Lower Extremity Amputations

• The educational guide enhances competence and confidence for novice practitioners providing safe, patient-centered care to the lower extremity limb loss community.
• The purpose of the educational guide is to increase the knowledge and awareness of rehabilitation therapists in the area of lower extremity prosthetics.

Lower Extremity Amputations

• Approximately two million people in the US are living with limb loss and it is projected to increase to 3.6 million by 2050.
• Limb loss etiology includes trauma, such as an accident (45% of amputations).
• Limb removal may result from a medical illness such as infection, pain, cancer, or blood vessel disease.
• Approximately 54% of all surgical amputations result from complications of vascular disease, such as diabetes and peripheral artery disease.
• The increasing rates of debilitating health trends such as type two diabetes, interdisciplinary healthcare services are needed.

Secondary Health Risks Following Amputation Surgery

• Heart attack
• Deep vein thrombosis
• Pneumonia

Associated Residual Limb Complications and Conditions

• Phantom limb pain and phantom limb syndrome
• Surgical site infection
• Neuroma
• Joint contractures

Types of Lower Extremity Amputations

• Include Syme's, Below the Knee, Through the Knee, Above the Knee, and Hip Disarticulation Amputations.

Syme's Amputation

• It is an amputation through the ankle joint.
• The most common indication is infection or congenital pseudarthrosis of the tibia.
• This is typically performed in 2 stages, with the first being removal of the ankle joint and the second being revision of the heel pad and redundant skin.
• One advantage to this procedure is the heel pad is preserved for direct weight bearing without a prosthesis.

Below the Knee Amputation

• This amputation is performed at any level between the ankle and knee joint, and is the most common lower extremity amputation.
• The knee joint is preserved which contributes to increased balance, control, and ambulation with a prosthesis.

Through the Knee Amputation

• This amputation is done through the knee joint and allows for increased weight bearing and prosthesis stability.
• Disadvantages include lack of internal knee mechanism and a bulky appearance of the residual limb.

Above the Knee Amputation

• This amputation is done at any level between the knee and hip joint.
• Disadvantages include increased energy expenditure to ambulate with a prosthesis, using compensatory muscle groups to control balance.

Hip Disarticulation Amputation

• This type of amputation happens through the hip joint and requires the most metabolic energy expenditure and control of a prosthesis.
• The level of amputation facilitates primary healing and optimizes prosthesis and rehabilitation potential.
• Rehabilitation therapists are to understand how the level of amputation affects patients' postoperative outcome and should educate patients that postoperative and prosthetic outcomes are individualized based upon multiple factors.

Secondary Complications

• Wound care & skin integrity
• Infection
• Osteomyelitis
• Dermatitis
• Muscle weakness & contractures
• Pain
• Edema
• Neuromas
• Residual limb pain versus phantom limb sensation
• Referral to the surgeon is appropriate for poor wound healing and additional secondary complications to the residual limb.

Introduction to the Field of Prosthetics

• A prosthesis is an externally applied device individually designed to replace the missing limb.
• A certified prosthetist is a specialized healthcare professional that evaluates, fabricates, and educates on utilizing artificial limbs to restore mobility.

Stages of Prosthetic Rehabilitation

• Typically starts before surgery if the amputation is planned, or following surgery if the cause is due to a traumatic event.
• Fabrication and building of the prosthesis will not occur until surgical staples are removed from the residual limb and physician clearance is given.

Stages of Prosthetic Rehabilitation

• Pre-operative
• Post-operative Management
• Pre-Prosthetic Training
• Prosthetic Prescription & Fabrication
• Prosthesis Delivery

Pre-Operative Stage

• The patient is educated on the surgical level decision and postoperative prosthetics plans

Post-Operative Management Pre-Prosthetic Training

• Promoting wound healing and continuous patient education regarding skin integrity and protecting surgical incision.
• Use the figure eight method for edema management.
• Preserving range of motion and contracture prevention education through donning immobilizers
• Pain management techniques and strategies
• Providing emotional support
• Resource information
• The medical team decides if a patient is a good prosthetic candidate.

Pre-Prosthetic Training

• Once surgery sutures are removed, patients are fitted with specific compression shrinkers based on the residual limbs circumference and length.
• The purpose of the shrinker is to reduce, prevent, and control edema to continue shaping the residual limb for the residual limb to seamlessly fit into the prosthesis.
• Prosthetists can monitor changes in the residual limb and prescribe appropriate shrinker sizes.
• Pain Management
• Desensitization techniques
• Muscle strengthening and range of motion exercises

Prosthetic Prescription & Fabrication

• Evaluation occurs which includes patient evaluation, medical history, level of cognition, living situation, and employment
• It also includes status, social history, recreational interests, prior and current level of function.
• Physical evaluation includes pain assessment, suture line, tissue density, edema, residual limb shape, ROM, MMT, sensation, proprioception
• Goals include transferring, standing, walking, cosmetic, and activity specific
• Fitting Appointment, Prosthetists use either "casting", which is a plaster impression, or a 3D scan of the residual limb to design the customized prosthetic socket.

Test Socket

• The plaster mold or 3D scan of the patient’s residual limb is sent to a fabrication lab for the development of a clear plastic mold of the residual limb, also known as the “test socket”.
• The purpose of the test socket is for prosthetists to make adjustments and modifications in order to achieve comfort and proper fit.
• The clear socket allows the prosthetist to see and mark any areas that have increased pressure, discomfort, or redness.
• Typically, 2-3 test socket appointments are needed for the prosthetist to modify the socket to best suit the patient’s residual limb shape.
• Some prosthetist clinics allow the patient to take the test socket home to use within their daily routine and provide feedback for additional adjustments.
• Once the patient expresses satisfaction and comfort with the test socket, the prosthetist sends the test socket to a lab to fabricate the socket out of carbon fiber.

Preparatory Prosthesis

• The “preparatory prosthesis’ is also known as a temporary prosthesis.
• Typically, patients do not wear this for more than a year due to shape and size changes from wearing the prosthesis.
• As patients increasingly gain balance, mobility, strength, and confidence, the prosthetist will re-evaluate prosthetic components and parts to best fit the patient's current level of function and goals.

Final Prosthesis Delivery

• This stage is the “definitive” or permanent prosthesis.
• Patients graduate to the definitive stage once their residual limb has stabilized in shape and volume.
• Rehabilitation therapists are to reinforce patient education, in addition to prosthetists education and treatment. This includes fall prevention strategies, daily limb care, hygiene routine, desensitization, and residual limb shaping, due to all these factors that can delay the process of prosthetics rehabilitation.
• Factors of prosthesis prescribed, is to be individualized

The design of a prosthesis includes

• The patient’s prior and current level of mobility
• The patient’s Overall condition of the residual limb
• The patient’s weight
• The patient’s activity level and level of assistance required for ADLs
• Cosmetic versus functional features

Prosthetic Design factors

• Socket: Device customized and attached to the residual limb
• Suspension: This refers to how the prosthesis is held to the residual limb
• Knee: Device designed to mimic natural movements when participating in activities
• Pylon: A rod composed of metal or fiber carbon forming the inner core of the prosthetic leg assisting with shock absorption.
• Ankle: Device designed to mimic ankle joint movements

Cosmesis

• The finished socket is usually made of carbon fiber and finishes can be customized.

Suspension Options

• Anatomical method is not preferred due to distal bony prominences.
• Pin lock with gel liner affixes a steel pin to the gel liner locking mechanism to the bottom.
• Lanyard with gel liner, also known as KISS suspension: a strap is connected to the distal end of the gel liner and inserted through a hole in the bottom of the prosthesis socket
• The BOA system is a micro adjustable dial that creates compression closing the prosthesis.
• Vacuum is an electric or mechanical pump that removes air from the socket
• Passive air pressure is forced via external sleeve

Osseointegration

• a mechanism for above knee amputation, implants insert into remaining femurs allowing prosthesis to attach directly without a socket

Knee Options

• Single Axis includes manual locking and stance braking
• Hydraulic controlled has a pneumatic component compressing when flexing which releases with extension
• Microprocessors are computerized to sense and adjust for any inclination

Foot Options

• Solid Ankle Cushion Heel Foot or SACH has durable cost effective material with no hinges offers energy absorption
• Single-axis provides plantarflexion and dorsiflexion to aid knee stability

Multi-Axis

• Provides all movements improving stability on uneven ground
• Dynamic response stored the energy from other movements
• Hydraulic adjusts to regulate normal mechanical ambulation
• Microprocessor adjusts to sense to environment during ambulation and stairs
• Powered feet battery powered to reduce required effort

Other factors

• Liners: serve as an interface between the socket and residual skin
• Ply Socks: Donned over liners reducing the amount of friction.
• Sweat Socks Or Sheaths: worn under gel liner

Important Information

• Over estimating and under estimating can further complications, so all should be considered when prescribed. An honest relationship is necessary

K Levels

• Is the rating system to potentially measure benefits
• The rating system to determine monetary reimbursement
• Level determine components

K Levels (Classification System)

• Level 0: No ambulation capabilities thus no prescription of prosthetics warranted
• Level 1: Ability to use transfers with simple mechanics assistance of ankle locking and manual motions
• Level 2: Potential to ambulate in community settings, rotation axis and assist is crucial
• Level 3: Variable cadence while moving with shock absorption
• Level 4: Ability to perform in high impact settings with special components

Therapist Role for K Levels

• K levels can change so continue to observe patient progress in multiple discipline settings with effective engagement.
• A therapist must note levels to function and new activity to achieve.

Insurance

• It Mostly comes via Medicare part B and requires out of pocket cost depending on various factors

Filing denied

• Is possible by filing appeals

Resources

• Limb loss community support

Post Operative Education

• Skin grafts or neuromas can become painful and limit soft tissue in bulbous

To avoid excess sodium retention

• Follow a low sodium diet post surgery

Residual Limb Volume change

• Should wear liners all the time only when necessary to change as material change
• Increase or reduce sock ply

Signs of increase, decrease in wear can note the limb volume

Hygiene

• Patients should establish a plan to wash limb and inspect it at all times with proper cleaning

Considerations

• Avoid shaving or hair removal via waxing
• Wash everything often
• Can use alcohol

Pain and Stimulation

• To maintain the use of limb monitor the potential and onset of symptoms at all times to measure a variety of factors to enhance awareness and success.

To properly stimulate for improved mental health one can try

• Mirror therapy
• Exercise
• Thermal use as needed

Medical attention

• Required to note unusual discharge and irritation to improve success

Interventions

• Exercises and promotion for any additional needed

Limb Loss can impact one’s emotions

• Be sure to take time to plan resources and offer tools for patient confidence

Adjusting post op is a time to be fully aware of challenges

• In this time be sure to have a professional goal setting with manageable expectations. This also improves the ability to help think more deeply about who they are.

Patient Activation

• One of a patients best tools in improving care with constant focus to be fully autonomous when care is self managed