Amputation caper 22 P Bella J. May, PT, EdD, FAPTA, CEEAA logical factors POSTSURGICAL DRESSINGS 1084 DETERMINING PROSTHETIC Ik 4, Develog an evaluation plan for any oft Dressings 1004 ~ india loa PHASES OF CARE: POSTSURGICAL SUMMARY 1026 arptation AND PREPROSTHETIC. 1005 | 2 riontize dota gathering forthe PostsurgicalPrase 1005 I rmmodiate postsuigicl peoc end the cpromteticPrase 1008 sreprasretcphove 5.Desgn an efecto pln ofc fortne immediate poseurgial peed. a fylenthe tional for an each { orient nd civagvers bosivering bs Teacnsting ere enkaneeransfers a roo. trate contin of | dears form 6.Designane pepoahetcpelsd ' a Teech proper rss cae inclidag bondvcng 2s dete chstandng ance otelp the ele tine Piha level of mebiy wh aproonite seelsy soo €:Teech eink senate rere cite j prostatic tng d Teach 04 excises 0 prevertaesite secondoiy t cores 7. fesgond appoaatey to patenutany | romananareren ofthe pice | rapact ower entreriy srput on 8 Anche andinterpret patient oat fori‘ realsteantpated goals od txpeceseutcemes and develona pan of are ven preerted wth acinical canst f b 1000Tation today continues to be peripheral vascular F disease (PVD), particularly with associated s, Two-thirds of all LE amputations in the d States today ate due to complications of dia- 1 Approximately 6 per 1,000 individuals wieh saver age 75 will undergo an LE amputation as fared with 1.78 of similar individuals who do not B diabetes. Major improvernents in, noninvasive Fe sess, vascularization, and wound healing wech- Ries have increased the age at which individuals BS diabexes may come to amputation. Periopecative lity has boen variously reported between 7% and Fy and is usually associated with other medical prob- such as cardiac disease and strokes?4 There ate peees and about 5% of the population is allected h some form of vascular disease.’ Many of the Rough ve are usually creating chem for some other Poslem. Physical cherapists can help by learning more GDC). Several studies have indicated a positive rela- fship berween easly patient education and proper FB: care and a reduction in amputations.5? 1 second leading cause of amputation is trauma, Pally from motor vehicle accidents, war, or gunshots. viduals with traumatic amputations are often young ts, more frequently men, and have often been froled in an zetive lifestyle before amputation, The Bicdence of ampuration from osteogenic sarcoma has Re Resection Exclion of any part of one or more toes Disarticulaton atthe metatarsal phalangeal joint ore elfective chemotherapy, and better imb salvage rocedares. Amputation may be necessary ifthe tumor large and cannot be resected without subscancial removal of bone and tissue. However, the surgeon may choose co remove the tumor and incorporate one of several limb salvage procedures. Many factors go into this decision, including the age of the pacient, the size of the tumor, and, if the patient is young, the porential for furure growth 8 Tumor excision does not affecr 5-year survival rates, whieh have increased from about 20% in the 1970s to 60% to 70% in more recene years.”!* Regardless ofthe cause of amputation, physical therapists hhave a major role in rehabilitation. Barly onset of appro- priate rearment influences the evencual outcome of the episode of care. It is critically imporcant, especially for the older individual, for the therapist in the acute care center to ensure continuity of care once the patient is di charged from the hospital. Too ofien, the patent is sent home and is nor seen again for several reeks or months By tha cime che patient has become debilirared and has developed contractures that interfere with prosthetic use and farction. MLEVELS OF AMPUTATION Traditionally, levels of ampucation have been identified by anatomical considerations such as below knee and above knee. In 1974, the Task Force on Standasdization. of Prostheric-Orshotie Terminology developed an inter ‘national classification system to define amputation levels Table 22.1 detcribes the major terms in common use colay. ofthe 3d, th Sth metatarsals and digts Ffisnsmetarasa “Amputalion trough the midsection ofall metatarsals with aliachrnent of heel pad to distal end of tibia f mal eoi and distal tcialbule fares 0% oF bil Iength Between 20% and SON of ubia length Tess than 20% of tballiegth “Aripuitation through the kr int Femur ntact Mor emipewvectorry Pemicorporeciomy han 60% of fernoral length Between 359% and 60% of fenoral length Tess than 3556 of femoral lengih “Amputation through hip joint; pelvis eta Resection of loner half ofthe peNs ‘Amputation both lower limbs and pels below L4-L5 level1002 SECTION tf Intervention Suategls for Rehabilitation ‘Traumatic amputations may be performed at any levels ehe surgeon tries to maintain the greatest bone length and save all possible joints. A variety of surgical techniques may be necessary to createa functional resid- ual limb. Guillotine amputations (skin, muucle, and bone all rransecred at approximacely thesame level) may precede secondary closuce with skin laps; occasionally, Free tissue laps, taken fiom some other area of the body, ray be used to caver the wound, Amputations for vas- ‘cular diseases are generally performed at pattial foot, reanatibial, oF eansfemoral level, The limited vascular supply milicares against effective residual limb healing at i disatticulacion level in most instances. nts with unifareral transtibial amputations re- gardless of age are quite likely to become functional pros- thetie userst many individuals with bilateral transibial amputations ein be successfully rehabilicated. Older adults with unilaeral cransfemoral amputations wich ‘good balance and coordination are also potential pros- ‘Seiecutssehough those who werenet independent ambulatory before ampuration ate likely not to became independent with a prosthesis. Patients with bilateral transfenioral amputations may become prosthetic users given coday'scomputer-criven components. Once again, ‘pood balance and coordination are a pretequisite. Hip cisarticulations, hemipelvectemies, and hemicorporee- tomics are generally performed cither for tumors of for severe trauma and represent 2 small percentage of the population of individuals with amputations. The most important factor in determining the prosthetic potential of an individual is her or his prior level of activity. Co-morbidities and the extent of injuries from war and ‘aun must be considered, but the individual who let an active life before amputation—even an individual with diabetes and related co-morbidicies—is likely to become a functional prosthetic user if he or she can demonstrate good balance and esordination."4 SURGICAL PROCESS “The specific rype of surgery is determined by the surgeon, whose decision depends on the status of the extremity at the time of amputation, ‘the surgeon muse allow for primary or secondary wound healing, and construct residual limb for optimal prosthetic fisting and function. Numerous factarsafeer the ection of level of amputa- tion, Conservation of residual limb lengeh and uncom plicated wound healing, for example, are both important. Although a description of each type of surgcal procedure is beyond the scope of this chapter, au understanding of the basic principles of amputation surgery is important. ‘Skin flaps areas broad as possible and the sear should be pliable, painless, and nonadherent. For mest trans femoral and transtibial amputations without vascular impairment, equal length ancetior and poscetior flaps are used, placing the sear at the distal end of the bone 22.1 and 22.2). Long posterior laps are often used Jn ranstbial amputations wich compromised cireutacion Ue Figure 22.1 Transtibial residual im with in eaquablength flaps from equal-length flaps. because the posterior tissues have a better biow than anterior skin, This places the scar ance the distal end of che sbia: care must be take thae the sear does not become adherent « (Fig, 22.3). fn recent years the routine use oft posterior Rap has come into question.'? The s ilevcloped in England, is believed by some su bea better approach for indivichsals wi promised distal circulation, ‘The skew flap ip aa medial-lareral incision that places the scat avi bony prominences, a problem with the long flap. Research on the use of diferent skin flaps clearly delineace the most advantageous approach all indicate similar eesuls in terms of rehabil Stabilization of major muscles allows for a retention of function. Muscle stabilization 1 achieved by myofascial dosure, myoplasey, nyo tenodesis, In mose transtibial and cransfemoral aif tions, a combination of myoplasty (muicle ©jd myofascial (muscle to fascial) closure is used the muscle are properly stabilized and do centers, myedesis (muscle attached to perios- hone) is employed, particularly in wanstibal lon attached famay be vsed for muscle stabilization, Whatever te, muscle abilization under some cension peripheral nerves form neuromas (a collec- re cell ends) in the residual limb. The neu- be well surrounded by soft tissue s0 as noe «0 ‘and interfere with prosthetic wear. Surgeons ‘major necves, pull them down under some then cue sher cleanly snd sharply and allow tract imo the soft tissue of che residual limb. it form close o sear tissue or bone generally ul may require later resection or revision. sis is achieve by ligating major veins and G4uterization is used only for small bleeders, comite circulation to diseal pavtcularly che skin flaps, which are imporcant fOnplicated wound healing Fare sectioned at a lengch to allow wound ithout excessive redundant issueat the end of Mion. Sharp bone ends are smoothed and BSG in transuibial amputations, the anterior portion Edisal cibia is beveled co reduce the pressace ‘ead of the bone and the prosthetic sock. 0 enaure thar the bone is physiologically the pressures of prosthetic wear. Fisstte y= osimated under normal physiologiealrension Berri coe ws wh eater sre tube may be insered as necesary. CHAPTER 22° Amputation 1003 In a craumatic amputation, the surgeon attempts to saveas much bone lenggh and viable skin as possibleand preserve proximal joints while providing for appropriate healing of tissues without secondary complications such asinfection. In potentially “itty” (involving foreign sub- stances) amputations che incision may be left open with, the proximal joint immobilized in a functional position for 5 09 days co prevent invasive infection, Secondary closure also allows the surgeon to shape the residual limb, appropriately for prosthetic wear and function, “Ampatation for vascular disease is gencrally considered an destive procedure; he surgeon determines te level of amputation by examining tissue viability through a variety of measures. Segmental limb bloedt pressures can he determined by Doppler systolic blood pressure meas- urement, Transewtaneous oxygen measaremient and skin blood flow by radioisotope or plethysmography are als decermined. Doppler syscolic blood pressure measures have been reported to be quite accurate in predicting viable level of ampucation. Improvements in noninvasive ‘amination techniques have ret sedced the ns of amceriography to determine amputation level. Videos of sctual amputation surgery & wanstibial and teansfemoral feyels may be seen at the Amputation Sargery Eelucation, Center websie (vwweampsing org BIHEALING PROCESS ‘Numerous factors influence the course of the healing proces in exch patient, One of the greatest postoperative ‘once i infection, whether from external or intemal sources. Individual with contaminated wounds from in jury, infected foot ulcers, or other causes are at greater tisk of infection. Research inclcates chat smoking is a major deterrent 0 wound healing: one study reported that cigarette smokers hae a 2.5% higher vate of1004 SECTION infection and ceamputation than nonsmokers. '? Other factors affecting wound healing are the severity ofthe vascular problems, diabetes, renal disease, and other physiological problems such as cardiac élsease.!9 The physical cherapist can influence positive wound heal- ing by teaching proper bed mobility and avoiding, pressure on the newly amputated limb. I POSTSURGICAL DRESSINGS. Surgeons have several options regarding the postoperative dressing, inclading (1) rigid dressing, (2) semirigid dress ing, oF (3) sofi dressing Ics important for some sort of edema control co be used because excessive edema in the residual limb can compromise healing and cause pain. Table 22.2 outlines the major postsurgical dressings in tse today with their advantages and disadvantages. Rigid Dressings “The rigid dressing, ceveloped in the carly 1960s is gen «rally known as an immediate postoperative prosthesis (POP).!820 the IPOP may be handmade from plaster of Paris by the suigeon or a prosthesist ancl follows the _general configuration of the prosthetic socket. These are not adjustable or removable. The socket must be cu like «cast for removal and a new one applied asthe residual limb heals, sutures are removed, and che limb changes shape. These are also removable rigid dressings (RRDs) that may be handmade from plaster or prefabricated from plastic materials and come in different sizes. Pre= fabricated RRDs are adjustable asthe limb changes and ‘may be removed as needed for wound inspection.#! The addition of « pylon and foot allows for caly, limited, weight-bearing ambulation. ‘Use of inmedite postoperative rigid dressings varies greatly and is move prevalent in some area ofthe county than others. Generally, orthopedic surgeons use the tech- nique more than vascular surgeons. Rigid postsurgical dhessings, whether used immediately after surgery or in RiP aIIeniD Lntervention Strategies for Rehabilitation the early postoperative perind, have een found suecessfl in teducing postoperaive edema and pal enhancing healing, even in case of delayed heal Semirigid Dressings 3 There are a number of semirigid dressings th been reported in che liceratuse and may oF may used in a particular center. All provide better of edema than the soft dressing but each hi disadvantage that limits its use, Unna's deal {gauze impregnated with a compound of zi gelatin, glycerin, and calamine, may be applied ‘operating room. Its major disadvantage is that loosen easily and is noc as rigid as the plaster oft resting. However, it has been shown 10 be sy to thesoft dressing in enhancing healing and derma?” s Soft Dressings “The aofi dressing is che oldest method of posts management of the residual limb and probably thac most physical therapists in acute care hesplt encounter. Currenily there are n4o forms of so Ings: the dastic wrap and the elastie shainker. Elastic Wraps “The clastic wrap oF elastic banulage, 4 inches rmore, may be applied aver che postsurgical rea care is taken to ensure proper compression. A desi applied ro the incision followed by some form 0 pad, then the compression wrap. ‘The so desi dlicated in cases of local infection, but isnot dhe weit of choice for the majority of individuals. The patie family member should learn to apply the wap as a pessbleafter wound care i no longer necessity Mi clder individuals wich transfemoral amputations dC have the necessary balance and coordination t¢ effectively 2 ‘Type of Dressing ‘Advantages Disadvantages Compressible soft dressing Fasy to apply Lite edema control 3 Inexpensive ‘Minimal esiua ib & protection Easy access to incision Requtesfiequertiemapping Shenker Easy toapely ‘Not wsed unt sutures are emoved inexpensive Requires chanaing as RL shrinks Semi essing Betierecome conti) then softckessng Needs eqqent changing RL protection Cant be appiec by patient No access toincision ror Excellent ederna contol Noaccess toincsion Facellent RL protection More expensive than ether diessirgs Requies proper taining for use Control ORL pain From May ailoclari®#® with germision 180P sinereise postop prosthesis.ne surgeons prefer delaying elastic wrap until the pit has healed and the sutures have been remaved. the residual limb without any pressure wrap ‘for [ull development of postoperative edema, may be quite uncomfortable and interfere with jon in the many small vessels in che skin and soft ‘thereby potentially compromising healing. The pfapist can discuss che benefits of early wrapping with = surgeon if no other form of rigid dressing is used. is strong evidence in the licerature of the benctits her the IPOP oF the RD. 2 ab against the becclothes, bending and extending the al joints, and general body movements will cause and changes in pressure, Covering the finished x ges inp 8 with stockinet helps co reduce some of che wrin- ig. However, careful and fiequene rewrapping is the fective way to prevent complications. Nutsing, family members, and the patient, as well as che al therapist or physical therapise assistant, need (0 responsibility for fequent inspection and ing of the residual limb. Resicual limb weapping bel in derail later in this chapter rare sock-like garments knitted of heavy, -cinforced cotton; they are conical in shape and in a variety of sizes (Fig. 22.4). Iv is difficule to use inker in the postoperative period because the of donaing may put unnecessary stress on the Bure 224 (Let) Transtibial stinker. (Right Tans tal shrinker, CHAPTER 22 Amputation 1005 unhealed incision. Shrinkers are best used after healing has taken place and che sutures have been removed. @ PHASES OF CARE: POSTSURGICAL26 AND PREPROSTHETIC Early onset ofrebabilication produces greater potential for success. A long delay is likely wo resul inthe development ‘of complications such as joint contractures, general dcbil- itation, and depressed psychological sete. "The rchabilita tion program can be arbitcarily divided ineo ewo phases: (1) che postsurgical phase i the time between surgery and. discharge from the hospital; (2) the preprosthetic phase runs from hospital discharge to proshetic fiting o: decision that the patient is not a candidate for prosthetic fing, these, of course are asbitrary periods but each has different goals and emphases within the POC, The desired expected outcome of the episode of care isto help the patient regain the presurgical level of function, For some, iewill mean return to gainful employmenc with an active recreational li. For others, wil mean independencein the home and community. For still others, it may mean living in the sheltered environment of a retirement center ‘or nursing home. If the amputation resulved from long- standing chronic disease, the rehabilitation approach may be to help the person function ac a higher level chan immediately before surgery. Postsurgical Phase ‘The postsurgical phase is the time berween surgery and. discharge from the hospital. While the primary goal of this phase of care is to get the patient discharged, iis not, adequate to give the patient a walker, teach the patient totransfer, and send him or her home, Box 22.1 outlines the general goals ofthe postsurgical phase of are. Box 22.2 outlines the critical dea necesiary to develop a POC for the hospitalized patient following amputation, Natucally, che data gathering must be priocitized accord ing to the person's physiological starus and cause of amputation; however, tke information obtained on inital examination and subsequent evaluation will influence discharge planning and fucure care. As indicated previ- ously, its of critical importance for the physical therapist to act as an ombudsman for the patient and ensure continuity of care fallowing hospital discharge. For all | Box22.1_ Postsurgical General Goals + Healing residual im + Protect remaining limb Gf dysvascular) + Independent in transfers and mobility «Demonstrate proper positoning + Begin psychological adjustment + Understand the process of prosthetic rehabilitation