POST-OPERATIVE MANAGEMENT OF LOWER LIMB AMPUTATIONS

1
POST-OPERATIVE MANAGEMENT OF LOWER LIMB
AMPUTATIONS
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Produced under a grant from the Department of
Education through the American Academy of
Orthotists and Prosthetists and the Prosthetics
Research Study by the Northwestern University
Prosthetics-Orthotics Center
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Learning Objectives

• After completing this on-line module the
  clinician should be able to
• Identify and describe the 5 basic post-operative
  strategies available.
• Compare and contrast the effectiveness of
  strategies to best manage their patient
  populations.
• Identify and understand the minimum standards of
  care required to achieve appropriate
  rehabilitation.

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Instruction for Use

• When you see this icon, please click your mouse
  on the icon to be linked to a required reading.
• When you see this icon, click your mouse to be
  linked to recommended readings.

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Table of Contents

• I. Literature Review
• II. Post-operative Strategies
• III. Comparison of Strategies
• Standards of Care
• IV. Team Approach
• V. Time frames
• VI. Wound Healing
• VII. Amputation Specific Goals
• VIII. Whole Person Goals
• IX. Education and Empowerment
• X. Case Studies

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I. Literature Review
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I. Literature Review

• Journal of Rehabilitation Research
• and Development
• Postoperative dressing and management strategies
  for transtibial amputations A critical review
• Conclusion the literature and evidence to date
  is primarily anecdotal and insufficient to
  support many of the claims made.
• Future randomized trials on TTA dressing and
  management strategies are clearly needed to
  collect evidence to best guide clinicians with
  their decisions
• Click here to read the full article

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Journal of Rehabilitation Research and
Development Postoperative dressing and
management strategies for transtibial
amputations A critical review

• After reading the journal article please answer
  the following self-assessment questions.
• Advance to the next slide to begin
• Click here to read the full article

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Review of Module I
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Overall, current research on post-operative
management

1. Lacks standard definitions for endpoints to
   measure success and failure
2. Compares all of the various management strategies
3. Is consistent in measurement outcomes
4. Compares individuals w/ the same level and
   etiology of amputation

1. Lacks standard definitions for endpoints to
   measure success and failure
2. Compares all of the various management strategies
3. Is consistent in measurement outcomes
4. Compares individuals w/ the same level and
   etiology of amputation

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Of the 10 controlled studies, which comparison
has not taken place?

1. Removable Rigid Cast to Soft Dressing
2. Thigh level Rigid IPOP to Soft Dressing
3. Removable Rigid Cast to any IPOP
4. Prefab IPOP to Soft Dressing

1. Removable Rigid Cast to Soft Dressing
2. Thigh level Rigid IPOP to Soft Dressing
3. Removable Rigid Cast to any IPOP
4. Prefab IPOP to Soft Dressing

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What fraction of transtibial amputations occur in
those with diabetes?

1. One-third
2. One-quarter
3. One-half
4. Two-thirds
5. All

1. One-third
2. One-quarter
3. One-half
4. Two-thirds
5. All

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Which is not a goal of post-operative management?

1. Prevent knee contractures
2. Reduce edema
3. Protect the limb from external trauma
4. Facilitate early weight bearing
5. Bill as much as possible

1. Prevent knee contractures
2. Reduce edema
3. Protect the limb from external trauma
4. Facilitate early weight bearing
5. Bill as much as possible

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Continue to Next Module Return to Table of
Contents
15
II. Introduction to Post-Operative Amputation
Management Strategies
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II. Introduction to Post-Operative Amputation
Management Strategies

• Definitions
• Strategy- specifically refers to the
  post-amputation dressing or device.
• Protocol- specifically refers to how the
  post-operative device or dressing is prescribed
  and used.

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Strategy

• Soft Dressings
• -Types
• Ace wraps
• compressive stockinette
• traditional shrinker socks
• Unna paste wraps
• (Semi-rigid)
• gel liners

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Soft Dressings

• The soft dressing is used routinely in
  post-operative management to control swelling.
• If soft compressive dressings are used, proper
  wrapping techniques must be taught to the staff,
  patient and caregivers to reduce complications.
• Instruction on the use of proper wrapping
  techniques can be found at the link below.

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Soft Dressings

• The use of soft dressings also may be used with
  adjunctive mechanisms to obtain compression as
  well as addressing knee flexion contractures.
• Soft dressings can be combined with the use of
  simple knee immobilizers, hinged knee
  immobilizers, and low temperature thermoplastic
  protective shells to minimize contracture or
  protect the amputation site.

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Soft Dressings

• While frequently used in many patient care
  settings, these devices do not directly offer a
  mechanism to promote residual limb maturation.
• There is currently minimal evidence to document
  the effectiveness of soft dressings.

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Elastic shrinkers

• Commercially ready-made and individually packaged
  is effective for residual limb shrinkage, but
  lacks protection of the residual limb from trauma
  such as accidental falls or weight-bearing
  exercise.
• Its use is limited by the cost and availability
  in the office

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Elastic shrinkers
Has limited sizes and lengths, lack of size for
obese patients with short residual limbs or for
children with amputated limbs May be either too
tight to put on or too loose to have enough
compression
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Elastic stockinette

• commercially available in rolls and in various
  sizes
• can be used in place of elastic bandage and stump
  shrinkers
• less expensive
• easily applied onto the residual limbs or
  edematous limbs
• most importantly, can achieve a desirable
  gradient pressure by adding layers of various
  length of elastic stockinette

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Elastic stockinette
The compression pressure on the distal part (with
increased tension) is higher than on the smaller
proximal area (with less tension from less
stretching of elastic stockinette)
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Strategy

• 2. Non-removable rigid dressings without
  immediate prosthetic attachment.
• Custom molded thigh high device made from
  plaster, fiberglass, or other rigid material.

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Non-removable rigid dressings without immediate
prosthetic attachment

• This strategy used at the transtibial level of
  amputation is usually worn for the first 1 to 2
  weeks after surgery to shape and protect the
  limb.
• The cast extends above the knee and does not
  allow the knee to bend.

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Non-removable rigid dressings without immediate
prosthetic attachment

• At the transfemoral level of amputation a this
  cast may or may not incorporate a preformed brim.
• This strategy also may or may not use a soft or
  rigid hip spica component around the waist.

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II. Introduction to Post-Operative Amputation
Management Strategies

• Non-removable rigid dressings
• with Immediate Post-Operative Prosthesis
  (IPOP).
• Custom molded thigh high device made from
  plaster, fiberglass, or other rigid material with
  pylon and foot attachment.

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IPOP

• The immediate post-operative
• prosthesis was initiated in the late
• 1950s by Dr. Berlemont (France)
• and Dr. Weiss (Poland).
• The technique was further
• developed in the United States
• by Dr. Burgess at Prosthetics
• Research Study in Seattle,
• WA

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IPOP

• General Principles
• Supervised weight bearing of no more than 5-10
  lbs of measured weight during the first 1-2 days
  post surgery.
• No more than 20 lbs of weight bearing in the
  parallel bars until after the first cast change.
• This usually occurs around 2 weeks
  postoperatively.

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II. Introduction to Post-Operative Amputation
Management Strategies

• 4. Removable Rigid Dressing (RRD)
• Removable rigid dressings made from plaster,
  fiberglass, or other rigid material may be used
  with or without a prosthetic attachment.

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The procedure was developed in 1978 and published
in

• Wu Y, Keagy RD, et al. An innovative removable
  rigid dressing technique for below-the-knee
  amputation.
• J Bone Joint Surg 197961A724-729.
• Wu Y,Krick HJ. Removable rigid dressing for
  below-knee amputees. Clin Prosthet Orthot
  19871133-44.

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It was developed to solve the common problems
from elastic bandaging such as

• Pressure sore over tibial tubercle
• 2) Distal edema
• 3) Knee contracture due to pain.

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Steps of applying RRD

• 1) apply the wound dressing as needed,
• 2) wear proper layers of tube socks or stump
  socks of various lengths,
• 3) apply the plaster cast use a plastic sheath
  to reduce friction,
• 4) pull the suspension stockinette upward
  covering the plaster cast,

• 5) place the supracondylar cuff and fasten the
  Velcro closure,
• 6) pull the suspension stockinette tight,
• 7) fold suspension stockinette downward and
  anchor on the suspension cuff
• 8) knee flexion is possible and encouraged.

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II. Introduction to Post-Operative Amputation
Management Strategies

• 5. Pre-fabricated post-operative prosthetic
  systems

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Pre-fabricated post-operative prosthetic systems
These devices provide varying degrees of
protection and contracture prevention and are
designed for early weight bearing. They maintain
some of the advantages of the removable rigid
dressing, in that they are easily removed and
replaced for wound evaluation.
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Examples of Pre-fabricated systems
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Review of Module II
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The use of elastic stockinette may be better than
Ace-type bandages because

1. It provides better protection
2. It is more expensive
3. Can apply gradient pressure
4. Eliminates contractures

1. It provides better protection
2. It is more expensive
3. Can apply gradient pressure
4. Eliminates contractures

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The RRD allows for all of the following except

1. Inspection of the limb
2. Protection of the limb
3. Graded weight-bearing
4. Immobilization of the knee

1. Inspection of the limb
2. Protection of the limb
3. Graded weight-bearing
4. Immobilization of the knee

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When using a prefabricated system for early
weight bearing, the patient should only
bear______ pounds of weight in the parallel bars.

• 5-10
• 20-40
• 60-80
• Full weight-bearing

• 5-10
• 20-40
• 60-80
• Full weight-bearing

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Continue to Next Module Return to Table of
Contents
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III. Comparison of Strategies
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III. Comparisons of Strategies

• The literature identifies the lack of scientific
  evidence to support the use of one strategy over
  another. Analysis of 10 controlled studies
  supported only four of the fourteen claims cited
  in uncontrolled, descriptive studies

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III. Comparisons of Strategies

• The literature supports that
• 1) Non-removable rigid dressings result in
  significantly accelerated rehabilitation times
  when compared to soft gauze dressings.
• 2) Non-removable rigid dressings result in
  significantly less edema when compared to soft
  gauze dressing.

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III. Comparisons of Strategies

• The literature supports that
• 3) Pre-fabricated post-operative prosthetic
  systems were found to have significantly fewer
  post-surgical complications when compared to
  soft gauze dressings.
• 4) Pre-fabricated post-operative prosthetic
  systems lead to fewer higher level
  revisions compared to soft gauze dressings.

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III. Comparisons of Strategies

• No studies directly compared pre-fabricated
  systems to rigid dressings, and no studies
  compared all types of dressings within one study.
• It is currently not possible to provide
  evidenced-based protocols, or make conclusive
  evidence-based recommendations for the use of one
  strategy over another.

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Assessing Outcomes

• Due to the lack of evidence based outcomes
  measures in the area of Post-operative
  management, the consensus conference also
  strongly suggested the adoption of reporting
  standards for the assessment of outcomes.
• These standards included
• Better classification systems
• Improved documentation of wound healing
• (module VI)
• Documentation of contralateral limb status
• Pre- and Post-amputation functional status
  evaluation

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Classification Systems

• Traumatic vs. diabetic amputation terminology
  is not complete
• Etiology and co-morbidities must be considered
• For example, a diabetic amputation may be due
  to
• Infection, Minor trauma, Poor circulation,
  Chronic ulceration, etc
• Systemic complications (death, myocardial
  infarction, deep venous thrombosis, pneumonia,
  strong, urinary infection) should also be
  tracked.

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Contralateral Limb status

• 28-51 undergo second leg amputation within 5
  years of initial
• 39-68 mortality at 5 years following amputation
• Therefore, ulceration, wounds, infection and
  amputation in the contralateral limb should be
  documented

Reiber, Boyko, and Smith (1995) in Diabetes in
America
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Pre- and Post- amputation functional status

• The consensus was that pre-amputation (whenever
  possible) and post-amputation functional status
  should be documented using standardized general
  outcome tools. e.g.
• SF-36 (Short form 36)
• MFA (Musculoskeletal Functional Assessment)
• SIP (Sickness Impact Profile)
• Or tools specific to amputation and prosthetics.
  e.g.
• AMP (Amputee Mobility Predictor)
• PEQ (Prosthetic Evaluation Questionnaire)

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Review of Module III
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A well-designed comparison of post-operative
management will

1. Randomize selection
2. Define outcome measures consistently
3. Better detail pain and complications
4. Compare all management methods
5. Quantify health care savings
6. All of the above

1. Randomize selection
2. Define outcome measures consistently
3. Better detail pain and complications
4. Compare all management methods
5. Quantify health care savings
6. All of the above

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Which of the following is an unsupported claim of
the descriptive studies?

1. NR Rigid dressings accelerate rehab time compared
   to soft dressings
2. Eventual use of a prosthesis is increased for an
   IPOP compared to soft dressings
3. IPOPs require fewer higher-level revisions
   compared to soft dressings
4. NR Rigid dressings significantly reduce edema
   compared to soft dressings

1. NR Rigid dressings accelerate rehab time compared
   to soft dressings
2. Eventual use of a prosthesis is increased for an
   IPOP compared to soft dressings
3. IPOPs require fewer higher-level revisions
   compared to soft dressings
4. NR Rigid dressings significantly reduce edema
   compared to soft dressings

NRNon-removable
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Systemic complications may be considered
perioperative if they occur within __ days of
surgery

• 5
• 10
• 30
• 60
• 365

• 5
• 10
• 30
• 60
• 365

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Continue to Next Module Return to Table of
Contents
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IV. Team Approach
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IV. Team Approach

• The goal of the rehabilitation team is to work
  together with the patient/ client and family to
  help a person with an amputation reach maximum
  potential.

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Team Members
Family
Social Worker
Surgeon
Psychologist
Physiatrist
Peer Support
Nurse
Case Manager
Prosthetist
Chaplain
Therapy
Patient
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Team Members

• Patient/ Client and Family
• The patient/ client and family are considered the
  most important members of the rehabilitation team.

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Team Members

• Surgeon
• The surgeon performs the amputation and provides
  medical care.
• Physiatrist
• A physician who is specially trained in Physical
  Medicine and Rehabilitation prescribes the
  individualized therapy programs and coordinates
  the team effort of the many professionals.

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Team Members

• Therapy
• The various therapies provide a vital role in the
  rehabilitation of the patient/ client.
• The various therapies include Physical therapy,
  Occupational therapy, Vocational therapy,
  Recreational therapy, and Speech therapy.

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Team Members

• Physical Therapist
• A therapist who designs an individualized program
  to help restore function for patients/ clients
  with problems related to movement, muscle
  strength, exercise, and joint function.

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Team Members

• The Rehabilitation Nurse
• Provides 24 hour a day nursing care.
• The nurse implements the plan of care, reinforces
  the skills learned in therapy, and teaches the
  patient/ client and family about self care and
  medications.

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Team Members

• Prosthetist
• Prepares patient/ client for prosthetic care
• Educates the patient/ client on prosthetic care
• Recommends prosthetic components based on
  rehabilitation potential

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Team Members

• Psychiatrist/ Psychologist
• A person who conducts cognitive (thinking and
  learning) assessments of the patient/ client.
• Helps the patient/ client and family adjust to
  the disability.

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Team Members

• Social worker
• A professional counselor who acts as a liaison
  for the patient/ client, family and
  rehabilitation team.
• The social worker helps patient/ client and
  families cope with their disability.
• The social worker makes arrangements for
  assistance from community agencies.

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Team Members

• Chaplain
• A spiritual counselor who helps patients/ clients
  and families during crisis periods.
• Serves as a liaison between the hospital and
  place of worship.

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Team Members

• Peer Support
• A person with a similar disability who provides
  insight for the patient /client
• Provides perspective of what living with a
  disability is like.

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Team Approach

• As health care has evolved, it is more difficult
  to have the whole team meet together at the same
  time.
• The team approach is still needed to optimize
  recovery from limb loss, perhaps now more than
  ever.

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IV. Team Approach

• The team without walls demands increased effort
  and attentiveness to work toward the common goal
  of maximum recovery and rehabilitation.
• The team should be flexible in that different
  people share the leadership and service
  responsibilities of the postoperative period

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IV. Team Approach

• Each member of the team has an obligation to
  educate, empower and allow client and/or advocate
  to take control and responsibility
• Act like a Team- No one health care provider
  has all the answers and everyone has specific
  skills and roles to assist in the pre-operative
  and post-operative process.

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IV. Team Approach

• Team members should keep an open mind and a
  positive, motivating approach to optimize
  appropriate care.
• All providers have the responsibility to envision
  the best possible outcome and help assure that
  medical care, prosthetic fabrication and fitting,
  training and therapy, navigation of the funding
  process and social re-integration occur.

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IV. Team Approach

• Team members should work together, support or
  discuss each members treatment recommendations
  and communicate directly when disagreements
  exists. Communication through the patient should
  be avoided at all costs.

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Review of Module IV
76
The most important member of the treatment team
is

1. Physician
2. Prosthetist
3. Physical Therapist
4. Case Manager
5. Patient/ Family

1. Physician
2. Prosthetist
3. Physical Therapist
4. Case Manager
5. Patient/ Family

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In the team approach, what should be avoided at
all costs?

1. Team members working together
2. Communicating with one another through the
   patient/client
3. Discuss each members treatment recommendations
4. Communicating with one another

1. Team members working together
2. Communicating with one another through the
   patient/client
3. Discuss each members treatment recommendations
4. Communicating with one another

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What is the obligation of each member of the
team?

1. Concentrate on his/her own profession and nothing
   else
2. Communicate to other professionals through the
   patient/client
3. Communicate only to the family
4. Educate, empower, and allow client and or
   advocate to take control and responsibility

1. Concentrate on his/her own profession and nothing
   else
2. Communicate to other professionals through the
   patient/client
3. Communicate only to the family
4. Educate, empower, and allow client and or
   advocate to take control and responsibility

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Continue to Next Module Return to Table of
Contents
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V. Time Frame of Surgery and Recovery
81
V. Time Frame of Surgery and Recovery

• Following amputation (regardless of etiology) the
  post-operative recovery period is typically 12 to
  18 months and simply cannot be rushed!

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V. Time Frame of Surgery and Recovery

• Stages of Recovery
• Pre-Operative Stage
• Acute Hospital Post-Operative Stage
• Immediate Post-Acute Hospital Stage
• Intermediate Recovery Stage
• Transition to Stable Stage

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V. Time Frame of Surgery and Recovery

• Stages of Recovery
• Pre-Operative Stage
• This stage begins with the decision to amputate,
  the vascular assessment and decisions or attempts
  to improve circulation. This stage also includes
  level selection, pre-operative education,
  emotional support, physical therapy and
  conditioning, nutritional support, and pain
  management.

84
V. Time Frame of Surgery and Recovery

• Acute Hospital Post-Operative Stage
• This includes the time in the hospital following
  the amputation surgery. This hospital time is
  typically 5-14 days.

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V. Time Frame of Surgery and Recovery

• Immediate Post-Acute Hospital Stage
• This stage begins at hospital discharge and can
  extend up to as much as 8 weeks following
  surgery.
• This time allows for recovery from surgery, wound
  healing, and early rehabilitation.
• Typical end points for this stage include the
  point of wound healing and the point of being
  ready for prosthetic fitting.

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V. Time Frame of Surgery and Recovery

• Immediate Post-Acute Hospital Stage
• However, wound healing is a continuous process,
  and does not have a clear end point of being
  healed.
• Much of the literature attempts to use these two
  elusive endpoints when comparing different
  post-operative strategies with varying results.

87
V. Time Frame of Surgery and Recovery

• Intermediate Recovery Stage
• This is the time of transition from a
  post-operative strategy to first formal
  prosthetic fitting. The most rapid changes in
  limb volume occur during this stage due to the
  beginning of ambulation and prosthetic use.
• This intermediate recovery stage begins with
  wound healing and usually extends out 4-6 months
  from the healing date.

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V. Time Frame of Surgery and Recovery

• Intermediate Recovery Stage
• This stage ends when relative stabilization of
  limb size occurs, as defined by consistency of
  prosthetic fit, for several months.
• The definitive prosthesis should not be fit prior
  to 6 months of temporary prosthetic use and when
  the stabilization of the limb occurs

89
V. Time Frame of Surgery and Recovery

• Transition to Stable Stage
• This stage includes maturation of the limb and
  less volume change.
• Patient should move toward social re-integration
  and higher functional training and development as
  well as becoming more empowered and independent.

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Clinical Concerns

• 14 clinical concerns were identified in the
  stages of recovery
• Each concern will take on different levels of
  importance at different stages of the healing
  process
• There may be overlap between stages which may
  vary with individual differences

91
Clinical Concerns

• 1. Determine amputation level
• Important earliest, in pre-operative stage
• Must include assessment of vascular status and
  circulation to determine level

92
Clinical Concerns

• 2. Minimize systemic complications including
• Myocardial infarction (MI)
• Deep Vein Thrombosis (DVT)
• Decubitus, etc.
• Risk must be assessed pre-operative
• High level of concern during acute hospital
  post-operative stage
• Moderate concern during initial healing
  (post-acute hospital stage)

93
Clinical Concerns

• 3. Prevent contractures
• Contractures should be addressed and treated
  pre-operatively, if possible
• Highest concern during acute hospital stage
• Isometric quad sets at day 2
• Continue at high risk during immediate post-acute
  stage
• Reduce to moderate concern for intermediate
  recovery
• Low concern during transition to stable

94
Clinical Concerns

• 4. Bed mobility and transfers
• High concern during acute and immediate
  post-acute stages
• Should reduce in level of concern as prosthesis
  use is begun

95
Clinical Concerns

• 5. Pain management
• High during most of the rehab process
• Pain pre-operatively should be addressed.
  Unresolved pre-op pain may lead to increased risk
  of phantom pain post-operatively
• Typically pain reduces as limb heals and
  prosthesis use is begun
• Concern may shift from acute pain management to
  identification and treatment of chronic pain
  issues in stages 4 and 5

96
Clinical Concerns

• 6. Protect amputated limb from trauma
• Highest immediately after surgery during acute
  hospital stay
• Still important during immediate post-acute stage
  as patient begins to transfer
• Post-operative management strategies that address
  this concern include
• Non-removable rigid dressings
• Removable rigid dressings
• Prefabricated IPOPs
• Post-operative management strategies that DO NOT
  address this concern include
• Soft dressings

97
Clinical Concerns

• 7. Fall prevention
• Moderate concern during pre-op phase
• High concern during acute and immediate
  post-acute stage since falls may traumatize limb
• Moderate concern during intermediate recovery as
  patient learns to walk with first prosthesis
• Lower concern during final transition to stable

98
Clinical Concerns

• 8. Emotional care/education
• High level of concern throughout rehabilitation
  process
• During earlier rehabilitation, concerns will be
  immediate, regarding amputation and healing
  process
• Later concerns may center around realization of
  limitations and work and family issues

99
Clinical Concerns

• 9. Manage and teach about wound healing
• The highest concern of the acute hospital stage
• As wounds heal, concern will decrease
• However, patient should be informed and educated
  to inspect residual limb daily and learn proper
  care and hygiene of limb as prosthesis use is
  begun

100
Clinical Concerns

• 10. Promote residual limb muscle activity
• Begins immediately after surgery
• In-patient therapy may include passive range of
  motion techniques
• High during post-acute stage and intermediate
  recovery stage
• Maintain activity during transition to stable

101
Clinical Concerns

• 11. Early ambulation
• During acute hospital stage, this will be
  secondary to bed mobility, transfers and toilet
  activities
• Early ambulation may be with walkers/crutches and
  no prosthesis during immediate post-acute stage
• Initial fitting of a prosthesis and early gait
  training important during intermediate recovery
  stage

102
Clinical Concerns

• 12. Advanced ambulation
• Therapy for advanced ambulation techniques may be
  prescribed during the transition to stable stage
  when a definitive prosthesis, with potentially
  more advanced components, is fit

103
Clinical Concerns

• 13. Control limb volume changes
• High during immediate post-acute stage as edema
  and swelling from surgical trauma reduces
• High during intermediate recovery stage
• Significant volume changes expected to occur
• Prosthesis fit and function must be accommodated
• Still of high during transition to stable stage,
  though at slower rate
• Should stabilize for at least 2-3 weeks prior to
  fitting of definitive device

104
Clinical Concerns

• 14. Trunk and body motor control and stability
• Balance and stability are important throughout
  rehabilitation process
• It is an especially high concern as patient
  begins therapy to learn independence in transfers
  
• Continues in importance as patient develops
  strength and balance for initial prosthetic gait
  training

105
Review of Module V
106
What is the primary clinical concern during the
acute hospital post-operative stage?

1. Trunk and body motor control
2. Control limb volume changes
3. Fall prevention
4. Manage and teach about wound healing

1. Trunk and body motor control
2. Control limb volume changes
3. Fall prevention
4. Manage and teach about wound healing

107
Limb stabilization typically takes at least ___
of prosthetic use to achieve

1. 3 months
2. 6 months
3. 12 months

1. 3 months
2. 6 months
3. 12 months

108
Physical therapy treatment occurs

1. Early in the rehab process and again at the end
2. Only at the end of the rehab process
3. Only at the beginning of the rehab process
4. Throughout the rehab process

1. Early in the rehab process and again at the end
2. Only at the end of the rehab process
3. Only at the beginning of the rehab process
4. Throughout the rehab process

109
Continue to Next Module Return to Table of
Contents
110
VI. Wound Healing
111
VI. Wound Healing

• SKIN ANATOMY
• The skin is an ever-changing organ that contains
  many specialized cells and structures.
• The skin functions as a protective barrier that
  interfaces with a sometimes-hostile environment.
  It is also very involved in maintaining the
  proper temperature for the body to function well.

112
VI. Wound Healing

• SKIN ANATOMY
• It gathers sensory information from the
  environment, and plays an active role in the
  immune system protecting us from disease.
• Understanding how the skin can function in these
  many ways starts with understanding the structure
  of the 3 layers of skin - the epidermis, dermis,
  and subcutaneous tissue.

113
SKIN ANATOMY

• Epidermis
• The epidermis is the most superficial layer of
  the skin and provides the first barrier of
  protection from the invasion of foreign
  substances into the body.

114
SKIN ANATOMY

• Dermis
• The dermis assumes the important functions of
  thermoregulation and supports the vascular
  network to supply the avascular epidermis with
  nutrients.
• The dermis contains mostly fibroblasts which are
  responsible for secreting collagen, elastin and
  ground substance that give the support and
  elasticity of the skin. Also present are immune
  cells that are involved in defense against
  foreign invaders passing through the epidermis.

115
SKIN ANATOMY
116
Wound Healing
The healing of a wound to the skin is a fairly
typical mixture of regeneration and
replacement. The more regeneration that can
occur, the less scaring will be left behind after
wound healing.
117
Wound Healing

• Many amputations do not heal in ideal primary
  fashion.
• Small areas of the wound may require secondary
  healing and possible wound care
• Revision surgery is frequently required in
  vascular amputations.

118
Wound Healing

• Wound healing problems are most often related to
• Type of injury
• Disease
• Vascularity
• Tobacco use
• The nature of amputation itself

119
Wound Healing

• Skin and wound problems are rarely caused by a
  single factor.
• In many individuals, wound problems are simply
  not preventable.

120
Wound Healing

• The healing of an amputated limb should be viewed
  as a continuous process
• There is no clear and decisive point of
  completed healing.

121
Wound Healing

• Using the outcome of time to heal is not a
  precise measurement.
• Documenting healing continues to be important for
  patient care and research.

122
Wound Healing

• Subjective interpretations associated with
  determining healing time include
• Completion of epitheliazation
• Interpretation of small open areas
• Individual bias
• Timing of the return to clinic visits
• Research savvy of the rehabilitation team

123
Wound Healing

• Future studies need to clearly define how the
  time to heal has been determined.
• Time to heal may always be difficult to
  standardize and to measure.
• It cannot be determined accurately from a simple
  retrospective review of a clinical chart

124
Wound Healing

• It is recommended that wound healing be
  documented as a type of wound healing for
  clinical and research purposes.
• The categories are defined in the following
  slides.

125
Categories of Wound Healing

• Primary
• -heals without open areas, infection or wound
  complications

126
Categories of Wound Healing

• Secondary
• -small open areas that can be managed, and
  ultimately heal with dressing strategies and
  wound care. Further surgery is not required.
  This may occasionally be intended with some
  portion of the amputation left open.

127
Categories of Wound Healing

• Requires minor revision
• skin and subcutaneous tissue.
• (No muscle or bone involvement)

128
Categories of Wound Healing

• Requires major revision
• but heals at initial amputation level (Example
  mid-transtibial level revised to shorter
  transtibial level)

129
Categories of Wound Healing

• Requires revision to a higher level
• (Example a transtibial amputation that must be
  revised to either a knee disarticulation or
  transfemoral amputation)

130
Wounds and Weight Bearing

• The presence of an open wound or the presence of
  sutures does not necessarily preclude
  weight-bearing.
• In many circumstances, institution of or
  continuation of activity can be helpful to
  control edema and facilitate healing.

131
Review of Module VI
132
Wound healing problems are related to all of the
following EXCEPT

• Type of injury
• Disease
• Vascularity
• Musculature

• Type of injury
• Disease
• Vascularity
• Musculature

133
The phrase Time to heal

1. Is easy to measure
2. Can be determine from chart notes
3. Is not a precise measurement
4. Is not useful in research

1. Is easy to measure
2. Can be determine from chart notes
3. Is not a precise measurement
4. Is not useful in research

134
Continuing activity in the presence of a wound

1. Is often encouraged to facilitate healing
2. Is not encouraged during the rehabilitation
   process
3. Will lead to revision
4. Will delay healing

1. Is often encouraged to facilitate healing
2. Is not encouraged during the rehabilitation
   process
3. Will lead to revision
4. Will delay healing

135
Continue to Next Module Return to Table of
Contents
136
VII. Amputation Specific Goals
137
Amputation Specific Goals
138
Amputation Specific Goals

• Prevention of contractures
• Reduce post-surgical edema
• Improve bed mobility
• Pain management
• Protection of limb from trauma
• Prevention of falls

• Emotional care
• Promote limb activity
• Establish trunk stability
• Begin ambulation
• Accommodate limb volume changes
• Achieve distal end loading

139
Prevention of contractures

• Is necessary at both the hip and knee
• Active strategies such as bed positioning, prone
  activities are well documented along with
  stretching techniques used by physical therapy

140
Prevention of contractures

• Several passive strategies such as knee
  immobilizers and rigid dressings attempt to
  address the goal of knee flexion contracture
• Literature is unavailable to support any one
  passive strategy
• Passive strategies to prevent hip flexion
  contractures have yet to be proposed

141
Reduce post-surgical edema

• Use of compressive strategies is important
  following any amputation.
• If soft compressive dressings are used, proper
  wrapping techniques must be taught to the staff,
  patient and caregivers to reduce complications.

142
Improve mobility

• Bed mobility, transfers (bed, toilet), and
  activities of daily living (ADLS) must be taught
  early in the post-amputation period
• This encourages independence, strength, and
  reduces the fear of falling
• Physical and Occupational therapy are essential
  to this process
• The addition of a pylon and foot may make bed
  mobility more difficult

143
Pain management

• Pain and contractures may be associated although
  no scientific evidence supports this claim
• Pain must be controlled throughout in order to
  facilitate mobility and eventual prosthetic use
• Careful evaluation will help determine the
  appropriate treatment modality

144
Pain Management

• It is important to vary pain management
  strategies such as, medicine or manual
  desensitization based on time from surgery, type
  of post operative dressing, and the cause of
  amputation
• Desensitization is believed to reduce pain in the
  residual limb and may help the amputee adjust to
  their new body image which includes limb loss
• Literature is lacking with any one approach

145
Protection of limb from trauma

• Evidence suggests the use of rigid dressings
  (custom or prefabricated) provide better limb
  protection than soft dressings
• Examples of limb protection systems can be found
  in the links below.

146
Prevention of Falls

• Fall prevention is an essential part of
  rehabilitation
• Complications secondary to falls may result in
  increased healing time, further surgical
  intervention, other injuries, and increased
  hospitalization

147
Prevention of falls

• Limb loss reminders, i.e. placing a chair next
  to the bed as a reminder to be careful, may
  reduce falls, but further studies are needed
• Strength and balance training can reduce the
  number of falls

148
Emotional care

• Treatment must be highly individualized and does
  not appear to be related to post-operative limb
  management strategy
• Documented options include supportive
  encouragement, educational literature,
  psychological counseling, peer counseling,
  amputee support groups, and chaplainry.

149
Emotional care

• The risk of depression in amputees is high
• When necessary, pharmacological intervention
  and/or psychiatric referral should be considered

150
Promote limb activity

• Promotion of residual limb activity
  (desensitization, muscle contraction, and
  endurance development) is an important strategy
• It may be instituted at various times based on
  post operative strategy, surgical procedure, and
  cause of amputation but conventional wisdom says
  that the earlier the intervention the better

151
Promote limb activity

• Exercise to improve gluteus (medius and maximus)
  and quadriceps strength may begin as early as day
  1
• Exercises to promote muscle action within the
  residual limb depend on pain tolerance, surgical
  procedure and healing response

152
Promote limb activity

• Muscle contraction within the residual limb may
  help with pain control, muscle re-education,
  improve muscle mass, edema control, and
  kinesthetic feedback
• The timing for beginning of muscle activity
  within the residual limb needs to be further
  evaluated

153
Establish trunk stability

• Trunk stability should be established as early as
  possible through core strengthening exercises
• Trunk stability will assist with mobility
  activities, provide the foundation for prosthetic
  control, sitting posture, and can reduce the
  stresses to the spine that cause low back pain
  and body motor control and stability problems

154
Establish trunk stability

• Trunk stability may improve body posture and
  readiness for gait training
• Trunk stability may decrease commonly seen gait
  deviations
• Improved motor control should decrease the energy
  expenditure of walking with a prosthesis

155
Ambulation

• Ambulation is described as non-pedal (wheelchair
  ambulation), uni-pedal (remaining limb with
  assistive device) or bi-pedal (using a prosthetic
  pylon) with or without assistive device
• Improvements in strength, mobility, balance, and
  endurance have been shown to decrease the
  potential for co-morbidities (Pulmonary embolism,
  myocardial infarction etc.)

156
Accommodate limb volume changes

• Critical to comfortable prosthetic use
• During this stage the limb volume is fluctuating
  wildly and may be difficult to manage
• Control of limb volume changes during this stage
  is a function of the preparatory prosthesis

157
Accommodate limb volume changes

• Strategies for limb volume control include the
  use of liners, socks, pads, adjustable sockets,
  temporary sockets or ambulatory check sockets
• When the patient is not wearing a prosthesis,
  wrapping and/or compression are critical to help
  control limb volume changes

158
Achieve distal end loading

• Distal end loading, desensitization, and residual
  limb weight bearing may assist with pain control,
  tolerance of a prosthesis, and reduction of
  adhesions
• This may begin with towel pulling on the distal
  end of the residual limb or using a rigid design
  and allow for pressure over the entire limb

159
Review of Module VII
160
If soft compression dressings are used, proper
wrapping techniques should be taught to which of
the following

1. Patient/client
2. Caregiver
3. Staff
4. All of the above

1. Patient/client
2. Caregiver
3. Staff
4. All of the above

161
Which of the following does not protect the limb
from trauma

1. RRD
2. Ace (Elastic) wrap
3. Flo-tector
4. PAL guard

1. RRD
2. Ace (Elastic) wrap
3. Flo-tector
4. PAL guard

162
Strategies for limb volume control include all of
the following except

1. Socks
2. Liners or pads
3. Adjustable sockets
4. Nylon sheath

1. Socks
2. Liners or pads
3. Adjustable sockets
4. Nylon sheath

163
Continue to Next Module Return to Table of
Contents
164
VIII. The Whole Person
165
The Whole Person

• Goals
• The consensus conference identified six whole
  person goals of care for anyone undergoing lower
  limb amputation.
• These goals are not directly related to the
  surgical amputation but are intended to prevent
  co-morbidity and to improve overall health and
  mobility.

166
Six Goals

• Musculo-skeletal reconditioning and
  cardiovascular training
• Contralateral lower limb preservation
• Emotional care, peer support and education
• Minimize systemic complications
• Social reintegration
• Setting realistic expectations and functional
  outcome goals

167

• The consensus conference stated that while all
  goals are important, focus should be attempted to
  address emotional care, social reintegration, and
  setting realistic functional goals.

168
Review of Module VIII
169
All of the following would beconsidered whole
person goals in therehabilitation of the
patient EXCEPT

1. Social reintegration
2. Emotional care
3. Cardiovascular training
4. Marriage counseling

1. Social reintegration
2. Emotional care
3. Cardiovascular training
4. Marriage counseling

170
Whole person rehabilitation goals are intended
to

1. Provide reimbursement
2. Prevent mobility
3. Preserve resources
4. Prevent co-morbidities

1. Provide reimbursement
2. Prevent mobility
3. Preserve resources
4. Prevent co-morbidities

171
The consensus conference identified three
whole person goals as critical in the
rehabilitation of the patient with an amputation.
These three are

1. Social reintegration, emotional care and
   musculoskeletal development
2. Social reintegration, emotional care and minimize
   complications
3. Social reintegration, emotional care and setting
   realistic goals
4. Social reintegration, emotional care and care of
   contralateral limb

1. Social reintegration, emotional care and
   musculoskeletal development
2. Social reintegration, emotional care and minimize
   complications
3. Social reintegration, emotional care and setting
   realistic goals
4. Social reintegration, emotional care and care of
   contralateral limb

172
Continue to Next Module Return to Table of
Contents
173
IX. Education and Empowerment
174
Education Empowerment

• Improve understanding of the surgical treatment
• Improve understanding of the recovery time frame
• Improve understanding of emotional adaptations
• Improve understanding of prosthetic plan and
  treatment
• Peer support and consumer groups
• Assist in navigation through marketing, hype and
  realities

175
There is nothing that man fears more than the
touch of the unknown

• Elias Canetti (b. 1905)
• The Columbia World of Quotations.  1996

176
Communication is Key

• The patient should be encouraged to ask questions
  and research on his/her own
• The amputee should learn to be an informed
  consumer of marketing material
• Education should begin as soon as possible

177
Surgical Treatment and Recovery

• Communication with surgeon
• May allow opportunity for pre-surgical consult
• Surprise factor for patient can be reduce
• Vital when using post-operative prosthetic
  systems

178
Surgical Treatment

• Medical team should explain
• Types of anesthesia
• Surgical techniques
• Possibility of phantom limb sensation/pain
• Pain control
• Possible complications

179
Important issues that Patient and Family should
understand

• Time frame of recovery
• Including all aspects of postoperative process
• Must have realistic time frames to help avoid
  unrealistic goals
• Usual expectation of 12 to 18 months
• Emotional adaptation
• Will be different for each individual

180
Important issues that Patient and Family should
understand

• Prosthetic plan
• Role of the prosthetist
• What a prosthesis is
• How it is funded
• Expectations to have of a prosthesis
• e.g. not the cure
• Other adaptive equipment for mobility that may be
  needed
• Fitting and adjustments required, especially
  early in rehab process

181
Important issues that Patient and Family should
understand

• Peer Support and Consumer groups
• Including educational materials
• Peer visitation
• National support networks
• Marketing
• Hype vs. reality
• Help to become an educated consumer

182
Available Educational Resources

• Brochures and Pamphlets
• Internet
• Local Support Groups
• National Support Groups

183
Examples of Available Brochures

• A Manual for Below-Knee (Trans-Tibial) Amputees
• A Manual for Above-Knee (Trans-Femoral) Amputees,
  A. L. Muilenburg A. B. Wilson, Jr. (1996)
• Patient Care Booklet for Below-Knee Amputees,
  Jack Uellendahl (1998)
• Below- Knee Amputation A Guide for
  Rehabilitation
• Above- Knee Amputation A Guide for
  Rehabilitation, T.Kuiken, M.Edwards, N. Miceli
  (2002)

Many of these, and more, are also available
through the ACA and the Academy. Click here for
a links to more items
184
Internet

• Manufacturers websites
• Be willing to discuss options that your
  patient/client may see on the internet
• Understand the pros and cons of each device and
  how to explain them to a consumer
• OandP.com

185
Support Groups

• Find out if there are support groups in the area
• National Support Groups, including the Amputee
  Coalition of American, can also be an excellent
  reference

186
Recreational Activities

• Recreational activities/groups can also be a
  support system
• Not just for Paralympic level individuals
• Special organizations exist for
• Golf
• Cycling
• Scuba

187
Review of Module IX
188
A new, active male transtibial amputee,
35-years-old and 350, arrives in your office
with an advertisement for a Dycor foot that says
how flexible, light-weight and comfortable it is.
You should?

1. Order the foot, since that is what they want
2. Explain that this foot is for geriatric patients
3. Explain that this foot is not designed for the
   individuals weight and activity level

1. Order the foot, since that is what they want
2. Explain that this foot is for geriatric patients
3. Explain that this foot is not designed for the
   individuals weight and activity level

189
A new amputee expresses concern to you that they
are the only person they know with an amputation,
they are never going to return to an active
lifestyle and they dont know how to handle it.
What are three things you could do?

1. Offer to introduce them to another amputee for
   peer counseling
2. Express your concerns to the referring primary
   physician so that psychological counseling can be
   prescribed if indicated
3. Give them reading materials that you have and let
   them know about the ACA

190
List at least five things that may affect
emotional adaptation to an amputation

1. Culture
2. Family history
3. Religious preference
4. Age
5. Education
6. Social support
7. Financial background

191
Continue to Next Module Return to Table of
Contents
192
X. Case Studies
193
Case Study 1

• 65 y/o male, BKA 2 PVD
• Prosthetist applied custom thigh-high plaster
  rigid dressing immediately post-surgery
• Soon after awaking, pt c/o pain 10/10
• Pt instructed pain was normal and pain medication
  was increased. Pain still present during course
  of treatment.
• Rigid dressing removed after 8 days
• Result Dressing removed, infection present.
  Limb revision to AKA required.

194
What about this case would be a concern

• How long the rigid dressing was left on
• The patients pain concerns were dismissed
• Protocol for application of rigid dressing may
  not have been followed (tightness of wrap,
  padding, drainage, etc)
• Non-removable dressing did not allow inspection
  of wound, and dressing not removed when chance of
  infection was presented

195
What should have been done?

• Pain management should have been addressed
• Rigid dressing should have been removed when pain
  did not abate.
• Communication with patient should have been
  better.

196
Case Study 2

• 25y/o male, BKA 2 traumatic motorcycle accident.
• Pt also suffered mild head injury during injury.
• Pt fit with soft dressing and compression sock.
• 2 days post-surgery, while alone in the room, pt
  is determined to use toilet independently.
• Pt falls, breaks open sutures, and requires minor
  soft tissue revision to re-close wound.

197
What about this case would be a concern

• Which post-operative strategy was used?
• Failure to evaluate fully cognitive ability of
  patient.
• Did practitioner educate patient/family/care-giver
  s of procedures.

198
What should have been done?

• A post-operative strategy which provided limb
  protection.
• Complete evaluation of patients head injury and
  cognitive level.

199
References

• M. Bergner, R.A. Bobbit, W.B. Carter and S.B.
  Gilson , The sickness impact profile development
  and final revision of a health state measurement.
  Med. Care 46 (1981), pp. 787805.
• J.E. Ware and C.D. Sherbourne , A 36-item
  short-form health survey (SF-36) conceptual
  framework and item selection. Med. Care 30
  (1992), pp. 473