open 3A, 3B) = 3 pts Very High E (Open 3C, Mangled) = 4 pts Limb Ischemia Pulse Decrease, Perfusion Normal = 1 pt Pulse Absent, Decreased Refill = 2 pts Pulse Absent, Cool, Paralyzed, Ins = 3 pts (Double Ischemia Score is > 6 Hours) Johansen K: J of Trauma, 1990
- 25. Details of MESS Age 0to 29 years = 1 pt 30 to 49 years = 2 pts Over 50 years = 3 pts Shock Systemic BP > 90 mm Hg = 1 pt Transient BP < 90 mm Hg = 2 pts Persistent BP < 90 mm Hg = 3 pts Can Have 11 Points if Ischemia is Less than 6 Hours (or Up to 14 Points if Greater than 6 Hours) Johansen K: J of Trauma, 1990
- 26. M Mangled E Extremity SSeverity S Score Bottom Line: - Useful Tool in the Thought Process - NOT a “Crystal Ball”
- 27. Open Amputation versusGuillotine Bone Length versus Soft Tissue Coverage Saving the Knee Skin Grafts and Amputations Few Thoughts on “Traumatic Amputations”
- 28. Open Amputations Avoid theWord and Technique of Guillotine Amputation Guillotine Amputation: Developed in War Time to Prevent Infections All Tissue Transected at One Level The Post-operative Goal is Not Delayed Closure Treatment Plan is Open Wound Care, Skin Traction, and Late Revision Open Amputations: Done With Careful Planning for Early Conversion to a Definitive Amputation Retain All Viable Tissue Debride All Non-viable Tissue Delay Final Bone Cuts Until Definitive Procedure Bone Can Help Splint and Stabilize the Soft Tissues Trend Nationally is Towards Longer BKA's If Suitable Soft Tissue Exists (Bowker)
- 30. If Not a“Guillotine” Then What? “Open, Length Preserving Amputation” Bone is a Great Internal Splint Debride Non-Viable Tissue Repeat Debridements Final Bone Cuts - At Time of Definitive Amputation
- 31. Bone Length versus Soft Tissue Coverage SoftTissue is More Important than Bone
- 32. Bone Length versus SoftTissue Coverage A Durable Soft Tissue Envelope that is Not Adherent is Far More Important Than any Specific Bone Length A Short Transmetatarsal Amputation with Good Soft Tissue is Infinitely Better Than a Scarred, Painful Forefoot Amputation A Well Done Transtibial Amputation, Above the Zone of Injury is Far More Functional Than a Syme with a Damaged Heel Pad or a Scarred Hindfoot Amputation
- 33. If the Kneeis Good (ie: NO Severe Tibial Plateau, NO Severe Arthritis) If the Extensor Mechanism is Intact If You Have a Reasonable Way to Cover the Tibia that will Avoid Adherent Scar and Retain Knee Motion Obtaining Full Extension is Far More Important to the Transtibial Amputee than Full Knee Flexion Extraordinary Measures are OK to Save the Knee
- 34. Severe Contusion ofthe Posterior Flap Soft Tissue Loss Anterior Aspect Posterior Flap Failed 41 y.o. Female, Motorcycle Accident Alaska Sept 2000
- 35. Transverse Abdominal FreeFlap to Save Knee Joint 41 y.o. Female, Motorcycle Accident in Alaska Sept 2000
- 36. Why Is ThisOK? Good Muscle Coverage that is Not Adherent Problem is No Sensation, but has good Padding Proximal Tibial Not Fractured Healthy Knee Joint Is It Great - No ! Better Than a Transfemoral - Yes !
- 37. 25 y.o. Logger- Crush Injury Severe crush anterior and lateral Sup Posterior Muscle - Much better than expected! Soleus brought over the distal tibial Gastroc split and wrapped medial and lateral
- 38. Why Is ThisOK? Good Muscle Coverage and Padding, With Healthy Muscle Skin Graft Applied Over Muscle, Not to Bone (Even with this, he still gets breakdown over hamstring tendons) Proximal Tibial Not Fractured Healthy Knee Joint Is It Great - No ! Better Than a Transfemoral - Yes !
- 39. Skin Grafts and Amputation: CanHold Up if Not Adherent to Bone Need Good Underlying Muscle Padding Donor Site - Use the Opposite Leg Donor Scars on the Amputated Limb Can Interfere with Suspension Elasotomeric Suspension Sleeves Can Help With or Without Pin Locks
- 40. Problem - Both Menhad Major Trouble with Skin Graft Donor Site Scars - Can Limit the Choices for Suspension DO NOT Take STSG From Ipsilateral Thigh (Usually happens during the salvage efforts !)
- 41. Partial Foot Syme Transtibial Knee Disarticulation Transfemoral HipDisarticulation Few Thoughts on Different Levels
- 42. MTP Amputations Through MTPJoints Leave the Cartilage Barrier to Infection Better End Bearing Gait - More Normal Progression Sequence than TMT Most Normal Dynamics of all Partial Foot Gait Most Active Ankle Motion and Calf Musculature Mick Dillon Queensland Univ.., Australia Ph.D. Thesis Prosthetic Device Everyone Wants This Cosmetic Slipper Style Device Rare that Anyone Uses it for More than a Few Months
- 43. Ray Amputations Toe andSome or All of Corresponding Metatarsal With Each Ray Removed - Increasing Loss of Distal Weight Bearing 1st Ray 2 Sesmoids - “2/6 ths” Rays 4-5 1 Point of Contact - “1/6 th each”
- 44. Ray Amputations thatUsually Work Isolated 2,3,4,5 Rays 4 and 5 in Combination First Ray - Can be Tough Second MT Head Overload Medial Edge of Residual First Ray Much Care Needed in Orthosis
- 45. Transmetatarsal / LisFrancAmputation Think of Both as Midfoot Amputations Very Similar Surgery, Rebalancing, Post-op, and Function Shorten Bone Level so Flap is Well Padded and has No Tension Can do First MT/Cuneiform Disarticulation plus TM at Base of 2,3,4,5 Keeps Peroneus Brevis Attachment Always Consider Tendon Achilles Lengthening Cast Post-Op to Prevent Equinus
- 46. In Diabetes - CanHave Fairly Healthy Flaps -
- 49. In Trauma “The Situationis Different”
- 50. Prosthetic Device Blocks Motion Pushoff Hurts Lacks Shock Absorption Too Long Better Off with Transtibial ? Probably Yes End Result - ONLY FAIR Walking - Just OK Unable to Run Impact Activity Hurts ROM - Not Functional Cannot “Push Off”
- 51. Hindfoot Amputations Chopart -Saves Talus and Calcaneus Boyd - Talectomy + Calcaneal / Tibial Fusion Forward Translation of Calcaneus Pirgoff - Talectomy + Calcaneal / Tibial Fusion Forward Rotation of Calcaneus Boyd and Pirgoff used primarily in children as alternative to the Syme. Preserves physeal growth and provides a more secure heel pad attachment
- 52. Chopart - SavesTalus and Calcaneus Old Technique Ant Tib Tendon to Talus Achilles Release No Bevel New Technique Ant Tib Tendon to Calcaneus Full Achilles Release Bevel Distal, Inferior Calcaneus
- 53. New Technique Ant TibTendon to Calcaneus Bevel Distal, Inferior Calcaneus Full Achilles Release
- 54. Partial Foot AmputationIn Trauma Harris WR, Silverstein EA: Partial Amputations of the Foot: a Follow-up Study. Can. J Surg. 7:6, 1964 Millstein SG, McCowan SA, and Hunter GA: Traumatic Partial Foot Amputations in Adults - A Long Term Review. J of Bone and Joint Surgery, Vol 70-B, p 251-254, 1988; Quality of the Soft Tissue Padding is MUCH More Important to the Outcome than Any Particular Length of Bone !!
- 55. Partial Calcanectomy “An Amputation ofthe Back of the Foot”
- 57. Free Flaps onthe Foot ? Can Be Done, But Leads to Predictable Problems Tissue Without Sensation - can lead to ulceration Excess Mobility - often dramatic Unstable in Weight Bearing Devices - Many Possible Designs Goals - Contain, Protect, Keep Centered, Pad Our Best Success - Custom Leather Lacers Circumferential Control Leather is skin friendly Stays can add extra Support and Control of Foot Silicon Pads in Select Areas We Have Not Had Great Success with Rigid Devices
- 58. Syme’s Amputation One orTwo Stage Surgery Wagner - Recommended two stage Current - One stage if experienced with techniques Stabilization of the Heel Pad Suture of Achilles to Posterior Tibia Excision of Subchondral Bone - Scar Temporary Pin Stabilization Attach Anterior Tendons to Fat Pad
- 59. Stabilization of theHeel Pad with Achilles Tenodesis
- 60. Used Much Morein Diabetes than in Trauma !
- 61. Bulbous Shape - makesSocket fit more challenging. “Dog-ears” - left to avoid narrowing the waist of the Flap.
- 62. Historically, physicians probablyhave overstated the actual ability for a person with a Syme level amputation to walk without a prosthesis. While some individuals can take a few steps without their artificial leg, especially when transferring, getting around the bathroom, and a few steps around the house, most need a prosthesis for routine walking. A person with a transtibial-level amputation is unable to do this at all, and must resort to hopping or crawling. With the Syme, some very limited walking without a prosthesis is possible (My Personal Experience and Opinion, Published In the Amputee Coalition of America’s inMotion Magazine, May-June 2003, DG Smith, )
- 63. Syme’s Amputation This Levelis Fairly Rare in Trauma !!! Usually the Heel Pad is Sufficiently Damaged and in the Zone of Injury Tender Heel Pad - Leads to Very Limited Function ! In This Situation - Transtibial Level is Better
- 64. Transtibial Amputation Posterior Flapis Standard - Cylindrical Not Conical Shaped Limb - Tolerates Total Contact Type Fit - More Durable But In Trauma - Sometimes there is no good posterior tissue.
- 65. - Flap Length= Diameter + 1cm - Ideal Limb Length Think End of Flap - Slight Angle Back to Incisions - Fibula 1 to 2 cm Shorter -Myodesis to Anterior Tibia Periosteum or Drill Holes Transtibial Amputation Surgical Tips
- 66. BKA with OnlyFasciocutaneous Flaps, and Very Limited Muscle Can Be Functional Especially With the Addition of Elastomeric (Silicone) Suspension Sleeve inside of the Pelite Liner
- 67. Optimal Transtibial AmputationLength Old School: "Always Cut the Tibia One Hands Breadth Below the Tibial Tubercle" John Bowker - the Value of Longer Transtibial Amputations Stronger Lever Arm More Surface Area for Prosthetic Interface More Balanced Muscles Do Not Amputate in the Distal 1/3 to 1/4 of the Tibia: No Suitable Soft Tissue Padding Limits Space Below the Residual Limb Prosthetic Components can Absorb Shock and Provide Elastic Response Ideal Length - Is For the Distal End of a Long Posterior Flap Technique to be at the Junction of the Soleus and the Achilles Tendon
- 68. Long BKA canBetter Distribute the Forces on the Pre-Tibial Regions, and Improve Comfort and Function. Note: Pedal Out Under the Toe on the Sound Limb, and Back Near the Hindfoot on the Amputated Side.
- 69. Knee Disarticulation Amazing HistoricalLove / Hate Relationship Surgeons Prosthetists Patients Technology
- 70. First Described inLiterature 1830 Benefits Disadvantages “ Current Technology Has Overcome All the Prosthetic Objections ” S. Perry Rogers, MD Chicago, IL JBJS Vol. 22, 1940
- 72. Must Consider: • HowWill the Patient Transfer • What Contractures are Present • What Contractures will Occur • Surface Area and Support for Sitting (Protect the Back Side) Non - Ambulatory Patients Different Concerns and Goals
- 73. • Longer LeverArm • Balanced Thigh Muscles • Improved Suspension • End Bearing • Lower Proximal Socket Brim • Sitting Comfort For Ambulatory Patients Knee Disarticulation is Usually More Functional Than a Transfemoral Amputation
- 74.
- 75. North American Experiencewith Knee Disarticulation with Use of a Posterior Myofasciocutaneous Flap. Healing Rate and Functional Results in Seventy-Seven Patients. 80 KDs in 77 Patients Age 19 - 92 y.o. (average 64) 31 Diabetes 29 PVD 14 Trauma 2 Sarcoma 1 Ollie's Disease RESULTS: 5 Patients Died Early in Post-op Period 67 Healed (89%) --- 63 primarily (84%) 7 Major Dehiscence revised to Transfemoral (9%) 22 of 27 who walked Pre-op Successfully Used a Prosthesis and Walked Post-op Technique Provided a Comfortable, Well Padded, End-Bearing Residual Limb Bowker JH, San Giovanni TP, Pinzur MS J Bone Joint Surg Am 2000 Nov;82-A(11)
- 76.
- 77. Sagittal Flap Technique: 38 of46 (83%) Healed Overall 30 of 34 (88%) Healed in Non-ambulators felt to have the potential to heal a BKA 8 of 12 (67%) Healed in Ambulators felt not to have the potential to heal a BKA Pinzur, Smith, Daluga, Osterman JBJS Vol. 70-A, 1988
- 78.
- 79. BKA TKA AKA (n=24)(n=17) (n=18) Don and Doff Prosthesis 100% 70% 56% Daily Use of Prosthesis 96% 76% 50% > 9 Hours / Day 54% 41% 22% 6- 9 Hours / Day 17% 11% 6% 3-6 Hours / Day 16% 24% 22% < 3 Hours / Day 13% 24% 28% No Use for Prosthesis 4% 12% 39% Function after Through-Knee Compared with Below-Knee and Above-Knee Amputation Hagberg E, Berlin OK, Renstrom P. -- University of Gothenburg, Sweden. Prosthet Orthot Int 1992 Dec;16(3):168-73
- 80. LEAP Study: With Outcome ToolsUsed: (SIP) No Difference Between Salvage, BKA and AKA Knee Disarticulation (n=18) Scored Worse - Case Review Could Not Find Why Looked at Patallectomy, Condylar Trimming, Muscle Coverage - There are several unique patients circumstances that makes analysis tricky. - Small numbers make definitive conclusions difficult.
- 81. Knee Disarticulation versus theSupracondylar Amputation Knee Disarticulation With Good Soft Tissue Envelope: Longer Lever Arm Balance Thigh Muscles End Bearing Suspension of the Prosthesis on the Femoral Condyles BUT: If the Flap Is Traumatized, Likely to Be Scarred, Painful, or Adherent … Then a Supracondylar Amputation Is Much Better
- 82. Transfemoral (Above Knee)Amputation Muscle Stabilization is Extremely Important Deforming Force into Flexion (Iliopsoas) and Abduction (Abductors) Myodesis with Post / Medial Muscle (Adductors) Stronger Limb Femur Centered in Muscle Mass Less Adductor Roll
- 83. Transfemoral - withNo Muscle Stabilization - Ouch! Transfemoral - with Good Muscle Stabilization !
- 86. Intra-Op Ace WrapSpica Up Around Waist At Day 3-5 Post-op Shrinker with Waist Belt Simple Wrap Rolls Down Hard To Re-Wrap b/o Pain “Extra Turn at the Top - To keep it in Place” Tourniquet Effect
- 87. Transfemoral Positioning Worry -Hip Flexion Contracture Post-Op Prevention Leg Flat on Bed Not Elevated Early Proning
- 88. Extraordinary Measures to Savethe Hip 19 y.o. Female, Victim of Shark Attack Transferred - South Pacific - Panama - Seattle
- 89. Occasionally Use Traction Techniquesin Amputations Skin Traction Dates Back Over 100 years Used Over Open Wounds to Save Length Elastomeric Sleeves Can be Used Instead of Glued Stockinette Home Set-up Possible Start at 2 lbs, Slowly Work Up Towards 5 lbs Decrease Weight if Skin Blisters
- 90. Traction facilitated closureand preservation of length. Revision performed after 18 months because of scar irritation.
- 91. Hip Disarticulation and TranspelvicAmputations (Hemi-Pelvectomy) Tumor or Severe Trauma Last Resort in Vascular Disease Prosthesis is Heavy and Difficult Many Patients Still Require Crutches or Walker Many Choose Not to Use Prosthesis
- 92. Works pretty wellwhile walking
- 93. Ouch !! - Sittingis Not Comfortable - Chooses Not to Wear Prosthesis
- 94. Occasionally, Heterotopic Bonecan help - Hip disarticulation fit as transfemoral amputee
- 95. Post-Operative Amputation Dressings Partial Foot,Syme, Transtibial, and Knee Disarticulation: Rigid Dressing - Avoids Knee Contractures, Protects the End of the Amputation, Documented Less Pain, Ability to Facilitate Rehabilitation Soft Dressings - Pain Response is for the Patient to Hold the Leg With Knee and Hip Flexion, This Can Cause Contractures. If ACE Bandages Are Applied Poorly, They Can Cause Congestion, Edema, and Wound Problems Removable Splints - Very Useful for Open Wounds, STSG, Post-operative Amputation Infections. The Splint Needs to Hold the Knee in Extension, and Protect the Distal End of the Amputation
- 96. Post-Operative Amputation Dressings Transfemoral andHip Disarticulation Levels Rigid Dressing Techniques Are Available and While They Facilitate Standing and Walking They Can Make Sitting, Transfers and Toilet Activity Very Difficult Shrinker Socks With Waistband or Spica ACE Wrap Work Well Avoid the Middle of the Night, Isolated AKA Wrap That Puts “An Extra Turn at the Top to Keep It On”
- 97. Active Young TraumaVictim Early Weight Bearing In Immediate Post-Operative Prosthetic Cast and Foot Attachment
- 98. Amputee Rehabilitation Traumatic AmputationAbove The Zone Of Injury: Casting and Early Weight Bearing Protocols Traumatic Amputation Involving the Zone Of Injury: Commonly These Amputations have some Marginal Tissue or Recent Skin Grafts A Rigid Dressing of Cast or Splints Is Used to Prevent Knee Flexion Contractures, and Protect the Limb From Outside Injury If Open Wound Care is Required, a Thermoplastic Posterior Amputation Splint can be Fabricated to Allow Wound Care but Provide the Benefits of Contracture Prevention and Pain Relief
- 99.
- 100. Prosthetic Components: Don’t Think: High Techversus Low Tech Think: First Year Modular Prosthesis then Prosthesis after Rehabilitation
- 101. Employment, Sports, and Recreational Activities NeverSay Never - You Will Be Proved Wrong
- 102. Many Amputees PreferNon-Impact Sports and Activities Although Running and Impact Sports Are Possible Many Choose Other Activities because of the Discomfort and Sores that Can Result from Repeated Impact
- 103. Employment, Sports, and Recreational Activities TheConcept of "Good Days and Bad Days" Makes Defining Work Conditions Difficult. What Will the Amputee Do on the 2 to 4 Days a Month When They Have a Skin Sore, Soreness From Overexertion, or Cannot Wear their Prosthesis.
- 104. Dr Burgess Understood TheAncient Philosophers ---------- The Purpose of Life Is To Create Enthusiasm Return to Lower Extremity Index