LE Amputation Surgery & Postoperative Care

LE Amputation Surgery & Postoperative Care

• Objectives include describing the epidemiology, etiology, and risk factors of lower extremity amputation surgery
• Understanding levels of amputation and related procedures
• Identifying postoperative dressings and discussing post and preprosthetic phase goals

Epidemiology/Etiology

• Approximately 2.3 million people in the U.S. are living with limb loss
• 465,000 amputations occur in the U.S. annually
• Vascular disease is the primary cause (54%), including diabetes and PAD, followed by trauma (45%), and CA (<2%)
• Half of vascular disease amputees die within five years
• 55% of diabetics with a lower limb amputation require amputation of the second leg within 2-3 years
• African Americans have four times the amputation risk compared to white Americans
• 13% of US adults (≥18 years) have diabetes (diagnosed and undiagnosed)
• 60% of non-traumatic amputations occur in individuals >20 years with diabetes
• 90% of diabetics undergoing amputation had a pre-existing foot ulcer

Risk Factors for LE Amputation (Diabetics)

• 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

• Peripheral artery disease (PAD) usually results from atherosclerosis
• Atherosclerotic plaque causes arterial stenosis or occlusion, reducing blood flow to the limb
• Most patients are asymptomatic
• Many patients experience intermittent claudication (pain on walking)
• Critical limb ischemia is a condition when reduced blood flow causes rest pain/tissue loss

Claudication

• Aching or burning is experienced in the leg muscles
• Pain is reliably reproduced at a distance of walking
• Pain is relieved within minutes on rest

Critical Limb Ischemia

• It involves ulcers or gangrene
• It involves rest pain in foot for over two weeks
• It may be resistant to opiate analgesia
• Hard to differentiate from neuropathy
• Hanging the leg out of bed helps patients find relief

ABPI and PAD

• ABPI of ≤0.9 is diagnostic of PAD
• ABPI of ≤0.5 suggests critical limb ischemia
• Incompressible (ABPI >1.2) values are seen in patients with arterial calcification, notably those with diabetes and/or chronic kidney disease

Levels of Amputation

• Surgical considerations include viability of tissue, nature of injury, and post-op function
• Levels include partial toe (excision of any part of one or more toes) and toe disarticulation (at the metatarsal phalangeal joint)
• Partial Foot/Ray Resection includes resection of the 3rd, 4th, 5th metatarsals and digits
• Transmetatarsal (Lisfranc) is an amputation through the midsection of all metatarsals
• Ankle disarticulation (Syme's) involves ankle disarticulation with heel pad attached to distal tibia end
• Long transtibial is >50% of tibia length while transtibial is between 20-50% of tibia length
• Short Transtibial is <20% of tibia length
• Knee disarticulation occurs through the knee joint
• Long transfemoral is >60% of the femoral length; transfemoral is between 30-60% of length
• Short transfemoral is <30% of femoral length; hip disarticulation is through the hip/pelvis
• Transpelvectomy/hemipelvectomy involves resection of part of the pelvis; hemicorporectomy amputates both lower limbs and the pelvis below L4-5

Principles of Surgery

• Involves limb length considerations
• Management of potentially painful neuromas
• Management of severed muscles

Surgical Principles

• Myofascial involves attaching muscle to fascia
• Myoplasty involves attaching anterior and posterior compartment muscles over the end of bone
• Myodesis involves anchoring muscle to bone, and tenodesis involves attaching tendon to bone
• Incisions and management of skin flaps determine residual limb shape

Transtibial Amputation

• Distal ends are beveled for comfort and Fibula is ~1 cm shorter than tibia
• Equal length AP flaps, or a long posterior flap gives improved padding/vascularity
• Bone bridge Ertl procedure

Transtibial Amputation Studies

• TAO (Transtibial Amputation Outcomes) Study
• The Burgess procedure involves a long posterior flap overlapping the distal residual end
• The Ertl procedure includes a bone bridge connecting the distal tibia and fibula
• Ertl procdure may provide a more stable base for prosthetic bearing

Transfemoral Amputation

• Myodesis of the adductor magnus to the femur
• Attachment of major adductor muscles may impact femoral alignment if not addressed
• Myoplasty of the quadriceps and hamstrings is a potential surgical option
• Skin Flaps may be of equal length or a long medial flap (sagittal plane)

Postoperative Dressings

• Goals involve protecting incision and residual limb (RL)
• Facilitating incision healing and managing edema and pain

Postoperative Dressings Types

• Elastic wraps are readily available/accessible; allow incision access, are difficult to don, minimally protect limb, and require frequent reapplication
• Shrinkers are easy to apply and manage edema; not used until after suture removal
• Semirigid dressings better manage edema and protect the limb; require frequent changing
• Removable rigid dressings are effective at edema management and limb protection; they are expensive and needs skilled clinician.
• Immediate post-operative prosthesis (IPOP) offer excellent limb protection and edema management; no incisional access are costly

Phases of Care

• The preoperative phase, the postsurgical phase, and the preprosthetic phase of care are all key
• Postsurgical: It is the period of time between surgery and the discharge from an acute care hospital
• Preprosthetic: It is the time between discharge and fitting of definitive prostheses

VA/DoD CPG

• There is a strong level of evidence to consider the patient's birth sex and self-identified gender identity in individualized treatment plans
• There is strong evidence for instituting rehabilitation training with both open and closed chain exercises and progressive resistance
• Valid, reliable, and responsive functional outcome measures should be used
• Factors that are associated with poorer outcomes following acquired limb loss such as smoking should be assessed

Postsurgical Phase Goals

• Goals include promoting healing of the residual limb by managing RL pain, optimizing ROM, protect remaining limb, provide HEP, encourage independence, and provide patient education & proper positioning to avoid contractures

Postsurgical Examination

• Review history like amputation type and level
• Review the status of residual limb, OOB status, and vital signs (pre and post activity)
• Review respiratory and Integumentary systems
• Neuromuscular system review also take place
• Pain is considered and tested
• Body Structure/Function tested alongside extremity strength, ROM
• Activity Level evaluated (seated/standing) & Functional status are all essential

Postsurgical Phase Interventions

• Includes positioning/AROM of RL
• Functional training is used, along with instruction to protect the RL like minimize pressure/drag
• Balance training of both Standing and seated and ambulation training
• Exercises for intact extremities and maintain strength
• Limb care, both intact and residual is a priority

Preprosthetic Phase Goals

• The goals are independence in residual limb care
• Functional mobility and transfers
• Performing a HEP and managing the uninvolved LE
• Demonstrate cardiorespiratory endurance for prosthetic use

Preprosthetic Examination

• Focuses on psychological/emotional status, amputation history, and associated diseases
• Systems Review includes cardiopulmonary measures, integumentary like skin grafts, neuromuscular measures
• Mental status, RL/phantom pain, sensation/coordination/balance are considered
• Pulses/color/temperature/edema/intermittent claudication are also focused on

Systems Review

• Musculoskeletal exam, ROM, as well as RL hip and knee should be conducted
• Strenght/endurance, and Core strenth are crucial

Residual Limb

• Length and bone vs soft tissue length need to be assessed
• Shape assessment and any abnormalies need reporting

Residual Limb Assesment

• Transtibial - Girth with Medial joint lines every 2-3 inches and length as well
• Transfemoral - Girth from Ischial Tuberosity to greater trochanter. Length and and proximalk landmark to end of bone

Phantom Limb Sensation

• Phantom limb sensation reports that the part of the amputated limb is still there
• "Telescoping" involves feeling the distal end, and not the mid-portion of the phantom limb
• Typically resolves itself within 2-3 years
• Phantom limb pain occurs in ~80% of all amputations

Balance/Mobility Activities

• Balance/Mobility activities of amputation care may include ROM exercises and Psychological Support
• Cardiopulmonary endurance exercises are utilized for rehabiltation

Metabolic costs of ambulation

• It becomes higher with prosthesis use Metabolic costs:
• partial foot: Increased ~15%
• Traumatic transtibial: Increased ~25%
• Vascular transtibial: Increased ~40%
• Traumatic transfemoral: Increased ~68%
• Vascular transfemoral: Increased ~100%

Pain Management

• Non-Pharmacological interventions include Mirror Therapy and TENS(positive effects however poor quality of evidence)
• Acupuncture (positive effects however poor quality of evidence)
• Includes Motor Imagery and Virtual Reality (positive effects however poor quality of evidence for both VR and Augmented reality)
• Virtual and Augmented realities have shown to impact positively those in rehabilitation