Aust. N . Z . J. SurR. 1992.62.774-779
REHABILITATION OF LOWER LIMB AMPUTEES AND SOME IMPLICATIONS FOR SURGICAL MANAGEMENT GRAEME PENINGTON,
SALLY WARMINGTON, SUSAN
HULLAND NICHOLASFREIJAH
Rehabilitation Unit, North West Hospital, Mount Royal Campus, Poplar Road, Parkville, Victoria, Australia Aspects of peri-operative management, amputation level and rehabilitation of the lower limb amputee are reported in the context of a review of a rehabilitation service for amputees which includes an integrated prosthetic service. Two hundred admissions were reviewed and some complex cases described. It is concluded that: a very close liaison between the surgeon and the rehabilitation team (ideally with preoperative consultation) is in the patient’s best interests; any person previously walking (or a potential walker) should be considered for a trial of prosthetic walking; an integrated prosthetic service enhances the efficiency of the rehabilitation service; and that modification of the current Artificial Limb Scheme to allow manufacture of first definitive limbs in prosthetic rehabilitation units would further enhance service to patients. Key words: amputation, amputation level, peri-operative care of amputee, prosthetics, rehabilitation.
Introduction Amputation surgery is sometimes viewed principally as an acknowledgement of failure to help the patient. Alternatively it may be seen as a positive step towards maximizing the patient’s mobility and quality of life in the face of adverse circumstances. If surgery is planned accordingly, the options for rehabilitation should be considered. Changes in patterns of rehabilitation delivery, and in available technology, have improved the prospects of patients (mostly elderly) facing possible amputation of a lower limb.
History of the service The rehabilitation service for amputees at Mount Royal Hospital (now the Mount Royal Campus of North West Hospital), Victoria has changed and grown considerably during the past 7 years. Previously, the service was centred on one physiotherapist, making plaster of Paris interim limbs for below-knee amputees in a kitchenette, with a weekly visit from a rehabilitation specialist and help from other allied health workers as required. There is now a closely integrated multi-disciplinary
Correspondence: Dr G. R. Penington. North West Hospital (Mount Royal Campus), PO Box 7000, Carlton South. Vic. 3053. Australia. Accrptcd for publication 24 April 1992.
team including two rehabilitation specialists, two physiotherapists, two prosthetists, a fully equipped prosthetics laboratory with an adjacent physical therapy area containing appropriate equipment, and also outdoor training equipment. A co-ordinated programme involves medical care, physiotherapy, prosthetics, occupational therapy, dietetics, social work (providing, inter alia, individual counselling and facilitating a patients’ support group). and specialist rehabilitation nursing. Unfortunately, funding does not permit a clinical psychologist on the team. Education of patients and carers in all relevant topics (including preventative health care, diet, and care of stump, other limb and prosthesis), is considered an essential part of the programme. Visits to home and (where relevant) workplace are routine, with provision of aids or small building modifications. Help with developing alternative lifestyles is also provided when appropriate and a club formed by ex-patients (‘the Footloose Club’) adds support and social activities for present and past patients. The specialist is available for consultation on request, and increasingly close liaison with referring surgeons (many of whom also consult in the unit if needed) facilitates early transfer of the patient to the unit and earlier commencement of physical, psychological and social rehabilitation. Pre-operative consultation can aid the patient’s adjustment to a changing and challenging future, and sometimes even the patient’s decision-making with regard to the operation. Discussion about the most appropriate type of amputation may also be involved.
115
AMPUTATION REHABILITATION AND SURGICAL CARE
Rehabilitation programme At the amputee rehabilitation unit of North West Hospital the aim (in consultation with the surgeon) is to admit the patients about 7-10 days postamputation, depending on the patient’s condition and bed availability. This minimizes the detrimental effects of prolonged bed rest and allows the commencement of the pre-prosthetic phase of management as early as possible. If there are minor problems of wound healing, the patient may benefit from therapy in the rehabilitation environment, while awaiting sufficient healing to allow prosthetic use. Should further surgery become necessary, the patient will often accept this better having a clearer understanding of rehabilitation and his or her own potential, and knowing that return to the unit will occur as soon as possible. The pre-prosthetic programme focuses on strength, stamina, mobility, balance, joint range of motion and the amputation stump. Reduction of stump oedema, by use of elasticized bandages or pressure garments and intermittent positive air pressure, facilitates healing, reduces stump volume and assists in shaping the stump in preparation for the first prosthesis. Mobilization of the suture line to minimize adhesion, and desensitization is also important. Safety in bed mobility and transfers (bed to chair, toilet etc.) are early priorities, as is also strengthening of limb and trunk muscles, and increasing cardiorespiratory reserve. Joint contractures, which are encouraged by prolonged lying with elevation of the painful leg and then of the painful postoperative stump, may need considerable attention, and balance may need to be re-educated. Psychological adjustment is addressed simultaneously by the whole team, particularly the social worker, usually assisted by the peer group of fellow amputees. Education in care of the stump and the other leg starts early, including advice (rarely heeded) about smoking. Diabetics may need to be counselled in the management of their diabetes. As soon as the stump condition permits, a cast is taken and a prosthetic socket is manufactured from a positive cast that is suitably modified to distribute weight bearing and skin contact appropriately. The patient commences gait training on the interim prosthesis, which can be easily modified to accommodate changes in the stump and to assess the appropriateness of various prosthetic components for the individual patient. Some patients are unable or unwilling to use a prosthesis, and in these cases, alternative mobility skills are optimized. If there is any doubt, a trial with an interim prosthesis will clarify the position. Pain control may require multi-factorial management, including physical, pharmacological and
psychological measures. Personal and domestic care activities are addressed as soon as is practicable. The home (and workplace when relevant) is visited and necessary modifications are facilitated. Patients are discharged as early as possible, normally wearing an interim limb, and attend as day patients until fitted with a satisfactory definitive limb. At present, this must be made by an external manufacturer under the Government’s Artificial Limb Scheme, unless funding is available from some other source. Even then, the unit must remain available to the patients and their treating doctors for ongoing consultation on problems that may be related to their amputations, and for referrals to the prosthetic manufacturer, surgeon or other service as indicated.
Patient population Referrals of new amputees have doubled during the past 6 years. Inpatient admission of amputees to the rehabilitation unit of Mount Royal Hospital during 1990-91 comprised 97 patients (24%) of all admissions. A review of the last 200 admissions of new amputees (over 4 years to June 1991) indicates referrals from all but one of the metropolitan teaching hospitals, and private hospitals throughout Melbourne, with 32 (16%) from country Victoria and southern New South Wales. Reasons for referral include preference of surgeon or patient, and presumably geographical proximity to home, family andlor acute hospital. In 8% of cases, admission had already been refused by another amputee rehabilitation service. The age of patients ranged from 25 to 94 years (Fig. 1). The most common cause of amputation was, as expected, peripheral vascular disease, often associated with diabetes (Fig. 2). Types of amputation are shown in Fig. 3, outcomes for those who were discharged from inpatient care to June 1991 are indicated in Table 1. Delays in admission or in progress of the physical aspects of rehabilitation, including fitting of the interim limb, are not uncommon, due to problems with wound healing or concomitant medical problems. Delay in wound healing. however, does not necessarily preclude active therapy or prosthetic fitting (e.g. case 3 following below-knee amputation). In some cases, walking in a well fitting prosthetic socket may actually facilitate healing by aiding oedema reduction and encouraging circulation. In this largely elderly population, a background of medical conditions influencing management is common, often causing significant delays in rehabilitation and sometimes influencing functional outcome. Those that are encountered included: diabetes; ischaemic heart disease; chronic obstructive airways
’
716
PENINGTON E T A L .
disease; end-stage renal disease; blindness; hemiplegia; and intellectual impairment which had significantly impaired living skills but in these patients did not prevent successful prosthetic rehabilitation. Patients often had more than one additional problem, but none of the above should automatically preclude a trial of prosthetic rehabilitation.
60 -
50 -
-
u)
.-5
40
-
I
m a
,j
2
30
-
Illustrative cases B I L A T E R A L B E L O W - K N E E A M P U T A T I O N IN A N ELDERLY MAN
20-40 41-50 51-60 61-70
71-80
61-90
An 87 year old male had undergone a right belowknee amputation the previous year, was using a prosthesis, living in a boarding house but was not housebound. Left below-knee amputation was performed for gangrene of the foot, and after 4 months in the unit he returned to his previous address and lifestyle using two prostheses. He died of an unrelated cause 6 months later at his boarding house but enjoyed his independence in the meantime.
91+
Age (years)
Fig. 1. Age distribution of patients in this series.
PVD [+/-diabetes)
TRANS-TARSAL AMPUTATION Diabetes Trauma
Embolus
Rheumatic disease Malignancy Unhealed#
A 72 year old widow was referred 2 months after trans-tarsal amputation for an unhealed ulcer on the foot, associated with diabetic neuropathy. The amputation wound remained unhealed and painful. The talo-tibia1 and talo-calcaneal joints became disrupted, with marked downward angulation of the calcaneum resulting in weight-bearing on its distal end (Fig. 4). Despite inventive efforts by several prosthetists working in collaboration, she was never able to walk comfortably and could only cope with a padded leather ‘elephant’s foot’ boot. Previously socially active, she is effectively housebound.
DL 2
50
2
100
200
150
Percentage
Fig. 2. Major contributory conditions leading to amputation (more than one present in some cases).
HEMlPLEClA
A 70 year old married woman had three strokes that left her with a left hemiplegia. She required assistance from her husband (an above-knee amputee) with personal care. Gangrene of the left foot led to below-knee amputation. A regional rehabilitation service considered her suitable only for permanent placement in a nursing home but she successfully mastered a prosthesis and regained her previous level of function. The couple resumed their previous lifestyle.
symeL1
Midtarsal
BLINDNESS
Bilateral AK
Bilateral
wC 0
,
,
,
,
,
,
,
10
20
30
40
50
60
70
Amputees
(Yo)
Fig. 3. Amputation levels. AK: above-knee; TK: throughknee; BK: below-knee.
A 70 year old married woman, fiercely independent despite blindness and pathological depression, was hit by a truck resulting in a left below-knee amputation and extensive skin grafting to a degloved right leg. She was admitted 6 weeks after the accident, and discharged home 2 months later. She learnt to walk with a prosthesis and maintains her previous lifestyle and level of independence.
771
AMPUTATION REHABILITATION AND SURGICAL CARE
Table 1. Outcome destination and prosthetic use Level Unilat AK Unilat BK Unilat TK Syme Tarsal Bilat AWBK Bilat BK
Died as IP
Returned to acute hospital
5% 3 Yo
2.5% 8 Yo 50 '/o
-
-
5 Yo 1 1%
-
6%
-
Home 85% * 83%
50% 1000/0 100%$
83%0
Special accommodatiodhostel Nursing home -
2.5% ( w/ch) 4%
-
-
-
-
-
2.5% **
78%$i:
-
5 % (w/ch) 2%t
3.50/"i-i1 I%(w/ch)
* 72% using prosthesis. t 1 % using prosthesis. $Refer case 2 and discussion re difficulty in achieving satisfactory prosthetic fitting and walking. $78% using prostheses. ** 2% using prostheses. t t O . S " % using prostheses. $$ 67% using prostheses. AK = above-knee; BK = below-knee; TK = through-knee.
Some significant advances in prosthetics
Fig. 4. Case 2. Comparative X-rays of patient's normal ankle and foot, and amputation stump.
Prosthetic technology and practice has advanced considerably in recent years, and this advance is accelerating, with implications for patient care and comfort, and for surgical technique. The advent of endo-skeletal modular componentry allows for interchange of parts and assessment of the most appropriate combination of parts to match the particular needs of the individual. These are reusable and allow for considerable cost saving. Light-weight materials, including titanium and carbon fibre, and newer shapes and styles of socket can greatly reduce the energy requirements for use.* This can be of particular advantage to elderly people with cardiovascular and respiratory problems and arthritis. Self-locking knee joints (with manual unlock) and 'safety knees' which lock on weight bearing improve stability and may allow a frail above-knee amputee to use a limb safely. Polycentric knees have greatly reduced the cosmetic problems formerly associated with through-knee amputation. The advent some years ago of the supra-condylar suspension, patellar-tendon-bearing (SPS) prosthesis facilitated prosthetic management of very short below-knee stumps. It also enhanced lateral stability of the knee which may be an asset where there is any instability in the joint, or the patient's occupation may stress the knee. Hydraulic and pneumatic knee joints with variable cadence can be a boon to active young amputees, as may various types of ankle-foot componentry. Older patients may also prefer a multi-axial or other foot to the more usual SACH foot, particularly if they are keen dancers or golfers. The four-bar linkage knee avoids most of the additional length which used to be a feature of through-knee prostheses and a significant cosmetic problem and which may have encouraged surgeons to opt for above-knee amputation
178
PENINGTON E T A L .
when through-knee would be biologically feasible and functionally more effective for the patient. A considerable variety of sports prostheses is also available. The presence of a prosthetist with a well equipped workshop within the rehabilitation unit allows for much closer liaison between team members. It also allows the sharing of expertise, immediate adjustments to the interim limb, ready experimentation with the componentry and socket during the interim limb phase, shorter inpatient stay and demonstrable cost savings. However, most patients rely on the Government’s Artificial Limb Scheme for funding of their prostheses (with a ‘patient contribution’ except for welfare recipients). Restrictions on componentry available under this scheme limits options for prescription in these patients. This can be a particular problem for previously active and energetic patients, with through-knee or above-knee amputations.
Discussion Although Melbourne does not have a fully integrated surgical and rehabilitation service like the STAMP teams of some veterans’ administration hospitals in the United state^,^ it has been found that preoperative consultation can be of great value to the patient, and may also influence the type of amputation. Continuing close liaison allows quicker transfer of the patient from the surgical bed without jeopardizing the monitoring of the healing wound, and earlier discharge into the community. Although the relative merits of amputation and vascular reconstruction have been argued, mainly on financial we certainly would, in most cases, support limb salvage where it is feasible without causing prolonged immobilization and associated increase in debility. Once amputation is necessary and the biologically feasible lower level for amputation has been established, the most suitable level should be decided in relation to rehabilitation prospects. While in most cases, the preservation of as much length as possible is the ideal, this may not always be so. In the foot, amputation proximal to the midmetatarsal level, with consequent loss of long tendon attachments, is likely to result in significant deformity which may preclude comfortable walking (cf. case 2 ) , unless arthrodesis and/or tendon surgery is performed as well (e.g. lengthening of Tendo Achilles, re-implantation of tibialis anterior).6 It is rarely possible to make a prosthesis that will remain really satisfactory for any length of time. Syme amputation, with its end-bearing stump that allows limited household ambulation without a prosthesis, or a below-knee amputation, are likely to give a much more functional result and a more active patient.
It is virtually mandatory that the knee be saved in a potential (or possible) walker, even if the resultant stump is short. Furthermore, a shortened stump (at any level of amputation) is preferable to a wound sutured under tension. The SPS prosthesis has been used very successfully in the case of very short below-knee stumps (provided the tibia extends beyond the head of the fibula). In below-knee amputations, an inadequate bevel of the tibia can create a ‘pressure point’ which can be difficult to protect satisfactorily and may encourage breakdown of the stump. Difficulty may also arise if the distal end of the fibula is at, or beyond, the end of the tibia. If a long posterior flap is used (and this can produce a very satisfactory stump), siting the suture line immediately over the distal end of the tibia1 crest, where a sharp point can occur at the start of the bevel, tends to result in a vulnerable scar tethered to the bony point. If the whole knee cannot be saved, then throughknee amputation should be c~nsidered,~.’-’~ as this long end-bearing stump has several advantages over above-knee amputation, including ease of donning and learning the use of the prosthesis, energy need for walking, and even better sitting balance which may be important for a non-prosthetic, chair-bound person.3 This amputation will not be satisfactory, however, in the presence of severe and persisting hip flexion contracture. Through-knee amputation has been found to be preferable to the Gritti-Stokes procedure .3,8*’0Indeed, the Gritti-Stokes procedure appears to be associated with problems rather than benefits, from a prosthetic point of view. Above all, every patient who recently walked (even if only to the toilet) or who had the potential to do so, should be given an opportunity of a rehabilitation trial. Improved health after amputation may surprise all, and even if walking is not feasible or desired. rehabilitation may have much to offer both patient and carers. Neither age, bilateral amputation,” blindness,” hemiplegia,13 renal failure,I4 cardiac or pulmonary disease’’ nor nursing home residence should preclude rehabilitation consultation (a prosthesis may facilitate outings and enhance dignity and quality of life). Pre-operative rehabilitation consultation with the patient has many advantages. The future programme and mobility potential may be explained, fears of the unknown discussed and hopefully dispelled, potential for an active life discussed in a positive manner, and phantom sensation and grief reaction may be better understood and therefore better handled by the patient. The calmer patient is likely to have less problem with pain than the anxious patient. Peri-operative pain relief should be maximal, in order to reduce the amount of subsequent stump or phantom pain. Medical and nursing staff should be encouraged not to concentrate on minimal analgesic
AMPUTATION REHABILITATION AND SURGICAL CARE
dose, ‘standard’ fixed time intervals for dosage, or risk of addiction, but rather to ensure that the patient is as free as possible from anxiety, fear and pain. Postoperatively, early active exercise within safe limits should be encouraged, to help morale and increase stamina. Active and passive extension of the hip and knee should be commenced as soon as surgically safe so that contractures are minimized. Pain management after amputation continues to present problems in some c a ~ e s . ~ ~Control ~ ” , ~ *of anxiety and support through the grieving process, an understanding that abnormal sensations are standard and normally subside, and a mind kept otherwise occupied, certainly can help. The amputee’s peer group is very useful in this respect and the services of a clinical psychologist would be invaluable. Physical handling and massage of the stump, oedema control and prosthetic walking all help. Trans-cutaneous electrical stimulation (TENS) has its place,” and anti-convulsants or tricyclic antidepressants may help. Referral to a comprehensive pain management service may be indicated. Any unusual or increasing pain requires investigation in case it is a result of underlying pathology. The benefits of prosthetics integrated into the rehabilitation service have already been discussed. Present government policy precludes funding, under the Artificial Limb Scheme, for the manufacture of ‘definitive’ limbs within the unit’s prosthetic department. Provision of the first definitive limb could be seen as an integral part of rehabilitation as opposed to replacement of obsolete or damaged limbs. Two recent government inquiries have recommended licensing of suitable workshops in rehabilitation units to manufacture limbs but no action has resulted. It is hoped that this impediment to comprehensive rehabilitation of amputees will soon be removed, and that ALS clients will no longer be disadvantaged in comparison with people entitled to treatment for their amputation under other schemes (e.g. Workcare, Traffic Accident Commission).
Acknowledgements The authors thank Mr Peter Field (Chief Vascular Surgeon, RMH) and Mr Kevin King (Chief Orthopaedic Surgeon RMH), for their comments on earlier drafts of the manuscript.
References F. U . , SUNWOO 1. S . & ROITGERR. F. I . STEINBERG ( 1985) Prosthetic rehabilitation of geriatric amputee patients: a follow up study. Arch. Phys. Med. Rehabil. 66. 742-5. F., BESKIN J . , CHAMBERS R. B., PERRYJ., 2. FLANDRY R. L. & CHAVEZ R. (1989) The effect of the WATERS
719
CAT-CAM above-knee prosthesis on functional rehabilitation. Cfin. Orfhop. 239, 249-62. 3. PINZUR M. S . , SMITHD. G., DALUCA D. J . & OSTERMAN H. (1988) Selection of patients for through-theknee amputation. J . Bone Joinf Surg. 70, 746-50. 4. RAVIOLA C. A,, NICHTER L. S., BAKER J . D., BUSUITIL R. W., MACHLEDER H. 1. & MOORE W . S. (1988) Cost of treating advanced leg ischemia. Bypass graft vs primary amputation. Arch. Surg. 123, 495-6. 5 . CALLOW A . D. & MACKEY W. C. (1988) Costs and benefits of prosthetic vascular surgery. Int. Surg. 73, 237-40. 6. BAUMGARTNER R. F. (1988) Partial foot amputations aetiology, principles, operative technique. In: Amputation Surgery and Lower Limb Prosthetics (Ed. G . Murdoch and R. G. Donovan), Chapter 22. Blackwell Scientific Publications, London. 7. HOUGHTON A., ALLENA , , LUFFR. & MCCOLL I . (1989) Rehabilitation after lower limb amputation: a comparative study of above-knee, through-knee and Gritti-Stokes amputations. Br. J . Surg. 76, 622-4. B. J . , BUTTENSHAW P., MULCAHY M. &ROBIN8. MORAN SON K. P. (1990) Through knee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation. Br. J . Surg. 77, I 1 18-20. 9. STIRNEMANN P., MLlNARlC Z., OESCHA., KIRCHOF B. & ALTHAUS U. (1987) Major lower extremity amputation in patients with peripheral arterial insufficiency with special reference to the transgenicular amputation. J . Curdiovusc. Surg. 28, 152-8. 10. JENSEN J . S . Through-knee amputation. Surgery, including transcondylar and supracondylar procedures. In: Amputation Surgery and Lower Limb Prosthetics (Ed. G. Murdoch and R. G. Donovan), Chapter 22. Blackwell Scientific Publications, London. 1 I . BRODZKA w. K., THORNHILL H. L., ZARAPKAR S. E., J . A. &WEBSL. (1990) Long-term function MALLOY of persons with atherosclerotic bilateral below-knee amputations living in the inner city. Arch. fh y s . Med. Rehabil. 71, 895-900. E. & DICKSTEIN R. (1990) Physical 12. PILLAR T . , GASPAR rehabilitation of the elderly blind patient. Int. Disubil. Stud. 12, 15-7. 13. KULLMAN L. & ENDRESM. (1987) Rehabilitation of hemiplegic amputees. Int. J . Rehabil. Res. 10, 159-65. 14. GREENSPUN B . & HARMON R. L . (1986) Rehabilitation of patients with end stage renal failure after lower extremity amputation. Arch. Phys. Med. Rehabil. 67, 336-8. 15. SiosoN E. R. (1990) The elderly amputee with severe chronic obstructive pulmonary disease. Case reports. J . Am. Geriutr. Soc. 38, 51-2. 16. SHERMAN R. A,, ERNSTJ . L.. BARJA R. H. & BRUNO G. M. (1988) Phantom pain: a lesson in the necessity for careful clinical research on chronic pain problems. J . Rehabil. Res. Dev. 25, vii-x. 17. RIBBERS G . , MULDER T . & RIJKENR. (1989) The phantom phenomenon: a critical review. Int. J . Rehabil. Res. 12, 175-86. 18. SHERMAN R. A. (1989) Stump and phantom limb pain. Neurol. Clin. I, 249-64. 19. CARABELLI R. A. & KELLERMAN W. C. (1985) Phantom limb pain: relief by application of TENS to contralateral extremity. Arch. Phys. Med. Rehabil. 66, 466-7.
REHABILITATION OF LOWER LIMB AMPUTEES AND SOME IMPLICATIONS FOR SURGICAL MANAGEMENT GRAEME PENINGTON,
SALLY WARMINGTON, SUSAN
HULLAND NICHOLASFREIJAH
Rehabilitation Unit, North West Hospital, Mount Royal Campus, Poplar Road, Parkville, Victoria, Australia Aspects of peri-operative management, amputation level and rehabilitation of the lower limb amputee are reported in the context of a review of a rehabilitation service for amputees which includes an integrated prosthetic service. Two hundred admissions were reviewed and some complex cases described. It is concluded that: a very close liaison between the surgeon and the rehabilitation team (ideally with preoperative consultation) is in the patient’s best interests; any person previously walking (or a potential walker) should be considered for a trial of prosthetic walking; an integrated prosthetic service enhances the efficiency of the rehabilitation service; and that modification of the current Artificial Limb Scheme to allow manufacture of first definitive limbs in prosthetic rehabilitation units would further enhance service to patients. Key words: amputation, amputation level, peri-operative care of amputee, prosthetics, rehabilitation.
Introduction Amputation surgery is sometimes viewed principally as an acknowledgement of failure to help the patient. Alternatively it may be seen as a positive step towards maximizing the patient’s mobility and quality of life in the face of adverse circumstances. If surgery is planned accordingly, the options for rehabilitation should be considered. Changes in patterns of rehabilitation delivery, and in available technology, have improved the prospects of patients (mostly elderly) facing possible amputation of a lower limb.
History of the service The rehabilitation service for amputees at Mount Royal Hospital (now the Mount Royal Campus of North West Hospital), Victoria has changed and grown considerably during the past 7 years. Previously, the service was centred on one physiotherapist, making plaster of Paris interim limbs for below-knee amputees in a kitchenette, with a weekly visit from a rehabilitation specialist and help from other allied health workers as required. There is now a closely integrated multi-disciplinary
Correspondence: Dr G. R. Penington. North West Hospital (Mount Royal Campus), PO Box 7000, Carlton South. Vic. 3053. Australia. Accrptcd for publication 24 April 1992.
team including two rehabilitation specialists, two physiotherapists, two prosthetists, a fully equipped prosthetics laboratory with an adjacent physical therapy area containing appropriate equipment, and also outdoor training equipment. A co-ordinated programme involves medical care, physiotherapy, prosthetics, occupational therapy, dietetics, social work (providing, inter alia, individual counselling and facilitating a patients’ support group). and specialist rehabilitation nursing. Unfortunately, funding does not permit a clinical psychologist on the team. Education of patients and carers in all relevant topics (including preventative health care, diet, and care of stump, other limb and prosthesis), is considered an essential part of the programme. Visits to home and (where relevant) workplace are routine, with provision of aids or small building modifications. Help with developing alternative lifestyles is also provided when appropriate and a club formed by ex-patients (‘the Footloose Club’) adds support and social activities for present and past patients. The specialist is available for consultation on request, and increasingly close liaison with referring surgeons (many of whom also consult in the unit if needed) facilitates early transfer of the patient to the unit and earlier commencement of physical, psychological and social rehabilitation. Pre-operative consultation can aid the patient’s adjustment to a changing and challenging future, and sometimes even the patient’s decision-making with regard to the operation. Discussion about the most appropriate type of amputation may also be involved.
115
AMPUTATION REHABILITATION AND SURGICAL CARE
Rehabilitation programme At the amputee rehabilitation unit of North West Hospital the aim (in consultation with the surgeon) is to admit the patients about 7-10 days postamputation, depending on the patient’s condition and bed availability. This minimizes the detrimental effects of prolonged bed rest and allows the commencement of the pre-prosthetic phase of management as early as possible. If there are minor problems of wound healing, the patient may benefit from therapy in the rehabilitation environment, while awaiting sufficient healing to allow prosthetic use. Should further surgery become necessary, the patient will often accept this better having a clearer understanding of rehabilitation and his or her own potential, and knowing that return to the unit will occur as soon as possible. The pre-prosthetic programme focuses on strength, stamina, mobility, balance, joint range of motion and the amputation stump. Reduction of stump oedema, by use of elasticized bandages or pressure garments and intermittent positive air pressure, facilitates healing, reduces stump volume and assists in shaping the stump in preparation for the first prosthesis. Mobilization of the suture line to minimize adhesion, and desensitization is also important. Safety in bed mobility and transfers (bed to chair, toilet etc.) are early priorities, as is also strengthening of limb and trunk muscles, and increasing cardiorespiratory reserve. Joint contractures, which are encouraged by prolonged lying with elevation of the painful leg and then of the painful postoperative stump, may need considerable attention, and balance may need to be re-educated. Psychological adjustment is addressed simultaneously by the whole team, particularly the social worker, usually assisted by the peer group of fellow amputees. Education in care of the stump and the other leg starts early, including advice (rarely heeded) about smoking. Diabetics may need to be counselled in the management of their diabetes. As soon as the stump condition permits, a cast is taken and a prosthetic socket is manufactured from a positive cast that is suitably modified to distribute weight bearing and skin contact appropriately. The patient commences gait training on the interim prosthesis, which can be easily modified to accommodate changes in the stump and to assess the appropriateness of various prosthetic components for the individual patient. Some patients are unable or unwilling to use a prosthesis, and in these cases, alternative mobility skills are optimized. If there is any doubt, a trial with an interim prosthesis will clarify the position. Pain control may require multi-factorial management, including physical, pharmacological and
psychological measures. Personal and domestic care activities are addressed as soon as is practicable. The home (and workplace when relevant) is visited and necessary modifications are facilitated. Patients are discharged as early as possible, normally wearing an interim limb, and attend as day patients until fitted with a satisfactory definitive limb. At present, this must be made by an external manufacturer under the Government’s Artificial Limb Scheme, unless funding is available from some other source. Even then, the unit must remain available to the patients and their treating doctors for ongoing consultation on problems that may be related to their amputations, and for referrals to the prosthetic manufacturer, surgeon or other service as indicated.
Patient population Referrals of new amputees have doubled during the past 6 years. Inpatient admission of amputees to the rehabilitation unit of Mount Royal Hospital during 1990-91 comprised 97 patients (24%) of all admissions. A review of the last 200 admissions of new amputees (over 4 years to June 1991) indicates referrals from all but one of the metropolitan teaching hospitals, and private hospitals throughout Melbourne, with 32 (16%) from country Victoria and southern New South Wales. Reasons for referral include preference of surgeon or patient, and presumably geographical proximity to home, family andlor acute hospital. In 8% of cases, admission had already been refused by another amputee rehabilitation service. The age of patients ranged from 25 to 94 years (Fig. 1). The most common cause of amputation was, as expected, peripheral vascular disease, often associated with diabetes (Fig. 2). Types of amputation are shown in Fig. 3, outcomes for those who were discharged from inpatient care to June 1991 are indicated in Table 1. Delays in admission or in progress of the physical aspects of rehabilitation, including fitting of the interim limb, are not uncommon, due to problems with wound healing or concomitant medical problems. Delay in wound healing. however, does not necessarily preclude active therapy or prosthetic fitting (e.g. case 3 following below-knee amputation). In some cases, walking in a well fitting prosthetic socket may actually facilitate healing by aiding oedema reduction and encouraging circulation. In this largely elderly population, a background of medical conditions influencing management is common, often causing significant delays in rehabilitation and sometimes influencing functional outcome. Those that are encountered included: diabetes; ischaemic heart disease; chronic obstructive airways
’
716
PENINGTON E T A L .
disease; end-stage renal disease; blindness; hemiplegia; and intellectual impairment which had significantly impaired living skills but in these patients did not prevent successful prosthetic rehabilitation. Patients often had more than one additional problem, but none of the above should automatically preclude a trial of prosthetic rehabilitation.
60 -
50 -
-
u)
.-5
40
-
I
m a
,j
2
30
-
Illustrative cases B I L A T E R A L B E L O W - K N E E A M P U T A T I O N IN A N ELDERLY MAN
20-40 41-50 51-60 61-70
71-80
61-90
An 87 year old male had undergone a right belowknee amputation the previous year, was using a prosthesis, living in a boarding house but was not housebound. Left below-knee amputation was performed for gangrene of the foot, and after 4 months in the unit he returned to his previous address and lifestyle using two prostheses. He died of an unrelated cause 6 months later at his boarding house but enjoyed his independence in the meantime.
91+
Age (years)
Fig. 1. Age distribution of patients in this series.
PVD [+/-diabetes)
TRANS-TARSAL AMPUTATION Diabetes Trauma
Embolus
Rheumatic disease Malignancy Unhealed#
A 72 year old widow was referred 2 months after trans-tarsal amputation for an unhealed ulcer on the foot, associated with diabetic neuropathy. The amputation wound remained unhealed and painful. The talo-tibia1 and talo-calcaneal joints became disrupted, with marked downward angulation of the calcaneum resulting in weight-bearing on its distal end (Fig. 4). Despite inventive efforts by several prosthetists working in collaboration, she was never able to walk comfortably and could only cope with a padded leather ‘elephant’s foot’ boot. Previously socially active, she is effectively housebound.
DL 2
50
2
100
200
150
Percentage
Fig. 2. Major contributory conditions leading to amputation (more than one present in some cases).
HEMlPLEClA
A 70 year old married woman had three strokes that left her with a left hemiplegia. She required assistance from her husband (an above-knee amputee) with personal care. Gangrene of the left foot led to below-knee amputation. A regional rehabilitation service considered her suitable only for permanent placement in a nursing home but she successfully mastered a prosthesis and regained her previous level of function. The couple resumed their previous lifestyle.
symeL1
Midtarsal
BLINDNESS
Bilateral AK
Bilateral
wC 0
,
,
,
,
,
,
,
10
20
30
40
50
60
70
Amputees
(Yo)
Fig. 3. Amputation levels. AK: above-knee; TK: throughknee; BK: below-knee.
A 70 year old married woman, fiercely independent despite blindness and pathological depression, was hit by a truck resulting in a left below-knee amputation and extensive skin grafting to a degloved right leg. She was admitted 6 weeks after the accident, and discharged home 2 months later. She learnt to walk with a prosthesis and maintains her previous lifestyle and level of independence.
771
AMPUTATION REHABILITATION AND SURGICAL CARE
Table 1. Outcome destination and prosthetic use Level Unilat AK Unilat BK Unilat TK Syme Tarsal Bilat AWBK Bilat BK
Died as IP
Returned to acute hospital
5% 3 Yo
2.5% 8 Yo 50 '/o
-
-
5 Yo 1 1%
-
6%
-
Home 85% * 83%
50% 1000/0 100%$
83%0
Special accommodatiodhostel Nursing home -
2.5% ( w/ch) 4%
-
-
-
-
-
2.5% **
78%$i:
-
5 % (w/ch) 2%t
3.50/"i-i1 I%(w/ch)
* 72% using prosthesis. t 1 % using prosthesis. $Refer case 2 and discussion re difficulty in achieving satisfactory prosthetic fitting and walking. $78% using prostheses. ** 2% using prostheses. t t O . S " % using prostheses. $$ 67% using prostheses. AK = above-knee; BK = below-knee; TK = through-knee.
Some significant advances in prosthetics
Fig. 4. Case 2. Comparative X-rays of patient's normal ankle and foot, and amputation stump.
Prosthetic technology and practice has advanced considerably in recent years, and this advance is accelerating, with implications for patient care and comfort, and for surgical technique. The advent of endo-skeletal modular componentry allows for interchange of parts and assessment of the most appropriate combination of parts to match the particular needs of the individual. These are reusable and allow for considerable cost saving. Light-weight materials, including titanium and carbon fibre, and newer shapes and styles of socket can greatly reduce the energy requirements for use.* This can be of particular advantage to elderly people with cardiovascular and respiratory problems and arthritis. Self-locking knee joints (with manual unlock) and 'safety knees' which lock on weight bearing improve stability and may allow a frail above-knee amputee to use a limb safely. Polycentric knees have greatly reduced the cosmetic problems formerly associated with through-knee amputation. The advent some years ago of the supra-condylar suspension, patellar-tendon-bearing (SPS) prosthesis facilitated prosthetic management of very short below-knee stumps. It also enhanced lateral stability of the knee which may be an asset where there is any instability in the joint, or the patient's occupation may stress the knee. Hydraulic and pneumatic knee joints with variable cadence can be a boon to active young amputees, as may various types of ankle-foot componentry. Older patients may also prefer a multi-axial or other foot to the more usual SACH foot, particularly if they are keen dancers or golfers. The four-bar linkage knee avoids most of the additional length which used to be a feature of through-knee prostheses and a significant cosmetic problem and which may have encouraged surgeons to opt for above-knee amputation
178
PENINGTON E T A L .
when through-knee would be biologically feasible and functionally more effective for the patient. A considerable variety of sports prostheses is also available. The presence of a prosthetist with a well equipped workshop within the rehabilitation unit allows for much closer liaison between team members. It also allows the sharing of expertise, immediate adjustments to the interim limb, ready experimentation with the componentry and socket during the interim limb phase, shorter inpatient stay and demonstrable cost savings. However, most patients rely on the Government’s Artificial Limb Scheme for funding of their prostheses (with a ‘patient contribution’ except for welfare recipients). Restrictions on componentry available under this scheme limits options for prescription in these patients. This can be a particular problem for previously active and energetic patients, with through-knee or above-knee amputations.
Discussion Although Melbourne does not have a fully integrated surgical and rehabilitation service like the STAMP teams of some veterans’ administration hospitals in the United state^,^ it has been found that preoperative consultation can be of great value to the patient, and may also influence the type of amputation. Continuing close liaison allows quicker transfer of the patient from the surgical bed without jeopardizing the monitoring of the healing wound, and earlier discharge into the community. Although the relative merits of amputation and vascular reconstruction have been argued, mainly on financial we certainly would, in most cases, support limb salvage where it is feasible without causing prolonged immobilization and associated increase in debility. Once amputation is necessary and the biologically feasible lower level for amputation has been established, the most suitable level should be decided in relation to rehabilitation prospects. While in most cases, the preservation of as much length as possible is the ideal, this may not always be so. In the foot, amputation proximal to the midmetatarsal level, with consequent loss of long tendon attachments, is likely to result in significant deformity which may preclude comfortable walking (cf. case 2 ) , unless arthrodesis and/or tendon surgery is performed as well (e.g. lengthening of Tendo Achilles, re-implantation of tibialis anterior).6 It is rarely possible to make a prosthesis that will remain really satisfactory for any length of time. Syme amputation, with its end-bearing stump that allows limited household ambulation without a prosthesis, or a below-knee amputation, are likely to give a much more functional result and a more active patient.
It is virtually mandatory that the knee be saved in a potential (or possible) walker, even if the resultant stump is short. Furthermore, a shortened stump (at any level of amputation) is preferable to a wound sutured under tension. The SPS prosthesis has been used very successfully in the case of very short below-knee stumps (provided the tibia extends beyond the head of the fibula). In below-knee amputations, an inadequate bevel of the tibia can create a ‘pressure point’ which can be difficult to protect satisfactorily and may encourage breakdown of the stump. Difficulty may also arise if the distal end of the fibula is at, or beyond, the end of the tibia. If a long posterior flap is used (and this can produce a very satisfactory stump), siting the suture line immediately over the distal end of the tibia1 crest, where a sharp point can occur at the start of the bevel, tends to result in a vulnerable scar tethered to the bony point. If the whole knee cannot be saved, then throughknee amputation should be c~nsidered,~.’-’~ as this long end-bearing stump has several advantages over above-knee amputation, including ease of donning and learning the use of the prosthesis, energy need for walking, and even better sitting balance which may be important for a non-prosthetic, chair-bound person.3 This amputation will not be satisfactory, however, in the presence of severe and persisting hip flexion contracture. Through-knee amputation has been found to be preferable to the Gritti-Stokes procedure .3,8*’0Indeed, the Gritti-Stokes procedure appears to be associated with problems rather than benefits, from a prosthetic point of view. Above all, every patient who recently walked (even if only to the toilet) or who had the potential to do so, should be given an opportunity of a rehabilitation trial. Improved health after amputation may surprise all, and even if walking is not feasible or desired. rehabilitation may have much to offer both patient and carers. Neither age, bilateral amputation,” blindness,” hemiplegia,13 renal failure,I4 cardiac or pulmonary disease’’ nor nursing home residence should preclude rehabilitation consultation (a prosthesis may facilitate outings and enhance dignity and quality of life). Pre-operative rehabilitation consultation with the patient has many advantages. The future programme and mobility potential may be explained, fears of the unknown discussed and hopefully dispelled, potential for an active life discussed in a positive manner, and phantom sensation and grief reaction may be better understood and therefore better handled by the patient. The calmer patient is likely to have less problem with pain than the anxious patient. Peri-operative pain relief should be maximal, in order to reduce the amount of subsequent stump or phantom pain. Medical and nursing staff should be encouraged not to concentrate on minimal analgesic
AMPUTATION REHABILITATION AND SURGICAL CARE
dose, ‘standard’ fixed time intervals for dosage, or risk of addiction, but rather to ensure that the patient is as free as possible from anxiety, fear and pain. Postoperatively, early active exercise within safe limits should be encouraged, to help morale and increase stamina. Active and passive extension of the hip and knee should be commenced as soon as surgically safe so that contractures are minimized. Pain management after amputation continues to present problems in some c a ~ e s . ~ ~Control ~ ” , ~ *of anxiety and support through the grieving process, an understanding that abnormal sensations are standard and normally subside, and a mind kept otherwise occupied, certainly can help. The amputee’s peer group is very useful in this respect and the services of a clinical psychologist would be invaluable. Physical handling and massage of the stump, oedema control and prosthetic walking all help. Trans-cutaneous electrical stimulation (TENS) has its place,” and anti-convulsants or tricyclic antidepressants may help. Referral to a comprehensive pain management service may be indicated. Any unusual or increasing pain requires investigation in case it is a result of underlying pathology. The benefits of prosthetics integrated into the rehabilitation service have already been discussed. Present government policy precludes funding, under the Artificial Limb Scheme, for the manufacture of ‘definitive’ limbs within the unit’s prosthetic department. Provision of the first definitive limb could be seen as an integral part of rehabilitation as opposed to replacement of obsolete or damaged limbs. Two recent government inquiries have recommended licensing of suitable workshops in rehabilitation units to manufacture limbs but no action has resulted. It is hoped that this impediment to comprehensive rehabilitation of amputees will soon be removed, and that ALS clients will no longer be disadvantaged in comparison with people entitled to treatment for their amputation under other schemes (e.g. Workcare, Traffic Accident Commission).
Acknowledgements The authors thank Mr Peter Field (Chief Vascular Surgeon, RMH) and Mr Kevin King (Chief Orthopaedic Surgeon RMH), for their comments on earlier drafts of the manuscript.
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