Amputation is performed when arterial reconstructive surgery has failed or is not technically possible.
Causes of Amputations
- Congenital–Deformities in infants (1% of all cases).
- Trauma–majority of patients have been in road traffic accidents and are young adults (8%).
- Malignancy (4%).
- Metabolic–diabetes giving rise to ulcers and gangrene(21%).
- Infection–bone disease (2%)
(Department of Health statistics, 1985) .
- Transmetatarsal–Difficulty in healing but no prosthesis required–only an adapted shoe.
- Symes (through ankle)–Rarely used for vascular patients but suitable for trauma and infection. Again, can walk without prosthesis.
- Below knee (BK)–Ideal amputation site. Stump length 12.5–15 cm from knee joint. If the stump is too long, no muscle bulk is left for myoplastic flap. This level retains the knee joint, giving more mobility with lower energy requirements. The main problem is poor healing, particularly in vascular disease.
- Through–knee disarticulation–No bone section is involved and the stump is strong with no muscle imbalance but the knee is cosmetically poor and prosthetically difficult. It is unsuitable in the presence of arthritis at the knee and a hip flexion deformity.
- Gritti–Stokes (femoral condyles)– Good healing qualities but unsightly prosthesis.
- Mid–thigh (above knee, AK)–Very good healing qualities but mobility is reduced due to loss of knee joint and higher energy requirements for function. The prosthetic knee mechanism must have 12 cm clearance, therefore, the soft tissues of the stump should be at least 12 cm above the knee joint.
- Hip disarticulation–This is used in trauma or malignancy, not for peripheral vascular disease. The hip joint is disarticulated and the pelvis is intact.
- Hemipelvectomy (hindquarter)–Removing the lower limb and half the pelvis with a muscle flap covering the internal organs. This level is used mainly in malignancy.
Pre–operative Period of Amputation
These patients are most successfully managed in specialized units using a team approach. A typical team will consist of the surgeon, physiotherapist, prosthetist, occupational therapist, social worker, nurse and the GP on discharge.
After an amputation the patient must have the rehabilitation program and what can be achieved with cooperation explained. For the elderly the main aim is to achieve independence but for the young adult a high level of physical activity can be attained.
Rehabilitation of lower limb amputations
The rehabilitation program can be divided into:
- The preoperative period.
- The post–operative period:
(a) Pre–prosthetic stage.
(b) Prosthetic stage.
Pre operative exercise
If possible the patient should be assessed and treated by the physiotherapist before surgery. The longer the preoperative treatment the greater its value. An assessment of the physical, social and psychological states of the patient should be made.
- Muscle strength of the upper limbs, trunk and lower limb apart from affected limb below the level of amputation.
- Joint mobility, particularly the joint proximal to the amputation level.
- Respiratory function.
- Balance reactions in sitting and standing.
- Functional abilities.
The patient’s social circumstances should be noted: family and friend’s support, living accommodation, (stairs, ramps, rails, width of door, wheelchair accessibility) proximity of shops.
Note the patient’s psychological approach to amputation and the motivation to walk.
A treatment program should include:
- Breathing exercises to clear secretions in the lungs because many vascular patients are smokers.
- Strengthening exercises for the shoulder extensors and adductors, elbow extensors, hand grip, abdominal and trunk extensors, hip extensors, adductors and abductors (and quadriceps for below–knee level).
- Mobilizing exercises for hip extension (and knee flexion and extension for BK level).
- Bed mobility–bridging, moving up and down the bed, rolling to prone and back to supine.
- Transfers from bed to chair and back.
- Wheelchair mobility–the ability to stop, start, turn and control the wheelchair. The patient should have a wheelchair supplied preoperatively because it will be necessary for at least a few weeks post–operatively.
- Stabilizations for the trunk in sitting and standing.
Post–operative Period of Amputation
The patient’s bed should have a firm mattress and be adjustable in height with a rope ladder of monkey pole and a cradle. Postoperatively the patient requires regular and adequate analgesics to combat pain which may arise from the wound site or the phantom of a limb. Uncontrolled pain may limit the rehabilitation program
Aims of treatment
- To prevent post–operative complications.
- To prevent deformities.
- To control stump edema.
- To maintain strength of whole body and increase strength of muscles controlling the stump.
- To maintain general mobility.
- To improve balance and transfers.
- To re–educate walking.
- To restore functional independence.
- To treat phantom pain.
Breathing exercises and brisk foot exercises for the unaffected leg to prevent respiratory and circulatory complications are given on the first post–operative day and continued until the chest is clear and the patients are ambulant.
Prevention of deformity
Postoperatively there is a tendency for knee flexion in BK and hip flexion, adduction or abduction in AK amputations. Deformities arise due to pain, unopposed muscle action and the patient sitting for long periods in a wheelchair. They can be prevented by the following:
Positioning in bed–The stump should be parallel to the unaffected leg without resting on pillows. The patient should lie as flat as possible for short periods during the day and progress to prone lying when the drains are out and the patient’s condition allows. The time should be progressed from 10 minutes to 30 minutes three times daily. If the patient has cardiac or respiratory problems or if the prone position is too uncomfortable he should remain supine for as long as possible.
Exercises Strong isometric work to counteract the deformity:
- For the quadriceps in a BK amputation.
- For the hip extensors and adductors in a high AK amputation.
- For the extensors and abductors in a low AK amputation.
Stump board–In a BK amputation the stump must rest on a stump board when the patient is sitting in a wheelchair. Long periods with the knee flexed must be avoided.
Control of stump edema
A swollen stump is slow to heal and will make fitting a prosthesis difficult. The stump board will help to control edema. In addition the bed end should be elevated 30°.
Stump compression socks or bandaging
The wound is covered in a non–stick dressing and fixed with a loose crepe bandage to avoid constriction and ischaemia to the stump. Sutures are removed 2–3 weeks post–operatively.
Elasticated stump compression socks are a convenient method of reducing any edema and conditioning the stump for all–round pressure which the patient experiences when wearing a prosthesis. The pressure should be even and firm, decreasing towards the groin. Diagonal rather than circular turns prevent a tourniquet effect. The bandage should be reapplied at least three times a day and worn day and night, but removed when wearing a prosthesis. When the patient is wearing a definitive limb all day and the stump fits it comfortably in the morning, the application of pressure to the stump can stop unless the patient is confined to bed for more than a day. Regular inspections of the skin must be undertaken and both the socks and bandage must be washed frequently.
If the stump does not heal or breaks down, ultraviolet radiation may be given. For an infected wound an E4 or double E4 is given to the open area only and for an uninfected wound and E1 can be given to both the open are and the surrounding skin.
Maintain body strength and strengthen muscles controlling stump.
The extensors and adductors of the shoulder and elbow extensors can be strengthened by working against weights or springs attached behind to the bed. For example:
- Lying, static quadriceps.
- Grasp stretch lying; shoulder extension and adduction (against springs or weights).
- Grasp lying (elbows bent), straighten elbow (against springs).
- Lying, slow reversals – flexion, adduction, lateral rotation – extension, abduction and medial rotation.
- Sitting, push down on hands, raise buttocks.
- Strong arm muscles are necessary for crutch walking.
- Trunk muscles can be strengthened by crook lying, bridging.
- Lying, rolling.
- Sitting, stabilizations to trunk.
- Crook lying; knee rolling side to side.
Improve balance and transfers
The patient is allowed to sit in a wheelchair from the first day provided that he is alert and cooperative. Transfer to the wheelchair from the bed may be achieved by a backward or a sideways transfer with the help of a sliding board. A sideways transfer is easier to the side of the remaining leg. Double amputees transfer forwards to the bed or toilet because a sideways transfer requires much more strength. Once the method of transfer has been determined, all team members must use the same method to reinforce it. Following transfers the patient is taught how to maneuver the wheelchair. This will enable him to move around the ward and give the patient a sense of freedom. Balance in sitting can be improved by encouraging balance reactions by tapping the patient in all directions, or by trunk stabilizations if the patient is unsteady. Later use can be made of a balance (wobble) board for advanced balance work.
Walking without a prosthesis
When the wound is healed the patient has the stump firmly supported with compression socks or a bandage and gait training can be done in the parallel bars. The patient can progress to a frame or crutches depending on stability. This form of mobility may be useful for the patient to move around the home because it may be easier and faster than using a prosthesis and all rooms may not be accessible to a wheelchair.
Restore functional independence
As soon as the patient is able, functional training should be carried out in the physiotherapy department approximately 4–6 days post–operatively. The patient is encouraged to dress each day and propel himself in a wheelchair to the department. The exercise program should now consist of resisted pulley work, mat exercise, slow reversal and repeated contractions to the trunk and limbs, spring resistance. During this time the occupational therapist will help the patient with any dressing difficulties, teach bath transfers and provide cooking practice. The patient must be encouraged to be as independent as possible.
Phantom LimbThere is pain or sensation in the stump or ‘Phantom limb’ and its incidence is higher in patients with a severely painful limb preoperatively. It should be explained to the patient that it is due to memory of the amputated part in the cortex and nerve impulses still traveling through nerve fibers in the part, but the pain is only temporary and will gradually fade within a year. Persistent severe phantom pain may be helped by non–invasive treatment. The patient should be give adequate analgesic preoperatively and be encouraged to handle the stump postoperatively to reduce its sensitivity. A number of modalities can be tried such as transcutaneous nerve stimulation (TENS), interferential, acupuncture, ultrasound and percussion manually or electrically.