LE Amputation Surgery & Postoperative Care

• Goal is LE Amputation Surgery & Postoperative Care, focusing on Prosthetics and Orthotics.

Amputation Surgery Objectives:

• Describe epidemiology, etiology, and risk factors associated with lower extremity amputation surgery.
• Define amputation levels and surgical procedures for each level.
• Identify postoperative dressing types and their pros and cons in clinical practice.
• Discuss goals of postoperative and preprosthetic phases.
• Distinguish between postoperative and preprosthetic phase examination processes.
• Describe phase-specific interventions for both postoperative and preprosthetic patients.

Epidemiology/Etiology:

• Approximately 2.3 million people in the U.S. live with limb loss.
• About 465,000 amputations occur in the U.S. annually.
• The primary cause of limb loss is vascular disease (54%, including diabetes and PAD).
• Trauma accounts for 45% of limb losses, and cancer (CA) for less than 2%.
• Half of vascular disease amputees die within 5 years.
• 55% of diabetic patients with a lower limb amputation require amputation of the second leg within 2-3 years.
• African Americans are 4x more likely to have an amputation than white Americans.
• 13% of US adults (18+) have diabetes (diagnosed or undiagnosed) as of 2018.
• 60% of non-traumatic amputations occur in individuals >20 years with diabetes.
• 90% of diabetics undergoing amputation had a pre-existing foot ulcer.
• Patient education is crucial.

Risk Factors for LE Amputation in Diabetics:

• Factors were identified in a study by Selby & Zhang in 1995.
• Independent predictors include level of glucose control, duration of diabetes, baseline systolic BP, microvascular changes (retinopathy, neuropathy, nephropathy), and history of stroke.
• Non-predictive factors include type of diabetes, cigarette smoking, and total cholesterol.

PAD Symptoms and Signs:

• PAD is commonly caused by atherosclerosis, leading to arterial stenosis or occlusion and reduced blood flow.
• Key symptoms include intermittent claudication (pain on walking) and critical limb ischemia (rest pain or tissue loss).
• Claudication involves aching or burning leg muscles reproduced at a set distance of walking, relieved by rest, and not affected by position.
• Critical limb ischemia includes ulceration, gangrene, and rest pain in the foot for >2 weeks, potentially resistant to opioid analgesia.
• The Ankle-Brachial Pressure Index (ABPI) helps diagnose PAD, with values ≤0.9 diagnostic and ≤0.5 suggestive of critical limb ischemia.
• Incompressible ABPI (>1.2) can occur in patients with arterial calcification due to diabetes or chronic kidney disease.

Levels of Amputation:

• Surgical considerations include viability of tissue, nature of injury, and desired post-op function (functional limb for future prosthesis).
• International classification system (O'Sullivan Table 22.1) covers various levels.
• Partial toe: Excision of any part of one or more toes.
• Toe disarticulation: Disarticulation at the metatarsal phalangeal joint.
• Partial foot/ray resection: Resection of the 3rd, 4th, 5th metatarsals and digits.
• Transmetatarsal (Lisfranc): Amputation through the midsection of all metatarsals.
• Ankle disarticulation (Syme's): Ankle disarticulation with heel pad attachment to the distal tibia end.
• Long transtibial: >50% of tibia length.
• Transtibial: Between 20 and 50% of tibia length.
• Short transtibial: <20% of tibia length.
• Knee disarticulation: Amputation through the knee joint.
• Long transfemoral: >60% of femoral length.
• Transfemoral: Between 30 and 60% of femoral length.
• Short transfemoral: <30% of femoral length.
• Hip disarticulation: Amputation through the hip/pelvis intact.
• Transpelvectomy or hemipelvectomy: Resection of part of the pelvis.
• Hemicorporectomy: Amputation of both lower limbs and pelvis below L4-5.

Principles of Surgery:

• Limb length and management of potentially painful neuromas are crucial.
• Management of severed muscles includes:
  • Myofascial: Attaching muscle to fascia for receptive tissue attachment.
  • Myoplasty: Attaching anterior and posterior compartment muscles (quads) over the end of the bone.
  • Myodesis: Anchoring muscle to bone.
  • Tenodesis: Attaching tendon to bone, improving the line of pull and reducing contraction.
• Incision and management of skin flaps/residual limb shape avoid areas of irritation.

Transtibial Amputation

• Distal ends are beveled for comfort.
• Fibula is ~1cm shorter than tibia to prevent rotation.
• Skin flaps and incisions should be equal length AP flaps, or a long posterior flap might be used for increased padding and improved vascularity.
• End-bearing can be achieved via a bone bridge (Ertl procedure).

Transtibial Amputation types:

• Transtibial Amputation Outcomes Study (TAO) by Bosse et al. (2017)
• Burgess procedure: Long posterior flap overlapping the distal residual end.
• Ertl procedure: Bone bridge connecting the distal tibia and fibula; provides a more stable base for prosthetic weight-bearing and better limb health and prosthetic fit.
• Ertl Procedure cons: Technically more complex, increased operative time, and implant-related complications.

Transfemoral Amputation:

• Surgical options:
  • Myodesis of the adductor magnus to the femur.
• Attachment of major adductor muscles is lost to the femoral level, which can impact femoral alignment if not addressed.
• Myoplasty of the quadriceps and hamstrings.
• Myodesis of the quadriceps muscle has hamstring tendons attached to either the adductor magnus or quadriceps.
• Skin flaps: Equal length or long medial (sagittal plane) for equal closure of the limb.

Osseointegration:

• Direct attachment of a prosthesis to the body via an implant in the amputated bone.
• FDA approved in 2015.
• Limitations exist when dealing with CAD because of healing issues.

Osseointegration vs. Socket Prosthesis:

• Examined walking ability and QOL, showing osseointegration increased time of use.
• TUG values improved by 44%.
• Ambulation improved, requiring 18% less energy and showed significant QOL rating score increase

Postoperative Care

Postoperative Dressings:

Goals are to Protect incision/residual limb (RL), facilitate healing of incision with appropriate stress, manage postoperative edema/swelling, and manage postoperative pain.

• Types include:
  • Elastic wraps.
  • Shrinkers.
  • Semirigid dressings.
  • Removable cast.
  • Immediate post-operative prosthesis (IPOP)

Phases of Care:

• Preoperative Phase
• Postsurgical Phase: Time between surgery and discharge.
• Preprosthetic Phase: Time between discharge and fitting of definitive prosthesis or deciding the individual is not a candidate.

VA/DoD CPG for Rehabilitation of Individuals with Lower Limb Amputation

• Strong Level of Evidence supports including patient’s birth sex and self-identified gender identity in treatment planning.
• Strong Level of Evidence supports instituting rehabilitation training interventions using open and closed chain exercises and progressive resistance is necessary to improve function.
• Use valid outcome measures (Comprehensive High Level-Activity Mobility Predictor, Amputee Mobility Predictor)
• Assess factors for poorer outcomes (smoking, illness, pain, psychosocial).

Postsurgical Phase Goals:

• Promote healing of the residual limb.
  • Manage RL pain/phantom limb pain and sensation.
  • Optimize UE/LE ROM without compromising healing and strength.
• Protect the remaining limb via proper footwear/foot care and HEP for strengthening/stretching.
• Promote independence in transfers and bed mobility, functional sitting/standing balance.
• Initiate upright mobility with walker or crutches.
• Demonstrate proper positioning and Minimize the development of contractures.
• Promote patient education on dressing use, continuum of care, caregiver trainign, assess behavioral health and psychosocial function with referral and dischage planning.
• Postsurgical Examination
• Evaluate History include amputation type, status of residual limb, OOB stauts
• Review Vital Signs and Cardiovascular and respiratory health: Check skin integrity and sensation.

Post-Surgical Exam:

• Includes evaluation of pain, testing, ROM, balance, and functional status.
• Interventions- Positioning/AROM, Functional and Ambulation training.

Preprosthetic Phase Goals:

• Achieve independence in residual limb care, mobility, transfers, and functional activities.
• Perform a HEP.
• Manage uninvolved LE.
• Demonstrate cardiorespiratory endurance for prosthesis use.
• Do not assume a prostesis is desired

Preprosthetic Examination:

• Assess Psychological/emotional status.
• Review Amputation history, Associated diseases/co-morbidities
• Do System reviews for cardiopulmonary, integumentary, neuromuscular, mental status, pain), sensation, vascular and musculoskeletal

Preprosthetic Examination:

• Residual Limb- measure length and check shape is correct, skin integrity.

Residual Limb Assesment :

• Transtibial limb- measure distal girth and length and ensure they are distally consistent Transfemoral- consistent from Ischial tuberosity to greater trochanter

Residual Limb Assesment: Phantom Limb Sensation, occurs in 80%

• Perception of sensation to the limb that has been removed in the part of the limb that is not there Can resolve after 2-3 years post amputation Maladaptive Neuroplasticity
• Phase Interventions include:
  • RL and skin management -ROM and Strengthening Exercises for Intact Extremities -Balance/Mobility Activities for strength Balance
  • Pain and Psych Support

Residual Limb(transitibial/ trans femoral) Management

• Use ace bandage with constant tension

Skin care is important

• Use lotions to help from pain-free and scar formation
• If there are a lot of edema management, need to have at least 2 shrinetes and a dr note to clear
• Use Ace wrap till Shrinker is used 25/7

Prosthesis users… have a higher Walking Cost, walk at slower speeds, making walking harder

• Partial Foot, Increased 15%
• Traumatic Transitibial: Increased 25%
• Vascular Transitibial: Increased 40%
• Traumatic Transfemoral: Increased 68%
• Vascular Transfemoral: Increase 100%

Pain Management:

• Mirror Therapy
• Tens
• Acupuncture
• Motor Imaginary
• Virtual Reality or Augmented Reality